Erector Spinae Plane Block Decreases Pain and Opioid Consumption in Breast Surgery: Systematic Review

Transforming care: Optimizing ERAS pathway in breast cancer surgery with latissimus dorsi flap

INTRODUCTION

This study aims to establish, execute, and assess the effectiveness of a perioperative enhanced recovery after surgery (ERAS) clinical care pathway in breast reconstruction patients with LD flap breast cancer treatment. The goal is to improve early recovery outcomes, reduce hospitalization time, and enhance patient satisfaction by implementing a standardized approach to postoperative care.

METHODS

This study was conducted at the University of Malaya Medical Center. The outcomes of 21 breast cancer patients who underwent autologous reconstructive breast surgery with the latissimus dorsi (LD) flap within six months before the implementation of the ERAS pathway (pre-ERAS) were compared with 26 patients who underwent the same surgery with the ultrasound-guided erector spinae plane (ESP) block for the (ERAS protocol implementation) cohort. The study was conducted from November 2019 to October 2020. The length of hospital stay, amount of analgesic usage, and incidence of postoperative nausea vomiting (PONV) were recorded.

RESULTS

The implementation of the ERAS clinical care pathway resulted in shorter hospital stays compared with the preceding care. On average, ERAS patients were mostly discharged on Day 2 post-surgery, whereas pre-ERAS patients were mostly discharged on Day 7. ERAS patients had a lower incidence of PONV from Days 1 to 5, starting with 88.5% not experiencing the condition on Days 1 and 2 and increasing to 100% on Day 5. All pre-ERAS patients experienced PONV in the first 5 days post-surgery. Fewer ERAS patients required antiemetics post-surgery (88.5%) compared with pre-ERAS patients (42.9%).

CONCLUSION

The implementation of the ERAS protocol as part of clinical care in autologous reconstructive breast surgery with the LD flap can improve recovery by shortening hospital stay, decreasing the use of analgesia, and alleviating PONV.

Assessing the Efficacy of Thoracic Erector Spinae Plane Block for Postoperative Analgesia in Lumbosacral Spine Surgery: A Prospective Quasi-experimental Study

Background and aims Optimal postoperative care and analgesia are the key factors in the management of cases of lumbosacral spine surgery. The erector spinae plane (ESP) block is a recently evolving entity and has a dynamic role in postoperative pain management. However, its role in the management of pain in lumber spinal surgeries is still not clear, and the literature remains anecdotal. Therefore, we planned to study the efficacy of ultrasound-guided preoperative ESP block at the T12 level using levobupivacaine for perioperative analgesia in lumbosacral spine surgeries. Methods A total of 60 patients scheduled for elective or emergency lumbosacral spine surgery were divided into two groups - the GA group received standard general anesthesia (GA) and the GA+ESP group received standard general anesthesia along with ultra-sound guided ESP block at the T12 level with a bilateral injection of 20 ml 0.25% levobupivacaine. Perioperative analgesia was assessed by total intra-operative fentanyl dose and frequency, intra-operative hemodynamic parameters, post-operative numeric rating scale (NRS) scores, time of first systemic rescue analgesia, tramadol usage, mobilization day, and hospital stay duration.  Results Intraoperative fentanyl sparing was observed in 83% of the GA+ESP group compared to 33% in the GA group. Postoperative tramadol sparing was observed in 80% of the GA+ESP group compared to 26.7% of the GA group. Twenty-four-hour postoperative NRS scores >3/10 were observed in 20% of the GA+ ESP group compared to 73.3% of the GA group. Conclusion In this study, superior perioperative analgesia, opioid-sparing effect, and decreased requirement of postoperative rescue analgesia were observed with ESP block.

T1 erector spinae plane block for first rib resections in patients with thoracic outlet syndrome: a case series

An erector spinae plane block (ESPB), in which a local anesthetic is injected into the plane anterior to the erector spinae muscles, is a relatively new technique for delivering regional anesthesia and is typically performed in the mid-thoracic region. ESPBs demonstrate great potential to control regional neuropathic pain, and, accordingly, may be particularly effective at the T1 level for controlling pain in patients undergoing first rib resections for thoracic outlet syndrome (TOS). Four patients undergoing first rib resections for TOS were administered an ultrasound-guided ESPB at the T1 level. Two patients received the injection sitting upright without general anesthesia; the other patients received the block in the lateral decubitus position while under general anesthesia. Each patient's postoperative pain was adequately controlled, and no complications were observed. T1 ESPBs offer the potential to mitigate postoperative pain. Better pain management may decrease the need for opioids and shorten recovery times. As such, further investigation to establish the safety and efficacy of T1 ESPBs in this patient population can greatly improve patient outcomes.

Use of Muscle Relaxants for Acute Postoperative Pain: A Practical Review

Background

Skeletal muscle relaxants have emerged as a broad category of analgesic adjuncts, aiming to improve pain relief and reduce opioid reliance. These drugs induce muscle relaxation and reduce muscle spasms, and therefore, they are commonly used in surgical procedures involving muscle manipulation, such as abdominal surgery, breast surgery, and spine surgery. However, their analgesic efficacy and opioid-sparing effects are poorly explored.

Methods

A scoping review of literature was performed with several electronic databases. We used a search string with a sequence of text words and word variants related to central muscle relaxants, pain management, postoperative pain, and specific muscle relaxants.

Results

Review of literature shows significant heterogeneity among the studies in terms of surgical procedures, patient populations, choice of muscle relaxant, and timing and duration of administration, potentially limiting the generalizability of the findings and the ability for pooled analysis.

Conclusions

Given the lack of evidence, we recommend that the use of skeletal muscle relaxants be reserved for patients in whom an optimal multimodal analgesic technique is not adequate. Also, there may be a limited role for these drugs in patients at high risk of postoperative pain undergoing surgical procedures with expected high opioid requirements. Due to the concerns of potential adverse effects, the decision to use muscle relaxants in vulnerable populations should be made carefully, weighing the benefits against the risks.

Liposomal Bupivacaine Analgesia in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Retrospective Cohort Study

Background

Liposomal bupivacaine (LB) can be used for postsurgical analgesia after breast reconstruction. We examined real-world clinical and economic benefits of LB versus bupivacaine after deep inferior epigastric perforator (DIEP) flap breast reconstruction.

