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Tokita HK, Assel M, Simon BA, Lin E, Sarraf L, Masson G, Pilewskie M, Vingan P, Vickers A, Nelson JA. Regional Blocks Benefit Patients Undergoing Bilateral Mastectomy with Immediate Implant-Based Reconstruction, Even After Discharge. Ann Surg Oncol 2024; 31:316-324. [PMID: 37747581 PMCID: PMC11200308 DOI: 10.1245/s10434-023-14348-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 09/05/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND There is limited evidence that regional anesthesia reduces pain in patients undergoing mastectomy with immediate implant-based reconstruction. We sought to determine whether regional blocks reduce opioid consumption and improve post-discharge patient-reported pain in this population. METHODS We retrospectively reviewed patients who underwent bilateral mastectomy with immediate implant-based reconstruction with and without a regional block. We tested for differences in opioid consumption by block receipt using multivariable ordinal regression, and also assessed routinely collected patient-reported outcomes (PROs) for 10 days postoperatively and tested the association between block receipt and moderate or greater pain. RESULTS Of 754 patients, 89% received a block. Non-block patients had an increase in the odds of requiring a higher quartile of postoperative opioids. Among block patients, the estimated probability of being in the lowest quartile of opioids required was 25%, compared with 15% for non-block patients. Odds of patient-reported moderate or greater pain after discharge was 0.54 times lower in block patients than non-block patients (p = 0.025). Block patients had a 49% risk of moderate or greater pain compared with 64% in non-block patients on postoperative day 5. There was no indication of any reason for these differences other than a causal effect of the block. CONCLUSION Receipt of a regional block resulted in reduced opioid use and lower risk of self-reported moderate and higher pain after discharge in bilateral mastectomy with immediate implant-based reconstruction patients. Our use of PROs suggests that the analgesic effects of blocks persist after discharge, beyond the expected duration of a 'single shot' block.
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Affiliation(s)
- Hanae K Tokita
- Department of Anesthesiology and Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Melissa Assel
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brett A Simon
- Department of Anesthesiology and Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emily Lin
- Department of Anesthesiology and Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Leslie Sarraf
- Department of Anesthesiology and Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Geema Masson
- Department of Anesthesiology and Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Perri Vingan
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Vickers
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonas A Nelson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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2
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Tageza Ilala T, Teku Ayano G, Ahmed Kedir Y, Tamiru Mamo S. Evidence-Based Guideline on the Prevention and Management of Perioperative Pain for Breast Cancer Peoples in a Low-Resource Setting: A Systematic Review Article. Anesthesiol Res Pract 2023; 2023:5668399. [PMID: 37953883 PMCID: PMC10637850 DOI: 10.1155/2023/5668399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/03/2023] [Accepted: 10/24/2023] [Indexed: 11/14/2023] Open
Abstract
Background Breast surgery for breast cancer is associated with significant acute and persistent postoperative pain. Surgery is the primary type of treatment, but up to 60% of breast cancer patients experience persistent pain after surgery, and 40% of them develop acute postmastectomy pain syndrome. Preoperative stress, involvement of lymph nodes while dissecting, and the postoperative psychological state of the patients play vital roles in managing the postoperative pain of the patients. The objective of this study is to develop evidence-based guideline on the prevention and management of perioperative pain for breast cancer surgical patients. Methods An exhaustive literature search was made from PubMed, Cochrane Review, PubMed, Google Scholar, Hinari, and CINAHIL databases that are published from 2012 to 2022 by setting the inclusion and exclusion criteria. After data extraction, filtering was made based on the methodological quality, population data, interventions, and outcome of interest. Finally, one guideline, two meta-analyses, ten systematic reviews, 25 randomized clinical trials and ten observational studies are included in this review, and a conclusion was made based on their level of evidence and grade of recommendation. Results A total of 38 studies were considered in this evaluation. The development of this guideline was based on different studies performed on the diagnosis, risk stratification and risk reduction, prevention of postoperative pain, and treatments of postoperative pain. Conclusion The management of postoperative pain can be categorized as risk assessment, minimizing risk, early diagnosis, and treatment. Early diagnosis is the mainstay to identify and initiate treatment. The perioperative use of a nonpharmacological approach (including preoperative positive inspirational words and positive expectation) as an adjunct to the intraoperative regional anesthetic technique with general anesthesia with proper dosage of the standard pharmacological multimodal regimens is the first-line treatment. For postoperative analgesia, an extended form of intraoperative regional technique, nonpharmacologic technique, and NSAIDs can be used with the opioid-sparing anesthesia technique.
