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Sivakumar S, Kressel A, Mendonca R, Girshin M. Battle of the Blocks: Which Pain Management Technique Triumphs in Gender-Affirming Bilateral Mastectomies? J Clin Med Res 2024; 16:284-292. [PMID: 39027810 PMCID: PMC11254309 DOI: 10.14740/jocmr5159] [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: 03/22/2024] [Accepted: 05/08/2024] [Indexed: 07/20/2024] Open
Abstract
Background Gender-affirming mastectomy, performed on transgender men and non-binary individuals, frequently leads to considerable postoperative pain. This pain can significantly affect both patient satisfaction and the overall recovery process. The study examines the efficacy of four analgesic techniques pectoral nerve (PECS) 2 block, erector spinae plane (ESP) block, thoracic wall local anesthesia infiltration (TWI), and systemic multimodal analgesia (SMA) in managing perioperative pain, with special consideration for the effects of chronic testosterone therapy on pain thresholds. Methods A retrospective analysis was conducted on patients aged 18 - 45 who underwent gender-affirming bilateral mastectomies at a New York City community hospital. The study compared intraoperative and post-anesthesia care unit (PACU) opioid consumption, postoperative pain scores, the interval to first rescue analgesia, and total PACU duration among the four analgesic techniques. Results The study found significant differences in intraoperative and PACU opioid consumption across the groups, with the PECS 2 block group showing the least opioid requirement. The PACU morphine milligram equivalent (MME) consumption was highest in the SMA group. Postoperative pain scores were significantly lower in the PECS and ESP groups at earlier time points post-surgery. However, by postoperative day 2, pain scores did not significantly differ among the groups. Chronic testosterone therapy did not significantly impact intraoperative opioid requirements. Conclusion The PECS 2 block is superior in reducing overall opioid consumption and providing effective postoperative pain control in gender-affirming mastectomies. The study underscores the importance of tailoring pain management strategies to the unique physiological responses of the transgender and non-binary community. Future research should focus on prospective designs, standardized block techniques, and the complex relationship between hormonal therapy and pain perception.
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Affiliation(s)
| | - Aron Kressel
- Department of Plastic Surgery, Metropolitan Hospitals, New York, NY 10029, USA
| | - Roni Mendonca
- Department of Anesthesia, Metropolitan Hospitals, New York, NY 10029, USA
| | - Michael Girshin
- Department of Anesthesia, Metropolitan Hospitals, New York, NY 10029, USA
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2
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Shalaby M, Sahni R, Puebla D, Fernandez S. Modified PECS II Block for Axillary Hidradenitis Suppurativa. J Emerg Med 2024; 66:e701-e703. [PMID: 38762374 DOI: 10.1016/j.jemermed.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 12/25/2023] [Accepted: 01/06/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Hidradenitis suppurativa (HS) is a painful, chronic inflammatory skin condition. Patients experience exacerbations, leading them to present to the emergency department (ED) for incision and drainage. Direct injection of local anesthetic into these lesions is extremely painful and seldom provides adequate anesthesia. A modified method of the PECS II block can provide anesthesia to the skin of the axilla, making management of HS much less painful for the patient. We performed a bilateral modified PECS II block on a patient requiring incision and drainage of HS lesions in both axillae. She subsequently required no local anesthetic for the procedure. DISCUSSION The second injection of the traditional PECS II block involves the deposition of anesthetic in the fascial plane between the pectoralis minor muscle and the serratus anterior muscles. This injection targets the lateral branch of the intercostal nerves, which provide sensory innervation to the axilla. CONCLUSIONS A modified technique of the PECS II block, in which only the second injection is performed, is a potentially effective method for anesthetizing the axilla of patients with HS prior to incision and drainage.
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Affiliation(s)
- Michael Shalaby
- Herbert Wertheim College of Medicine at Florida International University, Miami, Florida; Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, Florida
| | - Raghav Sahni
- Department of Emergency Medicine, Crozer Chester Medical Center, Upland, Pennsylvania
| | - Daniel Puebla
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, Florida
| | - Stephanie Fernandez
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, Florida
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3
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Kulturoglu G, Altinsoy S, Ergil J, Ozkan D, Ozguner Y. Investigation of the analgesic effects of rhomboid intercostal and pectoral nerve blocks in breast surgery. J Anesth 2024:10.1007/s00540-024-03351-3. [PMID: 38777932 DOI: 10.1007/s00540-024-03351-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 05/14/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE The objective of this study was to examine the hypothesis that the opioid consumption of patients who receive a rhomboid intercostal block (RIB) or a pectoral nerve (PECS) block after unilateral modified radical mastectomy (MRM) surgery is less than that of patients who receive local anesthetic infiltration. METHODS Eighty-one female patients aged 18-70 years who underwent unilateral MRM surgery with general anesthesia were randomly allocated to three groups. The first group received an RIB with 30 ml of 0.25% bupivacaine on completion of the surgery, and the second received a PECS block with the same volume and concentration of local anesthetic. In the third (control) group, local infiltration was applied to the wound site with 30 ml of 0.25% bupivacaine at the end of the surgery. The patients' total tramadol consumption, quality of recovery (QoR), postoperative pain scores, and sleep quality were evaluated in the first 24 h postoperatively. RESULTS Both the RIB (58.3 ± 22.8 mg) and PECS (68.3 ± 21.2 mg) groups had significantly lower tramadol consumption compared to the control group (92.5 ± 25.6 mg) (p < 0.001 and p = 0.002, respectively). Higher QoR scores were observed in the RIB and PECS groups than the control group at 6 h post-surgery. The lowest pain values were observed in the RIB group. The sleep quality of the patients in the RIB and PECS groups was better than that of the control group (p < 0.001). CONCLUSION Compared to local anesthetic infiltration, the RIB and PECS blocks applied as part of multimodal analgesia in MRM surgery reduced opioid consumption in the first 24 h and improved the quality of recovery in the early period.
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Affiliation(s)
- Gokcen Kulturoglu
- Department of Anesthesiology and Reanimation, Etlik City Hospital, Ankara, Turkey.
| | - Savas Altinsoy
- Department of Anesthesiology and Reanimation, Etlik City Hospital, Ankara, Turkey
| | - Julide Ergil
- Department of Anesthesiology and Reanimation, Etlik City Hospital, Ankara, Turkey
| | - Derya Ozkan
- Department of Anesthesiology and Reanimation, Etlik City Hospital, Ankara, Turkey
| | - Yusuf Ozguner
- Department of Anesthesiology and Reanimation, Etlik City Hospital, Ankara, Turkey
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4
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Ní Eochagáin A, Carolan S, Buggy DJ. Regional anaesthesia truncal blocks for acute postoperative pain and recovery: a narrative review. Br J Anaesth 2024; 132:1133-1145. [PMID: 38242803 DOI: 10.1016/j.bja.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 10/22/2023] [Accepted: 12/04/2023] [Indexed: 01/21/2024] Open
Abstract
Significant acute postoperative pain remains prevalent among patients who undergo truncal surgery and is associated with increased morbidity, prolonged patient recovery, and increased healthcare costs. The provision of high-quality postoperative analgesia is an important component of postoperative care, particularly within enhanced recovery programmes. Regional anaesthetic techniques have become increasingly prevalent within multimodal analgesic regimens and the widespread adoption of ultrasonography has facilitated the development of novel fascial plane blocks. The number of described fascial plane blocks has increased significantly over the past decade, leading to a burgeoning area of clinical investigation. Their applications are increasing, and truncal fascial plane blocks are increasingly recommended as part of procedure-specific guidelines. Some fascial plane blocks have been shown to be more efficacious than others, with favourable side-effect profiles compared with neuraxial analgesia, and are increasingly utilised in breast, thoracic, and other truncal surgery. However, use of these blocks is debated in regional anaesthesia circles because of limitations in our understanding of their mechanisms of action. This narrative review evaluates available evidence for the analgesic efficacy of the most commonly practised fascial plane blocks in breast, thoracic, and abdominal truncal surgery, in particular their efficacy compared with systemic analgesia, alternative blocks, and neuraxial techniques. We also highlight areas where investigations are ongoing and suggest priorities for original investigations.
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Affiliation(s)
- Aisling Ní Eochagáin
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland; Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Seán Carolan
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
| | - Donal J Buggy
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland; Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Euro-Periscope, The ESA-IC Oncoanaesthesiology Research Group, Europe
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5
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Nayak PP, Ramchandani S, Ramchandani R, Dey CK, Dubey R, Vijapurkar S. Comparison of Analgesic Efficacy of Ultrasound Guided PEC II Block Using Dexamethasone as an Adjuvant to Ropivacaine Versus Plain Ropivacaine in Patients Undergoing Modified Radical Mastectomy: A Double-Blind, Randomized Controlled Trial. Cureus 2024; 16:e58222. [PMID: 38745809 PMCID: PMC11091545 DOI: 10.7759/cureus.58222] [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: 04/11/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Pain after breast cancer surgery is one of the main reasons for postoperative morbidity and pulmonary complications leading to increased hospital stay. Therefore, effective management of postoperative pain becomes necessary to alleviate patients' suffering and allow early mobilization and hospital discharge. Traditionally, opioids have been used to manage perioperative pain but they are associated with side effects. So, an opioid-sparing multimodal analgesia approach is used nowadays. Ultrasound-guided pectoral type-II (PEC II) block is increasingly being used to address acute postoperative pain after breast cancer surgery. However, to date, not many studies have been done regarding prolonging the duration of analgesia of PEC II blocks for postoperative pain relief in patients undergoing modified radical mastectomy (MRM). So, we undertook this study to compare the analgesic efficacy of PEC II block using dexamethasone as an adjuvant to ropivacaine versus plain ropivacaine in patients undergoing MRM. METHODS After obtaining approval from the institute ethics committee and written informed consent from the patients, this prospective, double-blind, parallel group, randomized controlled study was carried out at All India Institute of Medical Sciences (AIIMS) Raipur, from March 2021 to March 2022. Sixty-four female patients, aged 18 years and above, belonging to the American Society of Anesthesiologists, physical status I, II, and III, undergoing unilateral, elective MRM under general anesthesia, were randomly allocated to two groups A and B, with 32 patients in each to receive 30 mL of 0.25% ropivacaine plus 2 mL (8 mg) of dexamethasone and 30 mL of 0.25% ropivacaine plus 2 mL of normal saline, respectively. The primary outcome measure was total opioid consumption till 12 hours postoperatively. Secondary outcome measures were the difference in pain scores based on the numeric rating scale till 12 hours postoperatively, post-operative sedation scores, the incidence of postoperative nausea vomiting (PONV), and other adverse events (if any). RESULTS The mean (SD) of morphine (mg) consumed intraoperatively was 5.50 (1.05) and 5.95 (0.86) with P = 0.033 and that consumed postoperatively was 1.00 (0.00) and 1.69 (0.93) with P <0.001 in group A and B respectively, with morphine consumption being higher in the group. The difference in the NRS score for pain at rest was statistically significant at 2 h (P=0.030), 4 h (P=0.004), 6 h (P=0.002), and, 12 h (P=0.039) time points with the score being higher in group B. The groups were comparable in terms of postoperative sedation score (P > 0.05) and incidence of postoperative nausea and vomiting. None of the patients in group A and 6.2% of the patients in group B had nausea (P = 0.492). None of the patients in either of the groups had vomiting. No other complication occurred during the entire study in either of the groups. CONCLUSION In comparison to plain ropivacaine, the addition of dexamethasone as an adjuvant to ropivacaine for PEC II block in patients undergoing MRM significantly reduced perioperative opioid consumption and postoperative NRS scores. No significant change was noted in terms of postoperative sedation score, incidence of PONV, and other side effects between the groups. Therefore, we conclude that the analgesic efficacy of US-guided PEC II block using dexamethasone, as an adjuvant to ropivacaine is superior to that of plain ropivacaine in patients undergoing MRM.