Methods

This retrospective cohort study used the IQVIA claims databases to identify patients undergoing primary DIEP flap breast reconstruction in 2016-2019. Patients receiving LB and those receiving bupivacaine were compared to assess opioid utilization in morphine milligram equivalents (MMEs) and healthcare resource utilization during perioperative (2 weeks before surgery to 2 weeks after discharge) and 6-month postdischarge periods. A generalized linear mixed-effects model and inverse probability of treatment weighting method were performed.

Results

Weighted baseline characteristics were similar between cohorts (LB, n = 669; bupivacaine, n = 348). The LB cohort received significantly fewer mean MMEs versus the bupivacaine cohort during the perioperative (395 versus 512 MMEs; rate ratio [RR], 0.771 [95% confidence interval (CI), 0.677-0.879]; P = 0.0001), 72 hours after surgery (63 versus 140 MMEs; RR, 0.449 [95% CI, 0.347-0.581]; P < 0.0001), and inpatient (154 versus 303 MMEs; RR, 0.508 [95% CI, 0.411-0.629]; P < 0.0001) periods; postdischarge filled opioid prescriptions were comparable. The LB cohort was less likely to have all-cause inpatient readmission (odds ratio, 0.670 [95% CI, 0.452-0.993]; P = 0.046) and outpatient clinic/office visits (odds ratio, 0.885 [95% CI, 0.785-0.999]; P = 0.048) 3 months after discharge than the bupivacaine cohort; other all-cause healthcare resource utilization outcomes were not different.

Conclusions

LB was associated with fewer perioperative MMEs and all-cause 3-month inpatient readmissions and outpatient clinic/office visits than bupivacaine in patients undergoing DIEP flap breast reconstruction.

Efficacy and Safety of Nerve Block for Postoperative Analgesia in Patients Undergoing Breast Cosmetic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

To evaluate the postoperative analgesic efficacy and safety of nerve block (NB) in patients undergoing breast surgery for cosmetic purposes.

METHODS

PubMed, Web of Science, Embase and Cochrane Libraries were searched from inception to September 2022, to identify all eligible randomized controlled trials (RCTs). Continuous data are presented as mean difference (MD) with 95% confidence intervals (CI), whereas dichotomous data are provided as odds ratios (OR) with 95% CI. This meta-analysis was performed in RevMan 5.4.

RESULTS

A total of 10 RCTs with 565 patients were meta-analyzed. Compared to the control group, the pain score of the NB group was significantly lower at postoperative 2, 3-4, 6-8, 12-16 and 24 h. Opioid consumption in the first postoperative 24 h was significantly lower in the NB group (MD = - 9.02, 95% CI - 14.29 to - 3.75, P < 0.05), I2 = 95%). In addition, the NB group showed a prolonged time to first postoperative analgesic requirement (MD = 43.15, 95% CI 4.74-81.56, P < 0.05, I2 = 96%), decreased incidence of additional postoperative analgesia (OR 0.14, 95% CI 0.07-0.28, P < 0.05, I2 = 0%) and reduced incidence of postoperative nausea or vomiting (OR 0.33; 95% CI 0.22-0.48; P < 0.05; I2 = 0%). There was no significant difference in operation duration between the two groups.

CONCLUSIONS

Nerve block is an effective and safe option for postoperative analgesia after breast cosmetic surgery.

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 .

Anaesthetic Management for Mastectomy in a Male With Unilateral Gynecomastia: The Utilization of Thoracic Segmental Spinal Anaesthesia and Erector Spinae Plane Block

Males are frequently affected by gynecomastia, a benign proliferative glandular tissue condition of the breast. Gynecomastia is usually treated with surgery to remove breast tissue. Using erector spinae plane block and thoracic segmental spinal anaesthesia in place of typical general anaesthesia during breast procedures has become more common in recent years. This case report presents the management of a 24-year-old male with long-standing left breast gynecomastia. Using a combination of erector spinae plane block and thoracic segmental spinal anaesthesia, the patient had the breast tissue excised. The regulation of the neuroendocrine stress response, lower need for analgesics after surgery, and decreased postoperative nausea and vomiting are among the many benefits of the anaesthetic methods. With better patient outcomes, fewer surgical complications, and efficient postoperative pain management, these methods offer a compelling substitute for general anaesthesia. The range of surgical scenarios in which these techniques can be applied could be expanded by additional research and clinical experience.

Pre-operative erector spinae plane block should be considered a viable option for laparoscopic colectomies

BACKGROUND

The Erector Spinae Plane (ESP) block is a recent development in the field of regional anaesthesia and has been increasingly explored for abdominal surgeries to reduce opioid use and improve pain control. Colorectal cancer is the commonest cancer in multi-ethnic Singapore and requires surgery for curative treatment. ESP is a promising alternative in colorectal surgeries, but few studies have evaluated its efficacy in such surgeries. Therefore, this study aims to evaluate the use of ESP blocks in laparoscopic colorectal surgeries to establish its safety and efficacy in this field.

METHODS

A prospective two-armed interventional cohort study comparing T8-T10 ESP blocks with conventional multimodal intravenous analgesia for laparoscopic colectomies was conducted in a single institution in Singapore. The decision for doing an ESP block versus conventional multimodal intravenous analgesia was made by a consensus between the attending surgeon and anesthesiologist. Outcomes measured were total intra-operative opioid consumption, post-operative pain control and patient outcome. Post-operative pain control was measured by pain score, analgesia use, and amount of opioids consumed. Patient outcome was determined by presence of ileus.

RESULTS

A total of 146 patients were included, of which 30 patients received an ESP block. Overall, the ESP group had a significantly lower median opioid usage both intra-operatively and post-operatively (p = 0.031). Fewer patients required patient-controlled analgesia and rescue analgesia post-operatively for pain control (p < 0.001) amongst the ESP group. Pain scores were similar and post-operative ileus was absent in both groups. Multivariate analysis found that the ESP block had an independent effect on reducing intra-opioid consumption (p = 0.014). Multivariate analysis of post-operative opioid use and pain scores did not yield statistically significant results.

CONCLUSIONS

The ESP block was an effective alternative regional anaesthesia for colorectal surgery that reduced intra-operative and post-operative opioid use while attaining satisfactory pain control.