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Affiliation(s)
- Tajera Tageza Ilala
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Gudeta Teku Ayano
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Yesuf Ahmed Kedir
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
| | - Selam Tamiru Mamo
- Department of Anesthesia, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
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Shamsunder MG, Chu JJ, Taylor E, Polanco TO, Allen RJ, Moo TA, Disa JJ, Mehrara BJ, Tokita HK, Nelson JA. Paravertebral Blocks in Tissue Expander Breast Reconstruction: Propensity-Matched Analysis of Opioid Consumption and Patient Outcomes. Plast Reconstr Surg 2023; 151:542e-551e. [PMID: 36729942 PMCID: PMC10065883 DOI: 10.1097/prs.0000000000009981] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The paravertebral block (PVB) is an adjunctive perioperative pain control method for patients undergoing breast reconstruction that may improve perioperative pain control and reduce narcotic use. This study determined the efficacy of preoperative PVBs for perioperative pain management in patients undergoing tissue expander breast reconstruction. METHODS A retrospective review was performed of patients who underwent tissue expander breast reconstruction from December of 2017 to September of 2019. Two patients with PVBs were matched using propensity scoring to one no-block patient. Perioperative analgesic use, pain severity scores on days 2 to 10 after discharge, and BREAST-Q Physical Well-Being scores before surgery and at 2 weeks, 6 weeks, and 3 months after surgery were compared between the two groups. RESULTS The propensity-matched cohort consisted of 471 patients (314 PVB and 157 no block). The PVB group used significantly fewer morphine milligram equivalents than the no-block group (53.7 versus 69.8; P < 0.001). Average daily postoperative pain severity scores were comparable, with a maximum difference of 0.3 points on a 0-point to 4-point scale. BREAST-Q Physical Well-Being scores were significantly higher for the PVB group than the no-block group at 6 weeks after surgery (60.6 versus 51.0; P = 0.015) but did not differ significantly at 2 weeks or 3 months after surgery. CONCLUSIONS PVBs may help reduce perioperative opioid requirements but did not reduce pain scores after discharge when used as part of an expander-based reconstruction perioperative pain management protocol. Continued research should examine additional or alternative regional block procedures as well as financial cost and potential long-term impact of PVBs. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Meghana G. Shamsunder
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jacqueline J. Chu
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Erin Taylor
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Thais O. Polanco
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert J. Allen
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Tracy-Ann Moo
- Anesthesiology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joseph J. Disa
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hanae K. Tokita
- Anesthesiology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
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Tiongco RFP, Puthumana JS, Khan IF, Aravind P, Cheah MA, Sacks JM, Manahan M, Cooney CM, Rosson GD. The Use of Alloderm® Coverage to Reinforce Tissues in Two-Stage Tissue Expansion Placement in the Subcutaneous (Prepectoral) Plane: A Prospective Pilot Study. Cureus 2022; 14:e27680. [PMID: 36072166 PMCID: PMC9440738 DOI: 10.7759/cureus.27680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose: Two-stage tissue expander (TE) to implant breast reconstruction is commonly performed by plastic surgeons. Prepectoral implant placement with acellular dermal matrix (ADM, e.g., AlloDerm®) reinforcement is evidenced by minimal postoperative pain. However, the same is not known for TE-based reconstruction. We performed this study to explore the use of complete AlloDerm® reinforcement of breast pocket tissues in women undergoing unilateral or bilateral mastectomies followed by immediate, two-stage tissue expansion in the prepectoral plane. Methods: Patients (n = 20) aged 18-75 years were followed prospectively from their preoperative consult to 60 days post-TE insertion. The pain visual analog scale (VAS), Patient Pain Assessment Questionnaire, Subjective Pain Survey, Brief Pain Inventory-Short Form (BPI-SF), postoperative nausea and vomiting (PONV) survey, BREAST-Q Reconstruction Module, and short-form 36 (SF-36) questionnaires were administered. Demographic, intraoperative, and 30- and 60-day complications data were abstracted from medical records. After TE-to-implant exchange, patients were followed until 60 days postoperatively to assess for complications. Results: Pain VAS and BPI-SF pain interference scores returned to preoperative values by 30 days post-TE insertion. Static and moving pain scores from the Patient Pain Assessment Questionnaire returned to preoperative baseline values by day 60. The mean subjective pain score was 3.0 (0.5 standard deviation) with seven patients scoring outside the standard deviation; none of these seven patients had a history of anxiety or depression. Median PONV scores remained at 0 from postoperative day 0 to day 7. Patient-reported opioid use dropped from 89.5% to 10.5% by postoperative day 30. BREAST-Q: Sexual well-being scores significantly increased from preoperative baseline to day 60 post-TE insertion. Changes in SF-36 physical functioning, physician limitations, emotional well-being, social functioning, and pain scores were significantly different from preoperative baseline to day 60 post-TE insertion. Five participants had complications within 60 days post-TE insertion. One participant experienced a complication within 60 days after TE-to-implant exchange. Conclusions: We describe pain scores, opioid usage, patient-reported outcomes data, and complication profiles of 20 consecutive patients undergoing mastectomy followed by immediate, two-stage tissue expansion in the prepectoral plane. We hope this study serves as a baseline for future research.
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Lukas A, Theunissen M, Boer DDKD, van Kuijk S, Van Noyen L, Magerl W, Mess W, Buhre W, Peters M. AMAZONE: prevention of persistent pain after breast cancer treatment by online cognitive behavioral therapy-study protocol of a randomized controlled multicenter trial. Trials 2022; 23:595. [PMID: 35879728 PMCID: PMC9310687 DOI: 10.1186/s13063-022-06549-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/15/2022] [Indexed: 11/10/2022] Open
Abstract
Background Surviving breast cancer does not necessarily mean complete recovery to a premorbid state of health. Among the multiple psychological and somatic symptoms that reduce the quality of life of breast cancer survivors, persistent pain after breast cancer treatment (PPBCT) with a prevalence of 15–65% is probably the most invalidating. Once chronic, PPBCT is difficult to treat and requires an individualized multidisciplinary approach. In the past decades, several somatic and psychological risk factors for PPBCT have been identified. Studies aiming to prevent PPBCT by reducing perioperative pain intensity have not yet shown a significant reduction of PPBCT prevalence. Only few studies have been performed to modify psychological distress around breast cancer surgery. The AMAZONE study aims to investigate the effect of online cognitive behavioral therapy (e-CBT) on the prevalence of PPBCT. Methods The AMAZONE study is a multicenter randomized controlled trial, with an additional control arm. Patients (n=138) scheduled for unilateral breast cancer surgery scoring high for surgical or cancer-related fears, general anxiety or pain catastrophizing are randomized to receive either five sessions of e-CBT or online education consisting of information about surgery and a healthy lifestyle (EDU). The first session is scheduled before surgery. In addition to the online sessions, patients have three online appointments with a psychotherapist. Patients with low anxiety or catastrophizing scores (n=322) receive treatment as usual (TAU, additional control arm). Primary endpoint is PPBCT prevalence 6 months after surgery. Secondary endpoints are PPBCT intensity, the intensity of acute postoperative pain during the first week after surgery, cessation of postoperative opioid use, PPBCT prevalence at 12 months, pain interference, the sensitivity of the nociceptive and non-nociceptive somatosensory system as measured by quantitative sensory testing (QST), the efficiency of endogenous pain modulation assessed by conditioned pain modulation (CPM) and quality of life, anxiety, depression, catastrophizing, and fear of recurrence until 12 months post-surgery. Discussion With perioperative e-CBT targeting preoperative anxiety and pain catastrophizing, we expect to reduce the prevalence and intensity of PPBCT. By means of QST and CPM, we aim to unravel underlying pathophysiological mechanisms. The online application facilitates accessibility and feasibility in a for breast cancer patients emotionally and physically burdened time period. Trial registration NTR NL9132, registered December 16 2020.
