Perioperative Breast Analgesia: A Qualitative Review of Anatomy and Regional Techniques

Hydromorphone combined with ropivacaine for erector spinae plane block in patients undergoing modified radical mastectomy: A prospective randomized controlled trial

BACKGROUND

Combining hydromorphone with ropivacaine in ultrasound-guided erector spinae plane blocks enhances postoperative analgesia and reduces interleukin-6 expression in breast surgery patients.

METHODS

In this study, breast cancer patients undergoing modified radical mastectomy were randomized into 3 groups for anesthesia (30 patients in each group): standard general (group C), Erector Spinae Plane Block (ESPB) with ropivacaine (group R), and ESPB with ropivacaine plus hydromorphone (group HR). Diagnosis: Breast cancer patients. Postsurgery, pain levels, IL-6, anesthetic doses, additional analgesia needs, and recovery milestones were compared to evaluate the efficacy of the ESPB enhancements.

RESULTS

The 3 groups were not significantly different in baseline characteristics, operation time, number of cases with postoperative nausea, and serum IL-6 concentrations at T1 (the time of being returned to the ward after surgery). At T2 (at 6:00 in the next morning after surgery), the serum IL-6 concentration in group HR was significantly lower than that in groups R and C (P < .05); the intraoperative doses of remifentanil, sufentanil, and propofol were significantly lower in groups HR and R than those in group C (P < .05); Groups HR and R had significantly lower visual analog scale scores at T3 (4 hours postoperatively), T4 (12 hours postoperatively), and T5 (24 hours postoperatively) than those in group C (P < .05); the proportions of patients receiving postoperative remedial analgesia were significantly lower in groups HR and R than in group C (P < .05); groups HR and R had significantly lower proportions of patients with postoperative nausea than group C (P < .05); the time to the first anal exhaust and the time to the first ambulation after surgery were significantly shorter in groups HR and R than those in group C (P < .05).

CONCLUSION

Hydromorphone combined with ropivacaine for ESPB achieved a greater postoperative analgesic effect for patients receiving MRM under general anesthesia. The combined analgesia caused fewer adverse reactions and inhibited the expression level of the inflammatory factor IL-6 more effectively, thereby facilitating postoperative recovery. ESPB using hydromorphone with ropivacaine improved pain control post-MRM, reduced adverse effects, and more effectively suppressed IL-6, enhancing recovery.

Classic incisional hernia repair under awake thoracic combined spinal -epidural anesthesia in a geriatric patient with multiple co-morbidities

INTRODUCTION AND IMPORTANCE

Routine general anesthesia with tracheal intubation is an undesirable and risky technique in individuals with pre-existing chronic respiratory diseases undergoing abdominal surgery. Instead, other modalities of regional anesthesia, such as combined thoracic spinal -epidural anesthesia, could be used as the only anesthetic technique with more excellent health care outcomes.

CASE PRESENTATION

We introduce a 72-year-old morbidly obese female with multiple comorbidities who underwent successful open surgical repair for incarcerated abdominal hernia under awake combined thoracic spinal -epidural anesthesia. The procedure proceeded smoothly without any cardio-pulmonary complications. The patient was then admitted to the Surgical Intensive Care Unit for close monitoring. Six days later, she was discharged home with good general status without any complications.

CLINICAL DISCUSSION

Superior results are reported for combined thoracic spinal -epidural anesthesia over GA in reducing postoperative respiratory events and enhancing outcomes by blunting the stress response. In particular, in challenging airways, combined thoracic spinal -epidural anesthesia offers various benefits, one of which is reducing airway handling. Hemodynamic stability is another frequently mentioned feature.

CONCLUSION

Patients with high-risk conditions are a big challenge for anesthesiologists. The standard practice of general anesthesia should be avoided in this group of patients, as it exposes them to many threats. In this report, we highly advocate using regional anesthesia in this group of patients. This type of anesthesia significantly decreases intra and post-operative anesthetic complications.

Reducing Disparities: Regional Anesthesia Blocks for Mastectomy with Reconstruction Within Standardized Regional Anesthesia Pathways

BACKGROUND

Recent data suggest disparities in receipt of regional anesthesia prior to breast reconstruction. We aimed to understand factors associated with block receipt for mastectomy with immediate tissue expander (TE) reconstruction in a high-volume ambulatory surgery practice with standardized regional anesthesia pathways.

PATIENTS AND METHODS

Patients who underwent mastectomy with immediate TE reconstruction from 2017 to 2022 were included. All patients were considered eligible for and were offered preoperative nerve blocks as part of routine anesthesia care. Interpreters were used for non-English speaking patients. Patients who declined a block were compared with those who opted for the procedure.

RESULTS

Of 4213 patients who underwent mastectomy with immediate TE reconstruction, 91% accepted and 9% declined a nerve block. On univariate analyses, patients with the lowest rate of block refusal were white, non-Hispanic, English speakers, patients with commercial insurance, and patients undergoing bilateral reconstruction. The rate of block refusal went down from 12 in 2017 to 6% in 2022. Multivariable logistic regression demonstrated that older age (p = 0.011), Hispanic ethnicity (versus non-Hispanic; p = 0.049), Medicaid status (versus commercial insurance; p < 0.001), unilateral surgery (versus bilateral; p = 0.045), and reconstruction in earlier study years (versus 2022; 2017, p < 0.001; 2018, p < 0.001; 2019, p = 0.001; 2020, p = 0.006) were associated with block refusal.

CONCLUSIONS

An established preoperative regional anesthesia program with blocks offered to all patients undergoing mastectomy with TE reconstruction can result in decreased racial disparities. However, continued differences in age, ethnicity, and insurance status justify future efforts to enhance preoperative educational efforts that address patient hesitancies in these subpopulations.

Prevention of Post-Mastectomy Pain Syndrome: A Review of Recent Literature on Perioperative Interventions

PURPOSE OF REVIEW

Up to 60% of breast cancer patients continue to experience pain three months or more after surgery, with 15 to 25% reporting moderate to severe pain. Post-mastectomy pain syndrome (PMPS) places a high burden on patients. We reviewed recent studies on perioperative interventions to prevent PMPS incidence and severity.