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Affiliation(s)
- Porika Prashanth Nayak
- Trauma and Emergency (Anesthesiology), All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Sarita Ramchandani
- Anesthesiology, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | | | - Chandan Kumar Dey
- Trauma and Emergency (Anesthesiology), All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Rashmi Dubey
- Anesthesiology, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Swati Vijapurkar
- Anesthesiology, All India Institute of Medical Sciences, Raipur, Raipur, IND
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Kinjo S, Chernin T, Siegmueller C, Sharrow CM, Shilling A. Advances in regional anesthesia for ambulatory surgery. Int Anesthesiol Clin 2024; 62:54-61. [PMID: 37990922 DOI: 10.1097/aia.0000000000000429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Affiliation(s)
- Sakura Kinjo
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | - Tyler Chernin
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | - Claas Siegmueller
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | | | - Ashley Shilling
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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7
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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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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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Luo M, Zhao X, Deng M, Hu Y, Yang X, Mei Z, Meng L, Wang Y. Scalp Nerve Block, Local Anesthetic Infiltration, and Postoperative Pain After Craniotomy: A Systematic Review and Network Meta-analysis of Randomized Trials. J Neurosurg Anesthesiol 2023; 35:361-374. [PMID: 36040025 DOI: 10.1097/ana.0000000000000868] [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: 03/11/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022]
Abstract
The most efficacious methods for controlling postoperative pain in craniotomy remain unknown. A systematic review and network meta-analysis were performed to compare the efficacies of different strategies of scalp nerve block (SNB), scalp infiltration (SI), and control in patients undergoing craniotomy. MEDLINE, Embase, and CENTRAL databases were searched for randomized controlled trials. The primary outcome was postoperative 24-hour pain score, and the secondary outcome was opioid consumption within the first 24 hour after surgery. The effect was estimated using the between-group mean difference and ranked using the surface under the cumulative ranking curve (SUCRA) score. Twenty-four randomized trials were identified for inclusion. SNB using ropivacaine reduced postoperative 24-hour pain score when compared with control (mean difference [95% credible interval], -2.04 [-3.13, -0.94]; low quality), and when compared with SI using ropivacaine (-1.77 [-3.04, -0.51]; low quality) or bupivacaine (-1.96 [-3.65, -0.22]; low quality). SNB using ropivacaine was likely the most efficacious method for pain control (SUCRA, 91%), and also reduced opioid consumption within the first postoperative 24 hours as compared with control (mean difference [95% credible interval], -11.91 [-22.42, -1.4]; low quality). SNB using bupivacaine, lidocaine, and epinephrine combined, and SNB using ropivacaine, were likely the most efficacious methods for opioid consumption reduction (SUCRA, 88% and 80%, respectively). In summary, different methods of SNB / SI seem to have different efficacies after craniotomy. SNB using ropivacaine may be superior to other methods for postcraniotomy pain control; however, the overall quality of evidence was low.
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Affiliation(s)
- Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Meng Deng
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Yue Hu
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Xiaoyu Yang
- Department of Anesthesiology, Huashan Hospital, Fudan University
| | - Zubing Mei
- Anorectal Disease Institute of Shuguang Hospital, Shanghai
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lingzhong Meng
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yingwei Wang
- Department of Anesthesiology, Huashan Hospital, Fudan University
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10
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Hoerner E, Stundner O, Naegele F, Fiala A, Bonaros N, Mair P, Holfeld J, Gasteiger L. The impact of PECS II blockade in patients undergoing minimally invasive cardiac surgery-a prospective, randomized, controlled, and triple-blinded trial. Trials 2023; 24:570. [PMID: 37667362 PMCID: PMC10476350 DOI: 10.1186/s13063-023-07530-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 07/20/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Classic neuraxial techniques, such as thoracic epidural anesthesia, or alternative approaches like the paravertebral block, are not indicated in cardiac surgery due to increased bleeding risk. To provide satisfactory analgesia without the need for excessive opioid use, novel ultrasound techniques gained popularity and are of growing interest. The pectoralis nerve block II (PECS II) has been shown to provide good postoperative analgesia in modified radical mastectomy and might also be suitable for minimally invasive cardiac surgery. METHODS In a single center, prospective, triple-blinded, two-group randomized trial, 60 patients undergoing elective, unilateral minimal invasive cardiac surgery will be randomized to receive a PECS II with 30 ml of ropivacaine 0.5% (intervention group) or sodium chloride 0.9% (placebo group). The primary outcome parameter is the overall opioid demand given as intravenous morphine milligram equivalents (MME) during the first 24 h after extubation. Secondary endpoints are the visual analog scale (VAS) 2, 4, 6, 8, 12, and 24 h after extubation, the Overall Benefit of Analgesia Score (OBAS) after 24 h, the interval until extubation, and intensive care unit (ICU) discharge within 24 h, as well as the length of hospital stay (LOS). DISCUSSION This prospective randomized, controlled, and triple-blinded trial aims to assess if a PECS II with ropivacaine 0.5% helps to decrease the opioid demand in the first 24 h and increases postoperative pain control after minimally invasive cardiac surgery. TRIAL REGISTRATION www.clinicaltrialsregister.eu ; EudraCT Nr: 2021-005452-11; Lukas Gasteiger MD, November 18, 2021.
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Affiliation(s)
- Elisabeth Hoerner
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Ottokar Stundner
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Felix Naegele
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria.
| | - Anna Fiala
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Peter Mair
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Lukas Gasteiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria
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11
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Versyck B, Vermeylen K, Willemse J, van Geffen GJ, Leunen I, Soetens F, Devos S, Roosens L. Serum concentrations of local anesthetics after unilateral interpectoral-pectoserratus plane block in breast cancer surgery: a pharmacokinetic study. Reg Anesth Pain Med 2023; 48:399-402. [PMID: 36787951 DOI: 10.1136/rapm-2022-104166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/30/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION The ultrasound-guided interpectoral-pectoserratus plane block is a fascial plane block for superficial surgery of the anterolateral chest wall. This technique involves injecting a relatively large volume of local anesthetics (typically 30 mL of 0.25%-0.50%, ie, 75-150 mg ropivacaine) underneath the major and minor pectoral muscles of the anterior thoracic wall. There is a potential risk of toxic serum concentrations of local anesthetics due to systemic absorption. METHODS 22 patients scheduled for elective unilateral breast cancer surgery were included in this study. All surgery was performed with general anesthesia and an ultrasound-guided interpectoral-pectoserratus plane block with 2.5 mg/kg ropivacaine. Ten venous blood samples were collected at 0 (two samples) 10, 20, 30, 45, 60, 90 and 120 min and at 4 hours after performing the block. Free and total ropivacaine levels were measured at each time point. Albumin and alpha-1-acid-glycoprotein were measured to monitor shifts between the free and bound fraction of ropivacaine. RESULTS Samples of 20 patients were analyzed. The mean dose of ropivacaine was 172.8 (22.5) mg. In 50% of the patients, the potentially toxic threshold of 0.15 µg/mL free ropivacaine concentration was exceeded. Mean peak serum concentration occurred at 20 min postinjection. CONCLUSIONS This pharmacokinetic study demonstrated that a 2.5 mg/kg ropivacaine interpectoral-pectoserratus plane block may result in exceeding the threshold for local anesthetic systemic toxicity.
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Affiliation(s)
- Barbara Versyck
- Department of Anesthesia and Intensive Care, AZ Turnhout Campus Sint-Jozef, Turnhout, Antwerpen, Belgium
- Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Kris Vermeylen
- Department of Anesthesia and Intensive Care, AZ Turnhout Campus Sint-Jozef, Turnhout, Antwerpen, Belgium
| | - Johan Willemse
- Department of Clinical Biology, AZ Turnhout Campus Sint Elisabeth, Turnhout, Antwerpen, Belgium
| | | | - Ine Leunen
- Department of Anesthesia and Intensive Care, AZ Turnhout Campus Sint-Jozef, Turnhout, Antwerpen, Belgium
| | - Filiep Soetens
- Department of Anesthesia and Intensive Care, AZ Turnhout Campus Sint-Jozef, Turnhout, Antwerpen, Belgium
| | - Sylvie Devos
- Department of Clinical Biology, University Hospital Antwerp, Edegem, Belgium
| | - Laurence Roosens
- Department of Clinical Biology, University Hospital Antwerp, Edegem, Belgium
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12
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Li J, Sun Q, Zong L, Li D, Jin X, Zhang L. Relative efficacy and safety of several regional analgesic techniques following thoracic surgery: a network meta-analysis of randomized controlled trials. Int J Surg 2023; 109:2404-2413. [PMID: 37402286 PMCID: PMC10442098 DOI: 10.1097/js9.0000000000000167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/27/2022] [Indexed: 07/06/2023]
Abstract
BACKGROUND This network meta-analysis was performed to assess the relative efficacy and safety of various regional analgesic techniques used in thoracic surgery. MATERIALSAND METHODS Randomized controlled trials evaluating different regional analgesic methods were retrieved from databases, including PubMed, Embase, Web of Science, and the Cochrane Library, from inception to March 2021. The surface under the cumulative ranking curve) was estimated to rank the therapies based on the Bayesian theorem. Moreover, sensitivity and subgroup analyses were performed on the primary outcomes to obtain more reliable conclusions. RESULTS Fifty-four trials (3360 patients) containing six different methods were included. Thoracic paravertebral block and erector spinae plane block (ESPB) were ranked the highest in reducing postoperative pain. As for total adverse reactions and postoperative nausea and vomiting, postoperative complications, and duration of hospitalization, ESPB was found to be superior to other methods. It should be noted that there were few differences between various methods for all outcomes. CONCLUSIONS Available evidence suggests that ESPB might be the most effective and safest method for relieving pain after thoracic surgery, shortening the length of hospital stay and reducing the incidence of postoperative complications.
