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Yılmaz ET, Gülmez DD, Apan A, Keles BO, Coşkun M, Döger C, Kesicioglu T, Serim VA, Uygur FA, Sengul I. A novel comparison of erector spinae plane block and paravertebral block in laparoscopic cholecystectomy. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e20231457. [PMID: 38656013 DOI: 10.1590/1806-9282.20231457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 10/29/2023] [Indexed: 04/26/2024]
Abstract
OBJECTIVE Erector spinae plane block is an updated method than paravertebral block, possessing a lower risk of complications. This study aimed to compare erector spinae plane and paravertebral blocks to safely reach the most efficacious analgesia procedure in laparoscopic cholecystectomy cases. METHODS The study included 90 cases, aged 18-70 years, classified as American Society of Anesthesiologists I-II, who underwent an laparoscopic cholecystectomy procedure. They were randomly separated into three groups, namely, Control, erector spinae plane, and paravertebral block. No block procedure was applied to Control, and a patient-controlled analgesia device was prepared containing tramadol at a 10 mg bolus dose and a 10-min locked period. The pain scores were recorded with a visual analog scale for 24 h postoperatively. RESULTS The visual analog scale values at 1, 5, 10, 20, and 60 min at rest and 60 min coughing were found to be significantly higher in Control than in paravertebral block. A significant difference was revealed between Control vs. paravertebral block and paravertebral block vs. erector spinae plane in terms of total tramadol consumption (p=0.006). Total tramadol consumption in the first postoperative 24 h was significantly reduced in the paravertebral block compared with the Control and erector spinae plane groups. CONCLUSION Sonography-guided-paravertebral block provides sufficient postoperative analgesia in laparoscopic cholecystectomy surgery. Erector spinae plane seems to attenuate total tramadol consumption.
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Affiliation(s)
- Elvan Tekir Yılmaz
- Giresun University, Faculty of Medicine, Department of Anesthesiology and Reanimation - Giresun, Turkey
| | | | - Alparslan Apan
- Giresun University, Faculty of Medicine, Department of Anesthesiology and Reanimation - Giresun, Turkey
| | - Bilge Olgun Keles
- Giresun University, Faculty of Medicine, Department of Anesthesiology and Reanimation - Giresun, Turkey
| | - Mücahit Coşkun
- Giresun University, Faculty of Medicine, Department of Anesthesiology and Reanimation - Giresun, Turkey
| | - Cihan Döger
- University of Health Sciences, Faculty of Medicine, Department of Anesthesiology and Reanimation - Ankara, Turkey
| | - Tugrul Kesicioglu
- Giresun University, Faculty of Medicine, Department of General Surgery - Giresun, Turkey
| | - Vedat Ataman Serim
- Giresun University, Faculty of Medicine, Department of Neurology - Giresun, Turkey
| | - Furkan Ali Uygur
- Giresun University, Faculty of Medicine, Department of General Surgery - Giresun, Turkey
| | - Ilker Sengul
- Giresun University, Faculty of Medicine, Department of General Surgery - Giresun, Turkey
- Giresun University, Faculty of Medicine, Division of Endocrine Surgery - Giresun, Turkey
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Wang J, Cui X, Zhang Y, Sang X, Shen L. The effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy: a randomized, double-blinded, controlled study. BMC Surg 2023; 23:218. [PMID: 37543575 PMCID: PMC10404371 DOI: 10.1186/s12893-023-02125-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 07/25/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND We aimed to investigate the effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy. METHODS Eighty 18-70 years old, American Society of Anesthesiologists level I-III patients scheduled for hepatectomy with a J-shaped subcostal incision were enrolled and randomized to receive either intermittent bolus paravertebral ropivacaine (0.5% loading, 0.2% infusion) or 0.9% saline infusion at 1:1 ratio (25 ml loading before surgery, 0.125 ml/kg/h bolus for postoperative 48 h). The primary outcome was set as postoperative 48 h cumulative intravenous morphine consumption recorded by a patient-controlled analgesic pump. RESULTS Thirty-eight patients in each group completed the study. The cumulative morphine consumptions were lower in the paravertebral block than control group at postoperative 24 (difference -10.5 mg, 95%CI -16 mg to -6 mg, P < 0.001) and 48 (difference -12 mg, 95%CI -19.5 mg to -5 mg, P = 0.001) hours. The pain numerical rating scales at rest were lower in the paravertebral block than control group at postoperative 4 h (difference -2, 95%CI -3 to -1, P < 0.001). The active pain numerical rating scales were lower in the paravertebral block than control group at postoperative 12 h (difference -1, 95%CI -2 to 0, P = 0.005). Three months postoperatively, the paravertebral block group had lower rates of hypoesthesia (OR 0.28, 95%CI 0.11 to 0.75, P = 0.009) and numbness (OR 0.26, 95%CI 0.07 to 0.88, P = 0.024) than the control group. CONCLUSIONS Intermittent bolus paravertebral block provided an opioid-sparing effect and enhanced recovery both in hospital and after discharge in patients undergoing hepatectomy. TRIAL REGISTRATION clinicaltrials.gov (NCT04304274), date: 11/03/2020.