RECENT FINDINGS

Recent studies on pharmacologic and regional anesthetic interventions were reviewed. Only nine of the twenty-three studies included reported a significant improvement in PMPS incidence and/or severity, sometimes with mixed results for similar interventions. Evidence for prevention of PMPS is mixed. Further investigation of impact of variations in dosing is warranted. In addition, promising newer interventions for prevention of PMPS such as cryoneurolysis of intercostal nerves and stellate ganglion block need confirmatory studies.

Construction of multi-component finite element model to predict biomechanical behaviour of breasts during running and quantification of the stiffness impact of internal structure

This study aims to investigate the biomechanical behaviour and the stiffness impact of the breast internal components during running. To achieve this, a novel nonlinear multi-component dynamic finite element method (FEM) has been established, which uses experimental data obtained via 4D scanning technology and a motion capture system. The data are used to construct a geometric model that comprises the rigid body, layers of soft tissues, skin, pectoralis major muscle, fat, ligaments and glandular tissues. The traditional point-to-point method has a relative mean absolute error of less than 7.92% while the latest surface-to-surface method has an average Euclidean distance (d) of 7.05 mm, validating the simulated results. After simulating the motion of the different components of the breasts, the displacement analysis confirms that when the motion reaches the moment of largest displacement, the displacement of the breast components is proportional to their distance from the chest wall. A biomechanical analysis indicates that the stress sustained by the breast components in ascending order is the glandular tissues, pectoralis major muscle, adipose tissues, and ligaments. The ligaments provide the primary support during motion, followed by the pectoralis major muscle. In addition, specific stress points of the breast components are identified. The stiffness impact experiment indicates that compared with ligaments, the change of glandular tissue stiffness had a slightly more obvious effect on the breast surface. The findings serve as a valuable reference for the medical field and sports bra industry to enhance breast protection during motion.

Comparison of midpoint transverse process to pleura (MTP) block and erector spinae plane block (ESP) for postoperative analgesia in modified radical mastectomy patients: A double-blinded, randomized control trial

Background and Aims

Modified radical mastectomy (MRM) is associated with moderate severity of postoperative pain. Besides intravenous (IV) analgesics, various nerve blocks are being described for pain relief of MRM patients. We compared erector spinae plane (ESP) block with midpoint transverse process to pleura (MTP) block in these patients for postoperative analgesia.

Material and Methods

After receiving ethical committee approval from the institutional ethics committee (AIIMS, Jodhpur) and written informed consent from study participants, 66 patients who were assigned American Society of Anesthesiologists (ASA) physical status I and II, aged 18-75 years, and were scheduled to undergo MRM were enrolled and randomly allocated into two groups. Unilateral block was given before surgery at T3 or T4 level and with 15 ml of 0.5% ropivacaine in both the groups. Infusion of 0.5% ropivacaine (Neon laboratories limited, Mumbai, India) and 0.2% ropivacaine at a rate of 5 ml/h was maintained intraoperatively and postoperatively, respectively. Pain was assessed using the Visual Analogue Scale (VAS) for the next 24 hours. The total number of patients needing rescue analgesia, the total amount of rescue analgesics consumed in the next 24 hours, and patient satisfaction score were also compared between groups.

Results

Demographics and baseline vitals were comparable in the groups. On comparing VAS scores in both the groups during rest and movement at different time intervals, there was no difference in pain scores during the initial two hours. From the third hour, there was a statistically significant difference (P < 0.001) in pain VAS scores in both groups. The ESP group had lower VAS scores compared to the MTP group when followed for the next 24 hours. There was a statistically significant difference in patient satisfaction.

Conclusion

ESP block is more efficacious when compared to MTP block for postoperative analgesia in MRM patients.

Ultrasound-guided fascial plane blocks for post-breast surgery pain syndrome

INTRODUCTION

Persistent pain following breast surgery is common and may be challenging to treat. In patients refractory to conservative treatments, ultrasound-guided fascial plane blocks of thoracic nerves can be a useful option.

RESULTS

This type of neuro blockade technique provides advantages in terms of safety and efficacy that are convenient for physicians managing refractory and complex cases of post-breast surgery syndrome.

CONCLUSION

This technical review aims to present an up-to-date summary of the most common ultrasound-guided fascial plane blocks for chronic pain in post-breast surgery patients, provide a detailed technical description of each intervention, and propose preferred injections based on the anatomical location of the pain.

Fascial plane blocks for cardiothoracic surgery: a narrative review

In recent years, there has been a growing awareness of the limitations and risks associated with the overreliance on opioids in various surgical procedures, including cardiothoracic surgery.This shift on pain management toward reducing reliance on opioids, together with need to improve patient outcomes, alleviate suffering, gain early mobilization after surgery, reduce hospital stay, and improve patient satisfaction and functional recovery, has led to the development and widespread implementation of enhanced recovery after surgery (ERAS) protocols.In this context, fascial plane blocks are emerging as part of a multimodal analgesic in cardiac surgery and as alternatives to conventional neuraxial blocks for thoracic surgery, and there is a growing body of evidence suggesting their effectiveness and safety in providing pain relief for these procedures. In this review, we discuss the most common fascial plane block techniques used in the field of cardiothoracic surgery, offering a comprehensive overview of regional anesthesia techniques and presenting the latest evidence on the use of chest wall plane blocks specifically in this surgical setting.

Analgesia-nociception index accurately predicts inadequate pectoralis muscle fascia block (PECS) in patients undergoing breast surgery: A prospective observational study

BACKGROUND

Postoperative opioid administration has been largely replaced by regional anesthesia techniques. We aimed to determine whether intraoperative Analgesia-Nociception Index (ANI) can aid in early evaluation of the effectiveness of regional blocks such as the pectoralis muscle fascia block (PECS, pectoserratus and interpectoral plane blocks) and predicting the need for analgesics postoperatively.

METHODS

This prospective observational study enrolled 30 women (age: 20-80 years) undergoing unilateral, non-intubated, breast tumor excision alone or in conjunction with sentinel lymph node biopsy. PECS block was performed following sedation. ANI readings were obtained at 1-min intervals, and polar coordinates were assigned to the distance from the nipple (0.5-cm intervals) and o'clock position (15-min intervals) for each reading. Pain scores were assessed using a numeric rating scale from 0 to 10, and analgesics were administered depending on pain score post-operatively.

