Pectoralis-II Myofascial Block and Analgesia in Breast Cancer Surgery

Optimizing accrual to a large-scale, clinically integrated randomized trial in anesthesiology: A 2-year analysis of recruitment

BACKGROUND

Performing large randomized trials in anesthesiology is often challenging and costly. The clinically integrated randomized trial is characterized by simplified logistics embedded into routine clinical practice, enabling ease and efficiency of recruitment, offering an opportunity for clinicians to conduct large, high-quality randomized trials under low cost. Our aims were to (1) demonstrate the feasibility of the clinically integrated trial design in a high-volume anesthesiology practice and (2) assess whether trial quality improvement interventions led to more balanced accrual among study arms and improved trial compliance over time.

METHODS

This is an interim analysis of recruitment to a cluster-randomized trial investigating three nerve block approaches for mastectomy with immediate implant-based reconstruction: paravertebral block (arm 1), paravertebral plus interpectoral plane blocks (arm 2), and serratus anterior plane plus interpectoral plane blocks (arm 3). We monitored accrual and consent rates, clinician compliance with the randomized treatment, and availability of outcome data. Assessment after the initial year of implementation showed a slight imbalance in study arms suggesting areas for improvement in trial compliance. Specific improvement interventions included increasing the frequency of communication with the consenting staff and providing direct feedback to clinician investigators about their individual recruitment patterns. We assessed overall accrual rates and tested for differences in accrual, consent, and compliance rates pre- and post-improvement interventions.

RESULTS

Overall recruitment was extremely high, accruing close to 90% of the eligible population. In the pre-intervention period, there was evidence of bias in the proportion of patients being accrued and receiving the monthly block, with higher rates in arm 3 (90%) compared to arms 1 (81%) and 2 (79%, p = 0.021). In contrast, in the post-intervention period, there was no statistically significant difference between groups (p = 0.8). Eligible for randomization rate increased from 89% in the pre-intervention period to 95% in the post-intervention period (difference 5.7%; 95% confidence interval = 2.2%-9.4%, p = 0.002). Consent rate increased from 95% to 98% (difference of 3.7%; 95% confidence interval = 1.1%-6.3%; p = 0.004). Compliance with the randomized nerve block approach was maintained at close to 100% and availability of primary outcome data was 100%.

CONCLUSION

The clinically integrated randomized trial design enables rapid trial accrual with a high participant compliance rate in a high-volume anesthesiology practice. Continuous monitoring of accrual, consent, and compliance rates is necessary to maintain and improve trial conduct and reduce potential biases. This trial methodology serves as a template for the implementation of other large, low-cost randomized trials in anesthesiology.

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.

Regional anaesthesia truncal blocks for acute postoperative pain and recovery: a narrative review

Significant acute postoperative pain remains prevalent among patients who undergo truncal surgery and is associated with increased morbidity, prolonged patient recovery, and increased healthcare costs. The provision of high-quality postoperative analgesia is an important component of postoperative care, particularly within enhanced recovery programmes. Regional anaesthetic techniques have become increasingly prevalent within multimodal analgesic regimens and the widespread adoption of ultrasonography has facilitated the development of novel fascial plane blocks. The number of described fascial plane blocks has increased significantly over the past decade, leading to a burgeoning area of clinical investigation. Their applications are increasing, and truncal fascial plane blocks are increasingly recommended as part of procedure-specific guidelines. Some fascial plane blocks have been shown to be more efficacious than others, with favourable side-effect profiles compared with neuraxial analgesia, and are increasingly utilised in breast, thoracic, and other truncal surgery. However, use of these blocks is debated in regional anaesthesia circles because of limitations in our understanding of their mechanisms of action. This narrative review evaluates available evidence for the analgesic efficacy of the most commonly practised fascial plane blocks in breast, thoracic, and abdominal truncal surgery, in particular their efficacy compared with systemic analgesia, alternative blocks, and neuraxial techniques. We also highlight areas where investigations are ongoing and suggest priorities for original investigations.

The analgesic effectiveness of perioperative lidocaine infusions for acute and chronic persistent postsurgical pain in patients undergoing breast cancer surgery: a systematic review and meta-analysis

BACKGROUND

Breast cancer is the most common cancer among women and tumour resection carries a high prevalence of chronic persistent postsurgical pain (CPSP). Perioperative i.v. lidocaine infusion has been proposed as protective against CPSP; however, evidence of its benefits is conflicting. This review evaluates the effectiveness of perioperative lidocaine infusions for breast cancer surgery.

METHODS

Randomised trials comparing perioperative lidocaine infusions with parenteral analgesia in breast cancer surgery patients were sought. The two co-primary outcomes were the odds of CPSP at 3 and 6 months after operation. Secondary outcomes included rest pain at 1, 6, 12, and 24 h; analgesic consumption at 0-24 and 25-48 h; quality of recovery; opioid-related side-effects; and lidocaine infusion side-effects. Hartung-Knapp-Sidik-Jonkman (HKSJ) random effects modelling was used.

RESULTS

Thirteen trials (1039 patients; lidocaine: 518, control: 521) were included. Compared with control, perioperative lidocaine infusion did not decrease the odds of developing CPSP at 3 and 6 months. Lidocaine infusion improved postoperative pain at 1 h by a mean difference (95% confidence interval) of -0.65 cm (-0.73 to -0.57 cm) (P<0.0001); however, this difference was not clinically important (1.1 cm threshold). Similarly, lidocaine infusion reduced oral morphine consumption by 7.06 mg (-13.19 to -0.93) (P=0.029) over the first 24 h only; however, this difference was not clinically important (30 mg threshold). The groups were not different for any of the remaining outcomes.

CONCLUSIONS

Our results provide moderate-quality evidence that perioperative lidocaine infusion does not reduce CPSP in patients undergoing breast cancer surgery. Routine use of lidocaine infusions for perioperative analgesia and CPSP prevention is not supported in this population.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42023420888.

Nerve block efficacy in breast augmentation: A systematic review and meta-analysis

Breast augmentation is often performed as a day-case general anaesthetic operation, with postoperative, opioid-based analgesia regimens. However, it may also be performed using regional anaesthesia; a variety of nerve block techniques are available to reduce postoperative pain and analgesic requirements. This systematic review and meta-analysis were undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines comparing breast augmentation using regional anaesthesia with general anaesthesia, versus general anaesthesia alone or with local field infiltration. All randomised or quasi-randomised studies that recruited adult female patients undergoing breast augmentation using regional anaesthesia were considered. The primary outcome measures were postoperative pain and analgesic requirements. A randomised effects model was used, with standardised mean difference or mean difference outcomes used as appropriate. Thirteen studies were included for systematic review, out of which eight met the inclusion criteria for meta-analysis. Nerve blocks had statistically significant standardised mean difference reductions in postoperative pain scores across all time points: 0 h (-1.2 [-2.1 to -0.3], p = 0.01, I2 = 85%), 1 h (-1.3 [-2.1 to -0.5], p = 0.002, I2 = 89%), 2 h (-1.8 [-2.8 to -0.9], p = 0.0002, I2 = 88%), 4-6 h (-1.2 [-2.1 to -0.4], p = 0.006, I2 = 89%), 24 h (-1.4 [-2.5 to -0.2], p = 0.02, I2 = 94%). There was also a statistically significant reduction in postoperative opioid requirements: -150 mcg fentanyl (-259.2 to -40.9), p = 0.007. Although an element of study heterogeneity is noted, this systematic review and meta-analysis support the concept that regional anaesthesia using nerve blocks in breast augmentation surgery, reduces both postoperative pain and opioid requirements, compared with general anaesthesia.

