Breast Regional Anesthesia Practice in the Italian Public Health System (BRA-SURVEY): A Survey-Based National Study

A French nationwide survey on the practice of regional anaesthesia for breast cancer surgery

BACKGROUND

To assess the impact of recent recommendations concerning regional anaesthesia for breast cancer surgery, a nationwide practice survey was carried out.

METHODS

This cross-sectional electronic survey, conducted in 2021, collected answers from a panel of anaesthetists currently working in French practicing centres. It addressed the sets of techniques they practiced for every type of surgical procedure and their perceptions of the difficulties and risks associated with these techniques.

RESULTS

The practice of regional anaesthesia was generally high (70%), involving all the current types of blocks. Surgeon-done infiltration was popular for lumpectomy only. For the other current procedures, the pectoralis nerve blocks were preferred to the paravertebral block, which was favoured for mastectomies, when a lymph node harvesting was planned, or for immediate or delayed pedicle flap. Catheters were mostly used for mastectomies with pedicle flap. The erector spinae plane block was emergent. Whatever the type of block, regional anaesthesia was preferentially started before surgery. Despite some deviations such as the adjunction of unlabelled molecules, the practice fitted well with the European recommendations, but training and within-centre guidance lacked standardisation. For each block, actual practice, perceived difficulty and risk were inter-correlated, but paravertebral block - either practiced or not - was considered as more difficult and riskier to perform than any other.

CONCLUSIONS

These encouraging results do not dispense with the need to improve anaesthetic practices both in quantity and quality. Such improvement in the anatomic fit to the procedure and in the timing of blocks will also have to be considered.

Simulation-Based Medical Education and Training Enhance Anesthesia Residents' Proficiency in Erector Spinae Plane Block

Background

Advances in regional anesthesia and pain management led to the advent of ultrasound-guided fascial plane blocks, which represent a new and promising route for the administration of local anesthetics. Both practical and theoretical knowledge of locoregional anesthesia are therefore becoming fundamental, requiring specific training programs for residents. Simulation-based medical education and training (SBET) has been recently applied to ultrasound-guided regional anesthesia (UGRA) with remarkable results. With this in mind, the anesthesia and intensive care residency program of the University of Milano-Bicocca organized a 4-h regional anesthesia training workshop with the BlockSim^® (Accurate Srl, Cesena) simulator. Our study aimed to measure the residents' improvement in terms of reduction in time required to achieve an erector spinae plane (ESP) block.

Methods

Fifty-two first-year anesthesia residents were exposed to a 4-h training workshop focused on peripheral blocks. The course included an introductory theoretical session held by a locoregional anesthetist expert, a practical training on human models and mannequins using Onvision^® (B. Braun, Milano) technologies, and two test performances on the BlockSim simulator. Residents were asked to perform two ESP blocks on the BlockSim: the first without previous practice on the simulator, the second at the end of the course. Trainees were also also asked to complete a self-assessment questionnaire.

Results

The time needed to achieve the block during the second attempt was significantly shorter (131 [83, 198] vs. 68 [27, 91] s, p < 0.001). We also observed a reduction in the number of needle insertions from 3 [2, 7] to 2 [1, 4] (p = 0.002), and an improvement aiming correctly at the ESP from 30 (58%) to 46 (88%) (p < 0.001). Forty-nine (94%) of the residents reported to have improved their regional anesthesia knowledge, 38 (73%) perceived an improvement in their technical skills and 46 (88%) of the trainees declared to be “satisfied/very satisfied” with the course.

Conclusions

A 4-h hands-on course based on SBET may enhance first-year residents' UGRA ability, decrease the number of punctures and time needed to perform the ESP block, and improve the correct aim of the fascia.

Opioid-free anesthesia in oncologic surgery: the rules of the game

BACKGROUND

Opioids are frequently used in the postoperative period due to their analgesic properties. While these drugs reduce nociceptive somatic, visceral, and neuropathic pain, they may also lead to undesirable effects such as respiratory depression, urinary retention, nausea and vomiting, constipation, itching, opioid-induced hyperalgesia, tolerance, addiction, and immune system disorders. Anesthesiologists are in the critical position of finding balance between using opioids when they are necessary and implementing opioid-sparing strategies to avoid the known harmful effects. This article aims to give an overview of opioid-free anesthesia.

MAIN BODY

This paper presents an overview of opioid-free anesthesia and opioid-sparing anesthetic techniques. Pharmacological and non-pharmacological strategies are discussed, highlighting the possible advantages and drawbacks of each approach.

CONCLUSIONS

Choosing the best anesthetic protocol for a patient undergoing cancer surgery is not an easy task and the available literature provides no definitive answers. In our opinion, opioid-sparing strategies should always be implemented in routine practice and opioid-free anesthesia should be considered whenever possible. Non-pharmacological strategies such as patient education, while generally underrepresented in scientific literature, may warrant consideration in clinical practice.

Incidence and Related Factors for Low-Extremity Deep Vein Thrombosis in Breast Cancer Patients Who Underwent Surgical Resection: What Do We Know and What Should We Care

Malignancy, surgical resection, and neoadjuvant and/or adjuvant chemotherapy increase the low-extremity deep vein thrombosis (LDVT) risk in patients with breast cancer, bringing in great physical burdens, disabilities, and worse survivals. However, LDVT in surgical breast cancer patients is scarcely reported. Therefore, this study aimed to evaluate the incidence and related factors for LDVT in these patients. Patients with breast cancer who underwent surgical resection were included. LDVT was examined on the day of discharge and 1 month after the discharge. A total of 491 eligible patients were included, among which 11 (2.2%) patients occurred LDVT. Besides, higher age, history of diabetes mellitus, advanced T and tumor node metastasis (TNM) stages, higher platelet count, and shorter activated partial thromboplastin time (APTT) were correlated with increased LDVT incidence (all p < 0.05). Additionally, higher age [p = 0.004, odds ratio (OR) (95% CI): 1.082 (1.023–1.144)], history of diabetes mellitus [p = 0.003, OR (95% CI): 10.426 (2.219–48.986)], and a higher platelet count [p = 0.008, OR (95% CI): 1.017 (1.004–1.029)] were independent factors for increased LDVT incidence, while higher APTT [p = 0.004, OR (95% CI): 0.636 (0.467–0.866)] was an independent factor for decreased LDVT incidence. Lastly, the risk prediction model involving age, history of diabetes mellitus, platelet count, and APTT showed a good ability to predict LDVT occurrence (area under curve: 0.919, 95% CI: 0.869–0.968). In conclusion, the LDVT incidence is 2.2%, and its independent factors consist of age, history of diabetes mellitus, platelet count, and APTT in patients with breast cancer who underwent surgical resection, which provides evidence for the prevention and surveillance of LDVT in surgical breast cancer.