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Al Ameri M, Shanbhag NM. Developing and Implementing Postoperative Pain Management Guidelines for Breast Cancer Surgery: A Leadership Perspective. Cureus 2023; 15:e50951. [PMID: 38143729 PMCID: PMC10741179 DOI: 10.7759/cureus.50951] [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: 12/22/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction Persistent postoperative pain significantly diminishes the quality of life in breast cancer patients. Effective pain management post-surgery is critical for patient satisfaction, reducing complications, and facilitating quick recovery and hospital discharge. This study addresses the lack of patient-centered postoperative pain management guidelines for breast cancer patients. Aim The primary goal of this study was to develop tailored postoperative pain management guidelines for the local community in the United Arab Emirates, integrating these into a broader network of oncology facilities. Methods and Materials Employing a mixed-methods approach with a qualitative emphasis, the study gathered data from 10 female breast cancer patients (aged 39-65 years) with postoperative satisfaction surveys. Additionally, semi-structured interviews with six healthcare professionals involved in guideline development were conducted. Results A significant 90% of patients reported experiencing moderate-to-extreme pain post-surgery, indicating a need for improved pain management. Key factors identified included the need for enhanced nurse training and patient education on pain management preoperatively. The study team unanimously recognized the necessity for dedicated postoperative guidelines. Conclusion The study underscores the critical need for adequate postoperative pain management in breast cancer care. The findings advocate for creating multidisciplinary, evidence-based guidelines focused on patient-centered care. Furthermore, the study highlights the importance of international collaboration and continuous quality improvement measures, such as the Plan-Do-Study-Act (PDSA) cycle, for developing and refining these guidelines.
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Affiliation(s)
| | - Nandan M Shanbhag
- Department of Oncology, Tawam Hospital, Al Ain, ARE
- Department of Internal Medicine, United Arab Emirates University, Al Ain, ARE
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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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J Ghadimi D, Looha MA, Akbari ME, Akbari A. Predictors of postoperative pain six months after breast surgery. Sci Rep 2023; 13:8302. [PMID: 37221396 DOI: 10.1038/s41598-023-35426-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/17/2023] [Indexed: 05/25/2023] Open
Abstract
Breast cancer, with a high prevalence and survival rate, leads to long-term complications. A major sequel is acute or chronic postoperative pain, and we investigated the possible relationship with clinical and psychological variables. Patients undergoing breast surgery filled out the loneliness (ULS-8) and depression (HADS) questionnaires. Patients rated their pain intensity with the Numerical Rating Scale (0-10, NRS) two days, seven days, and six months after surgery. Of 124 patients, the mean age was 45.86 years old, and the pain scores on the second and seventh postoperative days were 5.33 and 3.57, respectively. Sixth-month pain was significantly correlated with the acute scores with a mean of 3.27; and in the multivariate analysis, it was significantly associated with preoperative pain (p-value = 0.007), self-reported loneliness (p-value = 0.010), and adjuvant radiotherapy (p-value = 0.004). In conclusion, loneliness may be a risk factor for postoperative pain in breast surgery.
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Affiliation(s)
- Delaram J Ghadimi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Azizmohammad Looha
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Atieh Akbari
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Jin Z, Gan TJ, Bergese SD. Prevention and Treatment of Postoperative Nausea and Vomiting (PONV): A Review of Current Recommendations and Emerging Therapies. Ther Clin Risk Manag 2020; 16:1305-1317. [PMID: 33408475 PMCID: PMC7780848 DOI: 10.2147/tcrm.s256234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/05/2020] [Indexed: 12/16/2022] Open
Abstract
Postoperative nausea and vomiting is one of the most frequent adverse events after surgery and anesthesia. It is distressing for the patient and can lead to other postoperative complications. Management of PONV involves a framework of risk assessment, multimodal risk reduction, and prophylactic measures, as well as prompt rescue treatment. There has been a significant paradigm shift in the approach towards PONV prevention. There have also been several emerging therapeutic options for PONV prophylaxis and treatment. In this review, we will discuss the up-to-date PONV management guidelines and highlight novel therapeutic options which have emerged in the last few years.