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Affiliation(s)
- Jin Wang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xulei Cui
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
| | - Yuelun Zhang
- Center Research Lab, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinting Sang
- Department of Hepatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Le Shen
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
- State Key Laboratory of Complex Severe and Rare Disease, Beijing, China.
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3
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Higgins T, Mittendorf EA. Peritumoral Lidocaine Injection: A Low-Cost, Easily Implemented Intervention to Improve Outcomes in Early-Stage Breast Cancer. J Clin Oncol 2023:JCO2300418. [PMID: 37023390 DOI: 10.1200/jco.23.00418] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Affiliation(s)
- Tessa Higgins
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
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Kumar M, Yadav JBS, Singh AK, Kumar A, Singh D. Comparative Study Between Conventional Landmark Versus Ultrasound-Guided Paravertebral Block in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Controlled Study. Cureus 2023; 15:e36768. [PMID: 37123682 PMCID: PMC10133587 DOI: 10.7759/cureus.36768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 03/30/2023] Open
Abstract
INTRODUCTION Thoracic paravertebral block (TPVB) has emerged as an effective and safe regional technique for providing postoperative analgesia. We aimed to compare the ease and efficacy of conventional landmark and ultrasound-guided (USG) paravertebral blocks for postoperative analgesia in patients undergoing laparoscopic cholecystectomy. METHODS This was a randomized controlled study. Seventy-six patients of either sex, age 18-40 years, body mass index (BMI) 18-29 kg/m2, American Society of Anesthesiologists physical status classifications I and II posted for elective laparoscopic cholecystectomy under general anesthesia were randomly allocated into two groups of 38 each. Patients in group A were administered a paravertebral block using the anatomical landmark technique (ALT), and group B using an ultrasound-guided paravertebral block in the sitting position. In both groups, 20 ml of 0.5% bupivacaine injection was administered at the T7 vertebral level on the right side. The primary outcome was the first-pass success rate. Secondary outcomes were the number of passes and attempts, duration of analgesia, visual analog scale (VAS) score for pain during 24 h postoperatively and complications if any, were recorded. RESULTS No patients were excluded in the study. Demographic characteristics were comparable in both groups. The number of passes was less in group B (1.45±0.5) compared to group A (2.42±0.95) and was reported to be statistically significant (p = 0.001). The number of attempts was less in group B (1.00±0) as compared to group A (1.29±0.46) and was statistically significant (p = 0.001). The duration of analgesia was longer in group B (530.00±326.33 minutes) compared to group A (345.60±252.95 minutes) and was observed to be statistically significant (p<0.05). The VAS score was significantly lower in group B (1.87±0.78, 2.24 ±0.82) compared to group A (2.42±0.72, 3.13±1.07) at the second and fourth hours, respectively (p = 0.001). Conclusion: We concluded that paravertebral block using an ultrasound-guided technique is more efficacious than the conventional landmark technique for postoperative analgesia in patients undergoing laparoscopic cholecystectomy.
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AlBassam B. Combined Thoracic Paravertebral Block-Interscalene Block as a Primary Anesthetic for Modified Radical Mastectomy: A Case Report. Med Arch 2023; 77:326-328. [PMID: 37876557 PMCID: PMC10591238 DOI: 10.5455/medarh.2023.77.326-328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/02/2023] [Indexed: 10/26/2023] Open
Abstract
Background Regional anesthesia as a primary anesthetic can offer merits over general anesthesia for patients having multiple comorbidities who are at a high risk of perioperative morbidity and mortality. Thoracic paravertebral block (TPVB) and interscalene block (ISB) have been used widely to improve the quality of postoperative analgesia after breast surgery. Objective There are limited data on the feasibility of combining TPVB-ISB as a sole anesthetic technique for extensive breast surgery with axillary lymph nodes dissection. Case presentation In this report, the author presented a successful use of a combined TPVB and ISB as a sole anesthetic with conscious sedation in a 52-year-old patient with multiple comorbidities, including heart failure with reduced ejection fraction, who underwent modified radical mastectomy with left axillary lymph nodes dissection. Conclusion Combining TPVB-ISB can be used as a sole anesthetic for extensive breast surgery in patients with a high risk for general anesthesia.
