Treatment of postmastectomy pain with ambulatory continuous paravertebral nerve blocks: a randomized, triple-masked, placebo-controlled study

Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice

BACKGROUND/IMPORTANCE

Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity.

OBJECTIVE

We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults.

EVIDENCE REVIEW

We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels.

FINDINGS

Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia.

CONCLUSION

Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.

Continuous peripheral nerve blocks for analgesia following painful ambulatory surgery: a review with focus on recent developments in infusion technology

PURPOSE OF REVIEW

Continuous peripheral nerve blocks (cPNB) decrease pain scores and opioid consumption while improving patient satisfaction following ambulatory surgery. This review focuses on the history and evolution of ambulatory cPNBs, recent developments in infusion technology that may prolong the duration of analgesia, optimal choice of cPNB for various surgical procedures, and novel analgesic modalities that may prove to be alternatives or supplements to cPNBs.

RECENT FINDINGS

The primary factor limiting the duration of an ambulatory cPNB is the size of the local anesthetic reservoir. Recent evidence suggests the use of automated boluses, as opposed to continuous infusions, may decrease the rate of consumption of local anesthetic and, thereby, prolong the duration of analgesia. Utilizing a long-acting local anesthetic (e.g. ropivacaine) for initial block placement and an infusion start-delay timer may further increase this duration.

SUMMARY

Patients undergoing painful ambulatory surgery are likely to have less pain and require fewer opioid analgesics when receiving a cPNB for postoperative analgesia. Advances in electronic pumps used for cPNBs may increase the duration of these benefits.

The Intercostal Artery Perforator Flap: Expanding Breast-Conserving Therapy With a Modified Oncoplastic Approach

BACKGROUND

Historically, breast-conserving surgery may not be pursued when the oncologic deformity is too significant and/or not tolerant of radiotherapy. Reconstruction using recruitment of upper abdominal wall tissue based on the intercostal artery perforating vessels can expand breast conservation therapy indications for cases that would otherwise require mastectomy. This report aims to describe the expanded use of the intercostal artery perforator (ICAP) as well as detail its ease of adoption.

METHODS

All patients who underwent ICAP flaps for reconstruction of partial mastectomy defects at a single institution were included. Demographic data, intraoperative data, and postoperative outcomes were recorded. Intercostal artery perforator flap outcomes are compared with standard alloplastic reconstruction after mastectomy.

RESULTS

Twenty-seven patients received ICAP flaps compared with 27 unilateral tissue expanders (TE). Six cases included nipple-areolar reconstruction, and 6 included skin resurfacing. The average defect size was 217.7 (30.3-557.9) cm 3 . Plastic-specific operative time was significantly longer in the ICAP cohort ( P < 0.01) with no difference in total operative time ( P > 0.05). Length of stay was significantly longer, and major postoperative complications were significantly more common in TE patients ( P < 0.01, P > 0.05). Seven TE patients required outpatient opiate refills (26%) versus 1 ICAP patient (4%) ( P = 0.02). One ICAP patient required additional surgery. Patients reported satisfaction with aesthetic outcomes. Average follow-up in the ICAP cohort was 7 months.

CONCLUSIONS

Lumpectomy reconstruction using ICAP flaps can effectively expand breast conservation therapy indications in resection of breast skin, nipple-areola, or large volume defects. This technique is adoptable and of limited complexity. Enhancing breast-conserving surgery may improve outcomes compared with mastectomy reconstruction. Intercostal artery perforator patients may require fewer opioids, shorter hospital stays, and lower operative burden.

AMAZONE: prevention of persistent pain after breast cancer treatment by online cognitive behavioral therapy-study protocol of a randomized controlled multicenter trial

Background

Surviving breast cancer does not necessarily mean complete recovery to a premorbid state of health. Among the multiple psychological and somatic symptoms that reduce the quality of life of breast cancer survivors, persistent pain after breast cancer treatment (PPBCT) with a prevalence of 15–65% is probably the most invalidating. Once chronic, PPBCT is difficult to treat and requires an individualized multidisciplinary approach. In the past decades, several somatic and psychological risk factors for PPBCT have been identified. Studies aiming to prevent PPBCT by reducing perioperative pain intensity have not yet shown a significant reduction of PPBCT prevalence. Only few studies have been performed to modify psychological distress around breast cancer surgery. The AMAZONE study aims to investigate the effect of online cognitive behavioral therapy (e-CBT) on the prevalence of PPBCT.

Methods

The AMAZONE study is a multicenter randomized controlled trial, with an additional control arm. Patients (n=138) scheduled for unilateral breast cancer surgery scoring high for surgical or cancer-related fears, general anxiety or pain catastrophizing are randomized to receive either five sessions of e-CBT or online education consisting of information about surgery and a healthy lifestyle (EDU). The first session is scheduled before surgery. In addition to the online sessions, patients have three online appointments with a psychotherapist. Patients with low anxiety or catastrophizing scores (n=322) receive treatment as usual (TAU, additional control arm).

Primary endpoint is PPBCT prevalence 6 months after surgery.