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Affiliation(s)
- Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY 11794-8480, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY 11794-8480, USA
| | - Sergio D Bergese
- Department of Anesthesiology, Stony Brook University Health Science Center, Stony Brook, NY 11794-8480, USA.,Department of Neurological Surgery, Stony Brook University Health Science Center, Stony Brook, NY 11794-8480, USA
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Bakeer AH, Kamel KM, Abdelgalil AS, Ghoneim AA, Abouel Soud AH, Hassan ME. Modified Pectoral Nerve Block versus Serratus Block for Analgesia Following Modified Radical Mastectomy: A Randomized Controlled Trial. J Pain Res 2020; 13:1769-1775. [PMID: 32765052 PMCID: PMC7369370 DOI: 10.2147/jpr.s252539] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/23/2020] [Indexed: 12/15/2022] Open
Abstract
Background Modified pectoral nerves (PECSII) and serratus blocks have been recently used for analgesia in breast surgery, but evidence comparing their analgesic benefits is limited. This prospective randomized, controlled study aims to examine the analgesic efficacy and safety profile of ultrasound-guided PECSII versus serratus blocks in patients undergoing modified radical mastectomy (MRM) for breast cancer. Patients and Methods One-hundred and eighty adult females scheduled for MRM were randomly allocated to three groups. PECS group patients received a PECSII block with 30mL of bupivacaine 0.25%, whereas SAPB group received a serratus anterior plane block (SAPB) using the same volume of bupivacaine 0.25% before induction of anesthesia. The control group received general anesthesia alone. Outcomes included 24 hours morphine consumption, intraoperative fentanyl requirements, visual analogue scale (VAS) scores for pain at rest and during movement, time to first rescue analgesia, postoperative nausea and vomiting (PONV), and sedation scores. Results Both PECSII and serratus blocks were associated with reduced postoperative morphine consumption compared to the control group (p<0.001). Both blocks were associated with reduced intraoperative fentanyl requirements, VAS scores, and PONV as compared with the control group. Also, they were associated with prolonged time to first rescue analgesia and better sedation scores in comparison with the control group. However, there were no differences between both blocks for all outcomes. Conclusion PECSII and serratus blocks provide similarly adequate analgesia following modified radical mastectomy. Clinical Trial Registration NCT02946294.
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Affiliation(s)
- Ahmed H Bakeer
- Department of Anesthesia and Pain Management, National Cancer Institute, Cairo, Egypt
| | - Khaled M Kamel
- Department of Anesthesia and Pain Management, National Cancer Institute, Cairo, Egypt
| | - Ahmed S Abdelgalil
- Department of Anesthesia and Pain Management, National Cancer Institute, Cairo, Egypt
| | - Ayman A Ghoneim
- Department of Anesthesia and Pain Management, National Cancer Institute, Cairo, Egypt
| | - Ahmed H Abouel Soud
- Department of Anesthesia and Pain Management, National Cancer Institute, Cairo, Egypt
| | - Mohamed E Hassan
- Department of Anesthesia and Pain Management, National Cancer Institute, Cairo, Egypt
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Shiraishi M, Sowa Y, Fujikawa K, Kodama T, Okamoto A, Numajiri T, Taguchi T, Amaya F. Factors associated with chronic pain following breast reconstruction in Japanese women. J Plast Surg Hand Surg 2020; 54:317-322. [PMID: 32589082 DOI: 10.1080/2000656x.2020.1780246] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Chronic pain after breast surgery including breast reconstruction is a major concern for patients. However, the factors associated with chronic pain after breast surgery are uncertain in Japanese population. The aim of this study was to identify patient-specific and medical/surgical factors that predict chronic pain after breast surgery in Japanese patients. The subjects were 189 Japanese women undergoing breast surgery including tissue expander/implant (TE/implant), deep inferior epigastric perforator (DIEP) procedures and mastectomy only. Pain was assessed at one year postoperatively using a validated survey instrument: the Japanese version of the Short-Form McGill Pain Questionnaire (SF-MPQ-JV). A multiple linear regression model was used to examine the relationships of clinical factors with postoperative pain. Surveys were completed by 141 subjects. A younger age (p = .04) and bilateral procedures (p < .05) were both closely associated with the extent of increased postoperative pain at 1 year using the MPQ-Total pain rating. Compared to total mastectomy only, TE/implant procedures showed a significantly lower visual analog scale (VAS) (p = .04) and present pain index (PPI) (p = .03) scores. No factor related to chronic pain was also significantly related to the frequency of pain medication use postoperatively or the effect of social life of the patients. This study identified patients at risk for greater chronic pain after breast surgery. These findings will allow surgeons to improve patient comfort, reduce clinical morbidity and enhance patient satisfaction with their surgical outcome. Abbreviations: BMI: body mass index; CI: confidence interval; DIEP: deep inferior epigastric perforator flap; MPQ: McGill pain questionnaire; PPI: present pain index; SD: standard deviation; SF-MPQ-JV: Japanese version of the short-form McGill pain questionnaire; TE: tissue expander; VAS: visual analog scale.