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Affiliation(s)
| | | | | | | | | | - Liwei Zhang
- Department of Thoracic Surgery, Xinjiang Medical University, First Affiliated Hospital, Urumqi, China
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13
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Jin Z, Rismany J, Gidicsin C, Bergese SD. Frailty: the perioperative and anesthesia challenges of an emerging pandemic. J Anesth 2023; 37:624-640. [PMID: 37311899 PMCID: PMC10263381 DOI: 10.1007/s00540-023-03206-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 05/22/2023] [Indexed: 06/15/2023]
Abstract
Frailty is a complex and multisystem biological process characterized by reductions in physiological reserve. It is an increasingly common phenomena in the surgical population, and significantly impacts postoperative recovery. In this review, we will discuss the pathophysiology of frailty, as well as preoperative, intraoperative, and postoperative considerations for frailty care. We will also discuss the different models of postoperative care, including enhanced recovery pathways, as well as elective critical care admission. With discoveries of new effective interventions, and advances in healthcare information technology, optimized pathways could be developed to provide the best care possible that meets the challenges of perioperative frailty.
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Affiliation(s)
- Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Level 4, Room 060, Stony Brook, NY, 11794-8480, USA
| | - Joshua Rismany
- Department of Anesthesiology, Stony Brook University Health Science Center, Level 4, Room 060, Stony Brook, NY, 11794-8480, USA
| | - Christopher Gidicsin
- Department of Anesthesiology, Stony Brook University Health Science Center, Level 4, Room 060, Stony Brook, NY, 11794-8480, USA
| | - Sergio D Bergese
- Department of Anesthesiology, Stony Brook University Health Science Center, Level 4, Room 060, Stony Brook, NY, 11794-8480, USA.
- Department of Neurosurgery, Stony Brook University Health Science Center, Stony Brook, NY, 11794-8480, USA.
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14
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Liu G, Gao M, Hu Y, Wang B, Lin Y, Guan Y, Chen G, Zhang P, Hu Y, Cai Q, Qin W. Effects of Ultrasound-Guided Transversus Thoracic Muscle Plane Block on Postoperative Pain and Side Effects: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2023; 37:788-800. [PMID: 36435722 DOI: 10.1053/j.jvca.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/11/2022] [Accepted: 11/01/2022] [Indexed: 11/08/2022]
Abstract
The effects of the transversus thoracic muscle plane (TTP) block on postoperative pain have become increasingly controversial. This meta-analysis compared the effects of the TTP block versus no block on postoperative analgesia and side effects to determine whether this new technique is a reliable alternative for pain management. PubMed, Cochrane Library, Embase, Web of Science, ClinicalTrials.gov, China National Knowledge Infrastructure, Chongqing VIP information, and Wanfang Data were searched for clinical studies investigating the analgesic effect of the TTP block compared to controls. The primary outcomes included the postoperative pain scores at rest and during movement, morphine consumption in 24 hours, and the rate of postoperative nausea and vomiting (PONV). Eleven randomized controlled trials (RCTs), including 682 patients, were reviewed. The meta-analysis showed that the TTP block significantly could reduce the pain scores at 0 (at rest: mean difference [MD], -2.28; 95% CI: -2.67 to -1.90) (during movement: MD: -2.09, 95% CI: -2.62 to -1.56) and 12 hours (at rest: -1.42, 95% CI: -2.03 to -0.82) (during movement: MD: -2.13, 95% CI: -2.80 to -1.46) after surgery, 24-hour postoperative analgesic consumption (MD: -23.18, 95% CI: -33.71 to -12.66), and the incidence of PONV (odds ratio, 0.36, 95% CI: 0.15-0.88). Furthermore, the trial sequence analysis confirmed the result of less 24-hour postoperative analgesic consumption in the TTP block group. As a novel technique, the TTP block exhibited a superior postoperative analgesic effect during the early postoperative period. Nevertheless, additional well-designed RCTs are needed.
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Affiliation(s)
- Guoqing Liu
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Meiling Gao
- Department of Anesthesiology, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Yang Hu
- Department of Ultrasound, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Bangjun Wang
- Department of Ultrasound, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Yunhua Lin
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yuting Guan
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Gang Chen
- Department of Orthopedics, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Hubei, China
| | - Peng Zhang
- Department of Orthopedics, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Hubei, China
| | - Yinghua Hu
- Department of Orthopedics, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Hubei, China
| | - Qiang Cai
- Department of Orthopedics, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Hubei, China.
| | - Wen Qin
- Department of Ultrasound, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China.
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15
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Freedman Z, AuBuchon J, Montana M. A single-center descriptive account of the use of pectoral nerve I and II nerve blocks for post-operative pain relief following pediatric sternotomy. PAEDIATRIC & NEONATAL PAIN 2023; 5:16-22. [PMID: 36911785 PMCID: PMC9997121 DOI: 10.1002/pne2.12092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 10/05/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022]
Abstract
Regional anesthesia between the pectoralis major and minor was first described in 2011 as an alternative method to paravertebral blocks or epidurals for post-operative mastectomies. Since then, the use of pectoral nerve (PECS) blocks for post-operative pain management following thoracotomy, sternotomy, and other procedures in the anterior thorax has increased. While experience with this block is growing, the current understanding of its use in pediatric patients is limited. We reviewed pediatric cases at a single institution and provide a descriptive account of our use of PECS I and II blocks for post-operative pain management following operations involving sternotomy in pediatric patients. We performed a retrospective database analysis of the use of PECS I and II blocks following procedures requiring sternotomy from 2018 to 2021 at St. Louis Children's Hospital. Patients 21 years old and younger who received either a PECS I or II block following a sternotomy for a cardiac procedure were included in the analysis. Patient's demographics, pre-, intra-, and post-operative medications, operative time, extubation status, pain evaluations, and hospital course were assessed from the electronic medical record. From 2018 to 2021, 73 ultrasound-guided PECS blocks were performed for pain relief for pediatric sternotomy. The most commonly performed operations were atrial septal defect closure (n = 12), mitral valve repair (n = 8), and ventricle septal defect closure (n = 8). Out of the 73 patients, 47 received a PECS I block and 26 received a PECS II Block. 70 of the blocks were administered after closure of the sternum while 3 were done before incision. The time to perform blocks took on average of 6 (±4) min. Mean operating room time was 7.5 h. Local anesthetics used for the blocks were as follows: Ropivacaine 0.2% (n = 54), Ropivacaine 0.5% (n = 18), and Bupivacaine 0.25% (n = 1). Twenty-five out of 73 patients did not experience severe pain, defined as ≥7/10 on a numeric pain scale, at any point in the first 24 h following surgery. We describe the of use PECS I and II nerve block following pediatric sternotomy. Blocks were straight forward to perform, and typically took a short amount of time to administer (6 min), when compared to the total operating room time (7.5 h). While this study did not include a comparative group that did not receive a block, 34 percent of patients did not suffer from severe pain in the first 24 h following surgery. Further prospective studies are needed to assess the effectiveness of PECS blocks for pain relief following sternotomy in pediatric patients when compared to current standard of care. PECS blocks may be beneficial for a range of cardiac surgeries that typically result in severe postoperative pain.
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Affiliation(s)
| | - Jacob AuBuchon
- Department of Anesthesiology Washington University in St. Louis and St. Louis Children's Hospital St. Louis Missouri USA
| | - Michael Montana
- Department of Anesthesiology Washington University in St. Louis and St. Louis Children's Hospital St. Louis Missouri USA
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16
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Allen BFS, McEvoy MD. Regional Anesthesia for Thoracic and Abdominal Surgery: Tips and Tricks for the Surgeon. Am Surg 2023; 89:183-191. [PMID: 35798719 DOI: 10.1177/00031348221109499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The use of ultrasound-guided regional anesthesia (UGRA) has flourished over the past two decades with the description of many novel techniques and the incorporation of UGRA into patient care pathways for many types of surgery, including thoracic and abdominal surgery. Numerous facial plane blocks have been developed for analgesia of the chest and abdomen. Though analgesic efficacy varies based on the specific technique, it is important to be aware of the regional anesthesia techniques in common usage, their analgesic distributions, side effect profiles, and efficacy. In this review, we describe fascial plane blocks developed since 2010 as well as older regional anesthesia techniques and provide context for how and why they might be incorporated into patient care pathways. We will provide salient details on block coverage and briefly discuss evidence and relevant controversies around their use.
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Affiliation(s)
- Brian F S Allen
- Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew D McEvoy
- Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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17
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Luo M, Zhao X, Tu M, Yang X, Deng M, Wang Y. The effectiveness of scalp nerve block on hemodynamic response in craniotomy: a systematic review and meta-analysis of randomized trials. Minerva Anestesiol 2023; 89:85-95. [PMID: 36448987 DOI: 10.23736/s0375-9393.22.16775-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Strategies that blunt noxious stimuli and stabilize hemodynamics may reduce perioperative cardiovascular complications and enhance recovery after craniotomy. EVIDENCE ACQUISITION Our systematic literature review and meta-analysis investigated whether scalp nerve block (SNB) reduces the acute hemodynamic response compared with non-SNB (scalp infiltration or control) in adult patients undergoing elective craniotomy. We searched MEDLINE, EMBASE, CENTRAL, and two Chinese databases for randomized trials. Primary outcomes included mean arterial pressure and heart rate during skull pin insertion and surgical incision in craniotomy. Secondary outcomes included incidence of hypertension and dosage of intraoperative analgesic opioids used. Random-effects models were used for meta-analyses. EVIDENCE SYNTHESIS SNB significantly reduced the mean arterial pressure (mean difference: -14.00 mmHg; 95% confidence interval [CI]: -19.71 to -8.28) and heart rate (mean difference: -11.55 beat/min; 95% CI: -19.31 to -3.80), when compared with non-SNB during skull pin insertion. A similar trend was observed during skin incisions (SNB vs. non-SNB, mean difference in mean arterial pressure: -9.46 mmHg; 95% CI: -14.53 to -4.38; mean difference in heart rate: -9.34 beat/min; 95% CI: -15.40 to -3.28). Subgroup analysis showed that, compared with scalp infiltration, SNB reduced mean arterial pressure and heart during pin insertion but not during skin incisions. SNB also reduced the incidence of intraoperative hypertension, but no difference was observed in intraoperative opioid consumption when compared with non-SNB. CONCLUSIONS SNB alleviated the craniotomy-associated hemodynamic response. SNB may be superior to scalp infiltration in maintaining hemodynamic stability during pin insertion. However, high-quality trials are still needed to provide more conclusive evidence.