Secondary endpoints are PPBCT intensity, the intensity of acute postoperative pain during the first week after surgery, cessation of postoperative opioid use, PPBCT prevalence at 12 months, pain interference, the sensitivity of the nociceptive and non-nociceptive somatosensory system as measured by quantitative sensory testing (QST), the efficiency of endogenous pain modulation assessed by conditioned pain modulation (CPM) and quality of life, anxiety, depression, catastrophizing, and fear of recurrence until 12 months post-surgery.

Discussion

With perioperative e-CBT targeting preoperative anxiety and pain catastrophizing, we expect to reduce the prevalence and intensity of PPBCT. By means of QST and CPM, we aim to unravel underlying pathophysiological mechanisms. The online application facilitates accessibility and feasibility in a for breast cancer patients emotionally and physically burdened time period.

Trial registration

NTR NL9132, registered December 16 2020.

Racial Disparities in the Use of Peripheral Nerve Blocks for Postoperative Analgesia After Total Mastectomy: A Retrospective Cohort Study

BACKGROUND

Peripheral nerve blocks (PNBs) are used to provide postoperative analgesia after total mastectomy. PNBs improve patient satisfaction and decrease postoperative opioid use, nausea, and vomiting. Few studies have examined whether there is racial-ethnic disparity in the use of PNBs for patients having total mastectomy. We hypothesized that non-Hispanic Asian, non-Hispanic Black, non-Hispanic patients of other races, and Hispanic patients would be less likely to receive a PNB for postoperative analgesia compared to non-Hispanic White patients having total mastectomy. Secondarily, we hypothesized that PNBs would be associated with reduced odds of major complications after total mastectomy.

METHODS

We performed a retrospective cohort study using National Surgical Quality Improvement Program (NSQIP) data from 2015 to 2019. Patients were included if they underwent total mastectomy under general anesthesia. Unadjusted rates of PNB use were compared between race-ethnicity groups. Multivariable logistic regression was performed to determine whether race-ethnicity group was independently associated with receipt of a PNB for postoperative analgesia. Secondarily, we calculated crude and risk-adjusted odds ratios for major complications in patients who received a PNB.

RESULTS

There were 64,103 patients who underwent total mastectomy and 4704 (7.3%) received a PNB for postoperative analgesia. Patients who received a PNB were younger, more commonly women, were less likely to have diabetes and hypertension, and had less disseminated cancer (all P < .05). In our regression analysis, the odds of receiving a PNB differed significantly by race-ethnicity group (P < .001). Non-Hispanic Asian and non-Hispanic Black patients had reduced odds of receiving a PNB compared to non-Hispanic White patients (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.33-0.49 and OR, 0.37 [0.32-0.44]), respectively. Non-Hispanic patients of other races, including American Indian, Alaskan Native, and Pacific Islander, also had reduced odds of receiving a PNB (OR, 0.73 [95% CI, 0.64-0.84]) compared to non-Hispanic White patients, as did Hispanic patients (OR, 0.62 [0.56-0.69]). Patients who received a PNB did not have reduced odds of major complications after mastectomy (crude OR, 0.83 [0.65-1.08]; P = .17 and adjusted OR, 0.85 [0.65-1.10]; P = .21).

CONCLUSIONS

Significant disparity exists in the use of PNBs for postoperative analgesia in patients of different race-ethnicity who undergo total mastectomy in the United States. Continued efforts are needed to better understand the causes of disparity and to ensure equitable access to PNBs.

Single-injection regional analgesia techniques for mastectomy surgery: A network meta-analysis

BACKGROUND

Patients undergoing mastectomy surgery experience severe postoperative pain. Several regional techniques have been developed to reduce pain intensity but it is unclear, which of these techniques is most effective.

OBJECTIVES

To synthesise direct and indirect comparisons for the relative efficacy of different regional and local analgesia techniques in the setting of unilateral mastectomy. Postoperative opioid consumption at 24 h, postoperative pain at extubation, 1, 12 and 24 h, postoperative nausea and vomiting were collected.

DESIGN

Systematic review with network meta-analysis (PROSPERO:CRD42021250651).

DATA SOURCE

PubMed, Scopus, the Cochrane Central Register of Controlled Trials (from inception until 7 July 2021).

ELIGIBILITY CRITERIA

All randomised controlled trials investigating single-injection regional and local analgesia techniques in adult patients undergoing unilateral mastectomy were included in our study without any language or publication date restriction.

RESULTS

Sixty-two included studies randomising 4074 patients and investigating nine techniques entered the analysis. All techniques were associated with less opioid consumption compared with controls The greatest mean difference [95% confidence interval (CI)] was associated with deep serratus anterior plane block: mean difference -16.1 mg (95% CI, -20.7 to -11.6). The greatest reduction in pain score was associated with the interpectoral-pecto-serratus plane block (mean difference -1.3, 95% CI, -1.6 to - 1) at 12 h postoperatively, and with superficial serratus anterior plane block (mean difference -1.4, 95% CI, -2.4 to -0.5) at 24 h. Interpectoral-pectoserratus plane block resulted in the greatest statistically significant reduction in postoperative nausea/vomiting when compared with placebo/no intervention with an OR of 0.23 (95% CI, 0.13 to 0.40).