Optimal ropivacaine concentration for ultrasound-guided erector spinae plane block in patients who underwent video-assisted thoracoscopic lobectomy surgery

Background

An ultrasound-guided erector spinae plane block (ESPB) has emerged as an effective way to control postoperative pain and may be a good alternative way to an epidural block. However, relevant research on the appropriate concentration of local anesthetics for an ESPB remains scarce.

Aims

This study aimed to investigate the optimal concentration of ropivacaine for an ESPB in patients undergoing video-assisted thoracoscopic surgery (VATS).

Methods

A total of 68 patients who underwent a VATS lobectomy were enrolled. An ipsilateral ultrasound-guided ESPB was performed with three different ropivacaine concentrations as a local anesthetic: 0.189% (G1), 0.375% (G2), and 0.556% (G3). The total amount of perioperative remifentanil administered, patient-controlled analgesia (PCA) applied, and rescue drugs for postoperative analgesia during the 24 h after surgery were acquired, and numeric rating scale (NRS) scores were obtained.

Results

The total amount of intraoperative remifentanil administered was 7.20 ± 3.04 mcg/kg, 5.32 ± 2.70 mcg/kg, and 4.60 ± 1.75 in the G1, G2, and G3 groups, respectively. G2 and G3 had significantly lower amounts of remifentanil administered than the G1 group (P = 0.02 vs. G2; P = 0.003 vs. G3). The G3 group needed more inotropes than the G1 and G2 groups in the perioperative period (P = 0.045). The NRS scores, PCA, and rescue drug were not significantly different in the three groups.

Conclusion

The optimal concentration of ropivacaine recommended for an ESPB was 0.375%, which was effective in controlling pain and reducing the intraoperative opioid requirements with minimal adverse reactions such as hypotension.

Paravertebral Blocks in Tissue Expander Breast Reconstruction: Propensity-Matched Analysis of Opioid Consumption and Patient Outcomes

BACKGROUND

The paravertebral block (PVB) is an adjunctive perioperative pain control method for patients undergoing breast reconstruction that may improve perioperative pain control and reduce narcotic use. This study determined the efficacy of preoperative PVBs for perioperative pain management in patients undergoing tissue expander breast reconstruction.

METHODS

A retrospective review was performed of patients who underwent tissue expander breast reconstruction from December of 2017 to September of 2019. Two patients with PVBs were matched using propensity scoring to one no-block patient. Perioperative analgesic use, pain severity scores on days 2 to 10 after discharge, and BREAST-Q Physical Well-Being scores before surgery and at 2 weeks, 6 weeks, and 3 months after surgery were compared between the two groups.

RESULTS

The propensity-matched cohort consisted of 471 patients (314 PVB and 157 no block). The PVB group used significantly fewer morphine milligram equivalents than the no-block group (53.7 versus 69.8; P < 0.001). Average daily postoperative pain severity scores were comparable, with a maximum difference of 0.3 points on a 0-point to 4-point scale. BREAST-Q Physical Well-Being scores were significantly higher for the PVB group than the no-block group at 6 weeks after surgery (60.6 versus 51.0; P = 0.015) but did not differ significantly at 2 weeks or 3 months after surgery.

CONCLUSIONS

PVBs may help reduce perioperative opioid requirements but did not reduce pain scores after discharge when used as part of an expander-based reconstruction perioperative pain management protocol. Continued research should examine additional or alternative regional block procedures as well as financial cost and potential long-term impact of PVBs.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Erector spine plane block as single loco-regional anesthesia in non-intubated video-assisted thoracic surgery for unfit patients: a case-match study

In the present study, we analyzed the safety and efficacy of non-intubated video-assisted thoracoscopy (NI-VATS) for the diagnosis and palliation of malignant pleural effusion in the elderly population using erector-spinae plane block (ESPB) as single loco-regional anesthesia. From January 2016 to December 2020 a consecutive series of 158 patients who underwent surgery for malignant pleural effusion was analyzed. Of these, 20 patients were operated using ESPB NI-VATS, while 138 were operated under general anesthesia (GA). After propensity score matching, the NI-VATS population was older (81 vs. 76 years p 0.006), and had more severe pre-existing comorbidities, evaluated using Charlson Comorbidity Index (p = 0.029) and ASA score (p < 0.001). GA and NI-VATS patients did not differ in terms of postoperative opioid consumption, complication rate and postoperative hospitalization. Both short- and long-term efficacy of talc poudrage was equal in the two populations. The overall length of stay in the operative room was significantly shorter for the NI-VATS than for the GA-VATS group (67.5 vs. 105 min, p < 0.001), and operative time significantly differed in the two groups (35 vs. 47.5 min, respectively, p < 0.001). ESPB NI-VATS can be a safe and effective option for the diagnosis and palliation of malignant pleural effusion for elderly and frail patients.

A Comparative Study of Placebo Versus Opioid-Free Analgesic Mixture for Mastectomies Performed Under General Anesthesia Along With Erector Spinae Plane Block

Background and objectives Breast cancer is the most frequent cancer among women, globally. Postoperative pain after mastectomy not only causes slow recovery and prolonged hospital stay but can also increase the risk of chronic pain. For patients undergoing breast surgery, effective perioperative pain management is required. Various approaches have been introduced to overcome this, such as opioids, non-opioid analgesics, and regional blocks. The erector spinae plane block is a new regional anesthesia technique used in breast surgery to provide adequate intraoperative and postoperative analgesia. Opioid-free anesthesia is a multimodal analgesia technique that does not use opioids and thus prevents opioid tolerance after surgery. This study aims to investigate whether administering an opioid-free analgesic mixture lowers the pain score and the need for analgesics during and after surgery. Material and methods In this randomized prospective comparative clinical study, 66 patients of the American Society of Anesthesiologists (ASA) psychological status (PS) class 1 and 2, aged 18 to 80, were included. Group M received erector spinae plane block + general anesthesia + opioid-free analgesic mixture (1 mcg/cc dexmedetomidine + 1 mg/cc ketamine + 100 mg/cc magnesium sulfate prepared in a 20 ml syringe). Group N received erector spinae plane block + general anesthesia + 20ml of normal saline infusion. The primary outcome was to assess pain scores in the perioperative period. The secondary outcomes were to compare the time for the first rescue analgesia requirement perioperatively, intraoperative hemodynamic profile, and postoperative patient satisfaction. A p<0.05 was considered to be statistically significant. Results All patients were females undergoing modified radical mastectomy or breast conservative surgery + axillary sampling + latissimus dorsi flap reconstruction. The visual analog scale (VAS) scores were less than or equal to 3 in zero, first, and second hours postoperatively in both groups. The pain was moderate i.e., less than 4 in almost all time intervals in both groups. Group M had a better intraoperative hemodynamic profile, including mean arterial pressure and heart rate when compared to group N. In group M, the time of request for rescue analgesia was 726.67±390.99 minutes, while it was 468±278.79 minutes in group N. The total analgesic requirement was less in group M than in group N, but this was not statistically significant. Conclusion Multimodal analgesia with erector spinae plane block and opioid-free analgesic mixture provides effective perioperative analgesia and a better intraoperative hemodynamic profile in patients undergoing breast cancer surgery under general anesthesia.

