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Lizarraga IM, Huang K, Yalamuru B, Mott SL, Sibenaller ZA, Keith JN, Sugg SL, Erdahl LM, Seering M. A Randomized Single-Blinded Study Comparing Preoperative with Post-Mastectomy PECS Block for Post-operative Pain Management in Bilateral Mastectomy with Immediate Reconstruction. Ann Surg Oncol 2023; 30:6010-6021. [PMID: 37526752 DOI: 10.1245/s10434-023-13890-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/06/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Ultrasound-guided pectoralis muscle blocks (PECS I/II) are well established for postoperative pain control after mastectomy with reconstruction. However, optimal timing is unclear. We conducted a randomized controlled single-blinded single-institution trial comparing outcomes of block performed pre-incision versus post-mastectomy. METHOD Patients with breast cancer undergoing bilateral mastectomy with immediate expander/implant reconstruction were randomized to receive ultrasound-guided PECS I/II either pre-incision (PreM, n = 17) or post-mastectomy and before reconstruction (PostM, n = 17). The primary outcome was the average pain score using the Numerical Rating Score during post-anesthesia care unit (PACU) and inpatient stay, with the study powered to detect a difference in mean pain score of 2. Secondary outcomes included mean pain scores on postoperative day (POD) 2, 3, 7, 14, 90, and 180; pain catastrophizing scores; narcotic requirements; PACU/inpatient length of stay; block procedure time; and complications. RESULT No significant differences between the two groups were noted in average pain score during PACU (p = 0.57) and 24-h inpatient stay (p = 0.33), in the 2 weeks after surgery at rest (p = 0.90) or during movement (p = 0.30), or at POD 90 and 180 at rest (p = 0.42) or during movement (p = 0.31). Median duration of block procedure (PreM 7 min versus PostM 6 min, p = 0.21) did not differ. Median PACU and inpatient length of stay were the same in each group. Inpatient narcotic requirements were similar, as were length of stay and post-surgical complication rates. CONCLUSION Intraoperative ultrasound-guided PECS I/II block administered by surgeons following mastectomy had similar outcomes to preoperative blocks. TRIAL REGISTRATION This trial is registered with Clinical Research Information Service (NCT03653988).
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Affiliation(s)
- Ingrid M Lizarraga
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - K Huang
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - B Yalamuru
- Pain Division, Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - S L Mott
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Z A Sibenaller
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - J N Keith
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - S L Sugg
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - L M Erdahl
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - M Seering
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Bin Ghali K, AlKharraz N, Almisnid O, Alqarni A, Alyamani OA. The Pectoral (PECS) Regional Block: A Scoping Review. Cureus 2023; 15:e46594. [PMID: 37933365 PMCID: PMC10625794 DOI: 10.7759/cureus.46594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 11/08/2023] Open
Abstract
Among the various surgical procedures, breast surgeries rank as a frequently conducted procedure. Interfacial blocks such as the Pectoral (PECS) block became possible with the currently available knowledge on innervations and ultrasound. Interfacial blocks target the deep fascial planes, which are potential spaces for injecting local anesthetics. The Pectoral I (PECS I) consists of the injection of local anesthetics in the plane between the pectoralis major and minor muscles. The PECS II block, a modified version of the block, is achieved by adding another, deeper injection in the plane between the pectoralis minor and the serratus anterior muscle. We conducted a scoping review using Arkesy and O'Malley's framework, as described by Levac. We identified our research question as the uses of the PECS regional block technique with the choice of local anesthetics, including adjuncts, and its effectiveness in intraoperative and postoperative analgesia in the first 24 hours and incidence of postoperative nausea and vomiting. Subsequently, we identified the relevant studies that met our inclusion criteria and charted the data. Lastly, we summarized and reported the results. The PECS block was used in various breast surgeries, among which radical mastectomies with/without lymph node dissection were the most common. It was found that the PECS block reduced intraoperative opioid consumption in 60% and 24-hour postoperative opioid consumption in 93.3% of the included papers. Various local anesthetics were used such as ropivacaine, bupivacaine, and levobupivacaine. Ultrasound-guided interfacial plane blocks, such as the PECS block, are a recent development in regional anesthesia that offers analgesia for patients undergoing breast surgeries. The authors conclude that PECS block can provide a decrease in intraoperative and postoperative opioid consumption, a decrease in the incidence of nausea and vomiting, and can lead to overall patient satisfaction in terms of lower pain scores compared to systemic analgesia.