CONCLUSION

All techniques were associated with superior analgesia and less opioid consumption compared with controls. No single technique was identified as superior to others. In comparison, local anaesthetic infiltration does not offer advantages over multimodal analgesia alone.

TRIAL REGISTRATION

PROSPERO (CRD4202125065).

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery.

METHODS

In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting.

RESULTS

Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting.

CONCLUSION

Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice.

STUDY REGISTRATION

PROSPERO (CRD42020198244); registered 19 October 2020.

Serratus anterior plane versus paravertebral nerve blocks for postoperative analgesia after non-mastectomy breast surgery: a randomized controlled non-inferiority trial

Background

Paravertebral and serratus plane blocks are both used to treat pain following breast surgery. However, it remains unknown if the newer serratus block provides comparable analgesia to the decades-old paravertebral technique.

Methods

Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection serratus or paravertebral block in a subject-masked fashion (ropivacaine 0.5%; 20 mL unilateral; 16 mL/side bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room with serratus blocks (measurement: Numeric Rating Scale), and (2) opioid consumption would be non-inferior with serratus blocks in the operating and recovery rooms. In order to claim that serratus blocks are non-inferior to paravertebral blocks, both hypotheses must be at least non-inferior.

Results

Within the recovery room, pain scores for participants with serratus blocks (n=49) had a median (IQR) of 4.0 (0–5.5) vs 0 (0–3.0) for those with paravertebral blocks (n=51): 0.95% CI −3.00 to −0.00; p=0.001. However, the difference in morphine equivalents did not reach statistical significance for superiority with the serratus group consuming 14 mg (10–19) vs 10 mg (10–16) for the paravertebral group: 95% CI −4.50 to 0.00, p=0.123. Since the 95% CI lower limit of −4.5 was less than our prespecified margin of −2.0, we failed to conclude non-inferiority of the serratus block with regard to opioid consumption.

Conclusions

Serratus blocks provided inferior analgesia compared with paravertebral blocks. Without a dramatic improvement in safety profile for serratus blocks, it appears that paravertebral blocks are superior to serratus blocks for postoperative analgesia after non-mastectomy breast surgery.

Trial registration number

NCT03860974.

Percutaneous cryoneurolysis for acute pain management: current status and future prospects

Introduction: Conventional nerve blocks utilize local anesthetic drugs to provide pain relief for hours or days following surgery or trauma. However, postoperative and trauma pain can last weeks or months. Ultrasound-guided percutaneous cryoneurolysis is an anesthetic modality that offers substantially longer pain relief compared to local anesthetic-based nerve blocks.Areas covered: In this review, we discuss the history, mechanism of action, and use of ultrasound-guided percutaneous cryoneurolysis by anesthesiologists in the setting of acute pain management.Expert opinion: Ultrasound-guided percutaneous cryoneurolysis offers the potential to provide weeks or months of pain relief following surgery or trauma. Compared to continuous local anesthetic-based peripheral nerve blocks, currently the gold standard for providing long duration postoperative analgesia, cryoneurolysis has benefits that include: 1) longer duration measured in weeks or months rather than days; 2) no external reservoir of local anesthetic to be carried by the patient; 3) no risk of infection; and 4) no risk of catheter dislodgement. However, cryoneurolysis can induce a prolonged motor block in addition to the sensory block, decreasing the appropriate indications to those in which potential sensory and motor deficits are acceptable. Additionally, cryoneurolysis of multiple nerves can have a substantial time requirement relative to conventional nerve blocks.

Continuous Pectoral Nerve Block Compared With Continuous Thoracic Paravertebral Block and Intravenous Opioid Analgesia for the Postoperative Analgesic Efficacy in Patients Undergoing Modified Radical Mastectomy: A Prospective Randomized Trial

OBJECTIVES

Postoperative pain following mastectomy is often severe and pain management is necessary. We evaluated the analgesic efficacy of continuous pectoral nerve block (PEC) in comparison with that of the continuous thoracic paravertebral block (TPVB) and the intravenous opioid analgesia in patients scheduled for modified radical mastectomy (MRM).

MATERIALS AND METHODS

A total of 90 female patients aged 20 to 70 years, American Society of Anesthesiologists (ASA) I to III, undergoing unilateral MRM were randomly allocated into 3 groups. All patients received postoperative morphine patient-controlled analgesia (PCA). Continuous TPVB and continuous PECs were added in group II and group III, respectively. Postoperative morphine consumption during the first 48 hours and postoperative visual analog scale were recorded.

RESULTS

The cumulative morphine consumption in the first 24 hours postoperative was higher in the PCA-M group (27.47±4.95 mg) than that of the TPVB group (8.43±2.67 mg) and PEC group (13.47±3.89 mg) (P<0.001, confidence interval: 16.6-21.5 and 11.6-16.4, respectively). It was significantly higher in the PEC group as compared with the TPVB group (P<0.001, confidence interval: 2.6-7.5). On admission to postanesthesia care unit till 2 hours postoperative, the median visual analog scale score at rest was higher in the PCA-M group than that of the TPVB group (P<0.05) and PEC group (P<0.05) without statistical difference between the TPVB group and PEC group.

