Evaluation of ultrasound-guided rhomboid intercostal nerve block for postoperative analgesia in breast cancer surgery: a prospective, randomized controlled trial

Effectiveness of ultrasound-guided rhomboid intercostal and sub-serratus block for perioperative analgesia in male patients undergoing combined power-assisted liposuction with pull-through excision of the gland for breast definition and reshaping

BACKGROUND

The newly introduced ultrasound guided interfacial rhomboid intercostal and sub-serratus (RISS) block technique demonstrated promising efficacy in managing perioperative pain among patients undergoing abdominal and thoracic procedures. Thus, this study investigated the efficiency of bilateral ultrasound-guided RISS (US-RISS) as a perioperative pain control technique in male subjects receiving gynecomastia surgery.

METHODS

This prospective randomized study involved sixty patients who underwent gynecomastia surgery. Individuals were randomly divided into two groups: the RISS group (N.=30) and the control group (N.=30). After anesthesia induction, the patients received bilateral US-RISS using 40 mL of 0.25% levobupivacaine, or conventional intravenous analgesia with no intervention, respectively. The primary outcome was the overall morphine consumption in 24 hours, and the secondary endpoints involved the time elapsed till rescue analgesia was requested, the quality of recovery after 24 hours and side effects' incidence.

RESULTS

Morphine consumption was noticeably decreased in the RISS group compared to the control group, with 14.07±4.91 mg and 35.83±1.70 mg mean values, respectively (P<0.001). Furthermore, in the RISS group, the initial rescue analgesia request occurred significantly later than in the control group, with mean values of 15.58±1.41 hours and 0.96±0.63 hours, respectively (P<0.001). Additionally, within the RISS group, there was a high quality of recovery observed, with a low incidence of opioid-related adverse events in comparison to the control group.

CONCLUSIONS

Bilateral US-RISS block is a beneficial intervention in gynecomastia surgery for pain management and improves the quality of recovery.

Investigation of the analgesic effects of rhomboid intercostal and pectoral nerve blocks in breast surgery

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.

Novel Serratus Posterior Superior Intercostal Plane Block Provided Satisfactory Analgesia after Breast Cancer Surgery: Two Case Reports

The serratus posterior superior intercostal plane (SPSIP) block is a novel technique recently described for thoracic analgesia. This study presents two cases using this technique for postoperative pain after mastectomy with axillary lymph node dissection. The SPSIP block was administered to the patients in the preoperative period as part of multimodal analgesia, and postoperative pain was monitored using the numeric rating scale (NRS). In both patients, the NRS pain scores were below 3/10. SPSIP provided adequate postoperative analgesia in these cases without the need for any opioid agents. Thus, an SPSIP block can be a valuable treatment option for postoperative pain after breast surgery.

Efficacy of modified thoracoabdominal nerve block through perichondrial approach following laparoscopic inguinal hernia repair surgery: a randomized controlled trial

BACKGROUND

Modified thoracoabdominal nerve block through perichondrial approach is a novel fascial plane block and provides abdominal analgesia by blocking thoracoabdominal nerves. Our primary aim was to evaluate the efficacy of M-TAPA on quality of recovery and pain scores in patients who underwent laparoscopic inguinal hernia repair surgery (Trans Abdominal Pre-Peritoneal approach ‒ TAPP).

METHODS

Patients with American Society of Anesthesiologists (ASA) physical status I-II aged between 18 and 65 years scheduled for elective TAPP under general anesthesia were enrolled in the study. After intubation, the patients were randomized into two groups: M: M-TAPA group (n = 30) and the control group (n = 30). M-TAPA was performed with total 40 ml 0.25% bupivacaine in the M group. Surgical infiltration was performed in the control group. The primary outcome of the study was the global quality of recovery score, the secondary outcomes were pain scores, rescue analgesic demands, and adverse effects during the 24-h postoperative period.

RESULTS

The global quality of recovery scores at 24 h were significantly higher in the M group (p < 0.001). There was a reduction in the median static and dynamic NRS for the first postoperative 8 h in the M group compared to the control group (p < 0.001). The need for rescue analgesia was significantly lower in the M group compared to the control group (13 patients vs. 24 respectively, p < 0.001). The incidence of side effects was significantly higher in the control group (p < 0.001).

CONCLUSION

In our study, M-TAPA increased patient recovery scores, and provided pain relief in patients who underwent TAPP.

REGISTER NUMBER

NCT05199922.

Rhomboid intercostal block or thoracic paravertebral block for postoperative recovery quality after video-assisted thoracic surgery: A prospective, non-inferiority, randomised controlled trial

BACKGROUND

The analgesic characteristics of rhomboid intercostal block (RIB) remain unclear. Before it can be fully recommended, we compared the recovery quality and analgesic effects of RIB and thoracic paravertebral block (TPVB) for video-assisted thoracoscopic surgery (VATS).

OBJECTIVE

The current study aimed to investigate whether there is a difference in postoperative recovery quality between TPVB and RIB.