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.

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.

Safe Reproducible Breast Reduction

Breast reduction is a common operation performed by plastic surgeons. Patients can have significant improvement in physical symptoms in addition to increased self-esteem, body image, and quality of life as a result. The authors describe common techniques for breast reduction and provide representative photographs and videos of these techniques. An evidence-based review is provided for patient selection criteria, common surgical techniques, and methods to avoid and treat complications. Information is also provided on patient education about breast reduction. In most cases, breast reduction is safe to perform in the outpatient setting. The Wise pattern and vertical pattern are among the most common techniques for skin incisions, and the inferior and superomedial pedicles are two of the most common pedicles used in breast reduction. Enhanced Recovery After Surgery protocols are helpful to effectively control pain and reduce narcotic use postoperatively. Patient satisfaction after breast reduction surgery is typically high. Multiple techniques are available to successfully perform breast reduction. The plastic surgeon needs to select patients carefully and determine the appropriate technique to use. Patient education about the operation, recovery, expected result, and risks is an important component of achieving an optimal result.

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.

Combinations of nerve blocks in surgery for post COVID-19 pulmonary sequelae patient: A case report and review of literature

BACKGROUND

Regional anesthesia is a promising method in patients with post coronavirus disease 2019 (COVID-19) pulmonary sequelae for preserving pulmonary function and preventing postoperative pulmonary complications, compared with general anesthesia.

CASE SUMMARY

We provided surgical anesthesia and analgesia suitable for breast surgery by performing pectoral nerve block type II (PECS-II), parasternal, and intercostobrachial nerve blocks with intravenous dexmedetomidine administration in a 61-year-old female patient with severe pulmonary sequelae after COVID-19 infection.

CONCLUSION

Sufficient analgesia for 7 h was provided via PECS-II, parasternal, and intercostobrachial blocks perioperatively.

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.

Regional Anesthesia in the Emergency Department: an Overview of Common Nerve Block Techniques and Recent Literature

Purpose of Review

This review seeks to discuss the use of RA in the ED including benefits of administration, types of RA by anatomic location, complications and management, teaching methods currently in practice, and future applications of RA in the ED.

Recent Findings

The early use of RA in pain management may reduce the transition of acute to chronic pain. Multiple plane blocks have emerged as feasible and efficacious for ED pain complaints and are now being safely utilized.

Summary

Adverse effects of opioids and their potential for abuse have necessitated the exploration of substitute therapies. Regional anesthesia (RA) is a safe and effective alternative to opioid treatment for pain in the emergency department (ED). RA can manage pain for a wide variety of injuries while avoiding the risks of opioid use and decreasing length of stay when compared to other forms of analgesia and anesthesia, without compromising patient satisfaction.

Clinical Application of Pectoralis Nerve Block II for Flap Dissection-Related Pain Control after Robot-Assisted Transaxillary Thyroidectomy: A Preliminary Retrospective Cohort Study

Simple Summary

The main findings of the study are that pectoralis nerve block II (PECS II) may be a valuable analgesic option that alleviates flap dissection pain and stress during a robot-assisted transaxillary thyroidectomy (RATT) and reduces opioid consumption in the early recovery phase. Patients who received PECS II experienced a more comfortable recovery and required fewer painkillers. PECS II may serve as a valuable new pain relief modality in addition to the multimodal analgesic strategy for patients undergoing RATT. Although we have yet to investigate the optimal block duration, regions of sensory loss, optimal technique, and possible complications, our preliminary study suggests that PECS II reduces flap dissection pain and thus promotes recovery. Appropriate analgesia during RATT remains challenging, but is a key issue for postoperative recovery. A further prospective investigation is required to validate our results and establish the optimal pain control regimen for patients undergoing RATT.

Abstract

Few studies have examined the clinical utility of ultrasonography-guided pectoralis nerve block II (PECS II) during wide flap dissection of a robot-assisted transaxillary thyroidectomy (RATT). We assessed the ability of PECS II to reduce postoperative pain. We retrospectively reviewed 62 patients who underwent elective RATT from December 2021 to April 2022 at Seoul St. Mary’s Hospital (Seoul, Korea). The patients were divided into a block group (n = 28, 50.9%) and no-block group (n = 27, 49.1%). Pain was measured using a visual analog scale (VAS) at 4, 10, 20, 25, 35, and 45 h after surgery, and the requirements for rescue painkillers in the post-anesthesia care unit and ward were recorded. The VAS scores did not differ significantly between the two groups at 4 h postoperatively. The block group had significantly lower VAS scores at 10 and 25 h (p = 0.017 and p = 0.034, respectively). The block group required fewer painkillers in the post-anesthesia care unit than the no-block group, although the difference was not statistically significant in the ward. PECS II may serve as a new pain relief modality and valuable addition to the current multimodal analgesic strategy for patients undergoing RATT.

Efficacy of PECS block in addition to multimodal analgesia for postoperative pain management in patients undergoing outpatient elective breast surgery: A retrospective study

Background

Pectoralis nerve blocks (PECS) have been shown in numerous studies to be a safe and effective method to treat postoperative pain and reduce postoperative opioid consumption after breast surgery. However, there are few publications evaluating the PECS block effectiveness in conjunction with multimodal analgesia (MMA) in outpatient breast surgery. This retrospective study aims to evaluate the efficacy of PECS's blocks on perioperative pain management and opioid consumption.

Methods

We conducted a retrospective study to assess the efficacy of preoperative PECS block in addition to preoperative MMA (oral acetaminophen and/or gabapentin) in reducing opioid consumption in adult female subjects undergoing outpatient elective breast surgery between 2015 and 2020. A total of 228 subjects were included in the study and divided in two groups: PECS block group (received PECS block + MMA) and control Group (received only MMA). The primary outcome was to compare postoperative opioid consumption between both groups. The secondary outcome was intergroup comparisons of the following: postoperative nausea and vomiting (PONV), incidence of rescue antiemetic medication, PACU non-opioid analgesic medication required, length of PACU stay and the incidence of 30-day postoperative complications between both groups.