RESULTS

8 (27%), 19 (63%), and 3 (10%) patients received morphine, tramadol, and no analgesics, respectively. In total, 954 ANI measurements were obtained. At the proposed cut-off of 50, the sensitivity and specificity of the ANI nadir for need of post-operative opioids were 0.875 and 0.932, respectively. Block effectiveness was most satisfactory in the upper lateral quadrant of the breast with nipple-areolar complex (NAC) sparing effect. Most average ANI measurements for the NAC were <50. No patient experienced postoperative nausea/vomiting, although one reported dizziness.

CONCLUSIONS

The intraoperative ANI nadir <50 was strongly correlated with need for postoperative opioids. The ANI may aid in objectively evaluating the effectiveness of pectoralis muscle fascial blocks and predicting postoperative need for analgesics.

Insignificant influence of the intertransverse process block for major breast cancer surgery: a randomized, blinded, placebo-controlled, clinical trial

INTRODUCTION

The intertransverse process (ITP) block mimics the thoracic paravertebral block and allegedly ameliorates hemithoracic postoperative pain. However, concerning major reconstructive breast cancer surgery the modality has never been tested against placebo in a randomized clinical trial. We aimed to assess the efficacy of the multiple-injection ITP block and hypothesized that the blockade would reduce postoperative opioid consumption.

METHODS

We screened 58 patients with breast cancer scheduled for unilateral subpectoral implant-based primary breast reconstruction, involving mastectomy with complete fascial dissection of the major pectoral muscle. A randomization procedure allowed for the allocation of 36 patients to receive either unilateral multiple-injection active ITP block (0.5% ropivacaine 3×10 mL) or placebo ITP block (isotonic saline 3×10 mL) at T2, T4, T6 in a prospective, blinded, clinical trial. The primary outcome was total opioid consumption within the first 24 postoperative hours. Secondary outcomes included opioid consumption at 4-hour intervals, postoperative pain, patient satisfaction with block application, time to first opioid, ambulation and discharge, opioid-related side effects, and quality of recovery.

RESULTS

Opioid consumption within the first 24 postoperative hours showed no significant reduction when comparing the active and placebo group median (IQR): 75.0 mg (45-135) vs 62.5 mg (30-115), p=0.5, respectively. We did not find any consequential clinically relevant results of the secondary outcomes.

CONCLUSIONS

Following major reconstructive breast cancer surgery, a preoperative multiple-injection ITP block neither reduces 24-hour opioid consumption postoperatively nor promotes substantial clinical positive outcomes.

TRIAL REGISTRATION NUMBER

EudraCT2019-001016-35.

Regional Blocks Benefit Patients Undergoing Bilateral Mastectomy with Immediate Implant-Based Reconstruction, Even After Discharge

BACKGROUND

There is limited evidence that regional anesthesia reduces pain in patients undergoing mastectomy with immediate implant-based reconstruction. We sought to determine whether regional blocks reduce opioid consumption and improve post-discharge patient-reported pain in this population.

METHODS

We retrospectively reviewed patients who underwent bilateral mastectomy with immediate implant-based reconstruction with and without a regional block. We tested for differences in opioid consumption by block receipt using multivariable ordinal regression, and also assessed routinely collected patient-reported outcomes (PROs) for 10 days postoperatively and tested the association between block receipt and moderate or greater pain.

RESULTS

Of 754 patients, 89% received a block. Non-block patients had an increase in the odds of requiring a higher quartile of postoperative opioids. Among block patients, the estimated probability of being in the lowest quartile of opioids required was 25%, compared with 15% for non-block patients. Odds of patient-reported moderate or greater pain after discharge was 0.54 times lower in block patients than non-block patients (p = 0.025). Block patients had a 49% risk of moderate or greater pain compared with 64% in non-block patients on postoperative day 5. There was no indication of any reason for these differences other than a causal effect of the block.

CONCLUSION

Receipt of a regional block resulted in reduced opioid use and lower risk of self-reported moderate and higher pain after discharge in bilateral mastectomy with immediate implant-based reconstruction patients. Our use of PROs suggests that the analgesic effects of blocks persist after discharge, beyond the expected duration of a 'single shot' block.

Effect of ultrasound-guided thoracic paravertebral block on perioperative analgesia in elderly patients undergoing video-assisted thoracic lobectomy in China: An interventional clinical randomized controlled trial

BACKGROUND

The aim of this study was to investigate the analgesic effect and safety of ultrasound-guided thoracic paravertebral block (UG-TPVB) in Chinese elderly patients undergoing video-assisted thoracic lobectomy (VATL) and to study the influence of aging factors on these effects.

METHODS

This study was a single-center, single-blind, prospective, randomized, controlled trial. A total of 300 patients scheduled for VATL were recruited and randomly divided into the UG-TPVB group (T group) and conventional anesthesia group (C group) according to the recruitment order, and subgroups were set up according to whether the age was ≥65 years old or not. The postoperative 12, 24, and 48 h static/dynamic visual analog scale (VAS) scores, intraoperative fentanyl consumption, postoperative extubation time, post-anesthesia care unit (PACU) stay time, hospitalization days, postoperative complications, and other indicators were compared between the two groups.

RESULTS

The postoperative 12, 24, and 48 h static/dynamic VAS scores of the T group were significantly lower than those of the C group. The intraoperative fentanyl consumption, postoperative extubation time, PACU stay time, and postoperative hospitalization days were significantly lower than those of the C group. The incidence of postoperative 48 h urinary retention in the T group was significantly lower than that in the C group. These advantages showed no significant difference or slight difference between elderly patients and nonelderly patients, indicating that UG-TPVB did not influence the analgesic effect and safety of VATL patients by age or age difference.

CONCLUSION

UG-TPVB is an effective and safe perioperative analgesia method for elderly VATL patients. Its application improves the quality of life and prognosis of elderly VATL patients.