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Affiliation(s)
- Anne Lukas
- Department of Anesthesiology & Pain Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - Maurice Theunissen
- Department of Anesthesiology & Pain Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands.,Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
| | - Dianne de Korte-de Boer
- Department of Anesthesiology & Pain Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Sander van Kuijk
- Department of Clinical Epidemiology and Medical Technology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Lotte Van Noyen
- Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
| | - Walter Magerl
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Ruprecht-Karls-University Heidelberg, Medical Faculty Mannheim, Heidelberg, Germany
| | - Werner Mess
- Department of Clinical Neurophysiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Wolfgang Buhre
- Department of Anesthesiology & Pain Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Madelon Peters
- Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
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Pak LM, Pawloski KR, Sevilimedu V, Kalvin HL, Le T, Tokita HK, Tadros A, Morrow M, Van Zee KJ, Kirstein LJ, Moo TA. How Much Pain Will I Have After Surgery? A Preoperative Nomogram to Predict Acute Pain Following Mastectomy. Ann Surg Oncol 2022; 29:6706-6713. [PMID: 35699814 PMCID: PMC9196152 DOI: 10.1245/s10434-022-11976-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/16/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Acute postoperative pain affects time to opioid cessation and quality of life, and is associated with chronic pain. Effective screening tools are needed to identify patients at increased risk of experiencing more severe acute postoperative pain, and who may benefit from multimodal analgesia and early pain management referral. In this study, we develop a nomogram to preoperatively identify patients at high risk of moderate-severe pain following mastectomy. METHODS Demographic, psychosocial, and clinical variables were retrospectively assessed in 1195 consecutive patients who underwent mastectomy from January 2019 to December 2020 and had pain scores available from a post-discharge questionnaire. We examined pain severity on postoperative days 1-5, with moderate-severe pain as the outcome of interest. Multivariable logistic regression was performed to identify variables associated with moderate-severe pain in a training cohort of 956 patients. The final model was determined using the Akaike information criterion. A nomogram was constructed using this model, which also included a priori selected clinically relevant variables. Internal validation was performed in the remaining cohort of 239 patients. RESULTS In the training cohort, 297 patients reported no-mild pain and 659 reported moderate-severe pain. High body mass index (p = 0.042), preoperative Distress Thermometer score ≥4 (p = 0.012), and bilateral surgery (p = 0.003) predicted moderate-severe pain. The resulting nomogram accurately predicted moderate-severe pain in the validation cohort (AUC = 0.735). CONCLUSIONS This nomogram incorporates eight preoperative variables to provide a risk estimate of acute moderate-severe pain following mastectomy. Preoperative risk stratification can identify patients who may benefit from individually tailored perioperative pain management strategies and early postoperative interventions to treat pain and assist with opioid tapering.
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Affiliation(s)
- Linda M Pak
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hannah L Kalvin
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tiana Le
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Hanae K Tokita
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audree Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Laurie J Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 300 East 66th Street, New York, NY, USA.
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Opioid-sparing Strategies in Alloplastic Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3932. [PMID: 34796086 PMCID: PMC8594660 DOI: 10.1097/gox.0000000000003932] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 12/30/2022]
Abstract
Introduction: Pain and discomfort are frequently experienced following mastectomy with concomitant breast implant- or tissue expander-based alloplastic breast reconstruction (AlBR). Unfortunately, postoperative opioids have decreased efficacy in AlBR, short-term complication profiles, and are fraught by long-term dependence. This systematic review aims to identify opioid-sparing pain management strategies in AlBR. Methods: A systematic literature search of MEDLINE, Embase, Web of Science, and Cochrane Central Register was performed in September 2018. PRISMA guidelines were followed, and the review was prospectively registered in PROSPERO (CRD42018107911). The search identified 1184 articles. Inclusion criteria were defined as patients 18 years or older undergoing AlBR. Results: Fourteen articles were identified assessing opioid-sparing strategies in AlBR. This literature included articles evaluating enhanced recovery protocols (two), intercostal blocks (two), paravertebral blocks (four), liposomal bupivacaine (three), diclofenac (one), and local anesthesia infusion pumps (two). The literature included five randomized trials and nine cohort studies. Study characteristics, bias (low to high risk), and reporting outcomes were extensively heterogeneous between articles. Qualitative analysis suggests reduced opioid utilization in enhanced recovery after surgery (ERAS) pathways, paravertebral blocks, and use of liposomal bupivacaine. Conclusions: A variety of opioid-sparing strategies are described for pain management in AlBR. Multimodal analgesia should be provided via ERAS pathways as they appear to reduce pain and spare opioid use. Targeted paravertebral blocks and liposomal bupivacaine field blocks appear to be beneficial in sparing opioids and should be considered as essential components of ERAS protocols. Additional prospective, randomized trials are necessary to delineate the efficacy of other studied modalities.
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Lin ZM, Li MH, Zhang F, Li X, Shao CL, Li XY, Wang DX. Thoracic Paravertebral Blockade Reduces Chronic Postsurgical Pain in Breast Cancer Patients: A Randomized Controlled Trial. PAIN MEDICINE 2021; 21:3539-3547. [PMID: 33111950 PMCID: PMC7770235 DOI: 10.1093/pm/pnaa270] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Objective To evaluate the effect of multilevel single-shot thoracic paravertebral blockade (PVB) on the occurrence of chronic postsurgical pain (CPSP) in patients undergoing breast cancer surgery. Design A randomized controlled trial with two parallel groups. Setting A tertiary hospital. Methods Patients scheduled for breast cancer surgery were randomized to receive either ultrasound-guided multilevel single-shot PVB from T2 to T5 (the PVB group) or nothing (the control group). Surgery was then performed under general anesthesia. Patients were followed up for 12 months after surgery. The primary end point was incidence of CPSP at six months after surgery. Results A total of 218 patients were enrolled and randomized; of these, 208 and 204 completed six- and 12-month follow-up, respectively. The incidence of CPSP at six months was significantly lower in the PVB group (12.5% [13/104]) than in the control group (24.0% [25/104], relative risk = 0.52, 95% CI = 0.28–0.96, P = 0.031). Pain scores within 48 hours both at rest and with movement were lower in the PVB group than the control group (P = 0.006 and P < 0.001, respectively). The percentages of patients with neuropathic pain were also lower in the PVB group than the control group at both six and 12 months after surgery (P = 0.016 and 0.028, respectively). Adverse events did not differ between groups. Conclusions For patients undergoing breast cancer surgery, multilevel single-shot PVB reduces the incidence of CPSP at six months; it also improves early postoperative analgesia and reduces neuropathic pain at six and 12 months after surgery.