Results

Two hundred and twenty-eight subjects (n = 228) were included in the study. A total of 174 subjects were allocated in the control group and 54 subjects were allocated in the PECS block group. Breast reduction and mastectomy/lumpectomy surgeries were the most commonly performed procedures (48% and 28%, respectively). The total amount of perioperative (intraoperative and PACU) MME was 27 [19, 38] in the control group and 28.5 [22, 38] in the PECS groups (p = 0.21). PACU opioid consumption was 14.3 [7, 24.5] MME for the control group and 17 [8, 23] MME (p = 0.732) for the PECS group. Lastly, the mean overall incidence of postsurgical complications at 30 days was 3% (N = 5), being wound infection, the only complication observed in the PECS groups (N = 2), and hematoma (N = 2) and wound dehiscence (N = 1) in the control group.

Conclusion

PECS block combined with MMA may not reduce intraoperative and/or PACU opioid consumption in patients undergoing outpatient elective breast surgery.

Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy

BACKGROUND

As plastic surgeons continue to evaluate the utility of nonopioid analgesic alternatives, nerve block use in breast plastic surgery remains limited and unstandardized, with no syntheses of the available evidence to guide consensus on optimal approach.

METHODS

A systematic review was performed to evaluate the role of pectoralis nerve blocks, paravertebral nerve blocks, transversus abdominus plane blocks, and intercostal nerve blocks in flap-based breast reconstruction, prosthetic-based reconstruction, and aesthetic breast plastic surgery, independently.

RESULTS

Thirty-one articles reporting on a total of 2820 patients were included in the final analysis; 1500 patients (53 percent) received nerve blocks, and 1320 (47 percent) served as controls. Outcomes and complications were stratified according to procedures performed, blocks employed, techniques of administration, and anesthetic agents used. Overall, statistically significant reductions in opioid consumption were reported in 91 percent of studies evaluated, postoperative pain in 68 percent, postanesthesia care unit stay in 67 percent, postoperative nausea and vomiting in 53 percent, and duration of hospitalization in 50 percent. Nerve blocks did not significantly alter surgery and/or anesthesia time in 83 percent of studies assessed, whereas the overall, pooled complication rate was 1.6 percent.

CONCLUSIONS

Transversus abdominus plane blocks provided excellent outcomes in autologous breast reconstruction, whereas both paravertebral nerve blocks and pectoralis nerve blocks demonstrated notable efficacy and versatility in an array of reconstructive and aesthetic procedures. Ultrasound guidance may minimize block-related complications, whereas the efficacy of adjunctive postoperative infusions was proven to be limited. As newer anesthetic agents and adjuvants continue to emerge, nerve blocks are set to represent essential components of the multimodal analgesic approach in breast plastic surgery.

Clinical Observation of Patients Undergoing Glioma Surgery under Propofol and Sevoflurane Anesthesia: A Retrospective Study

Objective

To observe the effects of propofol and sevoflurane anesthesia on patients undergoing glioma surgery.

Methods

192 patients with gliomas treated in our hospital from January 2016 to January 2021 were selected. All patients were randomly divided into observation group and control group. The observation group was given sevoflurane and the control group was given propofol. The clinical effects of the two groups were observed.

Results

Comparison of clinical indexes related to intraoperative conditions between the two groups revealed that the time of anesthesia and extubation after operation in the observation group were shorter than those in the control group, and the difference was statistically significant (P < 0.05). The amount of intraoperative bleeding in the observation group was less than that in the control group, and the difference was statistically significant (P < 0.05). There was no significant difference in intracranial operation time, operation time, fluid volume, and urine volume between the two groups (P < 05). Comparing the recovery time of anesthesia between the two groups, the recovery time of orientation and the time of eye-opening in the observation group were significantly shorter than those in the control group (P < 0.05). Comparing the consciousness and cognitive function of the two groups, the OAAS score of the observation group after extubation, before leaving the operating room and 1 hour after extubation, was significantly higher than that of the control group (P < 0.05), and the MMSE score l h after extubation was significantly higher than that of the control group (P < 0.05). Comparing the incidence of postoperative complications between the two groups, the number of cases of restlessness, urinary infection, deep vein thrombosis, and hypertension in the observation group was lower than that in the control group, with statistical significance (P < 0.05).

Conclusion

The anesthesia time and extubation time of the sevoflurane anesthesia group were shorter than that of the propofol anesthesia group, and the orientation recovery time and eye-opening time were shortened. The OAAS score of the sevoflurane anesthesia group was higher than that of the propofol anesthesia group after extubation, before extubation, and 1 hour after extubation. The probability of postoperative complications in the sevoflurane anesthesia group was lower than that in the propofol anesthesia group. Sevoflurane anesthesia may be more suitable for surgical induction of glioma patients than propofol anesthesia.

A French nationwide survey on the practice of regional anaesthesia for breast cancer surgery

BACKGROUND

To assess the impact of recent recommendations concerning regional anaesthesia for breast cancer surgery, a nationwide practice survey was carried out.

METHODS

This cross-sectional electronic survey, conducted in 2021, collected answers from a panel of anaesthetists currently working in French practicing centres. It addressed the sets of techniques they practiced for every type of surgical procedure and their perceptions of the difficulties and risks associated with these techniques.

RESULTS

The practice of regional anaesthesia was generally high (70%), involving all the current types of blocks. Surgeon-done infiltration was popular for lumpectomy only. For the other current procedures, the pectoralis nerve blocks were preferred to the paravertebral block, which was favoured for mastectomies, when a lymph node harvesting was planned, or for immediate or delayed pedicle flap. Catheters were mostly used for mastectomies with pedicle flap. The erector spinae plane block was emergent. Whatever the type of block, regional anaesthesia was preferentially started before surgery. Despite some deviations such as the adjunction of unlabelled molecules, the practice fitted well with the European recommendations, but training and within-centre guidance lacked standardisation. For each block, actual practice, perceived difficulty and risk were inter-correlated, but paravertebral block - either practiced or not - was considered as more difficult and riskier to perform than any other.

CONCLUSIONS

These encouraging results do not dispense with the need to improve anaesthetic practices both in quantity and quality. Such improvement in the anatomic fit to the procedure and in the timing of blocks will also have to be considered.

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.

Efficacy and Safety of Pectoral Nerve Block (Pecs) Compared With Control, Paravertebral Block, Erector Spinae Plane Block, and Local Anesthesia in Patients Undergoing Breast Cancer Surgeries: A Systematic Review and Meta-analysis

OBJECTIVE

We aimed to compare the safety and efficacy of pectoral nerve block (Pecs) I and II with control or other techniques used during breast cancer surgeries such as local anesthesia, paravertebral block, and erector spinae plane block (ESPB).

METHODS

We searched 4 search engines (PubMed, Cochrane Library, Scopus, and Web of Science) for relevant trials, then extracted the data and combined them under random-effect model using Review Manager Software.