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Affiliation(s)
- Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mengyun Tu
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoyu Yang
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Meng Deng
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yingwei Wang
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China -
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18
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Yu L, Cui X, Song P, Li C, Zhao H, Chang Y. Perioperative pectoral nerve block type II and postoperative recurrence in breast cancer: a randomized controlled trial. BMC Surg 2022; 22:447. [PMID: 36585623 PMCID: PMC9805115 DOI: 10.1186/s12893-022-01895-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A new technique for analgesia called pectoral nerve block is widely used in surgeries of breast cancer. Pectoral nerve block type II (Pecs II) block has less influence on immunity when compared with general anesthesia method. The purpose of this research is to demonstrate whether Pecs II block has influence on the recurrence of breast cancer after surgical operation. METHODS 526 breast cancer patients were recruited in this research and randomized into general anesthesia group and general anesthesia with Pecs II block group. Recurrence-free survival (RFS), distant recurrence-free survival (DRFS), and overall survival (OS) were evaluated for the two groups. RESULTS Based on the statistical data, only the consumption of remifentanil was dramatically reduced by the performance of Pecs II block when compared with general anesthesia method. The performance of Pecs II block had no significant influence on OS, RFS, and DRFS of breast cancer patients after surgery. ASA physical status III, TNM stage 2 + 3, and mastectomy were proved to have association with lower recurrence-free survival. CONCLUSION In conclusion, the performance of Pecs II block declined the remifentanil consumption during surgery of breast cancer. Meanwhile, the performance of Pecs II block had no significant influence on the OS, RFS, and DRFS of breast cancer patients after surgical resection.
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Affiliation(s)
- Lili Yu
- grid.452270.60000 0004 0614 4777Department of Anesthesiology, Cangzhou Central Hospital, No.16, Xinhua Road, Cangzhou, 061000 Hebei China
| | - Xiuling Cui
- grid.452270.60000 0004 0614 4777Department of Anesthesiology, Cangzhou Central Hospital, No.16, Xinhua Road, Cangzhou, 061000 Hebei China
| | - Panpan Song
- grid.452270.60000 0004 0614 4777Department of Anesthesiology, Cangzhou Central Hospital, No.16, Xinhua Road, Cangzhou, 061000 Hebei China
| | - Chunlei Li
- grid.452270.60000 0004 0614 4777Department of Anesthesiology, Cangzhou Central Hospital, No.16, Xinhua Road, Cangzhou, 061000 Hebei China
| | - Haochen Zhao
- grid.452270.60000 0004 0614 4777Department of Anesthesiology, Cangzhou Central Hospital, No.16, Xinhua Road, Cangzhou, 061000 Hebei China
| | - Yulin Chang
- grid.452270.60000 0004 0614 4777Department of Anesthesiology, Cangzhou Central Hospital, No.16, Xinhua Road, Cangzhou, 061000 Hebei China
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19
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Leite ALDS, Rocha FTR, Oliveira MJC, Barros AV, Santos SMLD, Silva AMRDA, Silvestre DWDEA, Folha Filho EAC, Ferro CC, Bezerra TS, Fachin LP, Santos DC, Fraga CADEC, Sales-Marques C. Impact of Pectoralis Nerve Block (PECS) on postoperative pain in patients submitted to mastectomy with lymphadenectomy. Rev Col Bras Cir 2022; 49:e20223366. [PMID: 36515333 PMCID: PMC10578795 DOI: 10.1590/0100-6991e-20223366-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/08/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Breast cancer is the most common malignant neoplasm in women worldwide. Surgery has been traditional treatment and, generally, it´s mastectomy with lymphadenectomy, that can causes postoperative pain. Therefore, we seek to study regional anesthesic techniques that can minimize this effect, such as the interpectoral block (PECS). METHODS randomized controlled study with 82 patients with breast cancer who underwent mastectomy with lymphadenectomy from January 2020 to October 2021 in oncology hospital. INTERVENTIONS two randomized groups (control - exclusive general anesthesia and PECS group - received PECS block with levobupivacaine/ropivacaine and general anesthesia). We applied a questionnaire with Numeric Rating Scale for pain 24h after surgery. We used Shapiro-Wilk, Mann-Whitney and Chi-square tests, and analyzed the data in R version 4.0.0 (ReBEC). RESULTS in the PECS group, 50% were pain-free 24h after surgery and in the control group it was 42.86%. The majority who presented pain classified it as mild pain (VAS from 1 to 3) - (42.50%) PECS group and (40.48%) control group (p=0.28). Only 17.50% consumed opioids in the PECS group, similar to the control group with 21.43%. (p=0.65). There was a low rate of complications such as PONV in both groups. In the subgroup analysis, there was no statistical difference between the groups that used levobupivacaine or ropivacaine regarding postoperative pain and opioid consumption. DISCUSSION the studied group had a low rate of pain in the postoperative period and it influenced the statistical analysis. There wasn´t difference in postoperative pain in groups. CONCLUSION was not possible to demonstrate better results with the association of the PECS block with total intravenous analgesia. Need further studies to assess the efficacy of the nerve block.
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Affiliation(s)
- Amanda Lira Dos Santos Leite
- - Santa Casa de Misericórdia de Maceió, Department of Oncology Surgery - Maceió - AL - Brasil
- - Universidade Federal de Alagoas, Programa de Pós Graduação em Ciências Médicas, Faculdade de Medicina - Maceió - AL - Brasil
| | | | - Michelle Jacintha C Oliveira
- - Universidade Federal de Alagoas, Programa de Pós Graduação em Ciências Médicas, Faculdade de Medicina - Maceió - AL - Brasil
| | - Aldo Vieira Barros
- - Santa Casa de Misericórdia de Maceió, Department of Oncology Surgery - Maceió - AL - Brasil
| | | | | | | | - Elson A C Folha Filho
- - Santa Casa de Misericórdia de Maceió, Department of Oncology Surgery - Maceió - AL - Brasil
| | - Caroline C Ferro
- - Santa Casa de Misericórdia de Maceió, Department of Oncology Surgery - Maceió - AL - Brasil
| | - Taina Santos Bezerra
- - Santa Casa de Misericórdia de Maceió, Department of Oncology Surgery - Maceió - AL - Brasil
| | | | | | | | - Carolinne Sales-Marques
- - Universidade Federal de Alagoas, Programa de Pós Graduação em Ciências Médicas, Faculdade de Medicina - Maceió - AL - Brasil
- - Universidade Federal de Alagoas, Instituto de Ciências Biológicas e da Saúde, Programa de Pós Graduação em Ciências da Saúde - Maceió - AL - Brasil
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20
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Plunkett A, Scott TL, Tracy E. Regional anesthesia for breast cancer surgery: which block is best? A review of the current literature. Pain Manag 2022; 12:943-950. [PMID: 36177958 DOI: 10.2217/pmt-2022-0048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Breast cancer is the most common type of cancer worldwide. Fortunately, continual advances in diagnosis and treatment are resulting in increased survival rates. Earlier detection and treatment, to include surgical resection, can greatly improve patients outcomes. However, due to the complex innervation of the breast, management of postoperative pain has proven difficult in the past. Approximately, half of all women who undergo breast cancer surgery report postoperative pain syndrome. The paravertebral block has long been the anesthesiologist's choice for mitigating pain during and after the procedure. Newer techniques such as the pectoral nerve block and erector spinae plane block may prove to have some additional benefits. This literature review compares the risks, benefits and specific uses of these three regional nerve blocks in women undergoing breast cancer surgery. It aims to better inform anesthesiologists when they are choosing which technique is best for their patients.
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Affiliation(s)
| | - Trevor L Scott
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Erin Tracy
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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21
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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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22
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Analgesic Efficacies of Intraoperative Pectoralis Nerve II Block under Direct Vision in Patients Undergoing Robotic Nipple-Sparing Mastectomy with Immediate Breast Reconstruction: A Prospective, Randomized Controlled Study. J Pers Med 2022; 12:jpm12081309. [PMID: 36013257 PMCID: PMC9409644 DOI: 10.3390/jpm12081309] [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: 06/30/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
This prospective, randomized study aimed to evaluate the efficacy of an intraoperative pectoralis nerve II block (PECS II block) under direct vision in the reduction of fentanyl consumption during postoperative 24 h in patients undergoing robotic nipple-sparing mastectomy (RNSM) with immediate breast reconstruction (IBR) using direct-to-implant (DTI) or tissue expander (TE). Thirty patients scheduled for RNSM with IBR were randomly allocated to the PECS (n = 15) or control (n = 15) groups. The PECS II block was applied under direct vision after RNSM. The primary outcome was the cumulative dose of fentanyl consumption. The secondary outcomes were pain intensity using a numerical rating scale (NRS) at rest and acting during the postoperative 24 h. The cumulative dose of fentanyl at 24 h was significantly lower in the PECS group than in the control group (p = 0.011). Patients in the PECS group showed significantly lower NRS scores during the first postoperative 2 h compared to those in the control group in both resting and acting pain (p < 0.05). An intraoperative PECS II block under direct vision can reduce opioid consumption during the postoperative 24 h and provide effective analgesia in patients undergoing RNSM with IBR using DTI or TE.
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van den Broek RJC, Goeteyn J, Houterman S, Bouwman RA, Versyck BJB, Teijink JAW. Interpectoral-pectoserratus plane (PECS II) block in patients undergoing trans-axillary thoracic outlet decompression surgery; A prospective double-blind, randomized, placebo-controlled clinical trial. J Clin Anesth 2022; 82:110939. [PMID: 35907370 DOI: 10.1016/j.jclinane.2022.110939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/21/2022] [Accepted: 07/21/2022] [Indexed: 10/31/2022]
Abstract
STUDY OBJECTIVE To investigate if an interpectoral-pectoserratus plane (PECS II) block decreases postoperative pain, postoperative nausea and vomiting and improves quality of recovery in patients with neurogenic thoracic outlet syndrome (NTOS) undergoing trans-axillary thoracic outlet decompression surgery. DESIGN A prospective single center double blinded randomized placebo-controlled trial. SETTING Perioperative period; operating room, post anesthesia care unit (PACU) and hospital ward. PATIENTS Seventy patients with NTOS, undergoing trans-axillary thoracic outlet decompression surgery. INTERVENTIONS Patients were randomized to an interventional arm, receiving the block with 40 ml ropivacaine 0.5% (concentration was adjusted if the patient's weight was <66 kg), and a placebo group, receiving a sham block with 40 ml NaCl 0.9%. The interpectoral-pectoserratus plane block was performed ultrasound guided; the first injection below the pectoral minor muscle and the second below the pectoral major muscle. The hospitals' pharmacist prepared the study medication and was the only person able to see the randomization result. The study was blinded for patients, researchers and medical personnel. MEASUREMENTS Primary outcome parameters were postoperative pain, measured by numeric rating scale on the PACU (start and end) and on the ward on postoperative day (POD) 0 and 1, and postoperative morphine consumption, measured on the PACU and on the ward during the first 24 h. Secondary outcome parameters were postoperative nausea and vomiting, and quality of recovery. MAIN RESULTS There was no statistically significant difference in NRS on the PACU at the start (ropivacaine 4.9 ± 3.2 vs placebo 6.2 ± 3.0, p = .07), at the end (ropivacaine 4.0 ± 1.7 vs placebo 3.9 ± 1.7, p = .77), on the ward on POD 0 (ropivacaine 4.6 ± 2.0 vs placebo 4.6 ± 2.0, p = 1.00) or POD 1 (ropivacaine 3.9 ± 1.8 vs placebo 3.6 ± 2.0, p = .53). There was no difference in postoperative morphine consumption at the PACU (ropivacaine 11.0 mg ± 6.5 vs placebo 10.8 mg ± 4.8, p = .91) or on the ward (ropivacaine 11.6 mg ± 8.5 vs placebo 9.6 mg ± 9.4, p = .39). CONCLUSIONS The interpectoral-pectoserratus plane block is not effective for postoperative analgesia in patients with NTOS undergoing trans-axillary thoracic outlet decompression surgery.