The Shining Star of the Last Decade in Regional Anesthesia Part-I: Interfascial Plane Blocks for Breast, Thoracic, and Orthopedic Surgery

Regional anesthesia has benefits beyond just treating acute postoperative pain. Interfascial plane blocks, which have been very popular with ultrasound in recent years, function primarily by administering a high volume of a local anesthetic to the fascial plane. Contrary to traditional peripheral nerve blocks, the targeted nerve or structure in interfacial plane blocks is not fully defined, and the indications have not been fully revealed yet. Anatomical, cadaveric, and radiological studies show how effective the interfascial plane blocks play a role. This review focuses on the benefits, techniques, indications, and complications of interfascial plane blocks in the context of breast, thoracic, and orthopedic surgery.

Regional Pain Blocks and Perioperative Pain Control in Patients Undergoing Breast Implant Removal With Capsulectomy

Background

Demand for breast implant removal is on the rise, with more than 36,000 explants performed in 2020, an increase of 7.5% from previous years. Postoperative (PO) analgesia is an important consideration in this patient group due to scar tissue surrounding the implant and the potential for extensive dissection during capsulectomy.

Objectives

The authors sought to compare perioperative pain control between three different types of ultrasound (US)-guided regional anesthetic techniques in patients undergoing implant removal with capsulectomy.

Methods

The authors reviewed all patients who received an US-guided block and underwent breast implant removal with capsulectomy at their outpatient surgical center over a 2-year period. They compared intraoperative (IO), PO opioid requirement, and patient-reported pain on the first postoperative day (POD1) between 3 different block techniques using chi-square analysis. A P-value of <.05 was considered statistically significant.

Results

A total of 352 patients were included. Twenty-six patients (7.4%) underwent a serratus plane (SP) block, 13 (3.7%) underwent an erector spinae combined with pectointercostal fascial plane (ES + PIFP) block, and 313 (88.9%) underwent an erector spinae combined with pectoral nerve (ES + PECS1) block. ES + PECS1 was associated with less IO and PO opioid use compared with SP and ES + PIFP (1.9% vs 19.2% vs 61.5%, P < .001 for IO, 26.8% vs 34.6% vs 38.5% PO, P < .001). The ES + PECS1 block was associated with mild pain on POD1 compared with the other 2 regional block techniques (P = .001).

Conclusions

Regional pain blocks, and specifically the ES block, offer effective pain control for patients undergoing breast implant removal with capsulectomy, demonstrating high patient satisfaction in the PO period with low opioid requirements.

Level of Evidence 3

Pain Management After Open Liver Resection: Epidural Analgesia Versus Ultrasound-Guided Erector Spinae Plane Block

Background: Multimodal analgesia techniques, including regional analgesia, have been shown to provide effective analgesia and minimize opioid consumption after liver resection surgery. While thoracic epidural analgesia (TEA) is considered the gold standard, its role in the current era of enhanced recovery after surgery (ERAS) has been questioned. Erector spinae plane blocks (ESPBs) have the potential to provide effective postoperative analgesia without the risks associated with epidural analgesia. The primary aim of this quality improvement project was to evaluate the analgesic efficacy of ultrasound-guided ESPB in comparison with TEA in patients undergoing open liver resection.

Methods: Fifty patients who underwent open liver resection and received TEA (n=25) or ESPB (n=25) as part of an ERAS pathway were retrospectively identified. The primary outcome measure was cumulative postoperative opioid consumption at 24 hours. Secondary outcomes included opioid consumption, pain scores, the incidence of nausea and vomiting requiring antiemetics, lower extremity muscle weakness, and occurrence of hypotension requiring treatment on arrival to the post-anesthesia care unit and at 2, 6, 12, 24 hours, and daily through postoperative day 7. 

Results: Opioid requirements were significantly lower in the TEA group compared to the ESPB group. Postoperative pain scores at rest and with deep inspiration were significantly lower in the TEA group through postoperative day 5. There were no differences in other outcome measures.

Conclusions: These findings suggest that compared with ESPB, TEA provides superior pain relief after open liver resection.

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.

Comparison between erector spinae plane block and paravertebral block regarding postoperative analgesic consumption following breast surgery: a randomized controlled study

BACKGROUND

Pain control following breast surgery is of utmost importance in order to reduce the chance of chronic pain development, and facilitate early rehabilitation. The erector spinae plane block (ESPB) is a recently developed regional anaesthesia procedure successfully used for different types of surgical procedures including thoracic and abdominal surgeries.

METHODS

A double-blind, randomized, controlled trial was conducted on 90 patients who were scheduled for modified radical mastectomy (MRM). Patients were randomly categorized into groups I (women who underwent ESPB), II (women who underwent paravertebral block (PVB), and III (women who underwent general anaesthesia).

RESULTS

The ESPB (4.9 ± 1.2 mg) and PVB (5.8 ± 1.3 mg) groups had significantly lower total morphine consumption than the control group had (16.4 ± 3.1 mg; p < 0.001). Notably, patients in the ESPB group had insignificantly lower morphine consumption than those in the PVB group had (p = 0.076). Moreover, patients in the ESPB and PVB groups had a significantly longer time to first required anaesthesia than those in the control group (7.9 ± 1.2 versus 7.5 ± 0.9 versus 2 ± 1.2 h, respectively; p < 0.001). The postoperative visual analog scale scores were lower in the ESPB and PVB groups than in the control group on the first 24 h after the procedure (p < 0.001).