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Affiliation(s)
- Khalid Bin Ghali
- Anesthesiology, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
| | - Nourah AlKharraz
- Anesthesiology, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
| | | | - Adel Alqarni
- College of Medicine, King Saud University, Riyadh, SAU
| | - Omar A Alyamani
- Anesthesiology, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
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Assaf GR, Yared F, Dib MJ, Mouawad T, Tarabay O, Noujeim JP, El-Helou E, Kaady J, Abboud B. Efficacy of opioid-free anesthesia in modified radical mastectomy: a cross-sectional observational study. Ann Med Surg (Lond) 2023; 85:4289-4292. [PMID: 37663699 PMCID: PMC10473328 DOI: 10.1097/ms9.0000000000000718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 04/16/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction Perioperative management of female patients undergoing breast surgeries differs from other patients due to chronic pain and postoperative nausea and vomiting. The anesthesia could consist of opioid-free general anesthesia (OFA) or non-opioid-free general anesthesia (NOFA). OFA relies on multimodal analgesia preoperatively and postoperatively. However, it is not yet established whether OFA could replace NOFA as a standard regimen for the management of breast surgeries. The aim of this study is to evaluate the efficacy of OFA for breast surgeries in female patients. Materials and methods Patients undergoing modified radical mastectomy were retrospectively recruited. Two groups were defined: group 1, consisting of treated patients using OFA and group 2, consisting of treated patients using NOFA. Mean time to extubate and mean dose of morphine after recovery were computed. Postoperative morphine and antiemetic use were assessed for up to 24 h. A comparison of the computed data was conducted between both groups. Results A total of 116 patients were included with a mean age of 53±13 years. Group 1 consisted of 56 (mean age was 54±14 years). Group 2 consisted of 60 patients (mean age was 51±12 years). Demographic parameters and time to extubate did not yield significant differences. We noticed morphine sparing at T0 and T12 with statistically significant differences P=0.043 and P=0.006, respectively. Conclusion OFA could be considered in modified radical mastectomy management in female patients; nerve block seemed to act as morphine sparing in operative and postoperative settings by providing significantly less time to extubate with less postoperative morphine requirement.
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Affiliation(s)
| | | | | | | | | | | | - Etienne El-Helou
- Department of General Surgery, Lebanese Hospital Geitaoui – University Medical Center, Beirut, Lebanon
| | | | - Bassam Abboud
- Department of General Surgery, Lebanese Hospital Geitaoui – University Medical Center, Beirut, Lebanon
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Diana K, Teh MS, Islam T, Lim WL, Beh ZY, Taib NAM. Benefits of PECS Block as Part of the Enhanced Recovery After Surgery (ERAS) Protocol for Breast Cancer Surgery in an Asian Institution: A Retrospective Cohort Study. World J Surg 2023; 47:564-572. [PMID: 36599951 DOI: 10.1007/s00268-022-06881-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Regional analgesia techniques have been increasingly used for post-operative pain management following mastectomy. We aim to evaluate analgesic benefits of pectoral nerve (PECS2) block incorporated as part of the enhanced recovery after surgery (ERAS) protocol in patients undergoing mastectomy in University Malaya Medical Centre, Malaysia. MATERIAL AND METHODS A single centre, cohort study evaluating 335 women who have undergone unilateral mastectomy between January 2017 and March 2020 in Malaysia. Regional anaesthesia were given pre-operatively via ultrasound guided pectoral and intercostal nerves block (PECSII). RESULTS Utilization of regional anaesthesia increased from 11% in 2017 to 43% in 2020. Types and duration of surgeries were comparable. Opiod consumption was 3 mg lower in those who had PECS2 block ((27 [24-30] mg), in comparison with those who received general anaesthesia only (30 [26-34] mg), p < 0.001, and length of stay was half a day shorter in the regional anaesthesia group and these were statistically significant. However, pain score (2 [1-3]; 2 [1-3], p=0.719) and post-operative nausea and vomiting (PONV) (32.6-32.5%, p = 0.996) were similar. CONCLUSION This study highlights the importance of PECS2 block as a component of ERAS protocol for mastectomy in an Asian hospital. This study also inferred that patients may be safely discharged within 24 h of surgery and therefore, same day surgery may be feasible in selected group of patients undergoing mastectomy and this could imply overall cost benefits.