Additional intraoperative subpectoral plane block vs conventional pain control: A comparison of shoulder movement in patients with mastectomy

PURPOSE

Shoulder pain is common among mastectomy patients, with limiting shoulder mobility and negatively affecting their quality of life. Pectoral nerve blocks (PECs) have demonstrated efficacy in providing postoperative analgesia. We hypothesized that these nerve blocks could improve shoulder movement in patients undergoing mastectomy.

METHODS

This prospective, randomized, double-blind controlled trial enrolled female participants diagnosed with breast cancer and scheduled for mastectomy. Participants were randomly assigned to either the conventional analgesia group or the intervention group. In the intervention group, a PECs II block was applied prior to skin closure following a mastectomy. This study's primary outcome was the assessment of shoulder movement ratios in 5 different positions (forward elevation, external rotation, arm abduction, internal rotation, and cross-body adduction), which were recorded before surgery, at 24-h, 48-h, and 72-h intervals postoperatively, with follow-up at 1 month, 2 months, 3 months, and 6 months.

RESULTS

A total of 59 participants were included in the final analysis. Patients who underwent mastectomy with PECs II block exhibited better shoulder movement in terms of external rotation and arm abduction from the early post-surgery up to 6 months postoperatively. Shoulder forward elevation also showed superior gains during the early postoperative period, with statistical significance observed after 1 month following the surgery. However, no significant differences were found between the two groups in terms of internal rotation and adduction movements of the shoulder.

CONCLUSIONS

Compared to conventional analgesia, intraoperative pectoral nerve block under direct vision enhances shoulder mobility in forward elevation, external rotation, and arm abduction after mastectomy in breast cancer patients.

Chest Wall and Abdominal Blocks for Thoracic and Abdominal Surgeries: A Review

PURPOSE OF REVIEW

The purpose of this review is to provide an up-to-date description and overview of the rapidly growing literature pertaining to techniques and clinical applications of chest wall and abdominal fascial plane blocks in managing perioperative pain.

RECENT FINDINGS

Clinical evidence suggests that regional anesthesia blocks, including fascial plane blocks, such as pectoralis, serratus, erector spinae, transversus abdominis, and quadratus lumborum blocks, are effective in providing analgesia for various surgical procedures and have more desirable side effect profile when compared to traditional neuraxial techniques. They offer advantages such as reduced opioid consumption, improved pain control, and decreased opioid-related side effects. Further research is needed to establish optimal techniques and indications for these blocks. Presently, they are a vital instrument in a gamut of multimodal analgesia options, especially when there are contraindications to neuraxial or para-neuraxial procedures. Ultimately, clinical judgment and provider skill set determine which blocks-alone or in combination-should be offered to any patient.

The clinical impact of pectoral nerve block in an 'enhanced recovery after surgery' program in breast surgery

Background: Pectoral nerve block (PECS) is increasingly performed in breast surgery. Aim: The study evaluated the clinical impact of these blocks in the postoperative course. Patients & methods: In this case-control study, patients undergoing breast surgery with 'enhanced recovery after surgery' pathways were divided into group 1 (57 patients) in whom PECS was performed before general anesthesia, and group 2 (57 patients) in whom only general anesthesia was effected. Results: Postoperative opioid consumption (p < 0.002), pain at 32 h after surgery (p < 0.005) and the length of stay (p < 0.003) were significantly lower in group 1. Conclusion: Reducing opioid consumption and pain after surgery, PECS could favor a faster recovery with a reduction in length of stay, ensuring a higher turnover of patients undergoing breast surgery.

Comparison of the efficacy of ultrasound guided pectoralis-II block and intercostal approach to paravertebral block (proximal intercostal block) among patients undergoing conservative breast surgery: A randomised control study

Background and Aims

Regional anesthesia techniques have attributed a multimodal dimension to pain management after breast surgery. The intercostal approach to paravertebral block has been gaining interest, becoming an alternative to conventional paravertebral block, devoid of complexities in its approach, being recognized as the proximal intercostal block. Parallel to the widespread acceptance of fascial plane blocks in breast surgery, pectoralis II block has emerged as being non-inferior to paravertebral block. The aim of this study was to evaluate the efficacy of two independent fascial plane blocks, proximal intercostal block and pectoralis II block, in breast conservation surgery.

Material and Methods

This prospective, randomized control, pilot study included 40 patients, randomly allocated among two groups: proximal intercostal block and pectoralis II block.

Results

The pectoralis II block group had significantly lower pain scores at rest in the immediate postoperative period but became comparable with the proximal intercostal block group in the late postoperative period. Pain scores on movement though were lower at 0 h postoperatively and became comparable with the proximal intercostal block group subsequently. Although the pectoralis II group had earlier recovery in the post-anesthesia care unit, the overall time to discharge from the hospital was comparable and not influential. Both groups had high patient satisfaction scores and similar perioperative opioid consumption. Sedation, time to first rescue analgesia, and postoperative nausea vomiting scores were comparable.

Conclusion

Fascial plane blocks in the form of pectoralis II and proximal intercostal block facilitate pain alleviation, early return to shoulder arm exercise, and enhanced recovery, which should render them to be incorporated into multimodal interdisciplinary pain management in breast conservation surgery.

Research Progress on Serratus Anterior Plane Block in Breast Surgery: A Narrative Review

Breast surgery, especially radical mastectomy, is often accompanied by moderate to severe acute pain, which significantly reduces postoperative quality of life. Effective pain management can accelerate patient recovery. Serratus anterior plane block (SAPB) is a new type of fascial plane block technique, which can better target the nerve network innervating the chest wall and breast and provide good analgesia in the anterolateral chest wall. Current clinical research evidence indicates that SAPB has significant benefits in breast surgery. Further research avenues for this technology include optimal local anesthetic dosing strategy, the type of SAPB which is more suitable for breast surgery, comparison of SAPB and pectoral nerve block II (PECS II) in breast surgery, and high-quality randomized controlled study with outcomes of chronic pain or cancer prognosis.