RESULTS

We found 47 studies, 37 of them were included in our meta-analysis. Regarding intraoperative opioid consumption, compared with control, a significant reduction was detected in Pecs II (standardized mean difference [SMD]=-1.75, 95% confidence interval [CI] [-2.66, -0.85], P=0.0001) and Pecs I combined with serratus plane block (SMD=-0.90, 95% CI [-1.37, -0.44], P=0.0002). Postoperative opioid consumption was significantly lowered in Pecs II (SMD=-2.28, 95% CI [-3.10, -1.46], P<0.00001) compared with control and Pecs II compared with ESPB (SMD=-1.75, 95% CI [-2.53, -0.98], P<0.00001). Furthermore, addition of dexmedetomidine to Pecs II significantly reduced postoperative opioid consumption compared with Pecs II alone (SMD=-1.33, 95% CI [-2.28, -0.38], P=0.006).

CONCLUSION

Pecs block is a safe and effective analgesic procedure during breast cancer surgeries. It shows lower intra and postoperative opioid consumption than ESPB, and reduces pain compared with control, paravertebral block, and local anesthesia, with better effect when combined with dexmedetomidine.

Ambulatory surgery for cancer patients: current controversies and concerns

PURPOSE OF REVIEW

This review aims to describe the main concerns and controversies of ambulatory surgery in cancer patients while providing an overview of ambulatory cancer anaesthesia.

RECENT FINDINGS

Cancer patients can undergo a variety of ambulatory surgeries. The introduction of robotic approach and the implementation of enhanced recovery programmes have allowed patients to avoid hospital admissions after more complex or invasive surgeries. In this context, the anaesthesiologist plays a key role in ensuring that the ambulatory surgical centre or the hospital-based ambulatory department is equipped for the perioperative challenges of the cancer population. Cancer patients tend to be older and with more comorbidities than the general population. In addition, these individuals may suffer from chronic conditions solely because of the cancer itself, or the treatment. Consequently, frailty is not uncommon and should be screened on a routine basis. Regional analgesia plays a key role in the provision of opioid-sparing multimodal analgesia.

SUMMARY

Neither regional anaesthesia or general anaesthesia have proven to affect the long-term oncological outcomes of cancer patients undergoing ambulatory surgery. In addition, there is insufficient evidence to suggest the use of total intravenous anaesthesia or inhalational anaesthesia over the other to decrease cancer recurrence.

Intrathecal Morphine for Analgesia in Minimally Invasive Cardiac Surgery: A Randomized, Placebo-controlled, Double-blinded Clinical Trial

BACKGROUND

Intrathecal morphine decreases postoperative pain in standard cardiac surgery. Its safety and effectiveness have not been adequately evaluated in minimally invasive cardiac surgery. The authors hypothesized that intrathecal morphine would decrease postoperative morphine consumption after minimally invasive cardiac surgery.

METHODS

In this randomized, placebo-controlled, double-blinded clinical trial, patients undergoing robotic totally endoscopic coronary artery bypass received either intrathecal morphine (5 mcg/kg) or intrathecal saline before surgery. The primary outcome was postoperative morphine equivalent consumption in the first 24 h after surgery; secondary outcomes included pain scores, side effects, and patient satisfaction. Pain was assessed via visual analog scale at 1, 2, 6, 12, 24, and 48 h after intensive care unit arrival. Opioid-related side effects (nausea/vomiting, pruritus, urinary retention, respiratory depression) were assessed daily. Patient satisfaction was evaluated with the Revised American Pain Society Outcome Questionnaire.

RESULTS

Seventy-nine patients were randomized to receive intrathecal morphine (n = 37) or intrathecal placebo (n = 42), with 70 analyzed (morphine 33, placebo 37). Intrathecal morphine patients required significantly less median (25th to 75th percentile) morphine equivalents compared to placebo during first postoperative 24 h (28 [16 to 46] mg vs. 59 [41 to 79] mg; difference, -28 [95% CI, -40 to -18]; P < 0.001) and second postoperative 24 h (0 [0 to 2] mg vs. 5 [0 to 6] mg; difference, -3.3 [95% CI, -5 to 0]; P < 0.001), exhibited significantly lower visual analog scale pain scores at rest and cough at all postoperative timepoints (overall treatment effect, -4.1 [95% CI, -4.9 to -3.3] and -4.7 [95% CI, -5.5 to -3.9], respectively; P < 0.001), and percent time in severe pain (10 [0 to 40] vs. 40 [20 to 70]; P = 0.003) during the postoperative period. Mild nausea was more common in the intrathecal morphine group (36% vs. 8%; P = 0.004).

CONCLUSIONS

When given before induction of anesthesia for totally endoscopic coronary artery bypass, intrathecal morphine decreases use of postoperative opioids and produces significant postoperative analgesia for 48 h.

EDITOR’S PERSPECTIVE

The effect of PECS-1 block on postoperative pain in total implantable venous access port catheter (TIVAP) insertion

BACKGROUND

The aim of this prospective, randomized, controlled study was to evaluate the analgesic effect of US-guided Pectoral (PECS) I blocks on postoperative analgesia after TIVAP insertion.

METHODS

A hundred-twenty patients were included in this study. The patients were divided into two groups: Group PECS and Group INF (infiltration). A total 0.4 mL kg^-1 0.25% bupivacaine was injected to below the middle of the clavicle in the interfascial space between the pectoralis major and minor muscles for PECS-1. The skin and deep tissue infiltration of the anterior chest wall was performed with 0.4 mL kg^-1 0.25% bupivacaine for INF group. Tramadol and paracetamol consumption, visual analog scale pain scores were recorded at 0, 1, 4, 12, and 24 h postoperatively.

RESULTS

The use of the PECS in TIVAP significantly decreased the amount of paracetamol used in the first 24 h postoperatively (p < 0.001). There was a statistically significant difference in the number of tramadol rescue analgesia administered between the groups (p < 0.001) There was no significant difference between the groups in terms of the VAS scores at 0 and 24 h. However, VAS scores at 1, 4, and 12 h were found to be significantly lower in patients who underwent PECS than in those who received infiltration anesthesia (p < 0.001).

CONCLUSIONS

This study shows that US-guided PECS-1 provides adequate analgesia following TIVAP insertion as part of multimodal analgesia. The PECS-1 significantly reduced opioid consumption.