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Affiliation(s)
- Renee J C van den Broek
- Department of Anesthesiology and Pain medicine, Catharina hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands; Faculty of Health, Medicine and Life Sciences, Department of Epidemiology, CAPHRI School for Public Health and Primary Care, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands.
| | - Jens Goeteyn
- Faculty of Health, Medicine and Life Sciences, Department of Epidemiology, CAPHRI School for Public Health and Primary Care, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands; Department of Vascular Surgery, Catharina hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands.
| | - Saskia Houterman
- Department of Education and Research, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands.
| | - R Arthur Bouwman
- Department of Anesthesiology and Pain medicine, Catharina hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands; Department of Electrical Engineering, Eindhoven University of Technology, Groene Loper 19, 5612 AP Eindhoven, the Netherlands.
| | - Barbara J B Versyck
- Department of Anesthesiology and Pain medicine, Catharina hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands; Department of Anesthesiology and Pain Medicine, AZ Turnhout, Steenweg op Merksplas 44, 2300 Turnhout, Belgium.
| | - Joep A W Teijink
- Faculty of Health, Medicine and Life Sciences, Department of Epidemiology, CAPHRI School for Public Health and Primary Care, Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands; Department of Vascular Surgery, Catharina hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands.
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Nerve Blocks in Breast Plastic Surgery: Outcomes, Complications, and Comparative Efficacy. Plast Reconstr Surg 2022; 150:1e-12e. [PMID: 35499513 DOI: 10.1097/prs.0000000000009253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Sertcakacilar G, Kose S. Bilateral PECS II block is associated with decreased opioid consumption and reduced pain scores for up to 24 hours after minimally invasive repair of pectus excavatum (Nuss procedure): a retrospective analysis. J Cardiothorac Vasc Anesth 2022; 36:3833-3840. [DOI: 10.1053/j.jvca.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/21/2022] [Accepted: 06/01/2022] [Indexed: 11/11/2022]
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26
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Ardon AE, George JE, Gupta K, O’Rourke MJ, Seering MS, Tokita HK, Wilson SH, Moo TA, Lizarraga I, McLaughlin S, Greengrass RA. The Use of Pectoralis Blocks in Breast Surgery: A Practice Advisory and Narrative Review from the Society for Ambulatory Anesthesia (SAMBA). Ann Surg Oncol 2022; 29:4777-4786. [DOI: 10.1245/s10434-022-11724-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/21/2022] [Indexed: 01/30/2023]
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27
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Gayraud G, DE Castro D, Perrier K, Molnar I, Dualé C. A French nationwide survey on the practice of regional anaesthesia for breast cancer surgery. Minerva Anestesiol 2022; 88:668-679. [PMID: 35416468 DOI: 10.23736/s0375-9393.22.16532-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To assess the impact of recent recommendations concerning regional anaesthesia for breast cancer surgery, a nationwide practice survey was carried out. METHODS This cross-sectional electronic survey, conducted in 2021, collected answers from a panel of anaesthetists currently working in French practicing centres. It addressed the sets of techniques they practiced for every type of surgical procedure and their perceptions of the difficulties and risks associated with these techniques. RESULTS The practice of regional anaesthesia was generally high (70%), involving all the current types of blocks. Surgeon-done infiltration was popular for lumpectomy only. For the other current procedures, the pectoralis nerve blocks were preferred to the paravertebral block, which was favoured for mastectomies, when a lymph node harvesting was planned, or for immediate or delayed pedicle flap. Catheters were mostly used for mastectomies with pedicle flap. The erector spinae plane block was emergent. Whatever the type of block, regional anaesthesia was preferentially started before surgery. Despite some deviations such as the adjunction of unlabelled molecules, the practice fitted well with the European recommendations, but training and within-centre guidance lacked standardisation. For each block, actual practice, perceived difficulty and risk were inter-correlated, but paravertebral block - either practiced or not - was considered as more difficult and riskier to perform than any other. CONCLUSIONS These encouraging results do not dispense with the need to improve anaesthetic practices both in quantity and quality. Such improvement in the anatomic fit to the procedure and in the timing of blocks will also have to be considered.
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Affiliation(s)
- Guillaume Gayraud
- Anesthésie-Réanimation, Centre Jean-Perrin, Clermont-Ferrand, France
| | - Dalia DE Castro
- Anesthésie-Réanimation, Centre Jean-Perrin, Clermont-Ferrand, France
| | - Kevin Perrier
- Médecine Péri-Opératoire, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Ioana Molnar
- Délégation Recherche Clinique & Innovations, Centre Jean-Perrin, Clermont-Ferrand, France
| | - Christian Dualé
- Centre d'Investigation Clinique (INSERM CIC1405), CHU Clermont-Ferrand, Clermont-Ferrand, France - .,INSERM Neuro-Dol U1107, Clermont-Ferrand, France
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Gómez M, Izquierdo CE, Mayoral Rojals V, Pergolizzi Jr J, Plancarte Sanchez R, Paladini A, Varrassi G. Considerations for Better Management of Postoperative Pain in Light of Chronic Postoperative Pain: A Narrative Review. Cureus 2022; 14:e23763. [PMID: 35518528 PMCID: PMC9064707 DOI: 10.7759/cureus.23763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/02/2022] [Indexed: 12/02/2022] Open
Abstract
Chronic postoperative pain (CPOP) is prevalent, with particularly high rates in breast surgery, thoracotomy, and amputation. As the world emerges from the coronavirus disease 2019 (COVID-19) lockdowns, it is expected that there will be an increase in surgical procedures, elevating the importance of preventing CPOP in the coming years. Risk factors are emerging to better stratify patients at high risk for CPOP. Perioperative analgesia plays an important role in managing acute postoperative pain and in some cases may limit its transition to CPOP. Acute postoperative pain is adaptive, normal, expected, and has a well-defined trajectory, while CPOP is maladaptive and, as a form of chronic pain, is challenging to treat. Good analgesia, early ambulation, and rehabilitation efforts may be helpful in preventing CPOP following certain surgeries. Enhanced Recovery After Surgery (ERAS) protocols present guidance to help promote recovery and prevent CPOP.
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Singh NP, Makkar JK, Kuberan A, Guffey R, Uppal V. Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials. Can J Anaesth 2022; 69:527-549. [PMID: 35102494 DOI: 10.1007/s12630-021-02183-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery. METHODS In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting. RESULTS Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting. CONCLUSION Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice. STUDY REGISTRATION PROSPERO (CRD42020198244); registered 19 October 2020.
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Affiliation(s)
- Narinder Pal Singh
- Department of Anaesthesia, MMIMSR, MM (DU), Mullana-Ambala, Ambala, India
| | - Jeetinder Kaur Makkar
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aswini Kuberan
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Ryan Guffey
- Department of Anesthesia, Washington University in St. Louis, St. Louis, MO, USA
| | - Vishal Uppal
- Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Nova Scotia Health Authority and Izaak Walton Killam Health Centre, Halifax, NS, Canada.
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Xu X, Chen X, Zhu W, Zhao J, Liu Y, Duan C, Qi Y. Efficacy and Safety of Ultrasound Guided-Deep Serratus Anterior Plane Blockade With Different Doses of Dexmedetomidine for Women Undergoing Modified Radical Mastectomy: A Randomized Controlled Trial. Front Med (Lausanne) 2022; 9:819239. [PMID: 35198576 PMCID: PMC8860248 DOI: 10.3389/fmed.2022.819239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 01/10/2022] [Indexed: 11/21/2022] Open
Abstract
Background Ultrasound guided-deep serratus anterior plane block (USG-DSAPB) has been used for pain management of patients undergoing modified radical mastectomy (MRM), but evidence supporting their adjuvant analgesic benefits is limited. We explored the efficacy and safety of preemptive use of ropivacaine combined with different doses of dexmedetomidine (DEX) in USG-DSAPB for patients undergoing MRM. Methods Ninety-five female patients undergoing unilateral MRM were allocated randomly to two groups. Group RD1 had 20 mL of 0.5% ropivacaine with 5 mg of dexamethasone and 0.5 μg·kg−1 DEX in USG-DSAPB. Group RD2 had 20 mL of 0.5% ropivacaine with 5 mg of dexamethasone and 1 μg·kg−1 DEX in USG-DSAPB. The primary outcome was sufentanil consumption 72 h after USG-DSAPB. Secondary outcomes were: postoperative pain scores and level of sedation; intraoperative hemodynamics; duration of post-anesthesia care unit (PACU) stay; prevalence of moderate-to-severe pain; one-time puncture success; procedure time of blockade; time to first rescue analgesia; requirement of rescue analgesia; satisfaction scores of patients and surgeons; duration of hospital stay; adverse events; prevalence of chronic pain; quality of postoperative functional recovery. Results Compared with the RD1 group, the visual analog scale score for coughing was significantly lower at 4, 8, 12 h and sufentanil consumption was significantly lower at 4, 8, 12, 24, and 48 h after surgery in the RD2 group (P < 0.05). The time to first rescue analgesia was significantly longer in the RD2 group (P < 0.05). The requirement for rescue analgesia was significantly higher in the RD1 group (P < 0.05). The prevalence of moderate-to-severe pain, number of patients using vasoactive agents, duration of PACU stay, as well as consumption of propofol, remifentanil, and DEX were significantly lower in the RD2 group (P < 0.05). There were no significant differences between the two groups with respect to one-time puncture success, procedure time of blockade, total dermatomal spread, satisfaction scores of patients and surgeons, postoperative complications, duration of hospital stay, 40-item Quality of Recovery questionnaire (QoR-40) score, or prevalence of chronic pain (P > 0.05). Conclusions We discovered that 1 μg·kg−1 (not 0.5 μg·kg−1) DEX combined with 20 mL of 0.5% ropivacaine and 5 mg of dexamethasone in USG-DSAPB could provide superior postoperative analgesia for patients undergoing MRM. However, the quality of postoperative functional recovery and prevalence of chronic pain were similar. Clinical Trial Registration:http://www.chictr.org.cn/showproj.aspx?proj=54929, identifier: ChiCTR2000033685.