Combined fascial plane blocks as the sole regional anesthesia technique for breast surgery in high-risk patients

The quest for an effective regional anaesthesia technique in breast surgery has always been eluded by its apparent complexity. Various techniques had been described as anaesthetic techniques for breast cancer surgeries. Fascial plane blocks had been used as analgesic techniques for this procedure. We describe a case series of 12 patients who were given a combination of erector spinae plane block (ESP), Pectoralis I (Pecs I) and serratus anterior plane (SAP) block as sole anaesthetic technique with high risk surgical morbidity. Two patients had discomfort during retraction of axillary apex towards the end of surgery, and one patient had discomfort during medial parasternal incision, which needed a single bolus of low dose ketamine injection. Combined fascial plane blocks could be effectively utilized as a sole regional anesthesia modality for breast cancer surgeries with mild sedation.

Comparison between ultrasound-guided multi-injection intertransverse process and thoracic paravertebral blocks for major breast cancer surgery: a randomized non-inferiority trial

BACKGROUND

This study investigated whether a novel multi-injection intertransverse process block could provide non-inferior analgesia and recovery quality following major breast cancer surgery compared with the multi-injection thoracic paravertebral block.

METHODS

Eighty-eight females who underwent mastectomy plus sentinel or axillary lymph node dissection were randomized to receive either intertransverse process block or thoracic paravertebral block, both performed at T2-6 with 5 mL of 0.5% ropivacaine per level. The primary outcome was the worst resting pain score (11-point Numerical Rating Scale) within 30 min in the recovery room. The secondary outcome was recovery quality (15-item quality of recovery scale) 24 hours after surgery, which was tested following a gatekeeping procedure.

RESULTS

The worst resting pain scores were 0 (0, 1) in the intertransverse process block group vs 0.5 (0, 2) in the thoracic paravertebral block group, with a median difference of 0 (95% CI 0 to 0); the upper 95% CI limit was lower than the prespecified non-inferiority margin of 1 point (non-inferiority p<0.001). Aggregate scores of recovery quality at 24 hours postoperatively were 137.5 (126.5, 142.8) and 137.5 (127.8, 145.0) for the intertransverse process and thoracic paravertebral block groups, respectively, with a median difference of -1 (95% CI -6 to 3); the lower 95% CI limit was larger than the prespecified non-inferiority margin of -8 (non-inferiority p=0.006).

CONCLUSIONS

Compared with a multi-injection thoracic paravertebral block, the multi-injection intertransverse process block provided non-inferior analgesia within 30 min in the recovery room and recovery quality at 24 hours following major breast cancer surgery in females.

TRIAL REGISTRATION NUMBER

ChiCTR2000037963.

One year follow-up on a randomized study investigating serratus anterior muscle and pectoral nerves type I block to reduced neuropathic pain descriptors after mastectomy

Breast cancer is the second most common diagnosed type of cancer in women. Chronic neuropathic pain after mastectomy occurs frequently and is a serious health problem. In our previous single-center, prospective, randomized controlled clinical study, we demonstrated that the combination of serratus anterior plane block (SAM) and pectoral nerve block type I (PECS I) with general anesthesia reduced acute postoperative pain. The present report describes a prospective follow-up study of this published study to investigate the development of chronic neuropathic pain 12 months after mastectomy by comparing the use of general anesthesia alone and general anesthesia with SAM + PECS I. Additionally, the use of analgesic medication, quality of life, depressive symptoms, and possible correlations between plasma levels of interleukin (IL)-1 beta, IL-6, and IL-10 collected before and 24 h after surgery as predictors of pain and depression were evaluated. The results showed that the use of SAM + PECS I with general anesthesia reduced numbness, hypoesthesia to touch, the incidence of patients with chronic pain in other body regions and depressive symptoms, however, did not significantly reduce the incidence of chronic neuropathic pain after mastectomy. Additionally, there was no difference in the consumption of analgesic medication and quality of life. Furthermore, no correlation was observed between IL-1 beta, IL-6, and IL-10 levels and pain and depression. The combination of general anesthesia with SAM + PECS I reduced the occurrence of specific neuropathic pain descriptors and depressive symptoms. These results could promote the use of SAM + PECS I blocks for the prevention of specific neuropathic pain symptoms after mastectomy.Registration of clinical trial: The Research Ethics Board of the Hospital Sirio-Libanes/Brazil approved the study (CAAE 48721715.0.0000.5461). This study is registered at Registro Brasileiro de Ensaios Clinicos (ReBEC), and ClinicalTrials.gov, Identifier: NCT02647385.

Bilateral Ultrasound-Guided Erector Spinae Plane Block for Perioperative Analgesia in Breast Reduction Surgery: A Prospective Randomized and Controlled Trial

BACKGROUND

Ultrasound-guided erector spinae plane block (ESPB) is an interfascial plane block used for analgesia of the chest and abdominal wall. This study aimed to evaluate the perioperative analgesic efficacy of bilateral single-shot ESPB at T5 vertebral level in breast reduction surgery.

MATERIALS AND METHODS

Sixty adult female patients scheduled for breast reduction surgery were included and randomly allocated to two groups to receive either preoperative ESPB with a local anesthetic mixture of 10 mL 0.5% bupivacaine, 5 mL 2% lidocaine, and 5 mL saline, or sham block. Patients in both groups received intraoperative remifentanil infusion and, postoperatively, morphine via the patient-controlled analgesia (PCA) device. The primary outcome was 24-h total morphine consumption, and secondary outcomes included intraoperative opioid consumption, postoperative pain intensity, time to first PCA request, supplement analgesic requirements, functional recovery, patient satisfaction, length of hospital stay, and side effects and complications.

RESULTS

The 24-h total morphine consumption was significantly lower in the ESPB group vs. the sham group (mean ± SD, 6.7 ± 3.9, and 13.9 ± 5.7 mg, respectively, p < 0.001). Compared with sham block, ESPB reduced pain scores, intraoperative opioid consumption, supplement analgesic requirements, delayed time to first PCA request, and improved functional recovery and patient satisfaction.

CONCLUSION

In breast reduction surgery, preoperative single-shot ESPB reduces perioperative opioid consumption and provides adequate pain relief within 24 h postoperatively compared to systemic analgesics alone.