CONCLUSION

ESPB and PVB provide effective postoperative analgesia for women undergoing MRM. The ESPB appears to be as effective as the PVB.

TRIAL REGISTRATION

The study was registered before the enrolment of the first patient at the Pan African Clinical Trial Registry ( www.pactr.org ) database. Identification number for the registry is (PACTR202008836682092).

Ultrasound-guided erector spinae plane block for postoperative analgesia in patients after liver surgery: A systematic review and meta-analysis on randomized comparative studies

OBJECTIVE

To compare the analgesic efficacy and feasibility of erector spinae plane block (ESPB) with non-block care or other blocks in patients undergoing liver surgery.

METHOD

A meta-analysis of randomized controlled trials (RCTs) that compared ESPB to non-block care or local infiltration analgesia (LIA), intrathecal morphine (ITM) and quadratus lumborum block (QLB) for postoperative analgesia in liver surgery patients.

RESULTS

Six RCTs containing 392 patients were included. This meta-analysis found that ESPB did not significantly reduce postoperative 8 h [mean standard (MD) 0.20; 95% (confidence interval) CI: -1.62, 2.01; P = 0.83; I² = 99%] and 24 h [MD 0.10; 95% CI: -0.91, 1.11; P = 0.84; I² = 97%] resting pain scores in patients undergoing liver surgery compared to control groups. Furthermore, ESPB had no effect on postoperative 24 h cumulative opioid consumption [MD 1.74; 95% CI: 3.43, 6.91; P = 0.51; I² = 95%] or sleep quality [OR 1.00; 95% CI: 0.43, 2.35; P 0.99; I² = 0%]. In contrast, ESPB reduced postoperative 48 h resting pain score [MD -0.77; 95% CI -1.56, 0.02; P = 0.05; I² = 96%], the incidence of postoperative nausea and vomiting (PONV) [OR 0.29; 95% CI 0.18, 0.48; P = 0.001; I² = 0%]. Interestingly, in two RCTs, ESPB showed a higher incidence of shoulder pain compared to ITM [OR 2.89; 95%CI 1.03 to 8.09; P = 0.04; I² = 0%]. There have been no reports of complications from ESPB or other blocks.

CONCLUSION

Current literature supported that ESPB had no significant difference in analgesic efficacy in liver surgery patients compared to LIA, ITM, and QLB. More evidences, preferably from high quality RCTs are required to confirm these finding.

Multimodal Analgesia in the Aesthetic Plastic Surgery: Concepts and Strategies

Postoperative pain management is crucial for aesthetic plastic surgery procedures. Poorly controlled postoperative pain results in negative physiologic effects and can affect length of stay and patient satisfaction. In light of the growing opioid epidemic, plastic surgeons must be keenly familiar with opioid-sparing multimodal analgesia regimens to optimize postoperative pain control.

Methods

A review study based on multimodal analgesia was conducted.

Results

We present an overview of pain management strategies pertaining to aesthetic plastic surgery and offer a multimodal analgesia model for outpatient aesthetic surgery practices.

Conclusion

This review article presents an evidence-based approach to multimodal pain management for aesthetic plastic surgery.

Comparison of Intra- and postoperative effectiveness of erector spinae plane block and patient controlled analgesia in patients undergoing coronary artery bypass grafting surgery

The aim of our study was to compare bilateral erector spinae plane block (ESPB) efficacy on pain management with patient controlled analgesia (PCA) during the perioperative period in patients scheduled for coronary artery bypass grafting (CABG). After ethics committee approval (2019-7/31 dated 09.04.2019) from the Bursa Uludağ University Medical Trials Ethics Committee, (https://uludag.edu.tr/buuetikkurulu) ASA II-III, 50 patients aged between 18-80 years were included. They were randomly divided into two groups, ESPB (n=25) and control (n=25). In the preoperative period, bilateral ESPB with ultrasonography was applied to both groups with 0.25% bupivacaine (0.5 ml/kg) + dexamethasone (8 mg) or saline, respectively. PCA prepared with morphine was given to all patients postoperatively. Perioperative opioid use, extubation times, coughing/resting Visual Analog Scale (VAS) scores, duration for first PCA bolus dose requirement, rescue analgesia needs, mobilization times, and opioid side effects were evaluated. In the ESPB group, compared to the control group, intraoperative fentanyl consumption was lower (P=0.001). During the postoperative period; extubation time was shorter, the need for initial PCA was much later, morphine consumption and need for rescue analgesia was less (P=0.001; P<0.001; P<0.001; P=0.009, respectively). The postoperative VAS scores were lower for each measurement period (P<0.05). Opioid-related side effects were more common in the control group (P=0.040). First mobilization time in ESPB group was earlier (P<0.001). As a result, ESPB has a significant analgesic effect in CABG patients. It was concluded that bilateral ESPB reduces opioid requirement compared to intravenous morphine PCA alone and provides better pain management and more comfortable recovery.

The Efficacy and Safety of Ultrasound-Guided, Bi-Level, Erector Spinae Plane Block With Different Doses of Dexmedetomidine for Patients Undergoing Video-Assisted Thoracic Surgery: A Randomized Controlled Trial

Background: The anesthetic characteristics of ultrasound-guided bi-level erector spinae plane block (ESPB) plus dexmedetomidine (Dex) remain unclear. We compared the efficacy and safety of ultrasound-guided bi-level ESPB plus different doses of Dex in patients undergoing video-assisted thoracic surgery (VATS).

Methods: One-hundred eight patients undergoing VATS were randomized into three groups: R group (n = 38, 15 ml of 0.375% ropivacaine with 0.1 mg/kg dexamethasone), RD1 group (n = 38, 15 ml of 0.375% ropivacaine plus 0.5 μg/kg DEX with 0.1 mg/kg dexamethasone) and RD2 group (n = 38, 15 ml of 0.375% ropivacaine plus 1.0 μg/kg DEX with 0.1 mg/kg dexamethasone). The primary outcome was the pain 12 h after surgery. Secondary outcomes included the Prince Henry Hospital Pain Score; hemodynamics; consumption of sufentanil; anesthetized dermatomal distribution; recovery time; rescue analgesia; satisfaction scores of patients and surgeon; quick recovery index; adverse effects; the prevalence of chronic pain and quality of recovery.