DISCUSSION

Continuous PEC and continuous TPVB reduced the postoperative morphine consumptions as compared with the intravenous opioid analgesia in patients undergoing MRM with greater reduction in TPVB and without increased adverse effects.

What is the role of locoregional anesthesia in breast surgery? A systematic literature review focused on pain intensity, opioid consumption, adverse events, and patient satisfaction

BACKGROUND

Breast surgery in the United States is common. Pain affects up to 50% of women undergoing breast surgery and can interfere with postoperative outcomes. General anesthesia is the conventional, most frequently used anaesthetic technique. Various locoregional anesthetic techniques are also used for breast surgeries. A systematic review of the use of locoregional anesthesia for postoperative pain in breast surgery is needed to clarify its role in pain management.

OBJECTIVES

To systematically review literature to establish the efficacy and the safety of locoregional anesthesia used in the treatment of pain after breast surgery.

METHODS

Embase, MEDLINE, Google Scholar and Cochrane Central Trials Register were systematically searched in Mars 2020 for studies examining locoregional anesthesia for management of pain in adults after breast surgery. The methodological quality of the studies and their results were appraised using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist and specific measurement properties criteria, respectively.

RESULTS

Nineteen studies evaluating locoregional anesthesia were included: 1058 patients underwent lumpectomy/mastectomy, 142 breast augmentation and 79 breast reduction. Locoregional anesthesia provides effective anesthesia and analgesia in the perioperative setting, however no statistically significant difference emerged if compared to other techniques. For mastectomy only, the use of locoregional techniques reduces pain in the first hour after the end of the surgery if compared to other procedures (p = 0.02). Other potentially beneficial effects of locoregional anesthesia include decreased need for opioids, decreased postoperative nausea and vomiting, fewer complications and increased patient satisfaction. All this improves postoperative recovery and shortens hospitalization stay. In none of these cases, locoregional anesthesia was statistically superior to other techniques.

CONCLUSION

The results of our review showed no differences between locoregional anesthesia and other techniques in the management of breast surgery. Locoregional techniques are superior in reducing pain in the first hour after mastectomy.

Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons

Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.

A Comprehensive Review of the Diagnosis, Treatment, and Management of Postmastectomy Pain Syndrome

PURPOSE OF REVIEW

Postmastectomy pain syndrome (PMPS) remains poorly defined, although it is applied to chronic neuropathic pain following surgical procedures of the breast, including mastectomy and lumpectomy in breast-conserving surgery. It is characterized by persistent pain affecting the anterior thorax, axilla, and/or medial upper arm following mastectomy or lumpectomy. Though the onset of pain is most likely to occur after surgery, there may also be a new onset of symptoms following adjuvant therapy, including chemotherapy or radiation therapy.

RECENT FINDINGS

The underlying pathophysiology is likely multifactorial, although exact mechanisms have yet to be elucidated. In this regard, neuralgia of the intercostobrachial nerve is currently implicated as the most common cause of PMPS. Numerous pharmacological options are available in the treatment of PMPS, including gabapentinoids, tricyclic antidepressants, selective serotonin reuptake inhibitors, NMDA receptor antagonists, and nefopam (a non-opioid, non-steroidal benzoxazocine analgesic). Minimally invasive interventional treatment including injection therapy, regional anesthesia, botulinum toxin, and neuromodulation has been demonstrated to have some beneficial effect. A comprehensive update highlighting current perspectives on the treatment of postmastectomy pain syndrome is presented with emphasis on treatments currently available and newer therapeutics currently being evaluated to alleviate this complex and multifactorial condition.

PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations

Analgesic protocols used to treat pain after breast surgery vary significantly. The aim of this systematic review was to evaluate the available literature on this topic and develop recommendations for optimal pain management after oncological breast surgery. A systematic review using preferred reporting items for systematic reviews and meta-analysis guidance with procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Seven hundred and forty-nine studies were found, of which 53 randomised controlled trials and nine meta-analyses met the inclusion criteria and were included in this review. Quantitative analysis suggests that dexamethasone and gabapentin reduced postoperative pain. The use of paravertebral blocks also reduced postoperative pain scores, analgesia consumption and the incidence of postoperative nausea and vomiting. Intra-operative opioid requirements were documented to be lower when a pectoral nerves block was performed, which also reduced postoperative pain scores and opioid consumption. We recommend basic analgesics (i.e. paracetamol and non-steroidal anti-inflammatory drugs) administered pre-operatively or intra-operatively and continued postoperatively. In addition, pre-operative gabapentin and dexamethasone are also recommended. In major breast surgery, a regional anaesthetic technique such as paravertebral block or pectoral nerves block and/or local anaesthetic wound infiltration may be considered for additional pain relief. Paravertebral block may be continued postoperatively using catheter techniques. Opioids should be reserved as rescue analgesics in the postoperative period. Research is needed to evaluate the role of novel regional analgesic techniques such as erector spinae plane or retrolaminar plane blocks combined with basic analgesics in an enhanced recovery setting.