Anatomical basis of fascial plane blocks

Fascial plane blocks (FPBs) are regional anesthesia techniques in which the space ("plane") between two discrete fascial layers is the target of needle insertion and injection. Analgesia is primarily achieved by local anesthetic spread to nerves traveling within this plane and adjacent tissues. This narrative review discusses key fundamental anatomical concepts relevant to FPBs, with a focus on blocks of the torso. Fascia, in this context, refers to any sheet of connective tissue that encloses or separates muscles and internal organs. The basic composition of fascia is a latticework of collagen fibers filled with a hydrated glycosaminoglycan matrix and infiltrated by adipocytes and fibroblasts; fluid can cross this by diffusion but not bulk flow. The plane between fascial layers is filled with a similar fat-glycosaminoglycan matric and provides gliding and cushioning between structures, as well as a pathway for nerves and vessels. The planes between the various muscle layers of the thorax, abdomen, and paraspinal area close to the thoracic paravertebral space and vertebral canal, are popular targets for ultrasound-guided local anesthetic injection. The pertinent musculofascial anatomy of these regions, together with the nerves involved in somatic and visceral innervation, are summarized. This knowledge will aid not only sonographic identification of landmarks and block performance, but also understanding of the potential pathways and barriers for spread of local anesthetic. It is also critical as the basis for further exploration and refinement of FPBs, with an emphasis on improving their clinical utility, efficacy, and safety.

Mechanisms of action of fascial plane blocks: a narrative review

BACKGROUND

Fascial plane blocks (FPBs) target the space between two fasciae, rather than discrete peripheral nerves. Despite their popularity, their mechanisms of action remain controversial, particularly for erector spinae plane and quadratus lumborum blocks.

OBJECTIVES

This narrative review describes the scientific evidence underpinning proposed mechanisms of action, highlights existing knowledge gaps, and discusses implications for clinical practice and research.

FINDINGS

There are currently two plausible mechanisms of analgesia. The first is a local effect on nociceptors and neurons within the plane itself or within adjacent muscle and tissue compartments. Dispersion of local anesthetic occurs through bulk flow and diffusion, and the resulting conduction block is dictated by the mass of local anesthetic reaching these targets. The extent of spread, analgesia, and cutaneous sensory loss is variable and imperfectly correlated. Explanations include anatomical variation, factors governing fluid dispersion, and local anesthetic pharmacodynamics. The second is vascular absorption of local anesthetic and a systemic analgesic effect at distant sites. Direct evidence is presently lacking but preliminary data indicate that FPBs can produce transient elevations in plasma concentrations similar to intravenous lidocaine infusion. The relative contributions of these local and systemic effects remain uncertain.

CONCLUSION

Our current understanding of FPB mechanisms supports their demonstrated analgesic efficacy, but also highlights the unpredictability and variability that result from myriad factors at play. Potential strategies to improve efficacy include accurate deposition close to targets of interest, injections of sufficient volume to encourage physical spread by bulk flow, and manipulation of concentration to promote diffusion.

The Efficacy of Pectoralis Nerve Blockade in Breast Reductions: A Prospective Randomized Trial

BACKGROUND

Pectoralis nerve (Pecs) blocks have been shown to reduce perioperative opioid consumption in patients undergoing mastectomies, but the effectiveness of these blocks in breast reductions has not been established. This trial aims to evaluate the efficacy of Pecs blocks (I and II) on perioperative pain management in patients undergoing breast reductions.

METHODS

Thirty-six patients were enrolled in the randomized controlled trial divided into 2 groups. The treatment group (n = 16) received general anesthesia plus postinduction ultrasound-guided Pecs blocks. The control group (n = 20) received general anesthesia alone. The primary outcomes measured were perioperative narcotic requirements, need for postoperative antiemetics, pain scores, and length of time in the operating room (OR). We measured patient and procedural risk factors including pedicle/skin excision patterns, concurrent liposuction, weight of resection, and additional local anesthesia. Risk factors as well as outcomes were analyzed using Fischer exact and t tests.

RESULTS

No statistically significant difference was shown between the group receiving the Pecs blocks and the control with regard to narcotic requirements, pain scores, and need for antiemetics. Patients undergoing Pecs blocks had a significantly higher OR time before incision (P = 0.0073). Patient and procedural risk factors were well balanced (P > 0.41).

CONCLUSIONS

Pectoralis nerve blocks may be a valuable component of a multimodality pain regimen; however, when performed as a solitary adjunct, they do not seem to decrease perioperative narcotic requirements, pain scores, or the need for antiemetic medication in patients undergoing breast reductions. In addition, postinduction Pecs blocks significantly increase OR times.

Pectoral nerve blocks for breast surgery: A meta-analysis

BACKGROUND

Pectoral nerve blocks (PECS block) might be an interesting new regional anaesthetic technique in patients undergoing breast surgery.

OBJECTIVE

The aim of this meta-analysis was to investigate postoperative pain outcomes and adverse events of a PECS block compared with no treatment, sham treatment or other regional anaesthetic techniques in women undergoing breast surgery.

DESIGN

We performed a systematic review of randomised controlled trials (RCT) with meta-analysis and risk of bias assessment.

DATA SOURCES

The databases MEDLINE, CENTRAL (until December 2019) and clinicaltrials.gov were systematically searched.

ELIGIBILITY CRITERIA

All RCTs investigating the efficacy and adverse events of PECS compared with sham treatment, no treatment or other regional anaesthetic techniques in women undergoing breast surgery with general anaesthesia were included.

RESULTS

A total of 24 RCTs (1565 patients) were included. PECS (compared with no treatment) block might reduce pain at rest [mean difference -1.14, 95% confidence interval (CI), -2.1 to -0.18, moderate quality evidence] but we are uncertain regarding the effect on pain during movement at 24 h after surgery (mean difference -1.79, 95% CI, -3.5 to -0.08, very low-quality evidence). We are also uncertain about the effect of PECS block on pain at rest at 24 h compared with sham block (mean difference -0.83, 95% CI, -1.80 to 0.14) or compared with paravertebral block (PVB) (mean difference -0.18, 95% CI, -1.0 to 0.65), both with very low-quality evidence. PECS block may have no effect on pain on movement at 24 h after surgery compared with PVB block (mean difference -0.56, 95% CI, -1.53 to 0.41, low-quality evidence). Block-related complications were generally poorly reported.

CONCLUSION

There is moderate quality evidence that PECS block compared with no treatment reduces postoperative pain intensity at rest. The observed results were less pronounced if patients received a sham block. Furthermore, PECS blocks might be equally effective as PVBs. Due to mostly low-quality or very low-quality evidence level, further research is warranted.

PROTOCOL REGISTRATION

CRD42019126733.

Post-mastectomy pain syndrome: A timely review of its predisposing factors and current approaches to treatment

Background:

Post-mastectomy pain syndrome (PMPS) has been reported to occur in 25–60% of patients following surgeries for breast cancer, the highest occurring cancer in women worldwide. There has been much research interest due to this high prevalence. However, there is still a lack of incorporation of PMPS prevention strategies in standard perioperative plans, and our understanding of this condition is still incomplete.

Objectives:

This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and treatment and potential directions for future treatment and research.

Methods:

A PubMed search with the relevant keywords was done for articles published in the last 10 years.

Results:

The incidence of PMPS can be reduced by early recognition and management of modifiable risk factors as well as the perioperative use of analgesics and regional nerve blocks. These also have a significant role in the management of established PMPS together with surgical interventions and physical therapy.