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Affiliation(s)
- Kavinya Diana
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Mei-Sze Teh
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
| | - Tania Islam
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Woon-Lai Lim
- Department of Anaestesiology, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Zhi-Yuan Beh
- Department of Anaestesiology, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Nur Aishah Mohd Taib
- Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
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Uribe AA, Weaver TE, Echeverria-Villalobos M, Periel L, Pasek J, Fiorda-Diaz J, Palettas M, Skoracki RJ, Poteet SJ, Heard JA. Efficacy of PECS block in addition to multimodal analgesia for postoperative pain management in patients undergoing outpatient elective breast surgery: A retrospective study. Front Med (Lausanne) 2022; 9:975080. [PMID: 36045918 PMCID: PMC9420942 DOI: 10.3389/fmed.2022.975080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 07/21/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Alberto A. Uribe
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Tristan E. Weaver
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | | | - Luis Periel
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Joshua Pasek
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
| | - Marilly Palettas
- Department of Biomedical Informatics, The Ohio State University, Center of Biostatistics, Columbus, OH, United States
| | - Roman J. Skoracki
- Department of Plastic Surgery, The Ohio State University Medical Center, Columbus, OH, United States
| | - Stephen J. Poteet
- Department of Plastic Surgery, The Ohio State University Medical Center, Columbus, OH, United States
| | - Jarrett A. Heard
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, United States
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De Cassai A, Zarantonello F, Geraldini F, Boscolo A, Pasin L, De Pinto S, Leardini G, Basile F, Disarò L, Sella N, Mariano ER, Pettenuzzo T, Navalesi P. Single-injection regional analgesia techniques for mastectomy surgery: A network meta-analysis. Eur J Anaesthesiol 2022; 39:591-601. [PMID: 35759292 DOI: 10.1097/eja.0000000000001644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Patients undergoing mastectomy surgery experience severe postoperative pain. Several regional techniques have been developed to reduce pain intensity but it is unclear, which of these techniques is most effective. OBJECTIVES To synthesise direct and indirect comparisons for the relative efficacy of different regional and local analgesia techniques in the setting of unilateral mastectomy. Postoperative opioid consumption at 24 h, postoperative pain at extubation, 1, 12 and 24 h, postoperative nausea and vomiting were collected. DESIGN Systematic review with network meta-analysis (PROSPERO:CRD42021250651). DATA SOURCE PubMed, Scopus, the Cochrane Central Register of Controlled Trials (from inception until 7 July 2021). ELIGIBILITY CRITERIA All randomised controlled trials investigating single-injection regional and local analgesia techniques in adult patients undergoing unilateral mastectomy were included in our study without any language or publication date restriction. RESULTS Sixty-two included studies randomising 4074 patients and investigating nine techniques entered the analysis. All techniques were associated with less opioid consumption compared with controls The greatest mean difference [95% confidence interval (CI)] was associated with deep serratus anterior plane block: mean difference -16.1 mg (95% CI, -20.7 to -11.6). The greatest reduction in pain score was associated with the interpectoral-pecto-serratus plane block (mean difference -1.3, 95% CI, -1.6 to - 1) at 12 h postoperatively, and with superficial serratus anterior plane block (mean difference -1.4, 95% CI, -2.4 to -0.5) at 24 h. Interpectoral-pectoserratus plane block resulted in the greatest statistically significant reduction in postoperative nausea/vomiting when compared with placebo/no intervention with an OR of 0.23 (95% CI, 0.13 to 0.40). CONCLUSION All techniques were associated with superior analgesia and less opioid consumption compared with controls. No single technique was identified as superior to others. In comparison, local anaesthetic infiltration does not offer advantages over multimodal analgesia alone. TRIAL REGISTRATION PROSPERO (CRD4202125065).
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Affiliation(s)
- Alessandro De Cassai
- From the UOC Anesthesia and Intensive Care Unit, University Hospital of Padua (ADC, FZ, FG, AB, LP, TP, PN), UOC Anesthesia and Intensive Care Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy (SDP, GL, FB, LD, NS, PN), Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford (ERM) and Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA (ERM)
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Impact of Intraspinal Nerve Block Anesthesia on Intrapartum Fever and the Neonate. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:2600755. [PMID: 35677370 PMCID: PMC9168087 DOI: 10.1155/2022/2600755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/27/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022]
Abstract
Objective To evaluate the impact of intraspinal nerve block anesthesia on intrapartum fever and the neonate. Methods In this prospective study, between October 2019 and December 2020, 90 eligible primiparous women enrolled in the obstetrics and gynecology department of our hospital for delivery were recruited and assigned via the random number table method at a ratio of 1 : 1 to either an analgesic group given intraspinal nerve block anesthesia for labor or a nonanalgesic group without anesthesia for labor. Outcome measures included intrapartum body temperature, cases of intrapartum fever, Apgar scores of neonates, visual analogue scale (VAS) scores, delivery mode, and indomethacin use. Results Intraspinal nerve block anesthesia was associated with a higher body temperature at 4 h and 5 h after analgesia and more cases of intrapartum fever versus no anesthesia (P < 0.05). There were no significant differences in the Apgar scores between the two groups (P > 0.05). Participants given intraspinal nerve block anesthesia had lower VAS scores during labor versus those without anesthesia (P < 0.05). The differences in the delivery mode between the two groups were not significant (P > 0.05). Intraspinal nerve block anesthesia resulted in a significantly higher demand for indomethacin versus no anesthesia (P < 0.05). Conclusion Intraspinal nerve block anesthesia is clinically effective in labor analgesia but may cause increased body temperature or even overt clinical fever, so close clinical observation of maternal temperature changes is required to mitigate the effects of anesthesia on the mothers. No adverse consequences of intraspinal nerve block anesthesia on the newborns were reported in this study.