Clinical analgesic efficacy of pectoral nerve block in patients undergoing breast cancer surgery: A systematic review and meta-analysis

BACKGROUND

Breast cancer is the most commonly diagnosed cancer in women, and more than half of breast surgery patients experience severe acute postoperative pain. This meta-analysis is designed to examine the clinical analgesic efficacy of Pecs block in patients undergoing breast cancer surgery.

METHODS

An electronic literature search of the Library of PubMed, EMBASE, Cochrane Library, and Web of Science databases was conducted to collect randomized controlled trials (RCTs) from inception to November 2018. These RCTs compared the effect of Pecs block in combination with general anesthesia (GA) to GA alone in mastectomy surgery. Pain scores, intraoperative and postoperative opioid consumption, time to first request for analgesia, and incidence of postoperative nausea and vomiting were analyzed.

RESULTS

Thirteen RCTs with 940 patients were included in our analysis. The use of Pecs block significantly reduced pain scores in the postanesthesia care unit (weighted mean difference [WMD] = -1.90; 95% confidence interval [CI], -2.90 to -0.91; P < .001) and at 24 hours after surgery (WMD = -1.01; 95% CI, -1.64 to -0.38; P < .001). Moreover, Pecs block decreased postoperative opioid consumption in the postanesthesia care unit (WMD = -1.93; 95% CI, -3.51 to -0.34; P = .017) and at 24 hours (WMD = -11.88; 95% CI, -15.50 to -8.26; P < .001). Pecs block also reduced intraoperative opioid consumption (WMD = -85.52; 95% CI, -121.47 to -49.56; P < .001) and prolonged the time to first analgesic request (WMD = 296.69; 95% CI, 139.91-453.48; P < .001). There were no statistically significant differences in postoperative nausea and vomiting and block-related complications.

CONCLUSIONS

Adding Pecs block to GA procedure results in lower pain scores, less opioid consumption and longer time to first analgesic request in patients undergoing breast cancer surgery compared to GA procedure alone.

A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment

Over two-thirds of women will experience breast pain in their lifetime. As one of the leading breast symptoms for which women seek medical attention, breast pain is suspected to be underreported and under-studied. Cyclical breast pain is related to hormonal changes. Noncyclical breast pain is independent of the menstrual cycle and can be idiopathic and related to chronic pain syndromes, infections, ill-fitting bras, musculoskeletal abnormalities, pregnancy, perimenopause, and postsurgical causes. Breast pain can also present in transgender patients and may require additional considerations as to the underlying cause. Imaging of mastalgia depends upon the suspected etiology. Inappropriate imaging for breast pain is associated with significant utilization of health care resources. Cyclical breast pain does not require an imaging work-up. The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older. Management of breast pain is often supportive, as most breast pain resolves spontaneously. If pain persists, imaging and management should follow a step-wise approach. If conservative measures fail, second-line therapy is topical nonsteroidal anti-inflammatory drugs. If breast pain is severe and resistant to conservative methods, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications. While the causes of mastalgia are overwhelmingly benign, breast pain can significantly impact quality of life, and the breast radiologist should be familiar with causes, management, and treatment recommendations from a multidisciplinary approach.

Erector spinae plane versus paravertebral nerve blocks for postoperative analgesia after breast surgery: a randomized clinical trial

Background

Paravertebral nerve blocks (PVBs) are frequently used to treat pain during and following breast surgery, but have various undesirable risks such as pneumothorax. The erector spinae plane block (ESPB) also provides perioperative breast analgesia, but is purported to be easier to administer with a favorable safety profile. However, it remains unknown if the new ESPB provides comparable analgesia as the decades-old PVB technique.

Methods

Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection ESPB or PVB in a subject-blinded fashion (ropivacaine 0.5% with epinephrine; 20 mL unilateral or 16 mL/side for bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room as measured on a Numeric Rating Scale (NRS) with ESPB, and (2) opioid consumption would be non-inferior in the operating and recovery rooms with ESPB.

Results

Both pain scores and opioid consumption were higher in subjects with ESPBs (n=50) than PVBs (n=50; median NRS 3.0 vs 0; 95% CI −3.0 to 0; p=0.0011; and median morphine equivalents 2.0 vs 1.5 mg; 95% CI −1.2 to −0.1; p=0.0043). No block-related adverse events occurred in either group.

Conclusions

PVBs provided superior analgesia and reduced opioid requirements following non-mastectomy breast surgery. To compare the relatively rare complications between the techniques will require a sample size 1–2 orders of magnitude greater than the current investigation; however, without a dramatic improvement in safety profile for ESPBs, it appears that PVBs are superior to ESPBs for postoperative analgesia after non-mastectomy breast surgery.

Trial registration number

NCT03549234.

Ultrasound-guided percutaneous intercostal cryoanalgesia for multiple weeks of analgesia following mastectomy: a case series

Background

Acute post-mastectomy pain is frequently challenging to adequately treat with local anesthetic-based regional anesthesia techniques due to its relatively long duration measured in multiple weeks.