DESIGN

A prospective, non-inferiority, randomised controlled trial.

SETTING

Affiliated Hospital of Jiaxing University in China from March 2021 to August 2022.

PATIENTS

Eighty patients aged 18 to 80 years, with ASA physical status I to III, and scheduled for elective VATS were enrolled in the trial.

INTERVENTION

Ultrasound-guided TPVB or RIB was performed with 20 ml 0.375% ropivacaine.

MAIN OUTCOME MEASURES

The primary outcome of the study was the mean difference of quality of recovery-40 scores 24 h postoperatively. The non-inferiority margin was defined as 6.3. Numeric rating scores (NRS) for pain at 0.5, 1, 3, 6, 12, 24 and 48 h postoperatively in all patients were also recorded.

RESULTS

A total of 75 participants completed the study. The mean difference of quality of recovery-40 scores 24 h postoperatively was -1.6 (95% CI, -4.5 to 1.3), demonstrating the non-inferiority of RIB to TPVB. There was no significant difference between the two groups in the area under the curve for pain NRS over time, at rest and on movement, at 6, 12, 24 and 48 h postoperatively (all P  > 0.05), except for the area under the curve pain NRS over time on movement at 48 h postoperatively ( P  = 0.046). There were no statistical differences between the two groups in the postoperative sufentanil use at 0 to 24 h or 24 to 48 h (all P  > 0.05).

CONCLUSION

Our study suggests that RIB was non-inferior to TPVB for the quality of recovery, with almost the same postoperative analgesic effect as TPVB after VATS.

CLINICAL TRIAL REGISTRATION

chictr.org.cn: ChiCTR2100043841.

Rhomboid intercostal block versus serratus block for postoperative analgesia after thoracoscopic sympathectomy for primary palmar hyperhidrosis: a randomized controlled trial

BACKGROUND

Although thoracoscopic sympathectomy is made via small incisions, it is associated with severe postoperative pain. Both Rhomboid intercostal block (RIB) and serratus anterior plane block (SABP) are recent techniques used for pain control after such procedures. Herein, we compared RIB and SAPB regarding pain control in patients undergoing thoracoscopic sympathectomy for palmar hyperhidrosis.

PATIENTS AND METHODS

Three groups were enrolled in this prospective randomized study (71 patients in each group); Group S received SAPB, Group R received RIB and Group C as controls. The block procedures were performed after general anesthesia and prior to the skin incision.

RESULTS

The three groups showed comparable demographics and operative time (P ˃ 0.05). Pain scores showed a significant decline with the two block procedures compared to controls during the first day following surgery (both P ˂ 0.05), but Group R had better scores compared to Group S. Both block techniques were associated with a significant prolongation of the time to first rescue analgesic and less fentanyl consumption compared to controls (both P ˂ 0.05). However, both parameters were improved with RIB rather than SAPB (both P ˂ 0.05). Both blocks led to a significant improvement in patient satisfaction than in the control group (both P ˂ 0.05), but it was comparable between the two approaches (P ˃ 0.05).

CONCLUSION

Both RIB and SAPB are safe and effective in pain reduction after thoracoscopic sympathectomy procedures in patients with hyperhidrosis. Moreover, RIB is superior to SAPB as it is associated with better analgesic outcomes.

TRIAL REGISTRATION

Pan African Trial Registry PACTR202203766891354. https://pactr.samrc.ac.za/Researcher/TrialRegister.aspx?TrialID=21522.

The postoperative analgesic efficacy of different regional anesthesia techniques in breast cancer surgery: A network meta-analysis

Background

Regional anesthesia have been successfully performed for pain management in breast cancer surgery, but it is unclear which is the best regional anesthesia technique. The aim of the present network meta-analysis was to assess the analgesic efficacy and disadvantages of regional anesthesia techniques.

Methods

Multiple databases were searched for randomized controlled trials (RCTs). The association between regional anesthesia and analgesic efficacy was evaluated by Bayesian network meta-analysis.

Results

We included 100 RCTs and 6639 patients in this study. The network meta-analysis showed that paravertebral nerve block, pectoral nerve-2 block, serratus anterior plane block, erector spinae plane block, rhomboid intercostal block, and local anesthetic infusion were associated with significantly decreased postoperative pain scores, morphine consumption and incidence of postoperative nausea and vomiting compared with no block. Regarding the incidence of chronic pain, no significance was detected between the different regional anesthesia techniques. In the cumulative ranking curve analysis, the rank of the rhomboid intercostal block was the for postoperative care unit pain scores, postoperative 24-hour morphine consumption, and incidence of postoperative nausea and vomiting.

Conclusion

Regional anesthesia techniques including, paravertebral nerve block, pectoral nerve-2 block, serratus anterior plane block, erector spinae plane block, rhomboid intercostal block, and local anesthetic infusion, can effectively alleviate postoperative acute analgesia and reduce postoperative morphine consumption, but cannot reduce chronic pain after breast surgery. The rhomboid intercostal block might be the optimal technique for postoperative analgesia in breast cancer surgery, but the strength of the evidence was very low.