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Affiliation(s)
- Zeng-Mao Lin
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Mu-Han Li
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China.,Department of Anaesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Zhang
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Xue Li
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Chun-Li Shao
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Xue-Ying Li
- Department of Biostatics, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anaesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
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9
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Bozzuto LM, Bartholomew AJ, Tung S, Sosin M, Tambar S, Cox S, Perez-Alvarez IM, King CA, Chan MC, Pittman TA, Tousimis EA. Decreased postoperative pain and opioid use following prepectoral versus subpectoral breast reconstruction after mastectomy: A retrospective cohort study: Pain after pre- versus subpectoral reconstruction. J Plast Reconstr Aesthet Surg 2020; 74:1763-1769. [PMID: 33451949 DOI: 10.1016/j.bjps.2020.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 10/18/2020] [Accepted: 12/02/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prepectoral (PP) breast reconstruction is now commonly performed and minimizes dissection of the pectoralis major muscle. Data are lacking comparing the immediate postoperative recovery of these patients as compared with traditional subpectoral (SP) breast reconstruction. METHODS From December 2015 to February 2017, 73 patients underwent PP prosthetic-based reconstruction at a single academic institution. PP cases were matched 1:1, by age and stage, to patients undergoing traditional SP reconstruction. Analysis of postoperative pain (visual analog scale) and opioid use (oral morphine equivalents, OME), was performed with both bi- and multivariate analyses. Additional outcomes explored included length of stay (LOS) and reconstructive intervention by plane of prosthetic reconstruction. RESULTS A total of 146 patients were included in the final cohort. PP reconstruction was associated with higher rates of direct-to-implant reconstruction (84.9% vs. 34.3%, p <0.001) and higher rates of initial prosthetic fill (401.53 mL vs. 280.88 mL, p<0.001). Patients undergoing PP reconstruction had significantly reduced postoperative pain (4.29 vs. 5.44, p<0.001) and in-hospital opioid use (62.63 mg OME vs. 98.84 mg OME, p = 0.03) compared with SP patients. This result remained in multivariate analysis for both pain (3.94 vs. 5.25, p<0.001) and opioid use (17.14 mg OME vs. 63.03 mg OME, p = 0.03). Additionally, patients undergoing PP reconstruction had significantly reduced overall LOS on multivariate analysis (21.36 vs. 26.28 h, p = 0.02). CONCLUSION Following mastectomy, PP breast reconstruction results in significantly reduced pain, opioid use, and hospital LOS compared with SP reconstruction.
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Affiliation(s)
- Laura M Bozzuto
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Alex J Bartholomew
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Shawndeep Tung
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Michael Sosin
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States; Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
| | - Stuti Tambar
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States; Comprehensive Blood and Cancer Center, Bakersfield, CA, United States
| | - Solange Cox
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Idanis M Perez-Alvarez
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Caroline A King
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Mabel C Chan
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States
| | - Troy A Pittman
- Somenek+Pittman MD Advanced Plastic Surgery, Washington, DC, United States
| | - Eleni A Tousimis
- Department of Surgery, Medstar Georgetown University Hospital, Washington, D.C, United States.
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10
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Johnson AC, Colakoglu S, Reddy A, Kerwin CM, Flores RA, Iorio ML, Mathes DW. Perioperative Blocks for Decreasing Postoperative Narcotics in Breast Reconstruction. Anesth Pain Med 2020; 10:e105686. [PMID: 34150564 PMCID: PMC8207839 DOI: 10.5812/aapm.105686] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/03/2020] [Accepted: 08/07/2020] [Indexed: 02/07/2023] Open
Abstract
Context High rates of mortality and chemical dependence occur following the overuse of narcotic medications, and the prescription of these medications has become a central discussion in health care. Efforts to curtail opioid prescribing include Enhanced Recovery After Surgery (ERAS) guidelines, which describe local anesthesia techniques to decrease or eliminate the need for opioids when used in a comprehensive protocol. Here, we review effective perioperative blocks for the decreased use of opioid medications post-breast reconstruction surgery. Evidence Acquisition A comprehensive review was conducted using keywords narcotics, opioid, surgery, breast reconstruction, pain pump, nerve block, regional anesthesia, and analgesia. Papers that described a local anesthetic option for breast reconstruction for decreasing postoperative narcotic consumption, written in English, were included. Results A total of 52 papers were included in this review. Local anesthetic options included single-shot nerve blocks, nerve block catheters, and local and regional anesthesia. Most papers reported equal or even superior pain control with decreased nausea and vomiting, length of hospital stay, and other outcomes. Conclusions Though opioid medications are currently the gold standard medication for pain management following surgery, strategies to decrease the dose or number of opioids prescribed may lead to better patient outcomes. The use of a local anesthetic technique has been shown to reduce narcotic use and improve patients’ pain scores after breast reconstruction surgery.