Results: The visual analog scale (VAS) and the Prince Henry pain score were significantly lower in both the RD1 and RD2 groups during the first 24 h after surgery (P < 0.05). Both VAS with coughing and the Prince Henry pain score were significantly lower in the RD2 group than in the RD1 group 8–24 h after surgery (P < 0.05). Both heart rate and mean arterial pressure were significantly different from T2 to T6 in the RD1 and RD2 groups (P < 0.05). The receipt of remifentanil, propofol, Dex, and recovery time was significantly reduced in the RD2 group (P < 0.05). The requirement for sufentanil during the 8–72 h after surgery, less rescue medication, and total press times were significantly lower in the RD2 group (P < 0.05). The time to the first dose of rescue ketorolac was significantly longer in the RD2 group (P < 0.05). Further, anal exhaust, removal of chest tubes, and ambulation were significantly shorter in the RD2 group (P < 0.05). The incidence of tachycardia, post-operative nausea and vomiting, and chronic pain was significantly reduced in the RD2 group, while the QoR-40 score was significantly higher in the RD2 group (P < 0.05).

Conclusions: Pre-operative bi-level, single-injection ESPB plus 1 μg/kg DEX provided superior pain relief and long-term post-operative recovery for patients undergoing VATS.

Clinical Trial Registration:http://www.chictr.org.cn/searchproj.aspx.

Emerging drugs for the treatment of postsurgical pain

INTRODUCTION

Postoperative pain is a distressful experience and remains to be a significant concern after surgery. Current agents either fail to prevent or minimize postoperative pain or cause a series of adverse effects, addiction, or abuse. Opioids have been the gold standard in the treatment of postoperative pain despite their well-described adverse effects. Many new agents with different mechanisms of action have been recently introduced to address this issue.

AREAS COVERED

This current review summarizes the list of new and emerging drugs investigated for their efficacy in controlling the postoperative pain and decreasing the need for rescue opioid use, adverse effect profile, abuse, and addiction potential.

EXPERT OPINION

Opioids have unrivaled analgesic efficacy. However adverse effects of opioids led to the search for better options. In mild pain most of the emerging drugs have been shown to control postoperative pain and decrease the use of rescue opioid, however fail to control pain after major surgeries causing severe pain. Specific agents such as Oliceridine, new local anesthetics, etc., are effective in controlling severe pain and hold a promise to replace opioids in the near future.

Postoperative pain and opioid use after breast reduction with or without preoperative nerve block

BACKGROUND

Physician-prescribed opioids have been implicated as key contributing factors in the current opioid epidemic in the United States. Breast reduction mammoplasty is one of the most commonly performed procedures in plastic surgery and patients are often prescribed large amounts of postoperative opioids. Here we investigate the effects of erector spinae nerve blocks on postoperative pain, opioid consumption, and quality of life after breast reduction.

METHODS

Following the institutional review board (IRB) approval, a prospective cohort study of some patients undergoing breast reduction mammoplasty at Montefiore Medical Center between June and September 2019 was undertaken. The patients were stratified into two cohorts for further analysis: those who received preoperative erector spinae nerve block and those who did not. Primary outcomes measures analyzed included Likert pain scores, patient-reported outcome measures, and opioid consumption for the first five postoperative days.

RESULTS

Forty-seven patients were enrolled in the analysis. Thirteen patients (28%) received nerve blocks, 34 (72%) did not. On average, the patients were prescribed 114.3 (±34.6) morphine equivalents postoperatively and they consumed 45% (±35.3) by the end of the first five days post-surgery. There were no significant differences between cohorts in morphine equivalents prescribed or consumed, postoperative pain scores, or patient-reported outcome measures.

CONCLUSIONS

Following breast reduction mammoplasty, patients on average consumed < 50% of prescribed opioids, suggesting over-prescription of postoperative opioids for breast reduction recovery. Preoperative nerve block did not improve pain scores or decrease opioid consumption for the first five days after surgery.

Erector spinae plane block versus thoracic paravertebral block for pain management after total bilateral mastectomies

This prospectively designed, clinical quality improvement project compared pain scores and opioid consumption between ultrasound-guided, erector spinae plane blocks (ESPB) and thoracic paravertebral blocks (PVB) in patients undergoing total bilateral mastectomies without reconstruction. Twenty-five patients were included in an enhanced recovery pathway and received an ESPB on one side and a PVB on the contralateral side. Numeric rating scores at rest and with movement for each side were recorded in the recovery room at 2, 6, 12, 24, and 48 hours and on days 3 to 7. There were no significant differences in the resting or movement-evoked pain scores between sides receiving ESPB or PVB at any time point up to day 7 after surgery. Both ESPB and PVB confer equal analgesic effects in patients undergoing mastectomies. ESPB provides an alternative to PVB in reducing postoperative pain in patients undergoing mastectomy as part of an enhanced recovery pathway.

Fascial plane blocks: a narrative review of the literature

Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As 'new' FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.

Analgesic effects of erector spinae plane block for patients after breast surgery: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis investigated the analgesic effects of erector spinae plane block (ESPB) in patients undergoing breast surgery.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched from database establishment to January 31, 2020. Two reviewers independently extracted the data. The primary outcomes were pain scores and opioid consumption during the first 24 hours after surgery. The risk of bias of the included studies was assessed according to the Cochrane Handbook.

RESULTS

Six randomized controlled trials of 415 patients were included. Compared with the control value, the pain score was significantly lower in the ESPB group at different time points postoperatively. Patients who underwent ESPB required lower opioid consumption (standardized mean difference = -2.02, 95% confidence interval [CI] = -2.85 to -1.20, I²= 91%. The rates of postoperative nausea (risk ratio [RR] = 0.79, 95% CI = 0.48-1.30, I² = 47%) and postoperative vomiting (RR = 0.76, 95% CI = 0.30-1.96, I² = 33%) did not differ between the groups. The quality of evidence was low or very low.

CONCLUSIONS

ESPB significantly alleviated pain and reduced opioid consumption after breast surgery. Further research is needed to expand its clinical application.PROSPERO registration number CRD42020167900.