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Affiliation(s)
- Bassam AlBassam
- Department of Anesthesiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Sun C, Li M, Lan L, Pei L, Zhang Y, Tan G, Zhang Z, Huang Y. Prediction models for chronic postsurgical pain in patients with breast cancer based on machine learning approaches. Front Oncol 2023; 13:1096468. [PMID: 36923433 PMCID: PMC10009151 DOI: 10.3389/fonc.2023.1096468] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/06/2023] [Indexed: 03/03/2023] Open
Abstract
Purpose This study aimed to develop prediction models for chronic postsurgical pain (CPSP) after breast cancer surgery using machine learning approaches and evaluate their performance. Methods The study was a secondary analysis based on a high-quality dataset from a randomized controlled trial (NCT00418457), including patients with primary breast cancer undergoing mastectomy. The primary outcome was CPSP at 12 months after surgery, defined as modified Brief Pain Inventory > 0. The dataset was randomly split into a training dataset (90%) and a testing dataset (10%). Variables were selected using recursive feature elimination combined with clinical experience, and potential predictors were then incorporated into three machine learning models, including random forest, gradient boosting decision tree and extreme gradient boosting models for outcome prediction, as well as logistic regression. The performances of these four models were tested and compared. Results 1152 patients were finally included, of which 22.1% developed CPSP at 12 months after breast cancer surgery. The 6 leading predictors were higher numerical rating scale within 2 days after surgery, post-menopausal status, urban medical insurance, history of at least one operation, under fentanyl with sevoflurane general anesthesia, and received axillary lymph node dissection. Compared with the multivariable logistic regression model, machine learning models showed better specificity, positive likelihood ratio and positive predictive value, helping to identify high-risk patients more accurately and create opportunities for early clinical intervention. Conclusions Our study developed prediction models for CPSP after breast cancer surgery based on machine learning approaches, which may help to identify high-risk patients and improve patients' management after breast cancer.
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Affiliation(s)
- Chen Sun
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Mohan Li
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ling Lan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lijian Pei
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Outcomes Research Consortium, Cleveland, OH, United States
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Gang Tan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhiyong Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Han Y, Dai Y, Shi Y, Zhang X, Xia B, Ji Q, Yu X, Bian J, Xu T. Ultrasound-guided paravertebral blockade reduced perioperative opioids requirement in pancreatic resection: A randomized controlled trial. Front Surg 2022; 9:903441. [PMID: 36111230 PMCID: PMC9468231 DOI: 10.3389/fsurg.2022.903441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPerioperative opioid use for pain control has been found to be associated with side effects and adverse prognosis. In this study, we hypothesized that paravertebral block could reduce the consumption of opioids during pancreatic resection surgery.MethodsWe conducted a prospective, randomized trial. Patients with resectable pancreatic cancer were randomly assigned to one of the two groups: those who received bilateral paravertebral block combined with general anesthesia [bilateral paravertebral blockade (PTB) group] or those who received only general anesthesia (Control group). The primary endpoint was the perioperative consumption of opioids (sufentanil and remifentanil). The main secondary endpoints were pain scores, complications, and serum cytokine levels.ResultsA total of 153 patients were enrolled in the study and 119 cases were analyzed. Compared to the control group, patients in PTB patients had significantly lower perioperative (30.81 vs. 56.17 µg), and intraoperative (9.58 vs. 33.67 µg) doses of sufentanil (both p < 0.001). Numerical rating scale scores of pain were comparable between the two groups. No statistical differences in complications were detected.ConclusionBilateral paravertebral block combined with general anesthesia reduced the perioperative consumption of opioids by 45%.Registration numberChiCTR1800020291 (available on http://www.chictr.org.cn/).