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Affiliation(s)
- Ariel Clare Johnson
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Salih Colakoglu
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Angela Reddy
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Clara Marie Kerwin
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Roland A Flores
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Matthew L Iorio
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - David W Mathes
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Corresponding Author: MD, Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
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Huynh V, Rojas K, Ahrendt G, Murphy C, Jaiswal K, Cumbler E, Christian N, Tevis S. Reassessing Opioid Use in Breast Surgery. J Surg Res 2020; 254:232-241. [PMID: 32474196 DOI: 10.1016/j.jss.2020.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/11/2020] [Accepted: 04/17/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study aims to assess multimodal pain management and opioid prescribing practices in patients undergoing breast surgery. METHODS A retrospective review of patients undergoing breast surgery at an academic medical center between April 1, 2018 and September 30, 2019, was performed. Patients with a history of recent opioid use or conditions precluding use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (APAP) were excluded. Opioid-sparing pain regimens were assessed. Opioids prescribed on discharge were recorded as oral morphine equivalents (OMEs) and concordance with the Opioid Prescribing Engagement Network (OPEN) determined. RESULTS The total study population consisted of 518 patients. 358 patients underwent minor outpatient procedures (sentinel lymph node biopsy, lumpectomy, and excisional biopsy), 10-40% of whom were appropriately prescribed as per the OPEN. Perioperatively, 53.9% of patients received APAP, 24.6% NSAIDs, 20.4% gabapentin, and 0.3% blocks; intraoperatively, 95.8% received local anesthetic and 25.7% ketorolac. For mastectomy without reconstruction, 63-88% of prescriptions were concordant with the OPEN. For mastectomy with reconstruction, discharge opioids ranged from 25 to 400 OMEs with a mean of 134.4 OMEs; 25% of patients received a refill. Of all patients undergoing mastectomy ± reconstruction, 62.5% received APAP, 18.8% NSAIDs, 38.8% pregabalin, and 20.6% locoregional block perioperatively; 37.5% received local anesthetic and 15.6% ketorolac intraoperatively. Of 143 inpatient stays, 89% received APAP, 38% NSAID, and 29% benzodiazepines; 29 patients received no opioids inpatient but were still prescribed 25-200 OMEs on discharge. CONCLUSIONS There is need for a multidisciplinary approach to pain management with the use of enhanced recovery after surgery protocols as potential means to standardize perioperative regimens and mitigate opioid overprescription.
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Affiliation(s)
- Victoria Huynh
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Kristin Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Gretchen Ahrendt
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Colleen Murphy
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kshama Jaiswal
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ethan Cumbler
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Nicole Christian
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sarah Tevis
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Ahmed MJ, Ur Rehman A, Arshad RM, Amjad MWA, Khan Z, Furqan A. Efficacy of Dexmedetomidine vs Morphine as an Adjunct in a Paravertebral Block with Bupivacaine in Postoperative Analgesia Following Modified Radical Mastectomy. Cureus 2020; 12:e8231. [PMID: 32582491 PMCID: PMC7306667 DOI: 10.7759/cureus.8231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective To observe the efficacy of dexmedetomidine vs morphine as an adjunct in a paravertebral block (PVB) with bupivacaine in postoperative analgesia following modified radical mastectomy. Study design This was a randomized controlled trial performed from June 2018 to August 2019 in the Department of Anesthesia, Bakhtawar Amin Medical and Dental College, Ch. Pervaiz Ellahi Institute of Cardiology, Multan, Gurki Hospital, Services Institute of Medical Sciences, and Sheikh Zayed Hospital, Lahore. Methodology Seventy-eight patients were equally divided into group M, which received morphine (3 mg) and group D, which received dexmedetomidine (1 µg/kg), along with 20 cc 0.25% bupivacaine, for PVB. The primary outcome included morphine requirements in the post-anesthesia care unit (PACU). Secondary outcomes included the quality and duration of analgesia, intraoperative doses of fentanyl and propofol, postoperative doses of diclofenac required, postoperative nausea and vomiting (PONV), and the Ramsey sedation score. Data were entered into SPSS version 23 (IBM Corp., Armonk, NY) and analyzed by applying the independent t-test, Mann Whitney U-test, and the chi-square test or Fischer’s exact test, as appropriate. P≤0.05 was considered statistically significant. Results The mean time for the first analgesic administration was much shorter in group D as compared to group M (p<0.001). The average doses of ephedrine and morphine used were higher in group D (p-value 0.033 and 0.013, respectively). In the PACU, 33.3% of group D patients as compared to 12.8% of group M patients needed morphine (p=0.032). Postoperatively, diclofenac consumption was higher in group D (p<0.001). Postoperative pain was lower and sedation was higher in group M (p<0.05). Conclusion As an adjunct to bupivacaine in PVB for MRM, morphine is superior to dexmedetomidine.
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Affiliation(s)
| | - Abaid Ur Rehman
- Anaesthesia, Lahore Medical and Dental College, Ghurki Trust Teaching Hospital, Lahore, PAK
| | | | | | - Zeeshan Khan
- Anaesthesia, Sheikh Zayed Medical College and Hospital, Rahim Yar Khan, PAK
| | - Aamir Furqan
- Anaesthesia and Critical Care, Chaudhry Pervaiz Elahi Institute of Cardiology, Multan, PAK
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El Ghamry MR, Amer AF. Role of erector spinae plane block versus paravertebral block in pain control after modified radical mastectomy. A prospective randomised trial. Indian J Anaesth 2019; 63:1008-1014. [PMID: 31879425 PMCID: PMC6921308 DOI: 10.4103/ija.ija_310_19] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/08/2019] [Accepted: 09/03/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND AIMS Thoracic paravertebral block (TPVB) provides effective analgesia in breast surgery. Recently, use of erector spinae plane block (ESPB) in controlling post-operative pain has proved effective. This study aimed to compare the effect of ESPB with TPVB in post-mastectomy acute pain control. METHODS A prospective, randomised double-blinded study enrolled 70 adult female patients, scheduled for modified radical mastectomy. Patients were randomised into two groups, receiving 20 ml of 0.25% bupivacaine: group I (TPVB) and group II (ESPB). Post-operative 24 h morphine consumption, intra-operative fentanyl consumption, time of the first request for analgesia and post-operative visual analogue scale (VAS), heart rate (HR), mean blood pressure (MBP) and complications were recorded. RESULTS Post-operative 24 h morphine consumption and time of the first request for analgesia were comparable between both groups (P = 0.32 and 0.075, respectively). There was no significant difference in the intra-operative fentanyl consumption. There was also no significant difference in VAS between both groups over the 24 h of study. Four patients in group I developed pneumothorax with no significant differences between both groups (P = 0.114). Incidence of nausea and vomiting was comparable between both groups. All patients displayed a stable haemodynamic profile. CONCLUSION Both TPVB and ESPB can be effectively used in controlling post-mastectomy pain and reduce intra-operative and post-operative opioid consumption.