Systematic review registration

https://www.crd.york.ac.uk/prospero/(PROSPERO), identifier CRD 42020220763.

Association of peripheral nerve blocks with patient-reported quality of recovery in female patients receiving breast cancer surgery: a systematic review and meta-analysis of randomized controlled studies

PURPOSE

This systematic review and meta-analysis investigated the impact of peripheral nerve blocks (PNBs) on patient-reported quality of recovery (QoR) following breast cancer surgery.

SOURCE

Medline, EMBASE, Cochrane Library, and Google scholar databases were searched for randomized controlled trials (RCTs) comparing the QoR with or without PNBs in patients receiving breast cancer surgery from inception to September 2021. Using a random effects model, the primary outcome was total scores of postoperative QoR scales (i.e., QoR-15 and QoR-40).

PRINCIPAL FINDINGS

Eight RCTs (QoR-15, n = 4; QoR-40, n = 4) involving 653 patients published from 2018 to 2021 were included. For the QoR-40 scale, pooled results revealed a significantly higher total score (mean difference [MD], 12.8 [8.2%]; 95% confidence interval [CI], 10.6 to 14.9; I² = 59%; five RCTs; n = 251) and scores on all subscales, except psychological support, in the PNB group than in controls at 24 hr after surgery. For the QoR-15 scale, pooled results also showed favorable QoR (MD, 7.7 [5.2%]; 95% CI, 4.9 to 10.5; I² = 75%; four RCTs; n = 402) in the PNB group at 24 hr after surgery. Sensitivity analysis showed no effect on the QoR-40 score and the difference in total QoR-15 score was no longer significant when a single trial was omitted. The use of PNBs was associated with a significantly lower opioid consumption and risk of postoperative nausea and vomiting without significant differences in the pain score between the two groups.

CONCLUSION

Our results verified the efficacy of PNBs for enhancing postoperative QoR using two validated patient-reported tools in female patients receiving breast cancer surgery under general anesthesia.

STUDY REGISTRATION

PROSPERO (CRD42021272575); first submitted 9 August 2021.

Incidence, risk factors, prevention and treatment of postmastectomy pain syndrome in breast cancer: A multicenter study

BACKGROUND

Postmastectomy pain syndrome (PMPS) is a common postoperative condition after breast cancer surgery.

PURPOSE

The aim of this study was to investigate the incidence rate and risk factors of PMPS, and to propose prevention and treatment methods.

METHODS

The study included 1790 postoperative breast cancer patients from three hospitals from 2017 to 2021, of which 302 (13.0%) patients with PMPS were included in the study.

RESULTS

Age, breast surgery type, axillary surgery type and radiotherapy are the risk factors of PMPS. Age, radiotherapy and chemotherapy affect the pain degree of PMPS during movement.

CONCLUSIONS

For breast cancer patients with high risk factors, pain should be actively prevented during perioperative period. Oral pharmacological agents, multidisciplinary combination therapy, local anesthetics and regional anesthesia are the most common treatment of PMPS.

Effect of Scalp Nerve Block Combined with Intercostal Nerve Block on the Quality of Recovery in Patients with Parkinson’s Disease after Deep Brain Stimulation: Protocol for a Randomized Controlled Trial

Background: Parkinson’s disease (PD) patients who receive deep brain stimulation (DBS) have a higher risk of postoperative pain, which will affect their postoperative quality of recovery (QoR). Scalp nerve block (SNB) and intercostal nerve block (ICNB) can alleviate postoperative pain, yet their effect on postoperative QoR in PD patients has proven to be unclear. Therefore, we have aimed to explore the effect of SNB paired with ICNB on postoperative QoR. Methods: To explore the effect, we have designed a randomized controlled trial in which 88 patients with PD will be randomly assigned to either an SNB group or control group, receiving either SNB combined with ICNB or without before surgery. The primary outcome will be a 15-item QoR score at 24 h after surgery. The secondary outcomes will include: 15-item QoR scores at 72 h and 1 month after surgery; the numeric rating scale pain scores before discharge from the postanesthesia care unit (PACU) at 24 h, 72 h, and 1 month after surgery; rescue analgesics; nausea and vomiting 24 h after operation and remifentanil consumption during operation; emergence agitation; the duration of anesthesia and surgery; time to respiratory recovery, time to response, and time to extubation; the PACU length of stay; as well as adverse events. Proposed protocol and conclusion: Our findings will provide a novel method for the management of recovery and acute pain after DBS in PD patients. This research was registered at clinicaltrials.gov NCT05353764 on 19 April 2022.