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Affiliation(s)
| | | | | | | | | | | | - Xiya Yu
- Correspondence: Tao Xu Jinjun Bian Xiya Yu
| | | | - Tao Xu
- Correspondence: Tao Xu Jinjun Bian Xiya Yu
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Singh NP, Makkar JK, Kuberan A, Guffey R, Uppal V. Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials. Can J Anaesth 2022; 69:527-549. [PMID: 35102494 DOI: 10.1007/s12630-021-02183-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery. METHODS In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting. RESULTS Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting. CONCLUSION Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice. STUDY REGISTRATION PROSPERO (CRD42020198244); registered 19 October 2020.
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Affiliation(s)
- Narinder Pal Singh
- Department of Anaesthesia, MMIMSR, MM (DU), Mullana-Ambala, Ambala, India
| | - Jeetinder Kaur Makkar
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aswini Kuberan
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Ryan Guffey
- Department of Anesthesia, Washington University in St. Louis, St. Louis, MO, USA
| | - Vishal Uppal
- Department of Anesthesia, Perioperative Medicine and Pain Management, Dalhousie University, Nova Scotia Health Authority and Izaak Walton Killam Health Centre, Halifax, NS, Canada.
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Zhang J, Chang CL, Lu CY, Chen HM, Wu SY. Anesthesia With Propofol Sedation Reduces Locoregional Recurrence in Patients With Breast Cancer Receiving Total Mastectomy Compared With Non-Propofol Anesthesia. Front Oncol 2022; 12:708632. [PMID: 35311108 PMCID: PMC8927654 DOI: 10.3389/fonc.2022.708632] [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: 05/12/2021] [Accepted: 02/07/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose We examined locoregional recurrence (LRR) in patients with breast invasive ductal carcinoma (IDC) receiving total mastectomy (TM) under propofol-based paravertebral block-regional anesthesia (PB-RA) versus sevoflurane-based inhalational general anesthesia (INHA-GA) without propofol. All-cause death and distant metastasis were secondary endpoints. Patients and Methods Patients with breast IDC receiving TM were recruited through propensity score matching and categorized into INHA-GA with sevoflurane and PB-RA with propofol groups. Cox regression analysis was performed to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). Results In the multivariate Cox regression analysis, the adjusted HR (aHR; 95% CI) of LRR for the PB-RA with propofol group was 0.52 (0.28–0.96) compared with the INHA-GA with sevoflurane group. The aHRs of LRR for differentiation grade II, grade III, the American Joint Committee on Cancer clinical stage II, stage III, pathological tumor (pT) stage 2, pT stage 3–4, pathological nodal (pN) stage 1, and pN stage 2–3 were 1.16 (1.04–2.08), 1.28 (1.07–2.12), 3.71 (1.82–7.59), 4.67 (1.65–13.18), 1.09 (1.02–1.21), 1.17 (1.03–2.16), 1.10 (1.03–1.33), and 1.22 (1.06–2.41), respectively, compared with differentiation grade I, clinical stage I, pT1, and pN0. The aHR of LRR for adjuvant RT was 0.88 (0.64–0.94) compared with that for no adjuvant RT. Conclusion PB-RA with propofol might be beneficial for reducing LRR in women with breast IDC receiving TM compared with INHA-GA without propofol.
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Affiliation(s)
- Jiaqiang Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Chia-Lun Chang
- Department of Hemato-Oncology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chang-Yun Lu
- Department of General Surgery, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan
| | - Ho-Min Chen
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Szu-Yuan Wu
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung, Taiwan.,Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan.,Division of Radiation Oncology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan.,Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan.,Graduate Institute of Business Administration, College of Management, Fu Jen Catholic University, Taipei, Taiwan.,Centers for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Li M, Zhang Y, Pei L, Zhang Z, Tan G, Huang Y. Potential Influence of Anesthetic Interventions on Breast Cancer Early Recurrence According to Estrogen Receptor Expression: A Sub-Study of a Randomized Trial. Front Oncol 2022; 12:837959. [PMID: 35223519 PMCID: PMC8869606 DOI: 10.3389/fonc.2022.837959] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/14/2022] [Indexed: 12/24/2022] Open
Abstract
Background Effects of anesthetic interventions on cancer prognosis remain controversial. There is evidence that estrogen receptor (ER)-negative breast cancer patients have an early recurrence peak. We aimed to assess the potential benefit of regional anesthesia-analgesia versus general anesthesia regarding early recurrence in breast cancer according to ER expression. Methods Based on a multicenter randomized controlled trial (clinicaltrials.gov, NCT00418457), we included all the patients from Peking Union Medical College Hospital research center in this study. The primary outcome was breast cancer recurrence after surgery. The Cox proportional hazard model was used to compare recurrence between groups. Results In total, 1,253 breast cancer patients were included in this sub-study, among whom the median follow-up time was 53 months. In this sub-study, 320 patients were ER-negative, and 933 were ER-positive. As for ER-negative patients, the recurrence risk in the PPA (paravertebral blocks and propofol general anesthesia) group showed no statistical difference compared with the GA (sevoflurane and opioids general anesthesia) group (19.1% versus 23.4%; adjusted HR: 0.80, 95% CI: 0.50–1.30; P = 0.377). In the first 18 months after breast cancer surgery, which is considered as the classical early peak of recurrence, after adjustment for menstruation and the pathological stage of tumor, the decrease of early recurrence observed in the PPA group was not significant compared with the GA group (adjusted HR: 0.63, 95% CI: 0.34–1.14; P = 0.127). Conclusions In our study, the effects of early recurrence after breast cancer surgery in both ER-negative and ER-positive patients were similar between regional anesthesia-analgesia and general anesthesia. Large samples of ER-negative patients will be needed to clarify the effects of anesthetic interventions.