Erector spinae plane block in acute interventional pain management: a systematic review

Erector Spinae Plane Block (ESPB) was described by Forero in 2016. ESPB is currently widely used in acute postoperative pain management. The benefits of ESPB include simplicity and efficacy in various surgeries. The aim of this review was to conduct a comprehensive overview of available evidence on erector spinae plane block in clinical practice. We included randomized controlled trials and systematic reviews reporting the ESPB in human subjects. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twenty-one articles including five systematic reviews and 16 randomized controlled trials were included and analyzed. ESPB appears to be an effective, safe, and simple method for acute pain management in cardiac, thoracic, and abdominal surgery. The incidence of side effects has been reported to be rare. A critical issue is to make sure that new evidence is not just of the highest quality, in form of well powered and designed randomized controlled trials but also including a standardized and homogeneous set of indicators that permit to assess the comparative effectiveness of the application of ESPB in acute interventional pain management.

Preoperative Fluoroscopically Guided Regional Erector Spinae Plane Blocks Reduce Opioid Use, Increase Mobilization, and Reduce Length of Stay Following Lumbar Spine Fusion

STUDY DESIGN

Retrospective review.

OBJECTIVE

To determine the effectiveness of erector spinae plane (ESP) blocks at improving perioperative pain control and function following lumbar spine fusions.

METHODS

A retrospective analysis was performed on patients undergoing < 3 level posterolateral lumbar fusions. Data was stratified into a control group and a block group. We collected postop MED (morphine equivalent dosages), physical therapy ambulation, and length of stay. PROMIS pain interference (PI) and physical function (PF) scores, ODI, and VAS were collected preop and at the first postop visit. Chi-square and student's t-test (P = .05) were used for analysis. We also validated a novel fluoroscopic technique for ESP block delivery.

RESULTS

There were 37 in the block group and 39 in the control group. There was no difference in preoperative opioid use (P = .22). On postop day 1, MED was reduced in the block group (32 vs 51, P < .05), and more patients in the block group did not utilize any opioids (22% vs 5%, P < .05). The block group ambulated further on postop day 1 (312 ft vs 204 ft, P < .05), and had reduced length of stay (2.4 vs 3.2 days, P < .05). The block group showed better PROMIS PI scores postoperatively (58 vs 63, P < .05). The novel delivery technique was validated and successful in targeting the correct level and plane.

CONCLUSIONS

ESP blocks significantly reduced postop opioid use following lumbar fusion. Block patients ambulated further with PT, had reduced length of stay, and had improved PROMIS PI postoperatively. Validation of the block demonstrated the effectiveness of a novel fluoroscopic delivery technique. ESP blocks represent an underutilized method of reducing opioid consumption, improving postoperative mobilization and reducing length of stay following lumbar spine fusion.

Association between Paravertebral Block and Pain Score at the Time of Hospital Discharge in Oncoplastic Breast Surgery: A Retrospective Cohort Study

BACKGROUND

Using nonopioid analgesics may decrease the risk of patients chronically using opioids postoperatively. The authors evaluated the relationship between paravertebral block and pain score at the time of hospital discharge.

METHODS

The authors performed a retrospective cohort study of 89 women with American Society of Anesthesiologists Physical Status I to III undergoing oncoplastic breast surgery with 20 to 50 percent breast tissue removal and immediate contralateral reconstruction between August of 2015 and August of 2018. The primary outcome was pain score at hospital discharge with or without paravertebral block. The secondary outcome was postoperative length of stay. Data were analyzed using the Wilcoxon rank sum test, t test, Fisher's exact test, univariable and multivariable regression, Kaplan-Meier analyses, and Cox regression.

RESULTS

Median pain score at hospital discharge was lower with paravertebral block [2 (interquartile range, 0 to 2) compared to 4 (interquartile range, 3 to 5); p < 0.001]. Multivariable regression revealed that pain score at the time of hospital discharge was inversely associated with paravertebral block after adjusting for age, body mass index, American Society of Anesthesiologists class, extent of lymph node surgery, and duration of surgery (p < 0.001). Pain score at hospital discharge was also associated with total opioid consumption during the first 24 hours after surgery (p = 0.001). Patients who received paravertebral blocks had median total 24-hour postoperative opioid consumption in morphine equivalents of 7 mg (interquartile range, 3 to 10 mg) compared with 13 mg (interquartile range, 7 to 18 mg) (p < 0.001), and median length of stay of 18 hours (interquartile range, 16 to 20 hours) compared with 22 hours (interquartile range, 21 to 27 hours) (p < 0.001).

CONCLUSION

Paravertebral blocks are associated with decreased pain score at the time of hospital discharge.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Effectiveness of Bilateral Ultrasound-Guided Erector Spinae Plane Block in Percutaneous Lumbar Osteosynthesis for Spine Trauma: A Retrospective Study

BACKGROUND

Postoperative pain in spine surgery is an issue. Erector spinae plane block (ESPB) may reduce such postoperative pain, but its usefulness has never been evaluated in the specific context of trauma surgery. We thus studied the effect of bilateral ultrasound-guided ESPB on postoperative pain and opioid requirement after percutaneous lumbar arthrodesis for trauma.

METHODS

All patients who underwent percutaneous lumbar arthrodesis for spine trauma between December 2019 and March 2020 were retrospectively studied. Some patients received preoperative bilateral ESPB (30 mL of 0.375% ropivacaine on each side; ESPB group), others received the standard of care (i.e., postoperative muscular infiltration with 30 mL of 0.75% of ropivacaine; control group), according to the preference of the anesthesiologist in charge of the patient. The rest of the management was identical in all patients. The primary outcome was the cumulative morphine consumption at 24 hours postoperatively. Secondary outcomes included pain score at various time points until 24 hours.

RESULTS

Fifty-five patients were included, of whom 24 received an EPSB and 31 received the standard of care. The cumulative morphine consumption (mean [standard deviation]) at 24 hours was 13 (12) mg in the ESPB group, and 35 (17) mg in the control group (P < 0.001). Pain scores were significantly lower in the ESPB group compared with the control group up to 9 hours after surgery (P < 0.01).

CONCLUSIONS

In this pilot study, compared with standard analgesia, ESPB reduced opioid requirement and postoperative pain after percutaneous lumbar arthrodesis for trauma. A randomized controlled trial is required to prove this effectiveness.