Conclusions:

PMPS is still poorly defined and hence underdiagnosed and undertreated at this point. Perioperative peripheral nerve blocks have a very promising role as preventive analgesia to reduce the risk of developing PMPS, but large-scale randomised controlled studies will need to be done to evaluate their comparative efficacy. There is a need to prioritise PMPS prevention as a standard inclusion into the perioperative plans of mastectomy patients.

Effect of Isolated Serum from Breast Cancer Patients with Pectoral Nerves Block on Breast Cancer Cell Line (MDA-MB-231) Apoptosis Index

Background

Breast cancer (BC) is the most frequent cause of cancer death in women. The thoracic pectoral nerve (PECS) block has been described as the gold standard analgesic modality for BC surgery. It has been previously reported that PECS is associated with decreased BC recurrence post-mastectomy. Although several anesthetic drugs and techniques are used in surgical oncology, their effects on the behavior of cancer cells are yet to be known and the key question of whether the anesthetic technique affects cancer outcome remains unresolved.

Objectives

Since anesthetic drugs and techniques and post-operative pain may affect BC recurrence, this study aimed to determine whether the anesthetic choice and technique, PECS II block, affects in vitro apoptosis of the MDA-MB-231 BC cell line.

Methods

Twenty-two female BC patients, 20 to 75-years-old, with the same pathologic grades were included in this study. The patients were randomly divided into two groups. The first group received propofol general anesthesia (PGA) associated with PECS and the second group received standard PGA. Blood was sampled pre and post-operation from all patients. The sera were isolated and then exposed to the MDA-MB-231 human BC cell line. The mean percentage of apoptosis indices was analyzed by flow cytometry using Annexin V-fluorescein isothiocyanate 24 hours after treatment with patients' sera.

Results

A significant decrease was seen in the mean viability percentage of BC cell line in the PECS group, besides a significant increase in the mean percentage of necrosis and late apoptosis indices compared to the control group after exposure to sera collected from patients post-operation. Intra-group analysis of the control group showed that the exposure of the tumoral cell to post-operation sera resulted in a significant increase in the mean percentage of necrosis and late apoptosis index compared to pre-operation sera exposure. In the PECS group, the exposure of the tumoral cell to post-operation sera resulted in a significant increase in the mean percentage of cell viability and late apoptosis index compared to pre-operation sera exposure.

Conclusions

In conclusion, anesthesia and BC surgery may induce apoptosis indices in the MDA-MB-231 human BC cell line. We also found that sera collected from PECS II block patients with BC could induce more apoptosis in the MDA-MB-231 cell line compared to collected sera from systemic analgesia alone after BC surgery.

Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis

STUDY OBJECTIVE

Moderate to severe postoperative pain occurs in up to 60% of women following breast operations. Our aim was to perform a network meta-analysis and systematic review to compare the efficacy and side effects of different analgesic strategies in breast surgery.

DESIGN

Systematic review and network meta-analysis.

SETTING

Operating room, postoperative recovery room and ward.

PATIENTS

Patients scheduled for breast surgery under general anesthesia.

INTERVENTIONS

Following an extensive search of electronic databases, those who received any of the following interventions, control, local anesthetic (LA) infiltration, erector spinae plane (ESP) block, pectoralis nerve (PECS) block, paravertebral block (PVB) or serratus plane block (SPB), were included. Exclusion criteria were met if the regional anesthesia modality was not ultrasound-guided. Network plots were constructed and network league tables were produced.

MEASUREMENTS

Co-primary outcomes were the pain at rest at 0-2 h and 8-12 h. Secondary outcomes were those related to analgesia, side effects and functional status.

MAIN RESULTS

In all, 66 trials met our inclusion criteria. No differences were demonstrated between control and LA infiltration in regard to the co-primary outcomes, pain at rest at 0-2 and 8-12 h. The quality of evidence was moderate in view of the serious imprecision. With respect to pain at rest at 8-12 h, ESP block, PECS block and PVB were found to be superior to control or LA infiltration. No differences were revealed between control and LA infiltration for outcomes related to analgesia and side effects, and few differences were shown between the various regional anesthesia techniques.

CONCLUSIONS

In breast surgery, regional anesthesia modalities were preferable from an analgesic perspective to control or LA infiltration, with a clinically significant decrease in pain score and cumulative opioid consumption, and limited differences were present between regional anesthetic techniques themselves.

Comparison of PECS II and erector spinae plane block for postoperative analgesia following modified radical mastectomy: Bayesian network meta-analysis using a control group

The present study compared the effects of pectoral nerve block II (PECS II) and erector spinae plane (ESP) block for postoperative analgesia in patients who underwent modified radical mastectomy by performing a network meta-analysis (NMA) using indirect comparison with systemic analgesia. Studies comparing the analgesic effects of PECS II and ESP block were searched on MEDLINE, PubMed, EMBASE and the Cochrane Library. The primary outcome of this study was cumulative opioid consumption for 24 h postoperatively. Pain score during this period was also assessed. NMA was performed to compare the postoperative analgesic effects of plane blocks and systemic analgesia. A search of databases identified 17 studies, with a total of 1069 patients, comparing the analgesic efficacies of PECS II block, ESP block, and systemic analgesia. Compared with systemic analgesia, mean difference of opioid consumption was - 10 mg (95% credible interval [CrI] - 15.0 to - 5.6 mg) with PECS II block and - 5.7 mg (95% CrI - 11.0 to - 0.7 mg) with ESP block. Relative to systemic analgesia, PECS II block showed lower pain scores over the first postoperative 24 h, whereas ESP block did not. PECS II block showed the highest surface under the cumulative ranking curves for both opioid consumption and pain score. Both PECS II and ESP blocks were shown to be more effective than systemic analgesia regarding postoperative analgesia following modified radical mastectomy, and between the two blocks, PECS II appeared to have favorable analgesic effects compared to ESP block.

Local Anesthetic-Induced Central Nervous System Toxicity during Interscalene Brachial Plexus Block: A Case Series Study of Three Patients

Local anesthetics are commonly administered by nuchal infiltration to provide a temporary interscalene brachial plexus block (ISB) in a surgical setting. Although less commonly reported, local anesthetics can induce central nervous system toxicity. In this case study, we present three patients with acute central nervous system toxicity induced by local anesthetics applied during ISB with emphasis on neurological symptoms, key neuroradiological findings and functional outcome. Medical history, clinical and imaging findings, and outcome of three patients with local anesthetic-induced toxic left hemisphere syndrome during left ISB were analyzed. All patients were admitted to our neurological intensive care unit between November 2016 and September 2019. All three patients presented in poor clinical condition with impaired consciousness and left hemisphere syndrome. Electroencephalography revealed slow wave activity in the affected hemisphere of all patients. Seizure activity with progression to status epilepticus was observed in one patient. In two out of three patients, cortical FLAIR hyperintensities and restricted diffusion in the territory of the left internal carotid artery were observed in magnetic resonance imaging. Assessment of neurological severity scores revealed spontaneous partial reversibility of neurological symptoms. Local anesthetic-induced CNS toxicity during ISB can lead to severe neurological impairment and anatomically variable cerebral lesions.