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Affiliation(s)
- Xia Xu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Xingfang Chen
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Wenchao Zhu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Jing Zhao
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Yanchao Liu
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
| | - Caiping Duan
- Department of Anesthesiology, Ordos Central Hospital, Ordos, China
| | - Yingying Qi
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, China
- *Correspondence: Yingying Qi
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Sharma R, Louie A, Thai CP, Dizdarevic A. Chest Wall Nerve Blocks for Cardiothoracic, Breast Surgery, and Rib-Related Pain. Curr Pain Headache Rep 2022; 26:43-56. [PMID: 35089532 DOI: 10.1007/s11916-022-01001-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Perioperative analgesia in patients undergoing chest wall procedures such as cardiothoracic and breast surgeries or analgesia for rib fracture trauma can be challenging due to several factors: the procedures are more invasive, the chest wall innervation is complex, and the patient population may have multiple comorbidities increasing their susceptibility to the well-defined pain and opioid-related side effects. These procedures also carry a higher risk of persistent pain after surgery and chronic opioid use making the analgesia goals even more important. RECENT FINDINGS With advances in ultrasonography and clinical research, regional anesthesia techniques have been improving and newer ones with more applications have emerged over the last decade. Currently in cardiothoracic procedures, para-neuraxial and chest wall blocks have been utilized with success to supplement or substitute systemic analgesia, traditionally relying on opioids or thoracic epidural analgesia. In breast surgeries, paravertebral blocks, serratus anterior plane blocks, and pectoral nerve blocks have been shown to be effective in providing pain control, while minimizing opioid use and related side effects. Rib fracture regional analgesia options have also expanded and continue to improve. Advances in regional anesthesia have tremendously improved multimodal analgesia and contributed to enhanced recovery after surgery protocols. This review provides the latest summary on the use and efficacy of chest wall blocks in cardiothoracic and breast surgery, as well as rib fracture-related pain and persistent postsurgical pain.
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Affiliation(s)
- Richa Sharma
- Division of Regional Anesthesiology, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Aaron Louie
- Division of Regional Anesthesiology, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Carolyn P Thai
- Division of Regional Anesthesiology, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Anis Dizdarevic
- Division of Regional Anesthesiology, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, 10032, USA.
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LEITE AMANDALIRADOSSANTOS, ROCHA FREDERICOTHEOBALDORAMOS, OLIVEIRA MICHELLEJACINTHAC, BARROS ALDOVIEIRA, SANTOS SILVIOMARCOSLIMADOS, SILVA ALBERSONMAYLSONRAMOSDA, SILVESTRE DIEGOWINDSONDEARAÚJO, FOLHA FILHO ELSONAC, FERRO CAROLINEC, BEZERRA TAINASANTOS, FACHIN LAERCIOP, SANTOS DALMIRCAVALCANTI, FRAGA CARLOSALBERTODECARVALHO, SALES-MARQUES CAROLINNE. Impacto do Bloqueio Peitoral (PEC) na dor pós-operatória em pacientes submetidos a mastectomia com linfadenectomia. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RESUMO Introdução: o câncer de mama é a neoplasia maligna mais comum em mulheres no mundo. A cirurgia tem sido o tratamento tradicional e, geralmente consiste em mastectomia com linfadenectomia, podendo causar dor pós-operatória. Por isso, buscamos estudar técnicas anestésicas regionais que possam minimizar esse efeito, como o bloqueio interpeitoral (PEC). Métodos: estudo controlado randomizado com 82 pacientes com câncer de mama submetidos à mastectomia com linfadenectomia de Janeiro de 2020 a Outubro de 2021, em hospital oncológico. Intervenções: dois grupos randomizados (controle - anestesia geral exclusiva e grupo PECS - anestesia geral e bloqueio PEC com levobupivacaína/ropivacaína). Aplicou-se um questionário com Escala Visual Analógica da dor 24h pós-cirurgia. Utilizamos os testes de Shapiro-Wilk, Mann-Whitney e Quiquadrado e analisamos os dados em R versão 4.0.0. Estudo registrado em Ensaios Clínicos Brasileiros (REBec). Resultados: no grupo PEC, 50% não apresentava dor 24 horas após a cirurgia enquanto no grupo controle, 42,86% negava quadro álgico. A maioria que apresentou dor classificou-a como dor leve (EVA de 1 a 3) - (42,50%) grupo PEC e (40,48%) controle (p=0,28). Apenas 17,50% consumiram opioides no grupo PEC, semelhante ao grupo controle com 21,43%. (p=0,65), (17,50%) grupo PEC e (21,43%) grupo controle (p=0,65). Houve baixo índice de complicações como PONV (náuseas, vômitos, cefaleia) em ambos os grupos. Na análise de subgrupo, não houve diferença estatística entre os grupos que usaram Levobupivacaína ou Ropivacaína quanto a dor pós-operatória e o consumo de opioides. Discussão: o grupo estudado apresentou baixa taxa de dor no pós-operatório e isso influenciou na análise estatística. Não houve diferença estatística quanto a dor pós-operatória entre grupos. Conclusão: não foi possível demonstrar melhores resultados com a associação do bloqueio PEC com analgesia intravenosa total. São necessários novos estudos para avaliar a eficácia do bloqueio anestésico no intraoperatório e pós-operatório.
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Hoerner E, Gasteiger L, Ortler M, Pustilnik V, Mathis S, Brunner C, Neururer S, Schlager A, Egle D, Putz G. The impact of dexamethasone as a perineural additive to ropivacaine for PECS II blockade in patients undergoing unilateral radical mastectomy - A prospective, randomized, controlled and double-blinded trial. J Clin Anesth 2021; 77:110622. [PMID: 34872040 DOI: 10.1016/j.jclinane.2021.110622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/25/2021] [Accepted: 11/26/2021] [Indexed: 01/31/2023]
Abstract
STUDY OBJECTIVE Dexamethasone is commonly used as an adjuvant to local anesthetics to prolong duration of peripheral nerve blocks with minimal side-effects. The present study investigates the efficacy of dexamethasone added to ropivacaine 0.2% as compared to ropivacaine 0.2% alone for pectoral nerves block II (PECS II) in unilateral radical mastectomy. DESIGN A prospective, randomized, controlled and double-blinded trial. SETTING The study was performed at Innsbruck Medical University Hospital, Austria, between January 2019 and October 2020. PATIENTS Sixty female patients with an American Society of Anesthesiologists Score I-II (18-90 years, BMI 18-35) scheduled for unilateral radical mastectomy without one-stage immediate autologous breast reconstruction were randomly assigned to receive PECS II block with ropivacaine 0.2% with or without dexamethasone 8 mg. INTERVENTIONS Patients were randomly assigned to receive PECS II block with ropivacaine 0.2% with or without dexamethasone 8 mg. MEASUREMENTS Primary outcome parameter was the cumulative opioid consumption during the first 72 postoperative hours. Secondary outcome parameters were the duration of analgesia and the course of the visual analogue scale (VAS) and the area under the curve VAS (AUC-VAS). MAIN RESULTS There was no difference in cumulative opioid consumption after 72 h between the ropivacaine 0.2% plus dexamethasone group and the ropivacaine 0.2% plus placebo group (11.89 vs 11.90 morphine milligram equivalent, respectively; p 0.831). Duration of analgesia also did not differ significantly between the ropivacaine 0.2% plus dexamethasone group and the ropivacaine 0.2% plus placebo group (12.75 versus 8.75 h, respectively; p 0.680). There also was no difference in the course of VAS and AUC-VAS. CONCLUSIONS Dexamethasone 8 mg when added to ropivacaine 0.2% for PECS II block in unilateral radical mastectomy was not found to reduce total opioid consumption over 72 postoperative hours or to prolong duration of analgesia as compared to pure ropivacaine 0.2%.
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Affiliation(s)
- Elisabeth Hoerner
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Lukas Gasteiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria.
| | - Michael Ortler
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Vitaliy Pustilnik
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Simon Mathis
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Christine Brunner
- Department of Obstetrics and Gynaecology, Medical University of Innsbruck, Austria
| | - Sabrina Neururer
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Austria
| | - Andreas Schlager
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
| | - Daniel Egle
- Department of Obstetrics and Gynaecology, Medical University of Innsbruck, Austria
| | - Guenther Putz
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Austria
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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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Liao J, Li M, Gan J, Xiao J, Xiang G, Ding X, Jiang R, Li P. Systematic review and meta-analysis of the efficacy of general anesthesia combined with a thoracic nerve block in modified breast cancer surgery. Gland Surg 2021; 10:3106-3115. [PMID: 34926226 PMCID: PMC8637070 DOI: 10.21037/gs-21-719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/16/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Breast cancer is a malignant tumor disease that poses a significant threat to women's health. In recent years, the incidence of breast cancer in China has been increasing. This report aims to explore the effects of general anesthesia combined with a thoracic nerve block in modified breast cancer surgery. METHODS A computer-based search of PubMed, Web of Science, Embase, and the Cochrane Library was performed to identify randomized controlled studies on breast cancer, general anesthesia combined with a thoracic nerve block, modified breast cancer surgery, and other breast cancer treatments. Further search criteria included postoperative pain score, postoperative morphine equivalents given 24 hours after surgery, and operation duration. After an initial selection process, the studies were evaluated using the Jadad scale and the Cochrane Handbook for Systematic Reviews of Interventions to assess their suitability for inclusion in the subsequent meta-analysis of the experimental data, which was carried out using RevMan 5.3. RESULTS A total of 8 studies comprising a total of 624 patients were selected for inclusion in this report. According to the meta-analysis, the analytical structure of the thoracic nerve group and the control group had a mean difference (MD) of -1.27 [95% confidence interval (CI): -1.68 to -0.86], the structure of the statistical test was Z=6.08 (P<0.00001), the MD of the total analysis structure of morphine equivalents was -2.71 (95% CI: -4.98 to -0.44), and the statistical test structure was Z=2.34 (P=0.02). DISCUSSION General anesthesia combined with a thoracic nerve block in breast cancer surgery may effectively improve postoperative pain in patients and reduce the need for analgesic drugs. However, the outcome indicators included in this study are not sufficient. It is necessary to increase both the sample size and the number of outcome indicators to provide further theoretical evidence for the subsequent application of thoracic nerve block in modified breast cancer surgery.