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Sagun A, Rumeli S, Ozdemir L, Azizoglu M, Berkesoglu M, Mutlu V. Intraoperative pectoral block thoracic paravertebral block for postoperative analgesia after breast cancer surgery: A randomized controlled trial. J Surg Oncol 2022; 126:425-432. [PMID: 35536730 DOI: 10.1002/jso.26914] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/04/2022] [Accepted: 04/24/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND METHODS With the increasing rate of breast cancer surgery, the pain management of these patients gains importance. The aim of this study is to compare the ultrasound (US) guided thoracic paravertebral block (TPV) versus intraoperative pectoral nerve block (PECS) with a low volume local anaesthetic for postoperative analgesia after breast cancer surgery. A total of 41 patients underwent mastectomy and sentinel lymph node biopsy or modified radical mastectomy were included in this randomized controlled, single-blinded trial. The patients were divided into two groups as PECS and TPV blocks. In the PECS group, 10 ml of 0.5% bupivacaine was administered to the fascial plane by the surgeon. In the TPV group, 25 ml of 0.25% bupivacaine at T3 level was administered by the anaesthetist under US-guidance. Visual analogue scale (VAS) scores and additional analgesic requirements were recorded at postoperative 0, 6, 12, 24 and 48 h. RESULTS In the TPV group, mean VAS score (VAS0) was significantly lower (p ˂ 0.001). In other time periods, there was no significant difference between the groups. CONCLUSIONS It was observed that intraoperative PECS block was as effective as TPV in providing postoperative analgesia and additional analgesic requirements were similar. This result suggests PECS block may be a good alternative to TPV.
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Affiliation(s)
- Aslinur Sagun
- Department of Anesthesiology and Intensive Care, Mersin University School of Medicine, Mersin, Turkey
| | - Sebnem Rumeli
- Department of Anesthesiology and Intensive Care, Mersin University School of Medicine, Mersin, Turkey
| | - Levent Ozdemir
- Department of Anesthesiology and Intensive Care, Mersin University School of Medicine, Mersin, Turkey
| | - Mustafa Azizoglu
- Department of Anesthesiology and Intensive Care, Mersin University School of Medicine, Mersin, Turkey
| | - Mustafa Berkesoglu
- Department of General Surgery, Mersin University School of Medicine, Mersin, Turkey
| | - Veli Mutlu
- Department of General Surgery, Mersin University School of Medicine, Mersin, Turkey
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Elshanbary AA, Zaazouee MS, Darwish YB, Omran MJ, Elkilany AY, Abdo MS, Saadeldin AM, Elkady S, Nourelden AZ, Ragab KM. 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. Clin J Pain 2021; 37:925-939. [PMID: 34593675 DOI: 10.1097/ajp.0000000000000985] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/05/2021] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Alaa Ahmed Elshanbary
- Faculty of Medicine, Alexandria University, Alexandria
- International Medical Research Association (IMedRA), Cairo
| | - Mohamed Sayed Zaazouee
- Faculty of Medicine, Al-Azhar University
- International Medical Research Association (IMedRA), Cairo
| | - Youssef Bahaaeldin Darwish
- Faculty of Pharmacy, Mansoura University, Mansoura
- International Medical Research Association (IMedRA), Cairo
| | - Maha Jabir Omran
- International Medical Research Association (IMedRA), Cairo
- Faculty of Pharmacy, Al-Azhar University-Gaza, Gaza, Palestine
| | - Alaa Yousry Elkilany
- Faculty of Medicine, Menoufia University, Menoufia
- International Medical Research Association (IMedRA), Cairo
| | - Mohamed Salah Abdo
- Faculty of Medicine
- International Medical Research Association (IMedRA), Cairo
| | - Ayat M Saadeldin
- Department of Radiation Oncology, El Hussein University Hospital
- International Medical Research Association (IMedRA), Cairo
| | - Sherouk Elkady
- Department of Medical Biochemistry, Faculty of Medicine, Assiut University, Assiut
- International Medical Research Association (IMedRA), Cairo
| | - Anas Zakarya Nourelden
- Faculty of Medicine, Al-Azhar University
- International Medical Research Association (IMedRA), Cairo
| | - Khaled Mohamed Ragab
- International Medical Research Association (IMedRA), Cairo
- Faculty of Medicine, Minia University, Minia, Egypt
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Rokhtabnak F, Sayad S, Izadi M, Djalali Motlagh S, Rahimzadeh P. Pain Control After Mastectomy in Transgender Patients: Ultrasound-guided Pectoral Nerve Block II Versus Conventional Intercostal Nerve Block: A Randomized Clinical Trial. Anesth Pain Med 2021; 11:e119440. [PMID: 35070905 PMCID: PMC8771815 DOI: 10.5812/aapm.119440] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 02/06/2023] Open
Abstract
Background Mastectomy is sometimes performed in transgender patients, which may damage the regional nerves such as the pectoral and intercostobrachial nerves, leading to postoperative pain. An ultrasound-guided nerve block can be used to track and block the nerves properly. Objectives This study aimed to compare the ultrasound-guided type-II pectoral nerve block with the blind (conventional) intercostal nerve block (ICNB) for pain control after breast tissue reconstruction surgery in transgender patients. Methods In the present single-blind randomized clinical trial, 47 patients were randomly divided into two groups: (A) Ultrasound-guided type-II pectoral nerve block (n = 23) and (B) blind intercostal nerve block (n = 24). After nerve block in both groups, pain intensity at 3, 6, 12, and 24 hours after surgery, upper limb paresthesia, frequency of nausea and vomiting, shortness of breath, hematoma, and the length of hospital stay were assessed. Results Patients who received the ultrasound-guided type-II pectoral nerve block had a greater reduction in pain intensity (24 h after surgery), opioid use (24 h after surgery), nausea, vomiting, and hospital stay than those who received ICNB, whereas the recovery time did not differ between the study groups. Conclusions The pectoral nerve block under ultrasound guidance, compared to the intercostal nerve block, in transgender patients can reduce the required dosage of opioids within 24 hours, pain intensity within 24 hours after surgery, the incidence of postoperative nausea, and vomiting, and the hospital stay of patients.