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Affiliation(s)
- Mohan Li
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lijian Pei
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Outcomes Research Consortium, Cleveland, OH, United States
| | - Zhiyong Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Gang Tan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Lu W, Tu L, Xie D, Yao F, Lin L, Li Y, Li D, Mou C. A systematic review and meta-analysis: value of ultrasound-guided vacuum-assisted biopsy in the diagnosis and treatment of breast lesions. Gland Surg 2021; 10:3020-3029. [PMID: 34804888 DOI: 10.21037/gs-21-611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/11/2021] [Indexed: 12/24/2022]
Abstract
Background In recent years, according to global statistics, breast cancer is the main disease affecting women. Ultrasound-guided vacuum-assisted biopsy (VAB) has become a frequently used method for breast cancer detection because of its accuracy, simplicity, and fewer complications. Methods In PubMed, Medline, EMbase and Cochrane central register of controlled trials, the retrieval time was from the establishment of the database to March 2021, and the keywords included breast tumor, breast cancer-related diseases, breast lesions, vacuum-assisted breast biopsy, sensitivity and specificity. Meta-analysis was performed using RevMan5.3 software provided by the Cochrane Collaboration. Results A total of 10 articles were included using a random-effects model that pooled the sensitivity, specificity, and other accuracy measures of VAB. The summary receiver operating characteristic (SROC) characteristic curve was used to summarize the overall accuracy. The sensitivity range was 0.94 to 1.00 (mean, 0.981; 95% CI, 0.972-0.987) with a specificity range of 0.87-1.00 (mean, 0.999; 95% CI, 0.997-0.999). The preoperative platelet-lymphocyte ratio (PLR) was 93.84 (95% CI, 41.55-211.95), the neutrophil to lymphocyte ratio (NLR) was 0.05 (95% CI, 0.03-0.09), the sensitivity and specificity of χ2 were 37.10 (P=0.011) and 32.00 (P=0.043), respectively, while those of PLR, NLR, and duration of response (DOR) were 46.98 (P=0.001), 54.92 (P=0.001), and 43.49 (P=0.002), respectively. Differences were considerable. Discussion In this meta-analysis, a total of 10 articles were included. VAB is an accurate type of biopsy to detect female breast cancer. The results of the meta-analysis were stable, and VAB had high sensitivity (98%) and specificity (nearly 100%).