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Affiliation(s)
- Makoto Shiraishi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshihiro Sowa
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kei Fujikawa
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takuya Kodama
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akiko Okamoto
- Department of Breast Surgery, Kobe Kaisei Hospital, Kobe, Japan
| | - Toshiaki Numajiri
- Department of Plastic and Reconstructive Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuya Taguchi
- Department of Endocrinological and Breast Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumimasa Amaya
- Pain Management and Palliative Care Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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8
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van den Heuvel SAS, van der Wal SEI, Bronkhorst EM, Warlé MC, Ronday M, Plat J, van Alfen N, Joosten LAB, Lerou JGC, Vissers KCP, Steegers MAH. Acute Cytokine Response During Breast Cancer Surgery: Potential Role of Dexamethasone and Lidocaine and Relationship with Postoperative Pain and Complications - Analysis of Three Pooled Pilot Randomized Controlled Trials. J Pain Res 2020; 13:1243-1254. [PMID: 32547185 PMCID: PMC7266394 DOI: 10.2147/jpr.s252377] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Purpose An imbalance in perioperative cytokine response may cause acute pain and postoperative complications. Anesthetic drugs modulate this cytokine response, but their role in non-major breast cancer surgery is unclear. In an exploratory study, we investigated whether intravenous lidocaine and dexamethasone could modulate the cytokine response into an anti-inflammatory direction. We also evaluated interrelationships between cytokine levels, pain scores and postoperative complications. Our goal is to develop multimodal analgesia regimens optimizing outcome after breast cancer surgery. Patients and Methods Forty-eight patients undergoing a lumpectomy were randomly assigned to placebo or lidocaine (1.5 mg⋅kg−1 followed by 2 mg⋅kg−1⋅hour−1) supplemented by dexamethasone zero, 4 or 8 mg, yielding six groups of eight patients. Interleukin (IL)-1β, IL-1Ra, IL-6, IL-10 levels and pain scores were measured at baseline and four hours postoperatively. We assessed postoperative complications occurring within 30 days. We noted persistent pain and infections as potential immune-related complications (PIRC). We used multiple regression to disentangle the effects of the individual study drugs (given by their partial regression coefficients (b)). Odds ratios (OR) estimated the link between pain scores and complications. Results Dexamethasone 8 mg increased IL-10 (b=12.70 (95% CI=8.06–17.34), P<0.001). Dexamethasone 4 mg and 8 mg decreased the ratio IL-6/IL-10 (b=−2.60 (−3.93 to −1.26), P<0.001 and b=−3.59 (−5.04 to −2.13), P<0.001, respectively). We could not show modulatory effects of lidocaine on cytokines. High pain scores were linked to the occurrence of PIRC’s (OR=2.028 (1.134–3.628), P=0.017). Cytokine levels were not related either to acute pain or PIRC. Conclusion Dexamethasone modulated the perioperative cytokine response into an anti-inflammatory direction. An overall lidocaine effect was not found. Patients with higher pain scores suffered from more 30-day PIRCs. Cytokine levels were not associated with pain or more postoperative complications, even not with PIRC. Larger studies in breast cancer surgery are needed to confirm these explorative results.
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Affiliation(s)
- Sandra A S van den Heuvel
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Selina E I van der Wal
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Ewald M Bronkhorst
- Department of Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Michiel C Warlé
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - May Ronday
- Department of Anesthesiology, Alexander Monro Breast Cancer Hospital, Bilthoven, the Netherlands
| | - Judith Plat
- Department of Anesthesiology, Alexander Monro Breast Cancer Hospital, Bilthoven, the Netherlands
| | - Nens van Alfen
- Donders Institute for Brain Cognition and Behavior, Department of Neurology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Leo A B Joosten
- Department of Internal Medicine and Radboud Centre for Infectious Diseases, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Jos G C Lerou
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Kris C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Monique A H Steegers
- Department of Anesthesiology, Pain and Palliative Medicine, Amsterdam University Medical Centre, Amsterdam, the Netherlands
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Freys SM, Pogatzki-Zahn E. Pain therapy to reduce perioperative complications. Innov Surg Sci 2019; 4:158-166. [PMID: 33977126 PMCID: PMC8059349 DOI: 10.1515/iss-2019-0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/16/2019] [Indexed: 12/19/2022] Open
Abstract
The incidence rates of adverse events secondary to any operation are a well-known problem in any surgical field. One outstanding example of such adverse events is postoperative pain. Thus, the incidence of acute postoperative pain following any surgical procedure and its treatment are central issues for every surgeon. In the times of Enhanced Recovery After Surgery (ERAS) programs, acute pain therapy became an increasingly well investigated and accepted aspect in almost all surgical subspecialties. However, if it comes to the reduction of postoperative complications, in the actual context of postoperative pain, surgeons tend to focus on the operative process rather than on the perioperative procedures. Undoubtedly, postoperative pain became an important factor with regard to the quality of surgical care: both, the extent and the quality of the surgical procedure and the extent and the quality of the analgesic technique are decisive issues for a successful pain management. There is growing evidence that supports the role of acute pain therapy in reducing postoperative morbidity, and it has been demonstrated that high pain scores postoperatively may contribute to a complicated postoperative course. This overview comprises the current knowledge on the role of acute pain therapy with regard to the occurrence of postoperative complications. Most of the knowledge is derived from studies that primarily focus on the type and quality of postoperative pain therapy in relation to specific surgical procedures and only secondary on complications. As far as existent, data that report on the recovery period after surgery, on the rehabilitation status, on perioperative morbidity, on the development of chronic pain after surgery, and on possible solutions of the latter problem with the institution of transitional pain services will be presented.