Continuous Rhomboid Intercostal Block for Thoracoscopic Postoperative Analgesia

BACKGROUND

Rhomboid intercostal block is a type of plane block used for postoperative analgesia after video-assisted thoracoscopic surgery. This prospective randomized controlled trial was conducted to investigate the effects of ultrasound-guided continuous rhomboid intercostal block (CRIB) on the global Quality of Recovery (QoR-40) scores and postoperative analgesia after video-assisted thoracoscopic surgery.

METHODS

A total of 66 adult patients scheduled for elective unilateral video-assisted thoracoscopic surgery were randomly allocated to group C and group CRIB. In group C, patients were administered patient-controlled intravenous analgesia with sufentanil after operation. Patients in group CRIB received patient-controlled analgesia with ropivacaine CRIB. All patients completed the QoR-40 test during the preoperative evaluation and again 24 hours after the operation. Information on 48-hour postoperative pain and adverse events was recorded.

RESULTS

The QoR-40 scores of group C were significantly lower than the scores of group CRIB (155.4 ± 6.1 vs 172.6 ± 6.3; P < .001), with a mean difference of -17.2 (95% CI, -20.4 to -13.9) 24 hours after operation. The postoperative numeric rating scale scores in group CRIB at 6, 12, 18, and 24 hours after the surgical procedure, when patients were at rest, were significantly lower than the scores in group C (all P < .05). The postoperative numeric rating scale scores in group CRIB at 1, 3, 6, 12, 18, 24, and 36 hours after surgical procedure, when patients were moving, were significantly lower than the scores in group C (all P < .05).

CONCLUSIONS

In patients who underwent video-assisted thoracoscopic surgery, CRIB led to improved quality of recovery and postoperative analgesia.

Single-injection regional analgesia techniques for mastectomy surgery: A network meta-analysis

BACKGROUND

Patients undergoing mastectomy surgery experience severe postoperative pain. Several regional techniques have been developed to reduce pain intensity but it is unclear, which of these techniques is most effective.

OBJECTIVES

To synthesise direct and indirect comparisons for the relative efficacy of different regional and local analgesia techniques in the setting of unilateral mastectomy. Postoperative opioid consumption at 24 h, postoperative pain at extubation, 1, 12 and 24 h, postoperative nausea and vomiting were collected.

DESIGN

Systematic review with network meta-analysis (PROSPERO:CRD42021250651).

DATA SOURCE

PubMed, Scopus, the Cochrane Central Register of Controlled Trials (from inception until 7 July 2021).

ELIGIBILITY CRITERIA

All randomised controlled trials investigating single-injection regional and local analgesia techniques in adult patients undergoing unilateral mastectomy were included in our study without any language or publication date restriction.

RESULTS

Sixty-two included studies randomising 4074 patients and investigating nine techniques entered the analysis. All techniques were associated with less opioid consumption compared with controls The greatest mean difference [95% confidence interval (CI)] was associated with deep serratus anterior plane block: mean difference -16.1 mg (95% CI, -20.7 to -11.6). The greatest reduction in pain score was associated with the interpectoral-pecto-serratus plane block (mean difference -1.3, 95% CI, -1.6 to - 1) at 12 h postoperatively, and with superficial serratus anterior plane block (mean difference -1.4, 95% CI, -2.4 to -0.5) at 24 h. Interpectoral-pectoserratus plane block resulted in the greatest statistically significant reduction in postoperative nausea/vomiting when compared with placebo/no intervention with an OR of 0.23 (95% CI, 0.13 to 0.40).

CONCLUSION

All techniques were associated with superior analgesia and less opioid consumption compared with controls. No single technique was identified as superior to others. In comparison, local anaesthetic infiltration does not offer advantages over multimodal analgesia alone.

TRIAL REGISTRATION

PROSPERO (CRD4202125065).

Postoperative recovery: how and when is it assessed: a scoping review

BACKGROUND

There is no consensus about the type of instrument with which to assess postoperative recovery or the time points when assessments are most appropriate. It is also unclear whether instruments measure the four dimensions of postoperative recovery, that is physical, psychological, social, and habitual recovery. This scoping review had three objectives: (1) to identify and describe instruments used in clinical trials to assess postoperative recovery; (2) to determine how, when, and the number of times postoperative recovery was measured; and (3) to explore whether the four dimensions of postoperative recovery are represented in the identified instruments.

METHODS

A literature search was conducted in CINAHL, MEDLINE, and Web of Science. The search terms were related to three search strands: postoperative recovery, instrument, and clinical trials. The limits were English language and publication January 2010 to November 2021. In total, 5015 studies were identified.

RESULTS

A total of 198 studies were included in the results. We identified 20 instruments measuring postoperative recovery. Different versions of Quality of Recovery represented 81.8% of the included instruments. Postoperative recovery was often assessed at one time point (47.2%) and most often on postoperative day 1 (81.5%). Thirteen instruments had items covering all four dimensions of postoperative recovery.

CONCLUSIONS

Assessing recovery is important to evaluate and improve perioperative care. We emphasise the importance of choosing the right instrument for the concept studied and, if postoperative recovery is of interest, of assessing more than once. Ideally, instruments should include all four dimensions to cover the whole recovery process.