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Affiliation(s)
- Faranak Rokhtabnak
- Department of Anesthesiology, Pain and Intensive Care, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Soheila Sayad
- Department of Surgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Izadi
- Department of Anesthesiology, Pain and Intensive Care, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Soudabeh Djalali Motlagh
- Department of Anesthesiology, Pain and Intensive Care, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Department of Anesthesiology, Pain and Intensive Care, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Poupak Rahimzadeh
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
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11
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Dutton RP. Rewarding Best Practice: Tracking the Impact of Incentives in Anesthesiology. Anesth Analg 2021; 133:29-31. [PMID: 34127587 DOI: 10.1213/ane.0000000000005455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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12
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Abstract
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.
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13
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Wong HY, Pilling R, Young BWM, Owolabi AA, Onwochei DN, Desai N. Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis. J Clin Anesth 2021; 72:110274. [PMID: 33873002 DOI: 10.1016/j.jclinane.2021.110274] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Heung-Yan Wong
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Rob Pilling
- Department of Anaesthesia, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Bruce W M Young
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Adetokunbo A Owolabi
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Desire N Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; King's College London, London, United Kingdom
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; King's College London, London, United Kingdom
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14
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Hong B, Bang S, Oh C, Park E, Park S. Comparison of PECS II and erector spinae plane block for postoperative analgesia following modified radical mastectomy: Bayesian network meta-analysis using a control group. J Anesth 2021; 35:723-733. [PMID: 33786681 DOI: 10.1007/s00540-021-02923-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/13/2021] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Seunguk Bang
- Department of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, Daejeon, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Eunhye Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Seyeon Park
- Department of Nursing, Chungnam National University, Daejeon, Korea.
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15
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Pellini F, Di Filippo G, Mirandola S, Deguidi G, Filippi E, Pollini GP. Effects of Lean Thinking and Emerging Technologies on Breast Cancer Patients' Therapeutic Process During COVID-19 Pandemic: A Case-Control Matched Study. Front Surg 2021; 8:582980. [PMID: 33791333 PMCID: PMC8006315 DOI: 10.3389/fsurg.2021.582980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 02/01/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: The advent of the COVID-19 pandemic has led to the sudden disruption of routine medical care, and the subsequent reorganization of hospital structures and therapeutic algorithms, aiming at protecting patients and health professionals. This was inevitably bound to affect our Breast Unit, dilating both pre- and post-operative times. The aim of this study was to evaluate the effect on patients' flow of organizational and logistic changes (key interventions) based on lean thinking implemented after the COVID-19 outbreak. Materials and Methods: Clinical and demographic data were retrospectively collected from patients undergoing sentinel lymph node biopsy for breast cancer at the Verona University Hospital from January 2018 to June 2020. Patients enrolled (n = 341) were divided into two groups according to date of admission: before (Group A; n = 294) and after (Group B; n = 47) the implementation of key interventions. Each case in Group B was subsequently matched 1:1 by means of case-control matching with cases from Group A for age, comorbidities, and type of surgery (Subgroup A1; N = 47). Pre-admission time (T0) and length of stay (T1) were compared between the three groups. Results: Median T0 was 312 h, whereas median T1 was 24 h. Patients in Group B had a higher frequency of comorbidities (57.4 vs. 25.2%, p = 0.001) and underwent mastectomy more often than patients in Group A (61.7 vs. 36.7%, p = 0.001). Both median T0 and T1 were higher in group B than in group A (384 vs. 300 h, p = 0.001, 48 vs. 24 h, p = 0.001, respectively). Median T0 and T1 did not significantly differ between Group B and Subgroup A1 (all p > 0.05). Conclusions: Lean thinking and new technologies could prove useful to the optimization of preoperative and postoperative times during the current pandemic, minimizing healthcare personnel and patients' exposure to SARS-CoV-2, and promoting a rational use of limited resources, while complying with oncological principles.