TRIAL REGISTRATION NUMBER

NCT03621345 LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The efficacy of pectoral nerve block for pain control after breast augmentation: A meta-analysis of randomized controlled studies

BACKGROUND

The efficacy of pectoral nerve block for pain control remains unknown in patients undergoing breast augmentation. This meta-analysis aims to explore the analgesic efficacy of pectoral nerve block for breast augmentation.

METHODS

We systematically searched PubMed, Embase, Web of Science, EBSCO, and Cochrane library databases, and included randomized controlled trials reporting pectoral nerve block versus no block for breast augmentation.

RESULTS

Five randomized controlled trials were included in this meta-analysis. Compared with control group after breast augmentation, pectoral nerve block was associated with substantially reduced pain scores at 1 hour (standard mean difference [SMD] = -1.63; 95% confidence interval [CI] = -2.81 to -0.44; P = .007), maximal pain scores at 1 to 6 hours (SMD = -1.72; 95% CI = -2.75 to -0.69; P = .001) and 6 to 24 hours (SMD = -2.06; 95% CI = -3.40 to -0.72; P = .003), rescue analgesic (odd ratio = 0.17; 95% CI = 0.05-0.57; P = .004), nausea (SMD = 0.21; 95% CI = 0.08-0.54; P = .001), and vomiting (odd ratio = 0.15; 95% CI = 0.05-0.39; P = .0001).

CONCLUSIONS

Pectoral nerve block benefits to alleviate pain intensity after breast augmentation.

Measurement of Postoperative Quality of Pain in Abdominoplasty Patients-An Outcome Oriented Prospective Study

(1) Background: Postoperative pain is a frequently underestimated complication significantly influencing surgical outcome and patient satisfaction. While abdominoplasty is one of the most commonly performed plastic surgery procedures, studies investigating postoperative pain are limited in current literature. (2) Methods: In this prospective study, 55 subjects who underwent horizontal abdominoplasty were included. Pain assessment was performed by using the standardized questionnaire of the Benchmark Quality Assurance in Postoperative Pain Management (QUIPS). Surgical, process and outcome parameters were then used for subgroup analysis. (3) Results: We found a significantly decreased minimal pain level in patients with high resection weight compared to the low resection weight group (p = 0.01 *). Additionally, Spearman correlation shows significant negative correlation between resection weight and the parameter "Minimal pain since surgery" (rs = -0.332; p = 0.013). Furthermore, average mood is impaired in the low weight resection group, indicating a statistical tendency (p = 0.06 and a Χ² = 3.56). We found statistically significant higher maximum reported pain scores (rs = 0.271; p = 0.045) in elderly patients. Patients with shorter surgery showed a statistically significant (Χ² = 4.61, p = 0.03) increased claim for painkillers. Moreover, "mood impairment after surgery" shows a dramatic trend to be enhanced in the group with shorter OP duration (Χ² = 3.56, p = 0.06). (4) Conclusions: While QUIPS has proven to be a useful tool for the evaluation of postoperative pain therapy after abdominoplasty, only continuous re-evaluation of pain therapy is a prerequisite for constant improvement of postoperative pain management and may be the first approach to develop a procedure-specific pain guideline for abdominoplasty. Despite a high satisfaction score, we detected a subpopulation with inadequate pain management in elderly patients, patients with low resection weight and a short duration of surgery.

Assessment of cardiotoxicity and plasma ropivacaine concentrations after serratus intercostal fascial plane block in an experimental model

Serratus intercostal fascial plane block (SIFPB) has emerged as an alternative to paravertebral block in breast surgery. It involves the administration of high volumes and doses of local anesthetics (LA) that can potentially reach toxic levels. Ropivacaine is widely used in thoraco-fascial blocks; however, there is no information on the plasma concentrations attained after SIPFB and whether they are associated with cardiotoxicity. Plasma concentrations of ropivacaine and its electrophysiological effects were evaluated in eight pigs after bilateral SIFPB with ropivacaine in doses of 3 mg/kg. Plasma concentrations, electrophysiological and hemodynamic parameters were measured sequentially for the following 180 min until the end of the study. The area under the curve, the maximum plasma concentration (C_max) and the time to reach C_max (t_max) were calculated. The median arterial ropivacaine concentration C_max was, 2.34 [1.40 to 3.74] µg/ml. The time to reach the highest concentration was 15 [10 to 20] min. Twenty-five percent of the animals had arterial concentrations above the lower limit concentration of ropivacaine for LA systemic toxicity (3.4 µg/ml). No alterations were observed in the electrophysiological or electrocardiographic parameters except for a prolongation of the QTc interval, from 489 ± 30 to 544 ± 44 ms (Δ11.38 ± 6%), P = 0.01. Hemodynamic parameters remained in the physiological range throughout the study. SIFPB with ropivacaine in doses of 3 mg/kg has reached potentially toxic levels, however, it has not been associated with adverse electrophysiological or hemodynamic effects.

Serratus Plane Block in Breast Cancer Surgery: A Systematic Review and Meta-Analysis

The serratus plane block is a regional anesthesia technique awaiting efficacy and safety evaluation in breast cancer surgery, but evidence is unclear. This meta-analysis evaluates the analgesic effectiveness of serratus plane block vis-à-vis general anesthesia and paravertebral block for breast cancer surgery. We searched for randomized controlled trials in PubMed, the Cochrane Library, and Web of Science with no language limitation, comparing the serratus plane block with multimodal analgesia or the thoracic paravertebral block in breast cancer surgery. The Hartung-Knapp-Sidik-Jonkman method in combination with a random-effects model was used to pool data. We included 12 randomized controlled trials (799 patients). Compared with multimodal analgesia, pooled outcomes favored the use of serratus plane block for effectively alleviating acute postoperative pain severity at multiple time points. The serratus plane block also resulted in decreased postoperative analgesic consumption of 28.81mg (95% confidence interval [CI]: -51.20, -6.43), decreased intraoperative fentanyl consumption of -56.46 mg (95% CI: -79.61, -33.30), increased duration of postoperative anesthesia of 243.85 min (95% CI: 104.38, 383.31), and reduced postoperative nausea and vomiting with a log relative risk of -1.07 (95% CI: -1.90, -0.24). Compared with the thoracic paravertebral block, the serratus plane block was not statically worse for all of the outcomes assessed. No adverse effects were reported. The serratus plane block effectively alleviates acute postoperative pain, reduces the rate of postoperative nausea and vomiting, and improves perioperative anesthesia outcomes in breast cancer surgery, and it may represent an alternative to thoracic paravertebral block.