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Affiliation(s)
- Stephan M. Freys
- Chirurgische Klinik, DIAKO Ev. Diakonie-Krankenhaus, Gröpelinger Heerstr. 406-408, 28239 Bremen, Germany
| | - Esther Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Münster, Germany
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Zinboonyahgoon N, Luksanapruksa P, Piyaselakul S, Pangthipampai P, Lohasammakul S, Luansritisakul C, Mali-ong S, Sateantantikul N, Chueaboonchai T, Vlassakov K. The ultrasound-guided proximal intercostal block: anatomical study and clinical correlation to analgesia for breast surgery. BMC Anesthesiol 2019; 19:94. [PMID: 31164083 PMCID: PMC6549312 DOI: 10.1186/s12871-019-0762-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 05/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ultrasound-guided proximal intercostal block (PICB) is performed at the proximal intercostal space (ICS) between the internal intercostal membrane (IIM) and the endothoracic fascia/parietal pleura (EFPP) complex. Injectate spread may follow several routes and allow for multilevel trunk analgesia. The goal of this study was to examine the anatomical spread of large-volume PICB injections and its relevance to breast surgery analgesia. METHODS Fifteen two-level PICBs were performed in ten soft-embalmed cadavers. Radiographic contrast mixed with methylene blue was injected at the 2nd(15 ml) and 4th(25 ml) ICS, respectively. Fluoroscopy and dissection were performed to examine the injectate spread. Additionally, the medical records of 12 patients who had PICB for breast surgery were reviewed for documented dermatomal levels of clinical hypoesthesia. The records of twelve matched patients who had the same operations without PICB were reviewed to compare analgesia and opioid consumption. RESULTS Median contrast/dye spread was 4 (2-8) and 3 (2-5) vertebral segments by fluoroscopy and dissection respectively. Dissection revealed injectate spread to the adjacent paravertebral space, T3 (60%) and T5 (27%), and cranio-caudal spread along the endothoracic fascia (80%). Clinically, the median documented area of hypoesthesia was 5 (4-7) dermatomes with 100 and 92% of the injections covering adjacent T3 and T5 dermatomes, respectively. The patients with PICB had significantly lower perioperative opioid consumption and trend towards lower pain scores. CONCLUSIONS In this anatomical study, PICB at the 2nd and 4th ICS produced lateral spread along the corresponding intercostal space, medial spread to the adjacent paravertebral/epidural space and cranio-caudal spread along the endothoracic fascial plane. Clinically, combined PICBs at the same levels resulted in consistent segmental chest wall analgesia and reduction in perioperative opioid consumption after breast surgery. The incomplete overlap between paravertebral spread in the anatomical study and area of hypoesthesia in our clinical findings, suggests that additional non-paravertebral routes of injectate distribution, such as the endothoracic fascial plane, may play important clinical role in the multi-level coverage provided by this block technique.