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Affiliation(s)
- Francesca Pellini
- Complex Operative Unit of Breast Surgery, Breast Unit, Oncologic Surgery Department, AOUI, Ospedale Civile Maggiore, Verona, Italy
| | - Giacomo Di Filippo
- Complex Operative Unit of Breast Surgery, Breast Unit, Oncologic Surgery Department, AOUI, Ospedale Civile Maggiore, Verona, Italy
| | - Sara Mirandola
- Complex Operative Unit of Breast Surgery, Breast Unit, Oncologic Surgery Department, AOUI, Ospedale Civile Maggiore, Verona, Italy
| | - Giulia Deguidi
- Complex Operative Unit of Breast Surgery, Breast Unit, Oncologic Surgery Department, AOUI, Ospedale Civile Maggiore, Verona, Italy
| | - Elisa Filippi
- Complex Operative Unit of Breast Surgery, Breast Unit, Oncologic Surgery Department, AOUI, Ospedale Civile Maggiore, Verona, Italy
| | - Giovanni Paolo Pollini
- Complex Operative Unit of Breast Surgery, Breast Unit, Oncologic Surgery Department, AOUI, Ospedale Civile Maggiore, Verona, Italy
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16
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Chin KJ, Versyck B, Pawa A. Ultrasound-guided fascial plane blocks of the chest wall: a state-of-the-art review. Anaesthesia 2021; 76 Suppl 1:110-126. [PMID: 33426660 DOI: 10.1111/anae.15276] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2020] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- K J Chin
- Department of Anaesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Canada
| | - B Versyck
- Department of Anaesthesia and Pain Medicine, AZ Turnhout, Belgium.,Department of Anaesthesia and Pain Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | - A Pawa
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
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17
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Liu C, Wang W, Shan Z, Zhang H, Yan Q. Dexmedetomidine as an adjuvant for patients undergoing breast cancer surgery: A meta-analysis. Medicine (Baltimore) 2020; 99:e23667. [PMID: 33327355 PMCID: PMC7738154 DOI: 10.1097/md.0000000000023667] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The goal of this study was to comprehensively evaluate the analgesic and antiemetic effects of adjuvant dexmedetomidine (DEX) for breast cancer surgery using a meta-analysis. METHODS Electronic databases were searched to collect the studies that performed randomized controlled trials. The effect size was estimated by odd ratio (OR) or standardized mean difference (SMD). Statistical analysis was performed using the STATA 13.0 software. RESULTS Twelve published studies involving 396 DEX treatment patients and 395 patients with control treatment were included. Pooled analysis showed that the use of DEX significantly prolonged the time to first request of analgesia (SMD = 1.67), decreased the postoperative requirement for tramadol (SMD = -0.65) and morphine (total: SMD = -2.23; patient-controlled analgesia: SMD = -1.45) as well as intraoperative requirement for fentanyl (SMD = -1.60), and lower the pain score at 1 (SMD = -0.30), 2 (SMD = -1.45), 4 (SMD = -2.36), 6 (SMD = -0.63), 8 (SMD = -2.47), 12 (SMD = -0.81), 24 (SMD = -1.78), 36 (SMD = -0.92), and 48 (SMD = -0.80) hours postoperatively compared with the control group. Furthermore, the risks to develop postoperative nausea/vomiting (PONV) (OR = 0.38) and vomiting (OR = 0.54) were significantly decreased in the DEX group compared with the control group. The pain relief at early time point (2, 6, 12, 24 hours postoperatively) and the decrease in the incidence of PONV were especially obvious for the general anesthesia subgroup (P < .05) relative to local anesthesia subgroup (P >.05). CONCLUSION DEX may be a favorable anesthetic adjuvant in breast cancer surgery, which could lower postoperative pain and the risk to develop PONV. DEX should be combined especially for the patients undergoing general anesthesia.
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Affiliation(s)
- Changjun Liu
- Operating Room, Yidu Central Hospital of Weifang
| | - Wei Wang
- Operating Room, Yidu Central Hospital of Weifang
| | | | - Huapeng Zhang
- Department of Anesthesiology, Yidu Central Hospital of Weifang
| | - Qiang Yan
- Intensive Care Unit, Weifang People's Hospital, Weifang, Shandong, China
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18
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Abstract
Treating acute pain after thoracotomy surgery and preventing the development of chronic post-thoracotomy pain syndrome (PTPS) remain significant challenges in this surgical population. While appropriately treated acute thoracotomy pain often resolves, a significant number of patients develop PTPS, with up to 65% of patients experiencing some pain and 10% suffering life-altering, debilitating pain. Currently, there is very little known about specific molecular targets or novel therapeutic combinations that effectively prevent PTPS. Identifying modifiable clinical risk factors (procedure, physical and mental health, preoperative pain in the surgical area and another regions) seems to the most pragmatic approach for prevention for now. Effective acute pain management adopting a multimodal approach can result in a decreased incidence of PTPS. Interventional techniques such as paraverterbral blocks, intercostal blocks, and erector spinae blocks show some promise as well. Future research should be focused on minimally invasive surgeries and also the effect of ERAS protocols, including early mobilization, nutrition, and early removal of drains, on the development of PTPS.