Use of ultrasound guided single shot costotransverse block (intertransverse process) in breast cancer surgery: a prospective, randomized, assessor blinded, controlled clinical trial

BACKGROUND

Ultrasound guided costotransverse block (CTB) is a relatively new "peri-paravertebral" block that has been described recently. It has been previously reported that CTB, administered with a single high-volume injection, provides effective analgesia in breast conserving surgery. In this study we evaluated the effect of CTB when used in breast cancer surgery.

METHODS

Seventy patients due to undergo breast cancer surgery were included in this blinded, prospective, randomized, efficiency study. Patients were randomized into two equal groups (CTB group and control group) using the closed envelope technique. All patients underwent general anesthesia. In addition to standard analgesia methods, patients in group CTB also received CTB block while the remaining (control group) did not. Numeric rating (pain) scores and opioid consumption was compared between the two groups.

RESULTS

Opioid consumption in all time frames and pain scores at 1st and 3rd hours only were found to be significantly lower in Group CTB when compared to the control group.

CONCLUSIONS

Ultrasound guided CTB improves analgesia quality in breast cancer surgery.

TRIAL REGISTRATION

Clinicaltrials Registration ID: NCT04197206 , Registration Date: 13/12/2019.

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery.

METHODS

In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting.

RESULTS

Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting.

CONCLUSION

Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice.

STUDY REGISTRATION

PROSPERO (CRD42020198244); registered 19 October 2020.

Efficacy and safety of rhomboid intercostal block for analgesia in breast surgery and thoracoscopic surgery: a meta-analysis

BACKGROUND

Rhomboid intercostal block (RIB) is a new regional anesthesia technique that provides postoperative analgesia for breast surgery and thoracoscopic surgery. The published papers are not yet fully integrated and do not adequately address the impact and safety of the RIB on postoperative pain.

METHODS

The PubMed, Web of Science and Embase were searched from 2016 to 2021 for all available randomized controlled trials (RCTs) that evaluated the analgesic efficacy and safety of RIB after thoracic surgery and breast surgery. Random and fixed-effects meta-analytical models were used where indicated, and between-study heterogeneity was assessed. The primary outcome was Postoperative Numerical Rating Scale (NRS) scores of patients at rest recorded 0-1, 6-8, 24 h after surgery. The secondary outcomes included rate of postoperative nausea and vomiting (PONV), postoperative fentanyl consumption and presence of complications of the block.

RESULTS

From 81 records identified, four studies met our inclusion criteria, including 216 patients (RIB:108 patients; no block: 108 patients). In the primary outcome, RIB group showed significantly lower postoperative NRS at rest at first 0-1 h and 6-8 h (weighted mean difference [WMD] = -1.55; 95% confidence internal [CI] = -2.92 to -0.19; p < 0.05), (WMD = -0. 69; 95% CI = -1.29 to -0. 09; p < 0. 05). And there was no significant difference between groups in NRS at rest at 24 h (WMD = -0.78; 95% CI = -1.64 to -0.08; p = 0.77). Also, RIB group showed significantly lower postoperative NRS of breast surgery and thoracoscopic surgery at 0-1 h (WMD = -3.00; 95% CI = -3.13 to -2.87; p < 0.01), (WMD = -1.08; 95% CI = -1.98 to -0.18; p < 0.05). In the secondary outcome, the analysis also showed RIB group had significant lower of POVN rates (summary relative risk (RR) = 0.212;95%CI = 0.10 to 0.45; p < 0. 01) and the postoperative consumption of fentanyl (WMD = -57.52;95%CI = -106.03 to -9.02; p < 0. 05).

CONCLUSION

This review shows that RIB was more effective in controlling acute pain after breast surgery and thoracoscopic surgery than general analgesia. And it is a trend that RIB may be a kind of effective and safe nerve bock technology and it requires further studies.

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

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.

Evaluation of Rhomboid Intercostal Block in Video-Assisted Thoracic Surgery: Comparing Three Concentrations of Ropivacaine

Background: Ultrasound-guided rhombic intercostal block (RIB) is a novel regional block that provides analgesia for patients who have received video-assisted thoracoscopic surgery (VATS). The anesthetic characteristics of ultrasound-guided RIB with different concentrations of ropivacaine are not known. This research primarily hypothesizes that ultrasound-guided RIB, given in combination with the same volume of different concentrations of ropivacaine, would improve the whole quality of recovery-40 (QoR-40) among patients with VATS.

Approaches: This double-blinded, single-center, prospective, and controlled trial randomized 100 patients undergoing VATS to receive RIB. One hundred patients who have received elective VATS and satisfied inclusion standards were fallen into four groups randomly: control group with no RIB and R_0.2%, R_0.3%, and R_0.4%; they underwent common anesthesia plus the RIB with ropivacaine at 0.2%, 0.3%, and 0.4% in a volume of 30 ml.