Anesthetic effect of ultrasound-guided multiple-nerve blockade in modified radical mastectomy in patients with breast cancer

INTRODUCTION

Routine anesthesia modality for modified radical mastectomy (MRM) includes general anesthesia (GA), epidural blockade-combined GA and nerve blockade-combined GA. However, GA has been associated with postoperative adverse effects such as vertigo, postoperative nausea and vomiting and requirement for postoperative analgesia, which hinders recovery and prognosis. Moreover, combined blockade of thoracic paravertebral nerves or intercostal nerves and adjuvant basic sedation for massive lumpectomy provided perfect anesthesia and reduced opioid consumption, whereas the excision coverage did not attain the target of MRM. Regional anesthesia strategies involving supplementation of analgesics in ultrasound-guided multiple nerve blocks have garnered interests of clinicians. Nevertheless, the precise effects of intercostal nerves, brachial plexus and supraclavicular nerves in MRM in patients with breast cancer remain obscure.

METHODS

Eighty female patients with breast cancer scheduled for MRM were recruited in the present trial between May, 2019 and Dec., 2019 in our hospital. The patients ranged from 30 to 65 years of age and 18∼30 kg/m2 in body-mass index, with the American Society of Anesthesiologists I or II. The patients were randomized to ultrasound-guided multiple nerve blocks group and GA group. The patients in multiple nerve blocks group underwent ultrasound guided multiple intercostal nerve blocks, interscalene brachial plexus and supraclavicular nerve blocks, (local anesthesia with 0.3% ropivacaine: 5 ml for each intercostal nerve block, 8 ml for brachial plexus block, 7 mL for supraclavicular nerve block) and basic sedation and intraoperative mask oxygen inhalation. The variations of hemodynamic parameters such as mean arterial pressure, heart rate (HR) and pulse oxygen saturation were monitored. The visual analog scale scores were recorded at postoperative 0 hour, 3 hour, 6 hour, 12 hour and 24 hour in resting state. The postoperative adverse effects, including vertigo, postoperative nausea, and vomiting, pruritus, and urinary retention and so on, as well as the analgesic consumption were recorded.

CONCLUSIONS

The ultrasound guided multiple intercostal nerve blocks, brachial plexus and supraclavicular nerve blocks could provide favorable anesthesia and analgesia, with noninferiority to GA and the reduced incidence of adverse effects and consumption of postoperative analgesics.

Utility of the Pectoral Nerve Block (PECS II) for Analgesia Following Transaxillary First Rib Section

BACKGROUND

The transaxillary approach to resection of the first rib is one of several operative techniques for treating thoracic outlet syndrome. Unfortunately, moderate to severe postoperative pain is anticipated for patients undergoing this particular operation. While opioids can be used for analgesia, they have well-described side effects that has led investigators to search for clinically relevant alternative analgesic modalities. We hypothesized that a regional analgesic procedure, commonly called a pectoral nerve (PECS II) block, which anesthetizes the second through sixth intercostal nerves as well as the long thoracic nerve and the medial and lateral pectoral nerves, would improve postoperative analgesia for patients undergoing a transaxillary first rib resection.

METHODS

We performed a retrospective study by reviewing the charts of all patients that had undergone a transaxillary first rib resection for thoracic outlet syndrome during the defined study period. Patients that received a PECS II block were compared to those that did not. The primary outcome was a comparison of numeric rating scale pain scores during the first 24 hours following the operation. Secondary outcomes included cumulative opioid consumption during the same time period.

RESULTS

Pain scores during the first 24 hours following the operation were not statistically different between groups (Block Group: 3.9 [2.1-5.3] [median (IQR 25-75%)] versus Non-block Group: 3.6 [2.4-4.1]; P = 0.40. In addition, opioid use through the first 24 hours after the operation was not significantly different (43.5 [22.0-81.0] [median morphine equivalents in mg's] versus 42.0 [12.5-75.0]; P = 0.53).

CONCLUSIONS

An ultrasound-guided PECS II nerve block did not reduce postoperative pain scores or opioid consumption for patients undergoing a transaxillary first rib resection. However, a prospective, randomized, study with improved power would be beneficial to further explore the potential utility of a PECS II block for patients presenting for this surgical procedure.

Randomized controlled trial comparing the efficacy of pectoral nerve block with general anesthesia alone in patients undergoing unilateral mastectomy

This study was conducted to evaluate the efficacy of pectoral nerve block for post-operative analgesia in breast surgery patients. This double blinded, randomized controlled trial was conducted after Clinical Trials Registry-India registration. Sixty ASA grade I-II female patients undergoing unilateral modified radical mastectomy under general anesthesia, were recruited pre-operatively in two groups. PECS group (n  =  29) was given ipsilateral pectoral nerve block I & II while the CONTROL group (n  =  29) directly proceeded to surgery. Our primary outcome was comparison of immediate post-operative pain scores at rest and movement. The secondary outcomes were post-operative pain scores at 2, 4, 6, 12, 18, and 24 h, total intraoperative fentanyl consumption, time to rescue analgesia, post-operative nausea vomiting, and complications, if any. Categorical data was analyzed by using the chi-squared test or Fishers Exact test. Comparison of pain scores was analyzed by using the Independent sample t test. The immediate post-operative pain scores in two groups were comparable. The pain scores were also comparable at 4, 6, 12, and 24 h; but statistically significantly lower in PECS group at 2 and 18 h. The total intraoperative fentanyl consumption was also reduced in PECS group (P = 0.009). Only 9 patients in PECS group (796.5 min) as compared to 22 patients in CONTROL group (387.7 min) required rescue analgesia (P  =  0.001). Pectoral nerve block benefits patients undergoing mastectomy by achieving similar post-operative pain scores with decreased consumption of intraoperative and post-operative opioids. Registration. Clinical Trials Registry of India, (CTRI/2017/04/008289). ctri.nic.in.

Ultrasound-guided fascial plane blocks of the chest wall: a state-of-the-art review

Ultrasound-guided fascial plane blocks of the chest wall are increasingly popular alternatives to established techniques such as thoracic epidural or paravertebral blockade, as they are simple to perform and have an appealing safety profile. Many different techniques have been described, which can be broadly categorised into anteromedial, anterolateral and posterior chest wall blocks. Understanding the relevant clinical anatomy is critical not only for block performance, but also to match block techniques appropriately with surgical procedures. The sensory innervation of tissues deep to the skin (e.g. muscles, ligaments and bone) can be overlooked, but is often a significant source of pain. The primary mechanism of action for these blocks is a conduction blockade of sensory afferents travelling in the targeted fascial planes, as well as of peripheral nociceptors in the surrounding tissues. A systemic action of absorbed local anaesthetic is plausible but unlikely to be a major contributor. The current evidence for their clinical applications indicates that certain chest wall techniques provide significant benefit in breast and thoracic surgery, similar to that provided by thoracic paravertebral blockade. Their role in trauma and cardiac surgery is evolving and holds great potential. Further avenues of research into these versatile techniques include: optimal local anaesthetic dosing strategies; high-quality randomised controlled trials focusing on patient-centred outcomes beyond acute pain; and comparative studies to determine which of the myriad blocks currently on offer should be core competencies in anaesthetic practice.