Case

We report three cases in which preoperative ultrasound-guided percutaneous intercostal nerve cryoneurolysis was performed to treat pain following mastectomy. Across all postoperative days and all three patients, the mean pain score on the numeric rating scale was 0 for each day. Similarly, no patient required any supplemental opioid analgesics during the entire postoperative period; and, no patient reported insomnia or awakenings due to pain at any time point. This was a significant improvement over historic cohorts.

Conclusions

Ultrasound-guided percutaneous cryoanalgesia is a potential novel analgesic modality for acute pain management which has a duration that better-matches mastectomy than other currently-described techniques. Appropriately powered randomized, controlled clinical trials are required to demonstrate and quantify both potential benefits and risks.

Comparison of programmed intermittent bolus infusion and continuous infusion for postoperative patient-controlled analgesia with thoracic paravertebral block catheter: a randomized, double-blind, controlled trial

Background and objectives

In this randomized, double-blind, controlled study, we hypothesized that programmed intermittent bolus infusion (PIBI) of local anesthetic for continuous paravertebral block (PVB), combined with patient-controlled analgesia (PCA), provided better pain control, better patient satisfaction, and decreased in local anesthetic consumption when compared with a continuous infusion (CI) combined with PCA, after video-assisted thoracoscopic unilateral lung resection surgery.

Methods

Preoperatively, patients undergoing video-assisted thoracoscopic unilateral lung resection surgery received ipsilateral paravertebral catheters inserted at the level of thoracic vertebrae 4 and 5. All the subjects received an initial bolus of 15 mL 0.375% ropivacaine via the catheters. Subjects were randomized to receive 0.2 % ropivacaine 8 mL/h as either PIBI (n=17) or CI (n=17) combined with a PCA pump. The pain scores, frequency of PCA, local anesthetic consumption, patient satisfaction, and the need for rescue analgesia with tramadol were recorded until 48 hours postoperative.

Results

The numeric rating scale scores in the PIBI group were significantly lower than the CI group at 4, 8, 12 hours and 4, 8, 12, 24 hours postoperatively, at rest, and during coughing, respectively. PCA local anesthetic consumption (30 mg (20–60 mg) vs 120 mg (70–155 mg), p=0.000) and frequency of PCA use over 48 hours (3 (2–6) vs 12 (7–15.5), p=0.000) was lower in the PIBI group as compared with the CI group. Additionally, the PIBI group showed greater patient satisfaction. The need for tramadol rescue was similar in the two groups.

Conclusions

In PVBs, local anesthetic administered as a PIBI in conjunction with PCA provided superior postoperative analgesia to a CI combined with PCA in patients undergoing video-assisted thoracoscopic unilateral lung resection surgery.

Clinical trial registration

ChiCTR-IOR-17011253.

A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine

Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.

Pectoral nerve blocks to improve analgesia after breast cancer surgery: A prospective, randomized and controlled trial

STUDY OBJECTIVE

To evaluate the analgesic efficacy of ultrasound guided combined pectoral nerve blocks I and II in patients scheduled for surgery for breast cancer.

DESIGN

Prospective, randomized, control trial.

SETTING

Operating rooms in a tertiary care hospital of Northern India.

PATIENTS

Sixty American Society of Anesthesiologists status I to II adult women, aged 18-70years were enrolled in this study.

INTERVENTIONS

Patients were randomized into two groups (30 patients in each group), PECS (P) group and control (C) group. In group P, patients received both general anesthesia and ultrasound guided combined pectoral nerve blocks (PECS I and II). In group C, patients received only general anesthesia.

MEASUREMENTS

We noted pain intensity at rest and during abduction of the ipsilateral upper limb, incidence of postoperative nausea and vomiting; patient's satisfaction with postoperative analgesia and maximal painless abduction at different time intervals in both groups.

MAIN RESULTS

There was significant decrease in the total amount of fentanyl requirement in the in P group {(140.66±31.80μg) and (438±71.74μg)} in comparison to C group {(218.33±23.93μg) and (609±53.00μg)} during intraoperative and post-operative period upto 24h respectively. The time to first analgesic requirement was also more in P group (44.33±17.65min) in comparison to C group (10.36±4.97min) during post-operative period. There was less limitation of shoulder movement (pain free mobilization) on the operative site at 4h and 5h after surgery in P group in comparison to C group. However there was no difference in the incidence of post-operative nausea and vomiting (22 out of 30 patients in group P and 20 out of 30 patients in group C) but patients in group P had a better satisfaction score with postoperative analgesia than C group having a p value of <0.001(Score 1; 5 VS 20; Score 2; 12 VS 9; Score 3; 13 VS 1).

CONCLUSIONS

Ultrasound guided combined pectoral nerve blocks are an effective modality of analgesia for patients undergoing breast surgeries during perioperative period.

CLINICAL TRIAL REGISTRATION

CTRI/2015/12/006457.