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Affiliation(s)
- Mona Raafat El Ghamry
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, El Geish Street, Tanta, Egypt
| | - Asmaa Fawzy Amer
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, El Geish Street, Tanta, Egypt
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McGugin CJ, Coopey SB, Smith BL, Kelly BN, Brown CL, Gadd MA, Hughes KS, Specht MC. Enhanced Recovery Minimizes Opioid Use and Hospital Stay for Patients Undergoing Mastectomy with Reconstruction. Ann Surg Oncol 2019; 26:3464-3471. [DOI: 10.1245/s10434-019-07710-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Indexed: 11/18/2022]
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15
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Non-narcotic Perioperative Pain Management in Prosthetic Breast Reconstruction During an Opioid Crisis: A Systematic Review of Paravertebral Blocks. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2299. [PMID: 31624690 PMCID: PMC6635209 DOI: 10.1097/gox.0000000000002299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/24/2019] [Indexed: 12/27/2022]
Abstract
Background: Alternatives to postoperative, narcotic pain management following implant-based, postmastectomy breast reconstruction (IBR) must be a focus for plastic surgeons and anesthesiologists, especially with the current opioid epidemic. Paravertebral blocks (PVBs) are a regional technique that has demonstrated efficacy in patients undergoing a variety of breast cancer–related surgeries. However, a specific understanding of PVB’s efficacy in pain management in patients who undergo IBR is lacking. Methods: A systematic search of PubMed, EMBASE, and Cochrane Library electronic database was conducted to examine PVB administration in mastectomy patients undergoing IBR. Data were abstracted regarding: authors, publication year, study design, patient demographics, tumor laterality, tumor stage, type, and timing of reconstruction. The primary outcome was PVB efficacy, represented as patient-reported pain scores. Secondary outcomes of interest include narcotic consumption, postoperative nausea and vomiting, antiemetic use, and length of stay. Results: The search resulted in 1,516 unique articles. After title and abstract screening, 29 articles met the inclusion criteria for full-text review. Only 7 studies were included. Of those, 2 studies were randomized control trials and 5 were retrospective cohort studies. Heterogeneity of included studies precluded a meta-analysis. Overall, PVB patients had improved pain control, and less opioid consumption. Conclusion: PVBs are a regional anesthesia technique which may aid in pain management in the breast reconstructive setting. Evidence suggests that PVBs aid in controlling acute postoperative pain, reduce opioid consumption, and improve patient length of stay. However, some conflicting findings demonstrate a need for continued research in this area of pain control.
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Rivedal DD, Nayar HS, Israel JS, Leverson G, Schulz AJ, Chambers T, Afifi AM, Blake JM, Poore SO. Paravertebral block associated with decreased opioid use and less nausea and vomiting after reduction mammaplasty. J Surg Res 2018; 228:307-313. [DOI: 10.1016/j.jss.2018.03.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 12/22/2017] [Accepted: 03/14/2018] [Indexed: 11/16/2022]
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Eden C, Esses G, Katz D, DeMaria S. Effects of anesthetic interventions on breast cancer behavior, cancer-related patient outcomes, and postoperative recovery. Surg Oncol 2018; 27:266-274. [PMID: 29937181 PMCID: PMC6309684 DOI: 10.1016/j.suronc.2018.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 05/02/2018] [Indexed: 12/17/2022]
Abstract
This narrative review will summarize our current understanding of the effects of perioperative interventions on patients undergoing surgical removal of breast malignancies. It will focus on how different anesthetic agents and perioperative interventions might affect both breast cancer behavior and/or tumor recurrence as well as postoperative recovery. The main objective of this study will be to describe the evidence and critically analyze preclinical and clinical studies on the use of intravenous versus inhaled anesthetic agents, opioids, regional anesthetics, and anesthetic adjuncts in patients undergoing breast cancer resection. We will look both at the evidence regarding cancer-related outcomes and postoperative recovery. A search of PubMed, from inception to May 2017 was performed using Mesh terms Breast Neoplasms [Mesh] OR cancer AND breast AND Anesthesia [Mesh]; "Anesthetics"[Mesh] AND "Breast Neoplasms/surgery"[Mesh]. Although no optimal anesthetic combination has been identified for patients undergoing breast cancer resection, it should be noted that based on the available evidence, an ideal anesthetic in this patient population would involve a combination of TIVA (propofol), regional anesthesia (paravertebral block)), non opioid sedatives (clonidine or dexmedetomidine), and COX-2 inhibition (ketorolac). Based on the current evidence, this combination of anesthetic and analgesic agents has the best chance of improving cancer-related outcomes and postoperative recovery.
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Affiliation(s)
- Caroline Eden
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Gary Esses
- Department of Anesthesiology, The Mount Sinai Medical Center, New York, NY, USA
| | - Daniel Katz
- Department of Anesthesiology, The Mount Sinai Medical Center, New York, NY, USA
| | - Samuel DeMaria
- Department of Anesthesiology, The Mount Sinai Medical Center, New York, NY, USA
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Head LK, Lui A, Boyd KU. Efficacy and safety of bilateral thoracic paravertebral blocks in outpatient breast surgery. Breast J 2018; 24:561-566. [DOI: 10.1111/tbj.13008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 06/18/2017] [Accepted: 08/01/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Linden K. Head
- Division of Plastic and Reconstructive Surgery; Department of Surgery; University of Ottawa; Ottawa ON Canada
| | - Anne Lui
- Department of Anesthesiology and Pain Medicine; University of Ottawa; Ottawa ON Canada
| | - Kirsty Usher Boyd
- Division of Plastic and Reconstructive Surgery; Department of Surgery; University of Ottawa; Ottawa ON Canada
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El Mourad MB, Amer AF. Effects of adding dexamethasone or ketamine to bupivacaine for ultrasound-guided thoracic paravertebral block in patients undergoing modified radical mastectomy: A prospective randomized controlled study. Indian J Anaesth 2018; 62:285-291. [PMID: 29720754 PMCID: PMC5907434 DOI: 10.4103/ija.ija_791_17] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background and Aims: Pain after modified radical mastectomy (MRM) has been successfully managed with thoracic paravertebral block (TPVB). The purpose of this study was to evaluate the effect of adding dexamethasone or ketamine as adjuncts to bupivacaine in TPVB on the quality of postoperative analgesia in participants undergoing MRM. Methods: This prospective randomised controlled study enrolled ninety adult females scheduled for MRM. Patients were randomised into three groups (30 each) to receive ultrasound-guided TPVB before induction of general anaesthesia. Group B received bupivacaine 0.5% + 1 ml normal saline, Group D received bupivacaine 0.5% + 1 ml dexamethasone (4 mg) and Group K received bupivacaine 0.5% + 1 ml ketamine (50 mg). Patients were observed for 24 h postoperatively to record time to first analgesic demand as a primary outcome, pain scores, total rescue morphine consumption and incidence of complications. Results: Group K had significantly longer time to first analgesic demand than group D and control group (18.0 ± 6.0, 10.3 ± 4.5 and 5.3 ± 3.1 hours respectively; P = 0.0001). VAS scores were significantly lower in group D and group K compared to control group at 6h and 12 h postoperative (p 0.0001 and 0.0001 respectively) while group K had lower VAS at 18 hours compared to other two groups (P = 0.0001). Control group showed the highest mean 24 h opioid consumption (8.9 ± 7.9 mg) compared to group D and group K (3.60 ± 6.92 and 2.63 ± 5.24 mg, P = 0.008,0.001 respectively). No serious adverse events were observed. Conclusion: Ketamine 50 mg or dexamethasone 4 mg added to bupivacaine 0.5% in TPVB for MRM prolonged the time to first analgesic request with no serious side effects.