Erector spinae plane block versus paravertebral block in breast surgeries

This article (Correspondence) is in response to the recently published study by Elewa et al. in BMC Anesthesiology that compared the erector spinae plane block (ESPB) versus paravertebral block (PVB) regarding postoperative analgesic consumption following breast surgeries. I greatly appreciate the authors for publishing this study which is one among a very few studies available on this topic. I wish to present my reflections on this article as well as add a few more points on this topic.

A comparative study between ultrasound-guided thoracic paravertebral block, pectoral nerves block, and erector spinae block for pain management in cancer breast surgeries. A randomized controlled study

OBJECTIVES

Achieving adequate perioperative analgesia can be challenging in patients undergoing breast surgeries due to the complex nerve supply of the breast and axilla. The study aims to investigate the efficacy of ESPB in comparison to conventional regional anesthesia techniques (TPVB and PECS).

METHODS

Eighty female patients who were scheduled for elective MRM, with ASA score I-II, and aged between 18 and 60 years, were included in the study. Patients were randomized into four groups, the TPVB, PECS, ESPB, and the control group. All patients in either block groups received 25 ml bupivacaine 0.25% with ultrasound guidance. The control group received only opioids for perioperative pain management. The patients were observed for 48 h after surgery for the duration of analgesia (primary outcome).

RESULTS

ESPB has a shorter duration of analgesia than PECS block with no significant statistical difference compared with group TPVB. Morphine consumption is increased in ESPB compared to the PECS group, with an insignificant difference compared to group TPVB. There was an insignificant difference between the groups concerning hemodynamics and complications, with one pneumothorax case reported in the TPVB group.

CONCLUSION

PECS and ESPB represent a good alternative to TPVB for post-mastectomy analgesia with a superior analgesic effect of PECS block regarding opioid consumption, duration of the analgesia, and VAS score.

Analgesic Efficacies of Intraoperative Pectoralis Nerve II Block under Direct Vision in Patients Undergoing Robotic Nipple-Sparing Mastectomy with Immediate Breast Reconstruction: A Prospective, Randomized Controlled Study

This prospective, randomized study aimed to evaluate the efficacy of an intraoperative pectoralis nerve II block (PECS II block) under direct vision in the reduction of fentanyl consumption during postoperative 24 h in patients undergoing robotic nipple-sparing mastectomy (RNSM) with immediate breast reconstruction (IBR) using direct-to-implant (DTI) or tissue expander (TE). Thirty patients scheduled for RNSM with IBR were randomly allocated to the PECS (n = 15) or control (n = 15) groups. The PECS II block was applied under direct vision after RNSM. The primary outcome was the cumulative dose of fentanyl consumption. The secondary outcomes were pain intensity using a numerical rating scale (NRS) at rest and acting during the postoperative 24 h. The cumulative dose of fentanyl at 24 h was significantly lower in the PECS group than in the control group (p = 0.011). Patients in the PECS group showed significantly lower NRS scores during the first postoperative 2 h compared to those in the control group in both resting and acting pain (p < 0.05). An intraoperative PECS II block under direct vision can reduce opioid consumption during the postoperative 24 h and provide effective analgesia in patients undergoing RNSM with IBR using DTI or TE.

Ultrasound-guided transversus thoracic muscle plane-pectoral nerve block for postoperative analgesia after modified radical mastectomy: a comparison with the thoracic paravertebral nerve block

Background

Modified radical mastectomy (MRM) is the most effective and common type of invasive surgery for breast cancer. However, it causes moderate to severe acute pain and even lasts for a long postoperative period. Transversus thoracic muscle plane-pectoral nerve block (TTP-PECS) is a novel and promising interfacial plane block which can provide analgesia for MRM while thoracic paravertebral nerve block (TPVB) is also widely used for this purpose. This study compared the postoperative analgesia between the ultrasound-guided TTP-PECS and TPVB in patients undergoing MRM.

Methods

In this randomized controlled trial, eighty female breast cancer patients undergoing unilateral MRM with sentinel lymph node dissection (SLND) and axillary dissection (ALND) were enrolled. Patients were randomized to receive either ultrasound-guided TTP-PECS (TTP-PECS group, n = 40) or TPVB (TPVB group, n = 40) with 0.5% ropivacaine 30 ml. Evaluated variables included 24 h postoperative total PCA fentanyl consumption, including PCA background consumption and PCA press consumption (per bolus dosage multiply by the effective pressing times), and intraoperative fentanyl consumption, as well as postoperative flurbiprofen axetil requirement, duration of analgesia, blocking area, pain intensity at rest and during activity, ability to reduce the inflammatory response, and the quality of recovery 40 (QoR-40) score of patients.

Results

Compared with the TPVB, the main blocking area was T₂–T₆ in the TTP-PECS group, which was more suitable for the MRM. TTP-PECS has a longer analgesia duration than TPVB; 24 h postoperative total PCA fentanyl consumption, especially the PCA press consumption, and the postoperative flurbiprofen axetil requirement were decreased in the TTP-PECS group than those in the TPVB group. Furthermore, the VAS scores at rest and during activity and inflammatory response were lower in the TTP-PECS group compared with the TPVB group at 12 h postoperatively. Finally, the total QoR-40 score, especially for the scores of pain; emotional state; and patient support were better in the TTP-PECS group.

Conclusion

Compared with the TPVB, TTP-PECS can provide better postoperative analgesia in patients undergoing MRM, simultaneously reduce the inflammatory response, and prompt early recovery. These results suggest that TTP-PECS is an attractive alternative to TPVB for postoperative analgesia of modified radical mastectomy.

Interpectoral-pectoserratus plane (PECS II) block in patients undergoing trans-axillary thoracic outlet decompression surgery; A prospective double-blind, randomized, placebo-controlled clinical trial

STUDY OBJECTIVE

To investigate if an interpectoral-pectoserratus plane (PECS II) block decreases postoperative pain, postoperative nausea and vomiting and improves quality of recovery in patients with neurogenic thoracic outlet syndrome (NTOS) undergoing trans-axillary thoracic outlet decompression surgery.