Comparison of single-injection ultrasound-guided approach versus multilevel landmark-based approach for thoracic paravertebral blockade for breast tumor resection: a retrospective analysis at a tertiary care teaching institution

Background

The role of thoracic paravertebral blockade (TPVB) in decreasing opioid requirements in breast cancer surgery is well documented, and there is mounting evidence that this may improve survival and reduce the rate of malignancy recurrence following cancer-related mastectomy. We compared the two techniques currently in use at our institution, the anatomic landmark-guided (ALG) multilevel versus an ultrasound-guided (USG) single injection, to determine an optimal technique.

Methods

We retrospectively reviewed records of patients who received TPVB from January 2013 to December 2014. Perioperative opioid use, post anesthesia care unit (PACU) pain scores and length of stay, block performance, and complications were compared between the two groups.

Results

We found no statistical difference between the two approaches in the studied outcomes. We did find that the number of times attending physicians in the ALG group took over the blocks from residents was significantly greater than that of the USG group (p=0.006) and more local anesthetic was used in the USG group (p=0.04).

Conclusion

This study compared the ALG approach with the USG approach for patients undergoing mastectomy for breast cancer. Based on our observations, an attending physician is more likely to take over an ALG injection, and more local anesthetic is administered during USG single injection.

Post-mastectomy cancer recurrence with and without a continuous paravertebral block in the immediate postoperative period: a prospective multi-year follow-up pilot study of a randomized, triple-masked, placebo-controlled investigation

PURPOSE

Retrospective studies have associated perioperative regional anesthesia/analgesia during mastectomy for breast cancer with a decreased incidence of cancer recurrence. However, to date, no prospective data from a randomized controlled trial have been reported. In a previous study we found that extending a single-injection paravertebral block with a multiple-day perineural local anesthetic infusion improves analgesia. This follow-up study investigates the rates of cancer recurrence for the single-injection and multiple-day infusion treatments.

METHODS

Patients undergoing unilateral (n = 24) or bilateral mastectomy (n = 36) were included in the study. All patients had been diagnosed with breast cancer or tumor in situ, except for six patients who were receiving prophylactic bilateral mastectomy and were excluded from analyses. Patients received unilateral or bilateral single-injection thoracic paravertebral block(s) corresponding to their surgical site(s) with ropivacaine and perineural catheter(s). Subsequently, patients were randomized to receive either ropivacaine 0.4% (n = 30) or normal saline (n = 30) via their catheter(s) until catheter removal on postoperative day 3. Cancer recurrence from the date of surgery until at least 2 years post surgery was investigated via chart review.

RESULTS

Five of the 54 (9.2%) patients experienced a cancer recurrence following mastectomy-3 of 26 (11.5%) of the patients with perineural ropivacaine and 2 of 28 (7.1%) of the patients with perineural saline.

CONCLUSIONS

This pilot study found no evidence that extending a single-injection paravertebral block with a multi-day perineural local anesthetic infusion decreases the risk of post-mastectomy cancer recurrence. However, due to the small sample size of this investigation, further research is needed to draw definitive conclusions.

A review of postoperative analgesia for breast cancer surgery

An online database search with subsequent article review was performed in order to review the various analgesic modalities for breast cancer surgery. Of 514 abstracts, 284 full-length manuscripts were reviewed. The effect of pharmacologic interventions is varied (NSAIDS, opioids, anticonvulsants, ketamine, lidocaine). Likewise, data from high-quality randomized, controlled studies on wound infiltration (including liposome encapsulated) and infusion of local anesthetic are minimal and conflicting. Conversely, abundant evidence demonstrates paravertebral blocks and thoracic epidural infusions provide effective analgesia and minimize opioid requirements, while decreasing opioid-related side effects in the immediate postoperative period. Other techniques with promising – but extremely limited – data include cervical epidural infusion, brachial plexus, interfascial plane and interpleural blocks. In conclusion, procedural interventions involving regional blocks are more conclusively effective than pharmacologic modalities in providing analgesia to patients following surgery for breast cancer.

Treatment of Post-Latissimus Dorsi Flap Breast Reconstruction Pain With Continuous Paravertebral Nerve Blocks: A Retrospective Review

Objectives

The addition of a perioperative continuous paravertebral nerve block (cPVB) to a single-injection thoracic paravertebral nerve block (tPVB) has demonstrated improved analgesia in breast surgery. However, its use following isolated post-mastectomy reconstruction using a latissimus dorsi flap (LDF) has not previously been examined.

Methods

We performed a retrospective review of patients who underwent salvage breast reconstruction with a unilateral LDF by a single surgeon. Preoperatively, all patients received a single-injection tPVB with 0.5% ropivacaine. Additionally, patients had the option for catheter placement to receive a continuous 0.2% ropivacaine infusion with intermittent boluses. Infusions commenced in the recovery room and the catheters were removed on the morning of discharge. The primary endpoint was the mean pain numeric rating scale (NRS) scores for the 24-hour period beginning at 7:00 on post-operative day 1.

Results

A total of 22 patients were included in this study (11-cPVB and 11-tPVB). The mean NRS pain score of cPVB patients (3.5 (standard deviation (SD) 1.8) was lower than that of the single-injection tPVB patients (4.4 (SD 2.1), however this difference was not statistically significant (P = 0.31). The length of hospital stay and opioid use was not statistically different between groups.