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19
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Lepot A, Elia N, Tramèr MR, Rehberg B. Preventing pain after breast surgery: A systematic review with meta-analyses and trial-sequential analyses. Eur J Pain 2020; 25:5-22. [PMID: 32816362 DOI: 10.1002/ejp.1648] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 08/03/2020] [Accepted: 08/13/2020] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Ariane Lepot
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Nadia Elia
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, Institute of Global Health, University of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Martin Richard Tramèr
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benno Rehberg
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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20
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Current understanding of the fascial plane blocks for analgesia of the chest wall: techniques and indications update for 2020. Curr Opin Anaesthesiol 2020; 33:692-697. [DOI: 10.1097/aco.0000000000000909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Brenin DR, Dietz JR, Baima J, Cheng G, Froman J, Laronga C, Ma A, Manahan MA, Mariano ER, Rojas K, Schroen AT, Tiouririne NAD, Wiechmann LS, Rao R. Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons. Ann Surg Oncol 2020; 27:4588-4602. [PMID: 32783121 DOI: 10.1245/s10434-020-08892-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.
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Affiliation(s)
- David R Brenin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Jill R Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Baima
- Department of Physical Medicine and Rehabilitation, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gloria Cheng
- Department of Anesthesia, University of Texas Southwestern, Dallas, TX, USA
| | - Joshua Froman
- Department of Surgery, Mayo Clinic, Owatonna, MN, USA
| | | | - Ayemoethu Ma
- Surgery and Integrative Medicine, Scripps Health, La Jolla, CA, USA
| | - Michele A Manahan
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Edward R Mariano
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Kristin Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Anneke T Schroen
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Lisa S Wiechmann
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshni Rao
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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22
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Leong RW, Tan ESJ, Wong SN, Tan KH, Liu CW. Efficacy of erector spinae plane block for analgesia in breast surgery: a systematic review and meta-analysis. Anaesthesia 2020; 76:404-413. [PMID: 32609389 DOI: 10.1111/anae.15164] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2020] [Indexed: 12/31/2022]
Abstract
The erector spinae plane block is a new regional anaesthesia technique that provides truncal anaesthesia for breast surgery. This systematic review and meta-analysis was undertaken to determine if the erector spinae plane block is effective at reducing pain scores and opioid consumption after breast surgery. This study also evaluated the outcomes of erector spinae plane blocks compared with other regional blocks. PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov were searched. We included randomised controlled trials reporting the use of the erector spinae plane block in adult breast surgery. Risk of bias was assessed with the revised Cochrane risk-of-bias tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess trial quality. Thirteen randomised controlled trials (861 patients; 418 erector spinae plane block, 215 no blocks, 228 other blocks) were included. Erector spinae plane block reduced postoperative pain compared with no block: at 0-2 hours (mean difference (95% CI) -1.63 (-2.97 to -0.29), 6 studies, 329 patients, high-quality evidence, I2 = 98%, p = 0.02); at 6 hours (mean difference (95% CI) -0.90 (-1.49 to -0.30), 5 studies, 250 patients, high-quality evidence, I2 = 91%, p = 0.003); at 12 hours (mean difference (95% CI) -0.46 (-0.67 to -0.25), 5 studies, 250 patients, high-quality evidence, I2 = 58%, p < 0.0001); and at 24 hours (mean difference (95% CI) -0.50 (-0.70 to -0.30), 6 studies, 329 patients, high-quality evidence, I2 = 76%, p < 0.00001). Compared with no block, erector spinae plane block also showed significantly lower postoperative oral morphine equivalent requirements (mean difference (95% CI) -21.55mg (-32.57 to -10.52), 7 studies, 429 patients, high-quality evidence, I2 = 99%, p = 0.0001). Separate analysis of studies comparing erector spinae plane block with pectoralis nerve block and paravertebral block showed that its analgesic efficacy was inferior to pectoralis nerve block and similar to paravertebral block. The incidence of pneumothorax was 2.6% in the paravertebral block group; there were no reports of complications of the other blocks. This review has shown that the erector spinae plane block is more effective at reducing postoperative opioid consumption and pain scores up to 24 hours compared with general anaesthesia alone. However, it was inferior to the pectoralis nerve block and its efficacy was similar to paravertebral block. Further evidence, preferably from properly blinded trials, is required to confirm these findings.