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Affiliation(s)
- Weifeng Lu
- Department of Anesthesia Surgery Center, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Lili Tu
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China.,Department of Geriatric Endocrinology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Danxuan Xie
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China.,Department of Thyroid and Breast Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Eastern Hospital, Chengdu, China
| | - Fu Yao
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China.,Department of Thyroid and Breast Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Eastern Hospital, Chengdu, China
| | - Li Lin
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China.,Department of Thyroid and Breast Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Eastern Hospital, Chengdu, China
| | - Ying Li
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China.,Department of Thyroid and Breast Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Eastern Hospital, Chengdu, China
| | - Dexin Li
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China.,Department of Hepatobiliary Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Eastern Hospital, Chengdu, China
| | - Chengjin Mou
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China.,Department of Thyroid and Breast Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Eastern Hospital, Chengdu, China
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12
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Nair AS, Naik V, Saifuddin MS, Narayanan H, Rayani BK. Regional anesthesia prevents cancer recurrence after oncosurgery! What is wrong with the hypothesis? Indian J Cancer 2021; 58:447-454. [PMID: 34380844 DOI: 10.4103/ijc.ijc_331_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Several studies have investigated the hypothesis of the efficacy of regional anesthesia (RA) techniques in preventing cancer recurrence when used perioperatively during oncological surgeries. Although theoretically, the association appears beneficial, the patient outcomes after cancer surgeries with or without RA were comparable, that is, the use of RA did not improve patient survival or prevent cancer recurrence after surgery. Another problem with this data is its retrospective nature which makes its interpretation difficult. Moreover, there are a lot of other confounding factors like comorbidities, tumor biology, nosocomial infections, duration of hospital stay, and baseline immunity, which is not comparable, and hence make standardization for a well-designed prospective study difficult. Return to intended oncologic therapy (RIOT) involves treatment in the form of radiation or chemotherapy which, if received on time after the planned oncosurgery, could provide a better chance of preventing cancer recurrence and improved survival. However, none of the retrospective studies have correlated cancer recurrence with delay in RIOT or not receiving RIOT as a cause of cancer recurrence. This paper discusses why even a well-designed, prospective trial could possibly never establish the efficacy of RA in preventing cancer recurrence and improving survival due to the complexities involved in a patient undergoing oncosurgery.
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Affiliation(s)
- Abhijit S Nair
- Department of Anaesthesiology, Ibra Hospital, Ministry of Health-Oman, Ibra-414, Sultanate of Oman
| | - Vibhavari Naik
- Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Mohammed Salman Saifuddin
- Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Harini Narayanan
- Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Basanth Kumar Rayani
- Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
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13
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Wong HY, Pilling R, Young BWM, Owolabi AA, Onwochei DN, Desai N. Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis. J Clin Anesth 2021; 72:110274. [PMID: 33873002 DOI: 10.1016/j.jclinane.2021.110274] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE Moderate to severe postoperative pain occurs in up to 60% of women following breast operations. Our aim was to perform a network meta-analysis and systematic review to compare the efficacy and side effects of different analgesic strategies in breast surgery. DESIGN Systematic review and network meta-analysis. SETTING Operating room, postoperative recovery room and ward. PATIENTS Patients scheduled for breast surgery under general anesthesia. INTERVENTIONS Following an extensive search of electronic databases, those who received any of the following interventions, control, local anesthetic (LA) infiltration, erector spinae plane (ESP) block, pectoralis nerve (PECS) block, paravertebral block (PVB) or serratus plane block (SPB), were included. Exclusion criteria were met if the regional anesthesia modality was not ultrasound-guided. Network plots were constructed and network league tables were produced. MEASUREMENTS Co-primary outcomes were the pain at rest at 0-2 h and 8-12 h. Secondary outcomes were those related to analgesia, side effects and functional status. MAIN RESULTS In all, 66 trials met our inclusion criteria. No differences were demonstrated between control and LA infiltration in regard to the co-primary outcomes, pain at rest at 0-2 and 8-12 h. The quality of evidence was moderate in view of the serious imprecision. With respect to pain at rest at 8-12 h, ESP block, PECS block and PVB were found to be superior to control or LA infiltration. No differences were revealed between control and LA infiltration for outcomes related to analgesia and side effects, and few differences were shown between the various regional anesthesia techniques. CONCLUSIONS In breast surgery, regional anesthesia modalities were preferable from an analgesic perspective to control or LA infiltration, with a clinically significant decrease in pain score and cumulative opioid consumption, and limited differences were present between regional anesthetic techniques themselves.