Outcomes: Groups R_0.2%, R_0.3%, and R_0.4% displayed great diversities in the overall QoR-40 scores and QoR-40 dimensions (in addition to psychological support) by comparing with the control group (Group C) (p < 0.001 for all contrasts). Groups R_0.3% and R_0.4% displayed great diversities in the overall QoR-40 scores and QoR-40 dimensions (in addition to psychological support) by comparing with the R_0.2% group (p < 0.001 for all contrasts). The overall QoR-40 scores and QoR-40 dimensions [physical comfort (p = 0.585)] did not vary greatly between Groups R_0.3% and R_0.4% (p > 0.05 for all contrasts). Groups R_0.2%, R_0.3%, and R_0.4% showed significant differences in numerical rating scales (NRS) score region under the curve (AUC) at rest and on movement in 48 h when compared with the Group C (p < 0.001 for all contrasts). Groups R_0.3% and R_0.4% displayed great diversities in NRS score AUC at rest and on movement in 48 h when compared with the R_0.2% group (p < 0.001 for all contrasts). The NRS mark AUC at rest and, on movement in 48 h, did not vary greatly between the Group R_0.3% and R_0.4% (p > 0.05 for all contrasts).

Conclusion: In this study it was found that a dose of 0.3% ropivacaine is the best concentration for RIB for patients undergoing VATS. Through growing ropivacaine concentration, the analgesia of the RIB was not improved greatly.

Clinicaltrials.gov Registration:https://clinicaltrials.gov/, identifier ChiCTR2100046254.

Chest Wall Nerve Blocks for Cardiothoracic, Breast Surgery, and Rib-Related Pain

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.

Association between aesthetic satisfaction and chronic postsurgical pain in breast cancer patients treated with one stage prosthesis implantation

This study retrospectively studied the incidence of chronic post-surgical pain (CPSP) following single-stage implant-based breast reconstruction (IBBR) and evaluated the possible risk factors. This was a retrospective cohort study, involving all patients undergoing single-stage IBBR between January and December 2019. The follow-up was completed between January and March 2021. The scores for satisfaction (SS) were based on the BREAST-Q, while the pain burden index (PBI) was used to assess the degree of CPSP. The questionnaires were completed by 159 patients. CPSP occurred in 48.43% of the patients, 2.52% of them being severe cases. Significant predictors for the development of CPSP in the univariate analysis included severe acute postoperative pain (PP), a history of preoperative chronic pain, psychological disorders, SS with the reconstructed breasts, and whether there were any regrets about having had the reconstruction. Multivariate analysis identified severe acute PP (odds ratio (OR) = 2.80, 95% confidence interval (CI) = 1.16–6.79, p = 0.023), a history of preoperative chronic pain (OR = 3.39, 95% CI = 1.42–8.10, p = 0.006), and the SS (OR = 0.86, 95% CI = 0.75–0.99, p = 0.034) as being independently associated with the development of CPSP. In subgroup analysis, the PBI of the patients in the SS < 12 group (p < 0.001), the bilateral group (p < 0.01), and the severe acute PP group (p < 0.005) was significantly higher than the PBI of those in the control groups. This study demonstrated a significant incidence of CPSP following single-stage IBBR, and the patients with lower SS of their reconstructed breasts developed more CPSP. Lower SS, bilateral procedures, and severe acute PP were predictors of higher PBI.

Trial registration: Registered in Chictr.org.cn registry system on 24 February 2020 (ChiCTR2000030139).

Comparison of Rhomboid Intercostal Block, Erector Spinae Plane Block, and Serratus Plane Block on Analgesia for Video-Assisted Thoracic Surgery: A Prospective, Randomized, Controlled Trial

BACKGROUND

Thoracic surgery is one of the most painful surgical steps. An important tool for managing postoperative pain is effective postoperative analgesia. This research aimed at comparing the analgesic roles of three new fascial block techniques in the postoperative period after video-helped thoracoscopic operation (VATS).