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Affiliation(s)
- Juan Liao
- Department of Stomatology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Meiting Li
- Department of Anesthesiology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Jiaqi Gan
- Department of Anesthesiology, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, China
- Chengdu Medical College, Chengdu, China
| | - Jie Xiao
- Department of Anesthesiology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Chengdu Medical College, Chengdu, China
| | - Guilin Xiang
- Department of Anesthesiology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Chengdu Medical College, Chengdu, China
| | - Xizhi Ding
- Department of Anesthesiology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Rong Jiang
- Department of Anesthesiology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Peng Li
- Department of Anesthesiology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
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Pişkin Ö, Altınsoy B, Baytar Ç, Aydın BG, Okyay D, Küçükosman G, Bollucuoğlu K, Yılmaz AG, Ayoğlu H. The effect of PECS-1 block on postoperative pain in total implantable venous access port catheter (TIVAP) insertion. J Vasc Access 2021; 24:402-408. [PMID: 34320865 DOI: 10.1177/11297298211034615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aim of this prospective, randomized, controlled study was to evaluate the analgesic effect of US-guided Pectoral (PECS) I blocks on postoperative analgesia after TIVAP insertion. METHODS A hundred-twenty patients were included in this study. The patients were divided into two groups: Group PECS and Group INF (infiltration). A total 0.4 mL kg-1 0.25% bupivacaine was injected to below the middle of the clavicle in the interfascial space between the pectoralis major and minor muscles for PECS-1. The skin and deep tissue infiltration of the anterior chest wall was performed with 0.4 mL kg-1 0.25% bupivacaine for INF group. Tramadol and paracetamol consumption, visual analog scale pain scores were recorded at 0, 1, 4, 12, and 24 h postoperatively. RESULTS The use of the PECS in TIVAP significantly decreased the amount of paracetamol used in the first 24 h postoperatively (p < 0.001). There was a statistically significant difference in the number of tramadol rescue analgesia administered between the groups (p < 0.001) There was no significant difference between the groups in terms of the VAS scores at 0 and 24 h. However, VAS scores at 1, 4, and 12 h were found to be significantly lower in patients who underwent PECS than in those who received infiltration anesthesia (p < 0.001). CONCLUSIONS This study shows that US-guided PECS-1 provides adequate analgesia following TIVAP insertion as part of multimodal analgesia. The PECS-1 significantly reduced opioid consumption.
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Affiliation(s)
- Özcan Pişkin
- Department of Anesthesiology and Reanimation, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Bülent Altınsoy
- Department of Pulmonary Medicine, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Çağdaş Baytar
- Department of Anesthesiology and Reanimation, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Bengü Gülhan Aydın
- Department of Anesthesiology and Reanimation, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Dilek Okyay
- Department of Anesthesiology and Reanimation, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Gamze Küçükosman
- Department of Anesthesiology and Reanimation, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Keziban Bollucuoğlu
- Department of Anesthesiology and Reanimation, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Alkım Gizem Yılmaz
- Department of Anesthesiology and Reanimation, School of Medicine, Yeditepe University, Istanbul, Turkey
| | - Hilal Ayoğlu
- Department of Anesthesiology and Reanimation, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
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Raigon Ponferrada A, Guerrero Orriach JL, Molina Ruiz JC, Romero Molina S, Gómez Luque A, Cruz Mañas J. Breast Cancer and Anaesthesia: Genetic Influence. Int J Mol Sci 2021; 22:7653. [PMID: 34299272 PMCID: PMC8307639 DOI: 10.3390/ijms22147653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 12/20/2022] Open
Abstract
Breast cancer is the leading cause of mortality in women. It is a heterogeneous disease with a high degree of inter-subject variability even in patients with the same type of tumor, with individualized medicine having acquired significant relevance in this field. The clinical and morphological heterogeneity of the different types of breast tumors has led to a diversity of staging and classification systems. Thus, these tumors show wide variability in genetic expression and prognostic biomarkers. Surgical treatment is essential in the management of these patients. However, the perioperative period has been found to significantly influence survival and cancer recurrence. There is growing interest in the pro-tumoral effect of different anaesthetic and analgesic agents used intraoperatively and their relationship with metastatic progression. There is cumulative evidence of the influence of anaesthetic techniques on the physiopathological mechanisms of survival and growth of the residual neoplastic cells released during surgery. Prospective randomized clinical trials are needed to obtain quality evidence on the relationship between cancer and anaesthesia. This document summarizes the evidence currently available about the effects of the anaesthetic agents and techniques used in primary cancer surgery and long-term oncologic outcomes, and the biomolecular mechanisms involved in their interaction.
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Affiliation(s)
- Aida Raigon Ponferrada
- Institute of Biomedical Research in Malaga (IBIMA), 29010 Malaga, Spain; (A.R.P.); (A.G.L.)
- Department of Anaesthesiology, Virgen de la Victoria University Hospital, 29010 Malaga, Spain; (J.C.M.R.); (S.R.M.); (J.C.M.)
| | - Jose Luis Guerrero Orriach
- Institute of Biomedical Research in Malaga (IBIMA), 29010 Malaga, Spain; (A.R.P.); (A.G.L.)
- Department of Anaesthesiology, Virgen de la Victoria University Hospital, 29010 Malaga, Spain; (J.C.M.R.); (S.R.M.); (J.C.M.)
- Department of Pharmacology and Pediatrics, School of Medicine, University of Malaga, 29010 Malaga, Spain
| | - Juan Carlos Molina Ruiz
- Department of Anaesthesiology, Virgen de la Victoria University Hospital, 29010 Malaga, Spain; (J.C.M.R.); (S.R.M.); (J.C.M.)
| | - Salvador Romero Molina
- Department of Anaesthesiology, Virgen de la Victoria University Hospital, 29010 Malaga, Spain; (J.C.M.R.); (S.R.M.); (J.C.M.)
| | - Aurelio Gómez Luque
- Institute of Biomedical Research in Malaga (IBIMA), 29010 Malaga, Spain; (A.R.P.); (A.G.L.)
- Department of Anaesthesiology, Virgen de la Victoria University Hospital, 29010 Malaga, Spain; (J.C.M.R.); (S.R.M.); (J.C.M.)
- Department of Pharmacology and Pediatrics, School of Medicine, University of Malaga, 29010 Malaga, Spain
| | - Jose Cruz Mañas
- Department of Anaesthesiology, Virgen de la Victoria University Hospital, 29010 Malaga, Spain; (J.C.M.R.); (S.R.M.); (J.C.M.)
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Hughey S, Cole J, Booth GJ, Gliniecki R, Stedjelarsen E. Effect of needle type on plane block spread in a cadaveric porcine model. BMJ Mil Health 2021:bmjmilitary-2021-001827. [PMID: 34266972 DOI: 10.1136/bmjmilitary-2021-001827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 06/27/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Plane blocks are an increasingly common type of regional anaesthesia technique in the perioperative period. Increased spread of local anaesthesia during plane blocks is thought to be related to an increased area of pain coverage. This study sought to assess differences in injectate spread comparing Tuohy needles with standard insulated stimulating block needles. METHODS 10 Yorkshire-Cross porcine cadavers were used in this study. Immediately following euthanasia, the cadavers underwent bilateral ultrasound-guided transversus abdominis plane (TAP) block injection with radiopaque contrast dye, with one side placed with a 20 g Tuohy needle, and the other side with a 20 g insulated stimulating block needle. Injectate spread was assessed using plain film X-ray and area of spread was measured to compare differences. RESULTS All 10 animals underwent successful ultrasound-guided TAP block placement. In all 10 animals, the area of contrast spread was greater with the Tuohy than stimulating needle. Wilcoxon signed-rank test was used to analyse the difference between the groups. The average difference between the two sides was 33.02% (p=0.002). CONCLUSIONS This is the first study to demonstrate differences in injectate spread with different needle types. This suggests enhanced spread with Tuohy needle compared with standard block needle, and may encourage its use during plane blocks.
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Affiliation(s)
- Scott Hughey
- Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA .,Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - J Cole
- Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA.,Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - G J Booth
- Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA.,Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - R Gliniecki
- Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - E Stedjelarsen
- Anesthesiology and Pain Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA.,Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
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40
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Chin KJ, Versyck B, Elsharkawy H, Rojas Gomez MF, Sala-Blanch X, Reina MA. Anatomical basis of fascial plane blocks. Reg Anesth Pain Med 2021; 46:581-599. [PMID: 34145071 DOI: 10.1136/rapm-2021-102506] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 11/04/2022]
Abstract
Fascial plane blocks (FPBs) are regional anesthesia techniques in which the space ("plane") between two discrete fascial layers is the target of needle insertion and injection. Analgesia is primarily achieved by local anesthetic spread to nerves traveling within this plane and adjacent tissues. This narrative review discusses key fundamental anatomical concepts relevant to FPBs, with a focus on blocks of the torso. Fascia, in this context, refers to any sheet of connective tissue that encloses or separates muscles and internal organs. The basic composition of fascia is a latticework of collagen fibers filled with a hydrated glycosaminoglycan matrix and infiltrated by adipocytes and fibroblasts; fluid can cross this by diffusion but not bulk flow. The plane between fascial layers is filled with a similar fat-glycosaminoglycan matric and provides gliding and cushioning between structures, as well as a pathway for nerves and vessels. The planes between the various muscle layers of the thorax, abdomen, and paraspinal area close to the thoracic paravertebral space and vertebral canal, are popular targets for ultrasound-guided local anesthetic injection. The pertinent musculofascial anatomy of these regions, together with the nerves involved in somatic and visceral innervation, are summarized. This knowledge will aid not only sonographic identification of landmarks and block performance, but also understanding of the potential pathways and barriers for spread of local anesthetic. It is also critical as the basis for further exploration and refinement of FPBs, with an emphasis on improving their clinical utility, efficacy, and safety.