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Affiliation(s)
- Nantthasorn Zinboonyahgoon
- Department of Anesthesiology, Siriraj Hospital, Mahidol University, 2 Phranok road, Bangkoknoi, 10700 Thailand
| | - Panya Luksanapruksa
- Department of Orthopedic Surgery Siriraj Hospital, Mahidol University, 2 Phranok road, Bangkoknoi, 10700 Thailand
| | - Sitha Piyaselakul
- Department of Anatomy, Siriraj Hospital, Mahidol University, 2 Phranok road, Bangkoknoi, 10700 Thailand
| | - Pawinee Pangthipampai
- Department of Anesthesiology, Siriraj Hospital, Mahidol University, 2 Phranok road, Bangkoknoi, 10700 Thailand
| | - Suphalerk Lohasammakul
- Department of Surgery, Siriraj Hospital, Mahidol University, 2 Phranok road, Bangkoknoi, 10700 Thailand
| | - Choopong Luansritisakul
- Department of Anesthesiology, Siriraj Hospital, Mahidol University, 2 Phranok road, Bangkoknoi, 10700 Thailand
| | - Sunsanee Mali-ong
- Department of Anesthesiology, Siriraj Hospital, Mahidol University, 2 Phranok road, Bangkoknoi, 10700 Thailand
| | - Nawaporn Sateantantikul
- Department of Anesthesiology, Siriraj Hospital, Mahidol University, 2 Phranok road, Bangkoknoi, 10700 Thailand
| | - Theera Chueaboonchai
- Department of Orthopedic Surgery Siriraj Hospital, Mahidol University, 2 Phranok road, Bangkoknoi, 10700 Thailand
| | - Kamen Vlassakov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
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Afonso AM, Newman MI, Seeley N, Hutchins J, Smith KL, Mena G, Selber JC, Saint-Cyr MH, Gadsden JC. Multimodal Analgesia in Breast Surgical Procedures: Technical and Pharmacological Considerations for Liposomal Bupivacaine Use. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1480. [PMID: 29062649 PMCID: PMC5640354 DOI: 10.1097/gox.0000000000001480] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 07/12/2017] [Indexed: 02/05/2023]
Abstract
Enhanced recovery after surgery is a multidisciplinary perioperative clinical pathway that uses evidence-based interventions to improve the patient experience as well as increase satisfaction, reduce costs, mitigate the surgical stress response, accelerate functional recovery, and decrease perioperative complications. One of the most important elements of enhanced recovery pathways is multimodal pain management. Herein, aspects relating to multimodal analgesia following breast surgical procedures are discussed with the understanding that treatment decisions should be individualized and guided by sound clinical judgment. A review of liposomal bupivacaine, a prolonged-release formulation of bupivacaine, in the management of postoperative pain following breast surgical procedures is presented, and technical guidance regarding optimal administration of liposomal bupivacaine is provided.
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Affiliation(s)
- Anoushka M. Afonso
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Martin I. Newman
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Neil Seeley
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Jacob Hutchins
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Kevin L. Smith
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Gabriel Mena
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Jesse C. Selber
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Michel H. Saint-Cyr
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Jeffrey C. Gadsden
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
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Effects of systemic lidocaine versus magnesium administration on postoperative functional recovery and chronic pain in patients undergoing breast cancer surgery: A prospective, randomized, double-blind, comparative clinical trial. PLoS One 2017; 12:e0173026. [PMID: 28253307 PMCID: PMC5333858 DOI: 10.1371/journal.pone.0173026] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 02/14/2017] [Indexed: 02/03/2023] Open
Abstract
Introduction We aimed to compare the effects of intraoperative lidocaine and magnesium on postoperative functional recovery and chronic pain after mastectomy due to breast cancer. Systemic lidocaine and magnesium reduce pain hypersensitivity to surgical stimuli; however, their effects after mastectomy have not been evaluated clearly. Methods In this prospective, double-blind, clinical trial, 126 female patients undergoing mastectomy were randomly assigned to lidocaine (L), magnesium (M), and control (C) groups. Lidocaine and magnesium were administered at 2 mg/kg and 20 mg/kg for 15 minutes immediately after induction, followed by infusions of 2 mg/kg/h and 20 mg/kg/h, respectively. The control group received the same volume of saline. Patient characteristics, perioperative parameters, and postoperative recovery profiles, including the Quality of Recovery 40 (QoR-40) survey, pain scales, length of hospital stay, and the short-form McGill pain questionnaire (SF-MPQ) at postoperative 1 month and 3 months were evaluated. Results The global QoR-40 scores on postoperative day 1 were significantly higher in group L than in group C (P = 0.003). Moreover, in sub-scores of the QoR-40 dimensions, emotional state and pain scores were significantly higher in group L than those in groups M and C (P = 0.027 and 0.023, respectively). At postoperative 3 months, SF-MPQ and SF-MPQ-sensitive scores were significantly lower in group L than in group C (P = 0.046 and 0.036, respectively). Conclusions Intraoperative infusion of lidocaine improved the quality of recovery and attenuated the intensity of chronic pain in patients undergoing breast cancer surgery.
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Variawa ML, Scribante J, Perrie H, Chetty S. The prevalence of chronic postmastectomy pain syndrome in female breast cancer survivors. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2016. [DOI: 10.1080/22201181.2016.1191214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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