METHODS

We randomly allocated ninety patients into three teams experiencing ultrasound-directed serratus plane block, erector spinae plane block, and the rhomboid intercostal block, respectively. 0.4% ropivacaine of 20 mL was received by all groups. Outcomes. At 0-12 hours, sufentanil consumption was significantly lower in the RIB (35.2 ± 3.3 mg) and ESP (35.4 ± 2.8 mg) groups than that in the SAB (43.3 ± 2.7 mg) group (P < 0.001), and no obvious diversity in sufentanil consumption was shown between the RIB and ESP groups (P=0.813). At 12-24 hours, sufentanil consumption was greatly lower in the RIB and ESP groups than that in the SAB group (P < 0.001), and no great diversity in sufentanil consumption was found between the RIB and ESP groups (P=0.589). No great diversity in sufentanil consumption was shown between the RIB (50.4 ± 1.4 mg), ESP (50.4 ± 1.5 mg), and SAB (51.0 ± 1.7 mg) groups at 24-48 hours (P=0.192). At 6, 12, 18, and 24 hours, the postoperative dynamic NRS scores were significantly lower in the RIB and ESP groups than in the SAB group ((P < 0.05) for all contrasts). Nevertheless, no great diversity was observed in postoperative pain marks at 0.5, 1, 3, 6, 12, 18, 24, 36, and 48 hours after the surgery across the three groups. No statistical diversity was found in the postoperative NRS mark between groups RIB and ESP within 48 hours after surgery in case of active patients ((P < 0.05) for all contrasts). At 24 hours after surgery, a significant difference in IL-1β and IL-6 inflammatory factor concentrations was found between RIB and ESP compared with SAB block ((P < 0.05) for all contrasts). However, no great diversities were observed in IL-1β, and IL-6 inflammatory factor concentrations between RIB, ESP, and SAB at 24 hours preoperatively and at 48 hours postoperatively ((P < 0.05) for all comparisons).

CONCLUSION

The dosage of sufentanil can be effectively reduced by ultrasound-directed rhomboid intercostal block and erector spinae plane block within 24 hours after VATS surgery, and pain can be relieved effectively within 24 hours by comparing with serratus plane block.

Systematic review and meta-analysis of the efficacy of general anesthesia combined with a thoracic nerve block in modified breast cancer surgery

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.

Comparison of rhomboid intercostal nerve block, erector spinae plane block and serratus plane block on analgesia for modified radical mastectomy: A prospective randomised controlled trial

BACKGROUND AND OBJECTIVES

Breast cancer is one of the most common malignant tumours among women. In this study, we compared the analgesic efficacy of ultrasound (US)-guided rhomboid intercostal nerve block, erector spinae plane (ESP) block and serratus plane block (SAB) after modified radical mastectomy (MRM) of unilateral breast cancer.

METHODS

This study involved a double-blind clinical trial that was carried out in the Affiliated Hospital of Jiaxing University on 23 September 2020. The inclusion criteria were the following: The American Society of Anesthesiologists (ASA) grade needed to be 1-2, the patients needed to be between 18 and 80 years old, and MRM needed to be proposed in our hospital. The exclusion criteria were patients with contraindications related to nerve block. Ninety patients were randomly divided into three groups receiving US-guided SAB, ESP block and rhomboid intercostal block (RIB). All groups received 20 mL 0.5% ropivacaine. Within 24 hours after the operation, the patients received an intravenous injection of tramadol 1-2 mg/kg in the surgical ward for pain relief.

RESULTS

The dosage of tramadol 24 hours after the operation in the RIB (269.67 ± 48.75 mg) and ESP block groups (273.67 ± 36.90 mg) was significantly lower than that in the SAB group (314.33 ± 18.88 mg) (P < .001). There was no statistical difference in tramadol consumption between the ESP block and RIB groups within 24 hours (P = .676). The numerical rating scale (NRS) scores in the ESP block and RIB groups at 0.5, 1, 3, 6, 12, 18 and 24 hours after the operation once patients were active were significantly lower than that in the SAB group (P < .05 for all comparisons); however, the NRS scores of the RIB and ESP block groups did not differ significantly within 24 hours after surgery when patients were active.

CONCLUSIONS

US-guided rhomboid intercostal block (US-RIB) and ESP block can effectively reduce the dosage of tramadol within 24 hours after MRM, and they can effectively relieve pain within 24 hours after MRM compared with SAB.

Rhomboid Intercostal Block Combined With Interscalene Nerve Block for Sternoclavicular Joint Reconstruction

Background: Rhomboid intercostal block is a newer technique for chest wall analgesia and can be an effective alternative to thoracic epidurals and paravertebral blocks. We performed a rhomboid intercostal block after sternoclavicular joint reconstruction surgery.

Case Report: A healthy 26-year-old male who had chronic right sternoclavicular joint instability was scheduled for right medial clavicle resection with sternoclavicular joint allograft reconstruction. We performed a right interscalene single-shot nerve block followed by a rhomboid intercostal block with catheter placement under ultrasound guidance. The patient's pain was well controlled postoperatively with minimal use of opioids.

Conclusion: Rhomboid intercostal block with brachial plexus block is a potential option for analgesia after sternoclavicular joint reconstruction surgery.

Comparison of Ultrasound-Guided Type-II Pectoral Nerve Block and Rhomboid Intercostal Block for Pain Management Following Breast Cancer Surgery: A Randomized, Controlled Trial

PURPOSE

Although breast-conserving surgery-axillary dissection (BCS-AD) is a minimally invasive surgery, patients may suffer from moderate-to-severe pain. Several regional techniques can be used for pain control. The type II pectoral nerve block (PECS II) and the rhomboid intercostal block (RIB) are interfascial plane blocks that have been reported to provide effective analgesia after breast surgery. This study aims to compare the analgesic efficacy of the PECS II block and the RIB after breast surgery.