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Affiliation(s)
- Ki Jinn Chin
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Barbara Versyck
- Department of Anaesthesia and Pain Medicine, Catharina Ziekenhuis, Eindhoven, North Brabant, The Netherlands.,Department of Anaesthesia and Pain Medicine, AZ Turnhout, Turnhout, Belgium
| | - Hesham Elsharkawy
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Anesthesiology, Case Western Reserve University, MetroHealth Pain and Healing Center, Cleveland, Ohio, USA
| | | | - Xavier Sala-Blanch
- Anesthesiology, Hospital Clinic de Barcelona, Barcelona, Spain.,Human Anatomy and Embryology, University of Barcelona Faculty of Medicine, Barcelona, Spain
| | - Miguel A Reina
- Department of Anesthesiology, Madrid-Monteprincipe University Hospital, CEU-San-Pablo University School of Medicine, Madrid, Spain
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Chin KJ, Lirk P, Hollmann MW, Schwarz SKW. Mechanisms of action of fascial plane blocks: a narrative review. Reg Anesth Pain Med 2021; 46:618-628. [PMID: 34145073 DOI: 10.1136/rapm-2020-102305] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Fascial plane blocks (FPBs) target the space between two fasciae, rather than discrete peripheral nerves. Despite their popularity, their mechanisms of action remain controversial, particularly for erector spinae plane and quadratus lumborum blocks. OBJECTIVES This narrative review describes the scientific evidence underpinning proposed mechanisms of action, highlights existing knowledge gaps, and discusses implications for clinical practice and research. FINDINGS There are currently two plausible mechanisms of analgesia. The first is a local effect on nociceptors and neurons within the plane itself or within adjacent muscle and tissue compartments. Dispersion of local anesthetic occurs through bulk flow and diffusion, and the resulting conduction block is dictated by the mass of local anesthetic reaching these targets. The extent of spread, analgesia, and cutaneous sensory loss is variable and imperfectly correlated. Explanations include anatomical variation, factors governing fluid dispersion, and local anesthetic pharmacodynamics. The second is vascular absorption of local anesthetic and a systemic analgesic effect at distant sites. Direct evidence is presently lacking but preliminary data indicate that FPBs can produce transient elevations in plasma concentrations similar to intravenous lidocaine infusion. The relative contributions of these local and systemic effects remain uncertain. CONCLUSION Our current understanding of FPB mechanisms supports their demonstrated analgesic efficacy, but also highlights the unpredictability and variability that result from myriad factors at play. Potential strategies to improve efficacy include accurate deposition close to targets of interest, injections of sufficient volume to encourage physical spread by bulk flow, and manipulation of concentration to promote diffusion.
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Affiliation(s)
- Ki Jinn Chin
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Philipp Lirk
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam Medical Centre, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology (L·E·I·C·A), Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Stephan K W Schwarz
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
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42
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Kim DH, Kim SJ, Liu J, Beathe J, Memtsoudis SG. Fascial plane blocks: a narrative review of the literature. Reg Anesth Pain Med 2021; 46:600-617. [PMID: 34145072 DOI: 10.1136/rapm-2020-101909] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- David H Kim
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Sang Jo Kim
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Jiabin Liu
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Jonathan Beathe
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Stavros G Memtsoudis
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA .,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
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Sercan O, Karaveli A, Ozmen S, Uslu A. Comparison of the Effects of Pectoral Nerve Block and Local Infiltration Anesthesia on Postoperative Pain for Breast Reduction Surgery: A Prospective Observational Study. Eurasian J Med 2021; 53:102-107. [PMID: 34177291 DOI: 10.5152/eurasianjmed.2021.20111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To evaluate the effects of the Pecs II block on postoperative pain in patients undergoing breast reduction surgery. Materials and Methods This prospective, comparative, and observational study was conducted with 53 patients, with American Society of Anesthesiologists I-II, between the ages of 18 and 65, and undergoing bilateral breast reduction surgery. The patients were divided into two groups: Pecs II block with general anesthesia (Pecs group; n = 26) and local infiltration anesthesia with general anesthesia (control group; n = 27). The patients' demographic data, duration of surgery and anesthesia, hemodynamic parameters, perioperative analgesia requirements, postoperative visual analog scale (VAS) scores (at zero, one, three, six, nine, and 12 hours postoperative), the number of patients who needed analgesia at least once, the length of the hospital stay, and block-related complications were recorded. Results There was no statistical difference in terms of the duration of surgery and anesthesia and hemodynamic parameters. Intraoperative total fentanyl consumption (128.85 ± 25.19 mcg in the Pecs group and 227.77 ± 44.58 mcg in the control group; P < .001) and postoperative analgesic requirement were significantly lower in the Pecs group (P < .001). The number of patients who needed analgesia at least once in the Pecs group was four (15.3%). Postoperative VAS scores were significantly lower (P < .001) and the length of the hospital stay was significantly shorter in the Pecs group (P < .001). No block-related complications were observed. Conclusion Pecs II block with general anesthesia may significantly contribute to reducing intraoperative and postoperative analgesia requirements and provide long-lasting and more effective postoperative pain in breast reduction surgery.
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Affiliation(s)
- Orcun Sercan
- Department of Anesthesiology and Reanimation, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
| | - Arzu Karaveli
- Department of Anesthesiology and Reanimation, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
| | - Sadik Ozmen
- Department of Anesthesiology and Reanimation, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
| | - Asim Uslu
- Department of Plastic and Reconstructive Surgery, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
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Chest Wall Regional Anesthesia for Modified Radical Mastectomy and Axillary Lymph Node Dissection: A Case Report. A A Pract 2021; 15:e01482. [PMID: 34043596 DOI: 10.1213/xaa.0000000000001482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Restrictive chest wall disorders impair cardiopulmonary physiology and pose anesthesia-related safety challenges. Regional anesthesia, as the primary anesthetic modality, may mitigate general anesthesia-related risks in such patients presenting for breast cancer surgery. We describe the use of chest wall fascial plane blocks as the primary anesthetic, combined with high-flow humidified nasal oxygen and low-dose propofol sedation, in a patient with complex comorbidities presenting for modified radical mastectomy and axillary lymph node dissection.
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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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46
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Tan PY, Anand SP, Chan DXH. Post-mastectomy pain syndrome: A timely review of its predisposing factors and current approaches to treatment. PROCEEDINGS OF SINGAPORE HEALTHCARE 2021. [DOI: 10.1177/20101058211006419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Post-mastectomy pain syndrome (PMPS) has been reported to occur in 25–60% of patients following surgeries for breast cancer, the highest occurring cancer in women worldwide. There has been much research interest due to this high prevalence. However, there is still a lack of incorporation of PMPS prevention strategies in standard perioperative plans, and our understanding of this condition is still incomplete. Objectives: This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and treatment and potential directions for future treatment and research. Methods: A PubMed search with the relevant keywords was done for articles published in the last 10 years. Results: The incidence of PMPS can be reduced by early recognition and management of modifiable risk factors as well as the perioperative use of analgesics and regional nerve blocks. These also have a significant role in the management of established PMPS together with surgical interventions and physical therapy. Conclusions: PMPS is still poorly defined and hence underdiagnosed and undertreated at this point. Perioperative peripheral nerve blocks have a very promising role as preventive analgesia to reduce the risk of developing PMPS, but large-scale randomised controlled studies will need to be done to evaluate their comparative efficacy. There is a need to prioritise PMPS prevention as a standard inclusion into the perioperative plans of mastectomy patients.
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Affiliation(s)
- Pei Yu Tan
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore Health Services, Singapore
| | - Singh Prit Anand
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore Health Services, Singapore
| | - Diana Xin Hui Chan
- Division of Anaesthesiology and Perioperative Medicine, Department of Pain Medicine, Singapore General Hospital, Singapore Health Services, Singapore
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47
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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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Jiao B, Liu J, Chen C. Comment on: Postoperative opioid administration characteristics associated with opioid-induced respiratory depression: Results from the PRODIGY trial. J Clin Anesth 2021; 71:110199. [PMID: 33714855 DOI: 10.1016/j.jclinane.2021.110199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Bo Jiao
- Department of Anesthesiology, West China Hospital, Sichuan University, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, China
| | - Chan Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, China.
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Helmich EJ, Van Den Broek RJ, Bloemen JG. Combined transverse thoracis plane and pectoral nerve blocks for breast surgery under sedation. Anaesth Rep 2021; 9:e12097. [PMID: 33554124 DOI: 10.1002/anr3.12097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2020] [Indexed: 11/10/2022] Open
Abstract
The pectoral nerves 2 (pecs 2) block is widely used as adjunct to general anaesthesia for breast surgery. There are a few case reports and a single case series that describe regional anaesthesia as a single technique or supplemented by light to moderate sedation. Here we describe the management of a 91-year-old ASA physical status 4 patient who presented with a T4 breast malignancy. She was considered unfit for general anaesthesia due to significant valvular heart disease. A wide local excision was successfully performed under a pecs 2 block and a transverse thoracis plane block, supplemented with light sedation. We consider this technique to be a good option for selected patients who are considered unfit for general anaesthesia.
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Affiliation(s)
- E J Helmich
- Department of Anaesthesiology and Pain Medicine Catharina Hospital Eindhoven The Netherlands
| | - R J Van Den Broek
- Department of Anaesthesiology and Pain Medicine Catharina Hospital Eindhoven The Netherlands
| | - J G Bloemen
- Department of Surgery Catharina Hospital Eindhoven The Netherlands
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Kubodera K, Fujii T, Akane A, Aoki W, Sekiguchi A, Iwata K, Ban M, Ando R, Nakamura N, Shibata Y, Nishiwaki K. <Editors' Choice> Efficacy of pectoral nerve block type-2 (Pecs II block) versus serratus plane block for postoperative analgesia in breast cancer surgery: a retrospective study. NAGOYA JOURNAL OF MEDICAL SCIENCE 2021; 82:93-99. [PMID: 32273637 PMCID: PMC7103864 DOI: 10.18999/nagjms.82.1.93] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Thoracic wall nerve blocks reduce postoperative acute pain after breast cancer surgery (BCS); however, their short-term effects and the most effective technique remain unclear. To compare the effects of pectoral nerve block type-2 (Pecs II block) and serratus plane block for postoperative short-term analgesia, we retrospectively reviewed 43 BCS patients who underwent Pecs II block (n=22) or serratus plane block (n=21). The primary outcome was the proportion of patients with no complaints of pain 2 months post-BCS. The odds ratio (OR) was assessed, adjusting for axillary lymph node dissection. The secondary outcomes were pain severity 24 hours and 2 months post-operation using the numerical rating scale score, and morphine consumption within 24 hours. The proportion of patients without pain 2 months post-BCS was significantly less with Pecs II block than in patients with serratus plane block (55% vs. 19%, adjusted OR, 5.04; 95% confidence interval, 1.26-20.07; P=0.02); the median [interquartile range] score for pain 2 months post-operation was also significantly lower with Pecs II block (Pecs II block 0.5 [0-1] vs. serratus plane block 1 [1-2]); P=0.03). Regarding post-BCS acute analgesia, the median [interquartile range] postoperative 24-hour pain score was 2 [1-3] and 3 [1.5-3.5], and the median morphine consumption within 24 hours was 1.5 [0.75-5.5] and 3 [1.5-10] mg in Pecs II block and serratus plane block (P=0.47 and P=0.11), respectively. This study suggests that Pecs II block prevents short-term post-BCS pain better than serratus plane block. However, further studies are needed in order to support this finding.
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Affiliation(s)
- Kazumi Kubodera
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Tasuku Fujii
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akiko Akane
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Wakana Aoki
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Akiko Sekiguchi
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Keiko Iwata
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Makiko Ban
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Reiko Ando
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Nozomi Nakamura
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Yasuyuki Shibata
- Department of Surgical Center, Nagoya University Hospital, Nagoya, Japan
| | - Kimitoshi Nishiwaki
- Department of Anesthesiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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