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Affiliation(s)
- Mona Blough El Mourad
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Asmaa Fawzy Amer
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
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Offodile AC, Aycart MA, Segal JB. Comparative Effectiveness of Preoperative Paravertebral Block for Post-Mastectomy Reconstruction: A Systematic Review of the Literature. Ann Surg Oncol 2017; 25:818-828. [DOI: 10.1245/s10434-017-6291-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Indexed: 11/18/2022]
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Župčić M, Graf Župčić S, Duzel V, Šimurina T, Šakić L, Fudurić J, Peršec J, Milošević M, Stanec Z, Korušić A, Barišin S. A combination of levobupivacaine and lidocaine for paravertebral block in breast cancer patients undergoing quadrantectomy causes greater hemodynamic oscillations than levobupivacaine alone. Croat Med J 2017; 58:270-280. [PMID: 28857520 PMCID: PMC5577647 DOI: 10.3325/cmj.2017.58.270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
AIM To test for differences in hemodynamic and analgesic properties in patients with breast cancer undergoing quadrantectomy with paravertebral block (PVB) induced with a solution of either one or two local anesthetics. METHOD A prospective, single-center, randomized, double-blinded, controlled trial was conducted from June 2014 until September 2015. A total of 85 women with breast cancer were assigned to receive PVB with either 0.5% levobupivacaine (n=42) or 0.5% levobupivacaine with 2% lidocaine (n=43). Hemodynamic variables of interest included intraoperative stroke volume variation (SVV), mean arterial pressure, heart rate, cardiac output, episodes of hypotension, use of crystalloids, and use of inotropes. Analgesic variables of interest were time to block onset, duration of analgesia, and postoperative serial pain assessment using a visual analogue scale. RESULTS Although the use of 0.5% levobupivacaine with 2% lidocaine solution for PVB decreased the mean time-to-block onset (14 minutes; P<0.001), it also caused significantly higher SVV values over the 60 minutes of monitoring (mean difference: 4.33; P<0.001). Furthermore, the patients who received 0.5% levobupivacaine with 2% lidocaine experienced shorter mean duration of analgesia (105 minutes; P=0.006) and more episodes of hypotension (17.5%; P=0.048) and received more intraoperative crystalloids (mean volume: 550 mL; P<0.001). CONCLUSION The use of 0.5% levobupivacaine in comparison with 0.5% levobupivacaine with 2% lidocaine solution for PVB had a longer time-to-block onset, but it also reduced hemodynamic disturbances and prolonged the analgesic effect.
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Affiliation(s)
- Miroslav Župčić
- Miroslav Župčić, Anesthesiology, Reanimatology and Intensive Care Medicine, Clinical Hospital Dubrava, Av. G. Šuška 6, 10000 Zagreb, Croatia,
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Sundaramurthi T, Gallagher N, Sterling B. Cancer-Related Acute Pain: A Systematic Review of Evidence-Based Interventions for Putting Evidence Into Practice. Clin J Oncol Nurs 2017; 21:13-30. [DOI: 10.1188/17.cjon.s3.13-30] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ultrasound-Guided Bilateral Thoracic Paravertebral Blocks as an Adjunct to General Anesthesia in Patients Undergoing Reduction Mammaplasty. Plast Reconstr Surg 2017; 139:20e-28e. [DOI: 10.1097/prs.0000000000002842] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Pérez Herrero MA, López Álvarez S, Fadrique Fuentes A, Manzano Lorefice F, Bartolomé Bartolomé C, González de Zárate J. Quality of postoperative recovery after breast surgery. General anaesthesia combined with paravertebral versus serratus-intercostal block. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:564-571. [PMID: 27091641 DOI: 10.1016/j.redar.2016.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 03/03/2016] [Accepted: 03/12/2016] [Indexed: 06/05/2023]
Abstract
INTRODUCTION The quality of postoperative recovery is one of the most important among all the quality indicators used in clinical situations. This is even more important after cancer surgery. Our aim was to evaluate this after non-reconstructive breast surgery under general anesthesia and paravertebral blockade or serratus-intercostal plane blockade, in the early and late post-operative period. MATERIAL AND METHODS A prospective observational study was conducted on 60 patients (25 paravertebral blockade group and 35 serratus-intercostal plane blockade group) scheduled for non-reconstructive breast surgery during a 6 month period. Every patient received general anaesthesia and were randomised to receive either paravertebral blockade or serratus-intercostal plane blockade. The quality of post-anaesthetic recovery was quantified by Postoperative Quality Recovery Scale, which is used to assess physiological, nociceptive, emotional, autonomy, cognitive and general state domains at different times: baseline (before surgery), 15min after the end of surgery, at discharge to home, and one month after surgery. RESULTS A total recovery of 95.93% was achieved in the early postoperative period (15min PACU), 99.07% at discharge to home, and 99.25% at one month after the intervention. No significant differences were found between groups in total score or in each evaluated area. CONCLUSIONS A progressive improvement was observed in the scores assessed with the Postoperative Quality Recovery Scale, reaching values that would allow the discharge to home and early return to usual active life from the immediate postoperative period, with no significant differences between the 2 analgesic techniques. Savings in opioid use and the excellent recovery were observed in all measured domains observed.