PATIENTS AND METHODS

Ninety female patients aged 18 to 65 years with American Society of Anesthesiologists (ASA) classes I and II physical status who underwent unilateral BCS-AD surgery were included. Patients were divided into three groups (n = 30 in each): the PECS II group, the RIB group, or the control group. PECS II block and RIB were performed with 30 mL 0.25% bupivacaine. Ibuprofen 400 mg IV 3 × 1 was given in the postoperative period. A patient control analgesia device included a dose of 10 µg/mL fentanyl, which was prepared and connected to the patients.

RESULTS

There were no statistical differences between groups in terms of demographical data. Postoperative fentanyl consumption was significantly lower in the PECS II and RIB groups than the control group. The need for rescue analgesia use was significantly higher in the control group than the other groups. At all times, visual analog scale scores were significantly lower in the PECS II and RIB groups than the control group.

CONCLUSIONS

The PECS II block and the RIB provide similar effective analgesia after BCS-AD.

Rhomboid intercostal block combined with sub-serratus plane block versus rhomboid intercostal block for postoperative analgesia after video-assisted thoracoscopic surgery: a prospective randomized-controlled trial

BACKGROUND

Rhomboid intercostal block (RIB) and Rhomboid intercostal block with sub-serratus plane block (RISS) are the two types of plane blocks used for postoperative analgesia after video-assisted thoracoscopic surgery (VATS). This prospective randomized controlled trial was performed to analyze the postoperative analgesic effects of ultrasound-guided RIB block and RISS block after video-assisted thoracoscopic surgery.

METHODS

Ninety patients aged between 18 and 80 years, with American Society of Anesthesiologists physical status Classes I-II and scheduled for elective unilateral VATS were randomly allocated into three groups. In group C, no block intervention was performed. Patients in group RIB received ultrasound-guided RIB with 20-mL 0.375% ropivacaine and those in group RISS received ultrasound-guided RIB and serratus plane block using a total of 40-mL 0.375% ropivacaine. All patients received intravenous sufentanil patient-controlled analgesia upon arrival in the recovery room. Postoperative sufentanil consumption and pain scores were compared among the groups.

RESULTS

The dosages of sufentanil consumption at 24 h after the surgery in the RIB and RISS groups were significantly lower than that in group C (p < 0.001 and p < 0.001 for all comparisons, respectively), the postoperative Numerical Rating Scale (NRS) scores in the RIB and RISS groups at 0.5, 1, 3, 6, 12, 18, and 24 h after surgery when patients were at rest or active were significantly lower than that in group C (p < 0.05 for all comparisons). The required dosage of sufentanil and time to first postoperative analgesic request in groupRISS were less than those in the group RIB at 24 h after the surgery (p < 0.001 and p < 0.001 for all comparisons, respectively). Similarly, the Numerical Rating Scale scores for group RISS at 12, 18, and 24 h after the surgery when the patients were active were significantly lower than those for group RIB (p < 0.05 for all comparisons).

CONCLUSION

Both ultrasound-guided RIB block and RISS block can effectively reduce the demand for sufentanil within 24 h after VATS, and less sufentanil dosage is needed in patient with RISS block. Ultrasound-guided RIB block and RISS block can effectively relieve pain within 24 h after VATS, and RISS block is more effective.

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

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

Ultrasound guided rhomboid intercostal block: A pilot study to assess its analgesic efficacy in paediatric patients undergoing video-assisted thoracoscopy surgery

Background and Aims

Ultrasound guided rhomboid intercostal plane block (RIB) is a relatively new regional anaesthesia technique that has shown to provide dermatomal coverage from T2-9 on the whole anterior and posterior hemithorax. It has proved effective in providing preemptive analgesia in various surgeries like mastectomy and thoracotomy. The aim of the study was to study the efficacy of RIB in paediatric patients: 7 to 12 years undergoing thoracoscopic surgeries in terms of analgesic requirement, pain scores and adverse effects.

Methods

In this randomised, prospective double-blind study, 40 American Society of Anesthesiologists I/II patients, of the age group 7-12 years scheduled for Video-assisted thoracoscopy (VATS) surgery were recruited. The patients were allocated to one of the two groups: group R: general anaesthesia + RIB (RIB group) and group F: general anaesthesia (FENT group). Perioperative opioid consumption and postoperative pain scores were recorded. Adverse effects like respiratory depression and nausea were also noted.

Results

Patients in group R required less intraoperative fentanyl dose (1.45 ± 0.65 vs 2.90 ± 0.45) (P < 0.05). Postoperative opioid consumption was also less in this group R (2.90 ± 0.91 vs 5.56 ± 1.08) (P < 0.05). Less number of patients experienced nausea (2 vs 6) and respiratory depression (2 vs 7) in group R.

Conclusion

Ultrasound guided RIB reduces perioperative opioid consumption in patients undergoing VATS surgery with lesser postoperative pain scores.