Conclusions

Patients receiving a cPVB in addition to tPVB after LDF reconstruction experienced similar pain to those receiving tPVB alone. A larger, randomized clinical trial is warranted to fully determine the benefits of using cPVB in addition to tPVB for this procedure.

Continuous right thoracic paravertebral block following bolus initiation reduced postoperative pain after right-lobe hepatectomy: a randomized, double-blind, placebo-controlled trial

Background and Objectives

We hypothesized that continuous right thoracic paravertebral block, following bolus initiation, decreases opioid consumption after right-lobe hepatectomy in patients receiving patient-controlled intravenous analgesia with sufentanil.

Methods

Patients undergoing right-lobe hepatectomy with a right thoracic paravertebral catheter placed at T7 30 minutes before surgery were randomly assigned to receive through this catheter either a 10-mL bolus of 0.2% ropivacaine before emergence, followed by a continuous infusion of 6 mL/h for 24 hours (PVB group), or saline at the same scheme of administration (control group). All patients were started on patient-controlled intravenous analgesia with sufentanil in the postanesthesia care unit. The primary outcome measure was total sufentanil consumption during the first 24 postoperative hours. P = 0.05 was considered as significant. For the multiple comparisons of data at 5 different time points, the P value for the 0.05 level of significance was adjusted to 0.01.

Results

Sixty-six patients were assessed for eligibility, and a PVB catheter was successfully placed for 48 patients. Data were analyzed on 22 patients in group PVB and 22 patients in the control group. The cumulative sufentanil consumption in the PVB group (54.3 ± 12.1 μg) at 24 postoperative hours was more than 20% less than that of the control group (68.1 ± 9.9 μg) (P < 0.001). There was also a significant difference in pain scores (numerical rating scale) between groups, where the PVB group had lower scores than did the control group at rest and with coughing for the first 24 hours (P < 0.001).

Conclusions

Continuous right thoracic paravertebral block, following bolus initiation, has an opioid-sparing effect on sufentanil patient-controlled intravenous analgesia for right-lobe hepatectomy patients and reduces numerical rating scale pain scores at rest and with coughing in the first 24 postoperative hours.

Single-injection thoracic paravertebral block and postoperative analgesia after mastectomy: a retrospective cohort study

BACKGROUND

The treatment of postoperative pain after mastectomy is an area of increasing interest, as this treatment option is now considered a standard of care for those affected by breast cancer. Thoracic paravertebral nerve block (tPVB) using local anesthetics administered before mastectomy can theoretically provide postoperative analgesia, thereby facilitating a more comfortable and shorter hospitalization.

METHODS

In this retrospective cohort study, we aimed to determine the duration and degree to which tPVB provides postoperative analgesia in patients who underwent either unilateral or bilateral mastectomy (n = 182). We retrospectively examined the numeric rating scale (NRS) for pain scores recorded by nursing staff throughout individual patient hospitalizations, looking specifically at the following time points: arrival from the postanesthesia care unit to the surgical wards, noon on postoperative day 1 (POD1), and discharge. We also examined the number of days until patients were discharged from the hospital.

RESULTS

Our results revealed a statistically significant decrease in NRS in pain scores for patients who had received a tPVB (n = 92) on arrival from the postanesthesia care unit to the surgical wards (mean NRS decrease of 1.9 points; 99% confidence interval [CI], -3.0 to -0.8; P < .001) but did not show statistically significant decreases in NRS for pain scores for patients at noon on POD1 (mean NRS decrease of 0.3 points at noon on POD1, P = .43) or at discharge (mean NRS decrease of 0.1 point at discharge, P = .65). Moreover, use of tPVB did not have an impact on time until discharge (average decrease of 0.5 hours; 95% CI, -6 to +5 hours, P = .87).

CONCLUSIONS

Single-injection tPVB appears to provide meaningful postoperative analgesia in the immediate postoperative period after mastectomy but not after the first day of surgery.

Interventional modalities to treat cancer-related pain

Cancer-related pain is a significant cause of morbidity in those affected by both primary and metastatic disease. Although oral, transdermal, and parenteral opioid medications are an integral part of the World Health Organization's analgesic ladder, their use may be limited by side effects. Fortunately, there are advanced interventional pain management strategies effective in reducing pain in the cancer patient while mitigating the aforementioned side effects. Celiac plexus blocks and neurolysis have been proven effective in treating cancers of the abdominal viscera (ie, pancreas). Transversus abdominis plane blocks, neurolysis, and catheter placement can be used to treat cancer pain associated with the abdominal wall. Peripheral nerve blocks and catheter placement at the brachial and lumbosacral plexus or peripheral nerves treat cancer pain associated with the upper and lower limbs, whereas paravertebral and intercostal blocks treat cancer pain associated with the chest wall and ribs. Finally, alternate drug delivery methods such as intrathecal drug delivery systems concentrate medication at central opioid receptors without affecting the peripheral receptors implicated in unwanted side effects. This article provides an overview of these interventions, including indications, contraindications, and potential complications of advanced interventional pain management options available for the treatment of intractable cancer-related pain.