Analgesic efficacy and safety of erector spinae plane block in breast cancer surgery: a systematic review and meta-analysis

Background

Surgical resection is considered to be the primary and most effective therapy for breast cancer, postoperative pain is an issue gaining significant attention. In recent years, erector spinae plane block (ESPB) has attracted much attention in postoperative analgesia, but its effectiveness is still controversial. This meta-analysis was implemented to verify the clinical analgesic efficacy and safety of erector spinae plane block in patients undergoing breast cancer surgery.

Methods

We searched PubMed, EMBASE, Web of Science, the Cochrane Library and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing ESPB with general anesthesia (GA) in breast cancer surgery that were published before December 25, 2020. The primary outcome was opioid consumption at the first 24 h after surgery, while secondary outcomes included pain scores at 1, 6,12 and 24 h after surgery, opioid consumption at 1, 6 and 12 h after surgery, intraoperative opioid consumption, number of patients who need for rescue analgesia, and the incidence of postoperative nausea and vomiting (PONV).

Results

Eleven randomized controlled trials involving 679 patients met the study inclusion criteria and were included in this study. In comparison to GA group, the ESPB group showed a significant reduction in morphine consumption at the first 24 h after surgery by a mean difference (MD) of − 7.67 mg [95% confidence interval (CI) − 10.35 to − 5.00] (P <  0.01). In addition, the ESPB group showed lower pain scores than the GA group in the four time periods (1, 6, 12 and 24 h after surgery). ESPB group significantly reduce the intraoperative consumption of fentanyl, the need for postoperative rescue analgesia, and the incidence of PONV.

Conclusions

Ultrasound-guided ESPB is an effective approach for reducing morphine consumption and pain intensity within the first 24 h after breast cancer surgery, compared with GA alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01277-x.

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.

Perioperative Analgesic Modalities for Breast Cancer Surgeries: A Prospective Randomized Controlled Trial

Purpose

Various analgesic modalities are adopted for perioperative analgesia in breast cancer surgeries. This study aimed to compare the efficacy of intravenous morphine versus serratus anterior plane block (SAPB) and erector spinae plane block (ESPB) in breast cancer surgeries.

Patients and Methods

Seventy-five breast cancer patients undergoing modified radical mastectomy from January 2020 to June 2020 were randomly allocated into 3 groups; the morphine group received morphine 0.1 mg/kg, the SAPB group received ultrasound-guided SAPB with 25 mL bupivacaine 0.25% and the ESPB group received ultrasound-guided ESPB with 25 mL bupivacaine 0.25%. A visual analogue scale (VAS) 0–10 was used to evaluate pain postoperatively, where 0 denotes no pain and 10 worst pain. If any patient in the 3 studied groups reported breakthrough pain with VAS ≥ 4 then a bolus of 3 mg morphine was given.

Results

There was no difference in VAS scores between the 3 groups postoperatively. Morphine consumption was higher in the morphine group (9.19 ± 2.32 mg) than the SAPB group (4.00 ± 1.55 mg) and the ESPB group (4.20 ± 1.64 mg), respectively. First time to receive postoperative morphine was significantly longer for the ESPB and SAPB groups than the morphine group (20.40 ± 4.98 hours), (19.00 ± 5.9 hours), (5.00 ± 4.62 hours), respectively. Intraoperative hemodynamics and fentanyl consumption showed no difference between groups, whereas postoperative mean arterial blood pressure values at 2 and 4 hours were higher in the morphine group. Ramsay sedation score and postoperative nausea and vomiting values in the post anesthesia care unit were higher for the morphine group compared to the SAPB and ESPB groups. No complications related to the blocks were reported.

Conclusion

SAPB and ESPB can be used as an effective and safe alternative to opioids with fewer side effects in breast cancer patients undergoing modified radical mastectomy.

Trial Registration

This trial was prospectively registered at Clinical Trials.gov on 22 January 2020 with registration number NCT04248608 (https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0009JS5&selectaction=Edit&uid=U0004LIG&ts=7&cx=−81xkwa).

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.

Erector Spinae Plane Block and Paravertebral Block for Breast Surgery: A Retrospective Propensity-Matched Noninferiority Trial

Purpose

Thoracic paravertebral block (TPVB) is an established analgesic technique for breast surgery although it is technically challenging. Erector spinae plane block (ESPB) requires less technical expertise and may be an alternative to TPVB. However, whether ESPB has similar analgesic effects to TPVB for breast surgery is still inconclusive. Moreover, information on sensory blockade of ESPB is scarce. Accordingly, we conducted this retrospective propensity-matched study to see if ESPB could provide comparable analgesic effects to TPVB in patients undergoing breast surgery. We also compared cutaneous sensory block levels after the two techniques.

Patients and Methods

In this retrospective cohort study, we analyzed data saved in our database and compared the two techniques using a propensity matching method. The data of patients who underwent unilateral breast surgery under general anesthesia with the addition of either TPVB or ESPB were identified. We considered that the analgesic efficacy of ESPB was noninferior to TPVB if both postoperative fentanyl consumption and area under the curve (AUC) for pain scores within 24 h were within 50 µg and 240 mm･h margins, respectively. Cutaneous sensory block levels, additional analgesic requirements, and complications were also compared between the two groups.

Results

Among 93 patients, 30 patients for each group were matched. Both postoperative fentanyl consumption and AUC for pain scores after ESPB were noninferior to those after TPVB. ESPB did not produce sensory blockade consistently, and the number of dermatomes was smaller after ESPB [1 (0–3)] [median (interquartile range)] than after TPVB [4 (2–5)] (P=0.002). No serious complications related to blocks were observed.

Conclusion

ESPB and TPVB provided comparable postoperative analgesia for 24 h in patients undergoing breast surgery. Dermatomal sensory blockade was, however, less apparent and narrower after ESPB than after TPVB.

[Peripheral truncal blocks-Overview and assessment]

By implementation of sonography for regional anesthesia, truncal blocks became more relevant in the daily practice of anesthesia and pain therapy. Due to visualized needle guidance ultrasound supports more safety and helps to avoid complications during needle placement. Additionally, complex punctures are possible that were associated with higher risk using landmarks alone. Next to the blocking of specific nerve structures, interfascial and compartment blocks have also become established, whereby the visualization of individual nerves and plexus structures is not of relevance. The present review article describes published and clinically established puncture techniques with respect to the indications and procedures. The clinical value is reported according to the scientific evidence and the analgesic profile. Moreover, the authors explain potential risks, complications and dosing of local anesthetic agents.