Practical Review of Abdominal and Breast Regional Analgesia for Plastic Surgeons: Evidence and Techniques

Regional analgesia has been increasing in popularity due to its opioid- sparing analgesic effects and utility in multimodal analgesia strategies. Several regional techniques have been used in plastic surgery; however, there is a lack of consensus on the indications and the comparative efficacy of these blocks. The goal of this review is to provide evidence-based recommendations on the most relevant types of interfascial plane blocks for abdominal and breast surgery. A systematic search of the PUBMED, EMBASE, and Cochrane databases was performed to identify the evidence associated with the different interfascial plane blocks used in plastic surgery. The search included all studies from inception to March 2020. A total of 126 studies were included and used in the synthesis of the information presented in this review. There is strong evidence for using the transversus abdominis plane blocks in both abdominoplasties as well as abdominally-based microvascular breast reconstruction as evidenced by a significant reduction in post-operative pain and opioid consumption. Pectoralis (I and II), serratus anterior, and erector spinae plane blocks all provide good pain control in breast surgeries. Finally, the serratus anterior plane block can be used as primary block or an adjunct to the pectoralis blocks for a wider analgesia coverage of the breast. All the reviewed blocks are safe and easy to administer. Interfascial plane blocks are effective and safe modalities used to reduce pain and opioid consumption after abdominal and breast plastic surgery.

Statistically significant but clinically unimportant: a systematic review and meta-analysis of the analgesic benefits of erector spinae plane block following breast cancer surgery

The novel erector spinae plane block (ESPB) has been reported to provide important postoperative analgesic benefits following a variety of truncal and abdominal surgical procedures. However, evidence of its analgesic efficacy following breast cancer surgery, compared with parenteral analgesia, is unclear. This meta-analysis evaluates the analgesic benefits of adding ESPB to parenteral analgesia following breast cancer surgery.Databases were searched for breast tumor resection trials comparing ESPB to parenteral analgesia. The two co-primary outcomes examined were 24-hour postoperative oral morphine equivalent consumption and area-under-curve of rest pain scores. We considered reductions equivalent to 3.3 cm.h and 30 mg oral morphine in the first 24 hours postoperatively for the two co-primary outcomes, respectively, to be clinically important. We also assessed opioid-related side effects and long-term outcomes, including health-related quality of life, persistent postsurgical pain and opioid dependence. Results were pooled using random effects modeling.Twelve trials (699 patients) were analyzed. Moderate quality evidence suggested that ESPB decreased 24-hour morphine consumption and area-under-curve of rest pain by a mean difference (95% CI) of -17.60 mg (-24.27 to -10.93) and -2.74 cm.h (-3.09 to -2.39), respectively; but these differences were not clinically important. High-quality evidence suggested that ESPB decreased opioid-related side effects compared with parenteral analgesia by an OR (95% CI) of 0.43 (0.28 to 0.66). None of the studies evaluated long-term block benefits.Adding ESPB to parenteral analgesia provides statistically significant but clinically unimportant short-term benefits following breast cancer surgery. Current evidence does not support routine use of ESPB. Given the very modest short-term benefits and risk of complications, the block should be considered on a case-by-case basis.

Is the minimal clinically important difference (MCID) in acute pain a good measure of analgesic efficacy in regional anesthesia?

In the field of acute pain medicine research, we believe there is an unmet need to incorporate patient related outcome measures that move beyond reporting pain scores and opioid consumption. The term “minimal clinically important difference” (MCID) defines the clinical benefit of an intervention as perceived by the patient, as opposed to a mathematically determined statistically significant difference that may not necessarily be clinically significant. The present article reviews the concept of MCID in acute postoperative pain research, addresses potential pitfalls in MCID determination and questions the clinical validity of extrapolating MCID determined from chronic pain and non-surgical pain studies to the acute postoperative pain setting. We further suggest the concepts of minimal clinically important improvement, substantial clinical benefit and patient acceptable symptom state should also represent aspirational outcomes for future research in acute postoperative pain management.

Preventing pain after breast surgery: A systematic review with meta-analyses and trial-sequential analyses

BACKGROUND AND OBJECTIVE

The aim of this systematic review was to indirectly compare the efficacy of any intervention, administered perioperatively, on acute and persistent pain after breast surgery.

DATABASES AND DATA TREATMENT

We searched for randomized trials comparing analgesic interventions with placebo or no treatment in patients undergoing breast surgery under general anaesthesia. Primary outcome was intensity of acute pain (up to 6 hr postoperatively). Secondary outcomes were cumulative 24-hr morphine consumption, incidence of postoperative nausea and vomiting (PONV), and chronic pain. We used an original three-step approach. First, meta-analyses were performed when data from at least three trials could be combined; secondly, trial sequential analyses were used to separate conclusive from unclear evidence. And thirdly, the quality of evidence was rated with GRADE.

RESULTS

Seventy-three trials (5,512 patients) tested loco-regional blocks (paravertebral, pectoralis), local anaesthetic infiltrations, oral gabapentinoids or intravenous administration of glucocorticoids, lidocaine, N-methyl-D-aspartate antagonists or alpha2 agonists. With paravertebral blocks, pectoralis blocks and glucocorticoids, there was conclusive evidence of a clinically relevant reduction in acute pain (visual analogue scale > 1.0 cm). With pectoralis blocks, and gabapentinoids, there was conclusive evidence of a reduction in the cumulative 24-hr morphine consumption (> 30%). With paravertebral blocks and glucocorticoids, there was conclusive evidence of a relative reduction in the incidence of PONV of 70%. For chronic pain, insufficient data were available.

CONCLUSIONS

Mainly with loco-regional blocks, there is conclusive evidence of a reduction in acute pain intensity, morphine consumption and PONV incidence after breast surgery. For rational decision making, data on chronic pain are needed.

SIGNIFICANCE

This quantitative systematic review compares eight interventions, published across 73 trials, to prevent pain after breast surgery, and grades their degree of efficacy. The most efficient interventions are paravertebral blocks, pectoralis blocks and glucocorticoids, with moderate to low evidence for the blocks. Intravenous lidocaine and alpha2 agonists are efficacious to a lesser extent, but with a higher level of evidence. Data for chronic pain are lacking.