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Affiliation(s)
- R W Leong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - E S J Tan
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - S N Wong
- Central Library, National University of Singapore
| | - K H Tan
- Department of Pain Medicine, Singapore General Hospital, Singapore.,Department of Anaesthesiology, Singapore General Hospital, Singapore.,Department of Anaesthesiology, Duke-NUS Graduate Medical School, Singapore
| | - C W Liu
- Department of Anaesthesiology, Duke-NUS Graduate Medical School, Singapore.,Department of Pain Medicine, Singapore General Hospital, Singapore
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23
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24
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Jacobs A, Lemoine A, Joshi GP, Van de Velde M, Bonnet F. PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2020; 75:664-673. [PMID: 31984479 PMCID: PMC7187257 DOI: 10.1111/anae.14964] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2019] [Indexed: 12/17/2022]
Abstract
Analgesic protocols used to treat pain after breast surgery vary significantly. The aim of this systematic review was to evaluate the available literature on this topic and develop recommendations for optimal pain management after oncological breast surgery. A systematic review using preferred reporting items for systematic reviews and meta-analysis guidance with procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Seven hundred and forty-nine studies were found, of which 53 randomised controlled trials and nine meta-analyses met the inclusion criteria and were included in this review. Quantitative analysis suggests that dexamethasone and gabapentin reduced postoperative pain. The use of paravertebral blocks also reduced postoperative pain scores, analgesia consumption and the incidence of postoperative nausea and vomiting. Intra-operative opioid requirements were documented to be lower when a pectoral nerves block was performed, which also reduced postoperative pain scores and opioid consumption. We recommend basic analgesics (i.e. paracetamol and non-steroidal anti-inflammatory drugs) administered pre-operatively or intra-operatively and continued postoperatively. In addition, pre-operative gabapentin and dexamethasone are also recommended. In major breast surgery, a regional anaesthetic technique such as paravertebral block or pectoral nerves block and/or local anaesthetic wound infiltration may be considered for additional pain relief. Paravertebral block may be continued postoperatively using catheter techniques. Opioids should be reserved as rescue analgesics in the postoperative period. Research is needed to evaluate the role of novel regional analgesic techniques such as erector spinae plane or retrolaminar plane blocks combined with basic analgesics in an enhanced recovery setting.
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Affiliation(s)
- A. Jacobs
- Department of Cardiovascular SciencesKULeuven and University Hospital LeuvenLeuvenBelgium
| | - A. Lemoine
- Service d'Anesthésie – Réanimation et Médecine Péri‐opératoireHopital TenonAPHPParis, France/Médecine‐Sorbonne UniversitéParisFrance
| | - G. P. Joshi
- Department of Anesthesiology and Pain ManagementUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - M. Van de Velde
- Department of Cardiovascular SciencesKULeuven and University Hospital LeuvenLeuvenBelgium
| | - F. Bonnet
- Service d'Anesthésie – Réanimation et Médecine Péri‐opératoireHopital TenonAPHPParis, France/Médecine‐Sorbonne UniversitéParisFrance
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Scheflan M, Allweis TM. What Can Breast and Plastic Surgeons Do to Help Fight the Opioid Crisis: The Interpectoral Block for Pain Control Following Aesthetic and Reconstructive Breast Surgery. Aesthet Surg J Open Forum 2020; 2:ojaa009. [PMID: 33791629 PMCID: PMC7780501 DOI: 10.1093/asjof/ojaa009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
With the heightened awareness of the dangers of opioid administration, the importance of providing effective non-opioid postoperative pain management is evident. Regional analgesia for breast surgery has been described, but it is unclear how widely it is utilized. The authors describe a simple block performed during ablative, aesthetic, and reconstructive breast surgery to improve postoperative pain control and significantly decrease the need for postoperative pain medications. The interpectoral (PECS I) block covers the lateral and medial pectoral nerves and can be administered by the anesthesiologist under ultrasound guidance after induction of general anesthesia, or by the surgeon under direct vision, using a blunt cannula, at the time of surgery. The authors have been practicing this technique in every patient undergoing aesthetic, ablative, and reconstructive breast surgery in the last 4 years. In approximately 350 patients, none received opioids after discharge, which was either same day or the following day. The authors provide a brief review of the literature and a detailed description of the technique along with a video demonstrating the procedures. Intraoperative pectoral block is a simple and effective technique for decreasing postoperative pain and analgesic requirements and could be widely adopted as a standard of care in breast surgery.
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Affiliation(s)
- Michael Scheflan
- Plastic Surgeon, Scheflan Plastic Surgery, Tel Aviv, Israel
- Corresponding Author: Dr. Michael Scheflan, Scheflan Plastic Surgery, 18 Raul Wallenberg, Tel Aviv 69710, Israel. E-mail: ; Twitter: @MichaelScheflan
| | - Tanir M Allweis
- Breast Surgeon, Assuta Medical Center and Kaplan Medical Center, Tel Aviv, Israel
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Pectoral Nerve Block and Erector Spinae Plane Block and Post-Breast Surgery Complications. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2020. [DOI: 10.5812/ijcm.100893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Urits I, Ostling PS, Novitch MB, Burns JC, Charipova K, Gress KL, Kaye RJ, Eng MR, Cornett EM, Kaye AD. Truncal regional nerve blocks in clinical anesthesia practice. Best Pract Res Clin Anaesthesiol 2019; 33:559-571. [DOI: 10.1016/j.bpa.2019.07.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/09/2019] [Indexed: 11/29/2022]
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