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Affiliation(s)
| | - S López Álvarez
- Complejo Hospitalario Universitario de A Coruña, A Coruña, España
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Abdelsattar JM, Boughey JC, Fahy AS, Jakub JW, Farley DR, Hieken TJ, Degnim AC, Goede W, Mohan AT, Harmsen WS, Niesen AD, Tran NV, Bakri K, Jacobson SR, Lemaine V, Saint-Cyr M. Comparative Study of Liposomal Bupivacaine Versus Paravertebral Block for Pain Control Following Mastectomy with Immediate Tissue Expander Reconstruction. Ann Surg Oncol 2015; 23:465-70. [DOI: 10.1245/s10434-015-4833-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Indexed: 11/18/2022]
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Postoperative nausea and vomiting in the post-anesthetic care unit, a 5-year survey of a quality assurance program in surgical cancer patients. Bull Cancer 2015; 102:405-10. [DOI: 10.1016/j.bulcan.2015.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 03/05/2015] [Indexed: 11/18/2022]
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Abstract
This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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Bouman EAC, Theunissen M, Kessels AG, Keymeulen KB, Joosten EA, Marcus MA, Buhre WF, Gramke HF. Continuous paravertebral block for postoperative pain compared to general anaesthesia and wound infiltration for major oncological breast surgery. SPRINGERPLUS 2014; 3:517. [PMID: 25279309 PMCID: PMC4169785 DOI: 10.1186/2193-1801-3-517] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 08/16/2014] [Indexed: 11/16/2022]
Abstract
We hypothesized that improved acute postoperative pain relief will be achieved using general anaesthesia (GA) either in combination with continuous thoracic paravertebral block (GA-cPVB) or single shot (GA-sPVB) as compared to GA supplemented by local wound infiltration (GA-LWI) after unilateral major breast cancer surgery. A randomised controlled trial was conducted in 46 adult women in a day-care or short-stay hospital setting after major breast cancer surgery. Pain-intensity was measured using an 11-point visual analogue scale (VAS) until postoperative day 2. GA-sPVB was stopped due to slow inclusion. No significant difference in VAS score was noted between GA-LWI (VAS median 0.5 (interquartile range 0.18–2.00)) and GA-cPVB, (VAS 0.3 (0.00–1.55, p = 0.195)) 24 hours after surgery or at any point postoperatively until postoperative day 2. We conclude that both GA-LWI and GA-cPVB anaesthetic techniques are equally effective in treatment of acute postoperative pain after major oncological breast surgery. As GA-LWI is easily to perform with fewer complications and it is more cost-effective it should be preferred over GA-cPVB.
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Affiliation(s)
- Esther A C Bouman
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Center, P. Debyelaan 25, 6202 AZ Maastricht, The Netherlands
| | - Maurice Theunissen
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Center, P. Debyelaan 25, 6202 AZ Maastricht, The Netherlands
| | - Alfons Gh Kessels
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Kristien Bmi Keymeulen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Elbert Aj Joosten
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Center, P. Debyelaan 25, 6202 AZ Maastricht, The Netherlands
| | - Marco Ae Marcus
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Center, P. Debyelaan 25, 6202 AZ Maastricht, The Netherlands ; Department of Anaesthesiology, ICU and Perioperative Medicine, HMC, Doha, Qatar
| | - Wolfgang F Buhre
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Center, P. Debyelaan 25, 6202 AZ Maastricht, The Netherlands
| | - Hans-Fritz Gramke
- Department of Anaesthesiology and Pain Management, Maastricht University Medical Center, P. Debyelaan 25, 6202 AZ Maastricht, The Netherlands
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Fahy AS, Jakub JW, Dy BM, Eldin NS, Harmsen S, Sviggum H, Boughey JC. Paravertebral blocks in patients undergoing mastectomy with or without immediate reconstruction provides improved pain control and decreased postoperative nausea and vomiting. Ann Surg Oncol 2014; 21:3284-9. [PMID: 25034821 DOI: 10.1245/s10434-014-3923-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Indexed: 01/25/2023]
Abstract
BACKGROUND Mastectomy is associated with postoperative nausea and pain. We evaluated whether paravertebral block (PVB) use altered opioid use, antiemetic use, and length of stay in patients undergoing mastectomy. METHODS We performed a retrospective cohort analysis of all patients who underwent mastectomy with or without PVB from 2008 to 2010. Patient demographics, operative procedure, intraoperative medications, postoperative opioid and antiemetic use, and length of stay were reviewed. Statistical analysis included univariable and multivariable analysis. RESULTS A total of 605 patients were identified, of whom 526 patients were evaluable. A total of 294 patients underwent mastectomy without PVB (132 bilateral), and 232 patients underwent mastectomy with PVB (148 bilateral). Immediate reconstruction was performed in 203 (39 %) patients. Need for any postoperative antiemetic was less frequent in the PVB group (39 vs. 57 %, p < 0.0001). Day of surgery opioid use was lower in the PVB group than the non-PVB group (mean ± SD 40.1 ± 15.2 vs. 47.6 ± 17.7 morphine equivalents, p < 0.0001). Decreased opioid use was seen in unilateral mastectomy without reconstruction and bilateral mastectomy with and without immediate reconstruction. The proportion of patients discharged within 36 h of surgery was significantly higher in the PVB group (55 vs. 42 %, p = 0.0031). On multivariable analysis controlling for year of surgery, patient age and surgeon, PVB use affected antiemetic use and opioid use but not hospital length of stay. CONCLUSIONS PVB results in decreased opioid use and decreased need for postoperative antiemetic medication in patients undergoing mastectomy. The greatest benefit is seen in patients undergoing bilateral mastectomy with immediate breast reconstruction.
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Wallaert M, Courivaud P, Mati EH, Shiniara M, Guilbert JM. Bloc interpectoral avec mise en place d’un cathéter pour analgésie postopératoire après chirurgie mammaire. ACTA ACUST UNITED AC 2014; 33:269-71. [DOI: 10.1016/j.annfar.2014.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 02/07/2014] [Indexed: 10/25/2022]
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Vogt A. Paravertebral block – A new standard for perioperative analgesia. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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