DESIGN

A prospective single center double blinded randomized placebo-controlled trial.

SETTING

Perioperative period; operating room, post anesthesia care unit (PACU) and hospital ward.

PATIENTS

Seventy patients with NTOS, undergoing trans-axillary thoracic outlet decompression surgery.

INTERVENTIONS

Patients were randomized to an interventional arm, receiving the block with 40 ml ropivacaine 0.5% (concentration was adjusted if the patient's weight was <66 kg), and a placebo group, receiving a sham block with 40 ml NaCl 0.9%. The interpectoral-pectoserratus plane block was performed ultrasound guided; the first injection below the pectoral minor muscle and the second below the pectoral major muscle. The hospitals' pharmacist prepared the study medication and was the only person able to see the randomization result. The study was blinded for patients, researchers and medical personnel.

MEASUREMENTS

Primary outcome parameters were postoperative pain, measured by numeric rating scale on the PACU (start and end) and on the ward on postoperative day (POD) 0 and 1, and postoperative morphine consumption, measured on the PACU and on the ward during the first 24 h. Secondary outcome parameters were postoperative nausea and vomiting, and quality of recovery.

MAIN RESULTS

There was no statistically significant difference in NRS on the PACU at the start (ropivacaine 4.9 ± 3.2 vs placebo 6.2 ± 3.0, p = .07), at the end (ropivacaine 4.0 ± 1.7 vs placebo 3.9 ± 1.7, p = .77), on the ward on POD 0 (ropivacaine 4.6 ± 2.0 vs placebo 4.6 ± 2.0, p = 1.00) or POD 1 (ropivacaine 3.9 ± 1.8 vs placebo 3.6 ± 2.0, p = .53). There was no difference in postoperative morphine consumption at the PACU (ropivacaine 11.0 mg ± 6.5 vs placebo 10.8 mg ± 4.8, p = .91) or on the ward (ropivacaine 11.6 mg ± 8.5 vs placebo 9.6 mg ± 9.4, p = .39).

CONCLUSIONS

The interpectoral-pectoserratus plane block is not effective for postoperative analgesia in patients with NTOS undergoing trans-axillary thoracic outlet decompression surgery.

Analgesia and stress attenuation of ultrasound-guided modified pectoral nerve block type-II with different volumes of 0.3% ropivacaine in patients undergoing modified radical mastectomy for breast cancer: A prospective parallel randomized double-blind controlled clinical trial

WHAT IS KNOWN AND OBJECTIVE

A previous randomized clinical trial concluded that an optimal concentration of 0.3% ropivacaine could provide satisfactory analgesia for breast cancer patients undergoing modified radical mastectomy. We wondered if a smaller volume (30 ml vs. 40 ml) of 0.3% ropivacaine could still provide adequate analgesia in an ultrasound-guided PECS II block in modified radical mastectomy.

METHODS

We performed a prospective parallel randomized double-blind controlled clinical trial. Eligible patients were assigned to either the P₃₀ or P₄₀ group (30 or 40 ml of 0.3% ropivacaine, respectively). The skin area of hypoesthesia, anaesthetic plane determined with ultrasound, pain visual analogue scale (VAS), anaesthetic dosages, and complications were recorded. Serum levels of interleukin-1β and interleukin-6 were measured postoperatively.

RESULTS AND DISCUSSION

A total of 40 patients completed the trials, with 20 patients in each group. Although the skin area of hypoesthesia and the anaesthetic planes were significantly larger in the P₄₀ group compared with the P₃₀ group (p < 0.05), the VAS, analgesic and opioid doses, serum cytokine levels, anaesthetic toxicity, and complications had no significant differences between the two groups.

WHAT IS NEW AND CONCLUSION

Compared with 40 ml, 30 ml of 0.3% ropivacaine could provide adequate analgesia and reduce surgical stress in patients undergoing modified radical mastectomy for breast cancer.

"Combination of Thoracic Epidural Anesthesia, Supraclavicular Brachial Plexus Block and Supraclavicular Nerve Block as Surgical Anesthesia for Modified Radical Mastectomy-A Case Series"

Sensory innervation of the breast is complex, thereby making it difficult to perform any surgical procedure with a single regional anesthesia technique. Because of the involvement of pectoral muscles and extension of the incision into the axilla, a modified radical mastectomy makes it further challenging and requires multiple techniques. We have used a new combination of regional techniques in this case series and found that it provided complete surgical anesthesia with a smaller volume of local anesthetic.

A Multimodal Analgesic Protocol with Gabapentin-dexmedetomidine for Post-operative Pain Management after Modified Radical Mastectomy Surgery: A Randomized Placebo-Controlled Study

Background and Aim: Modified radical mastectomy (MRM) is accompanied by severe acute postoperative pain. This study evaluated the safety and efficacy of oral gabapentin plus dexmedetomidine infusion as an analgesic multimodal protocol in patients undergoing MRM. Methods: This prospective randomized, double-blind placebo-controlled study included 30 females scheduled for MRM from June 2021 to December 2021. They were randomly divided into two groups. GD Group (n=15) received oral gabapentin 400 mg and IV infusion of Dexmedetomidine 0.4 µg/kg/h over 10 min after a bolus of 0.5 µg/kg before induction of general anesthesia. Placebo Group (n=15) received a placebo capsule and saline infusion identical to the GD Group. The primary outcome measure was total morphine consumption, and secondary outcomes were pain and sedation scores and intraoperative fentanyl consumption. Results: Pain score was significantly lower in the GD Group than the Placebo group, starting immediately postoperative up to 24 hours except after 18 hours. The total intraoperative fentanyl consumption and postoperative morphine consumption were significantly lower in the GD Group. The sedation score was significantly higher in the GD Group compared to the Placebo group immediately postoperative and after 2 hours. The heart rate and mean arterial pressure were within the clinically accepted ranges intra- and postoperatively in the two groups. Conclusion: Preemptive oral gabapentin plus dexmedetomidine IV infusion is a safe and effective analgesic alternative for patients undergoing MRM.