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Affiliation(s)
- Heung-Yan Wong
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Rob Pilling
- Department of Anaesthesia, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Bruce W M Young
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Adetokunbo A Owolabi
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Desire N Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; King's College London, London, United Kingdom
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; King's College London, London, United Kingdom
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14
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Heydinger G, Tobias J, Veneziano G. Fundamentals and innovations in regional anaesthesia for infants and children. Anaesthesia 2021; 76 Suppl 1:74-88. [PMID: 33426659 DOI: 10.1111/anae.15283] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/18/2022]
Abstract
Regional anaesthesia in children has evolved rapidly in the last decade. Although it previously consisted of primarily neuraxial techniques, the practice now incorporates advanced peripheral nerve blocks, which were only recently described in adults. These novel blocks provide new avenues for providing opioid-sparing analgesia while minimising invasiveness, and perhaps risk, associated with older techniques. At the same time, established methods, such as infant spinal anaesthesia, under-utilised in the last 20 years, are experiencing a revival. The impetus has been the concern regarding the potential long-term neurocognitive effects of general anaesthesia in the young child. These techniques have expanded from single shot spinal anaesthesia to combined spinal/epidural techniques, which can now effectively provide surgical anaesthesia for procedures below the umbilicus for a prolonged period of time, thereby avoiding the need for general anaesthesia. Continuous 2-chloroprocaine infusions, previously only described for intra-operative regional anaesthesia, have gained popularity as a means of providing prolonged postoperative analgesia in epidural and continuous nerve block techniques. The rapid, liver-independent metabolism of 2-chloroprocaine makes it ideal for prolonged local anaesthetic infusions in neonates and small infants, obviating the increased risk of local anaesthetic systemic toxicity that occurs with amide local anaesthetics. Debate continues over certain practices in paediatric regional anaesthesia. While the rarity of complications makes comparative analyses difficult, data from large prospective registries indicate that providing regional anaesthesia to children while under general anaesthesia appears to be at least as safe as in the sedated or awake patient. In addition, the estimated frequency of serious adverse events demonstrates that regional blocks in children under general anaesthesia are no less safe than in awake adults. In infants, the techniques of direct thoracic epidural placement or caudal placement with cephalad threading each have distinct advantages and disadvantages. As the data cannot support the safety of one technique over the other, the site of epidural insertion remains largely a matter of anaesthetist discretion.
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Affiliation(s)
- G Heydinger
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - J Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - G Veneziano
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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15
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Guo F, Chen H, Cai X, Ge J, Du B, Song J. Effects of dexmedetomidine as an adjuvant in thoracic paravertebral block on EC50 of propofol for successful laryngeal mask insertion: a randomized controlled trial. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1480. [PMID: 33313225 PMCID: PMC7729349 DOI: 10.21037/atm-20-5174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Background Dexmedetomidine as an adjuvant can improve the duration and the quality of thoracic paravertebral block (TPVB); however, its quantitative effect on propofol infusion is unclear. This study aimed to investigate the effect of dexmedetomidine as an adjuvant in TPVB on the medium effective concentration (EC50) of propofol for successful laryngeal mask insertion. Methods Sixty breast cancer patients who underwent elective modified radical mastectomy were enrolled and randomized at a 1:1 ratio into control group (Group C, n=30) or dexmedetomidine group (Group D, n=30). Ultrasound-guided T3 paravertebral block was performed before induction of anesthesia. In Group C, 0.5% ropivacaine 0.3 mL/kg was injected into T3 paravertebral space, while subjects in Group D received 0.5% ropivacaine 0.3 mL/kg with dexmedetomidine (1 µg/kg). Propofol target-controlled infusion (TCI) was performed, with an initial target effect-site concentration of 5 µg/mL determined for both groups. The laryngeal mask was inserted once the effect chamber achieved the target concentration. Subsequent target concentrations were adjusted by Dixon up-down sequential method, where dose modifications were performed by 0.5 mg/mL intervals, based on the success of the laryngeal mask insertion. Probit analysis was used to determine the propofol EC50. Mean arterial pressure (MAP), heart rate (HR), bispectral index (BIS) and application of atropine or ephedrine was recorded. Participants, TPVB giver, and data recorder were blinded to group assignment. Results Propofol EC50 for successful laryngeal mask insertion were statistically significant, with 5.256 µg/mL (95% CI: 4.833, 5.738 µg/mL) in Group C and 3.172 µg/mL (95% CI: 2.701, 3.621 µg/mL) in Group D. Both groups displayed significantly lower MAP and HR, post propofol TCI (P<0.05). However, subjects in Group D exhibited lower MAP and HR levels compared to patients in Group C (P<0.05). Application of atropine (0% vs. 10%) and ephedrine (20.0% vs. 13.3%) were not significantly different between two groups. Conclusions Dexmedetomidine, administered as an adjuvant in TPVB, can reduce the TCI concentration of propofol for successful laryngeal mask placement in females. The target concentration of propofol requires adjustment and close monitoring of hemodynamic changes, post induction is warranted. Trial registration Chinese Clinical Trial Registry ChiCTR1800016614.
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Affiliation(s)
- Fei Guo
- Department of Anesthesiology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Hao Chen
- Department of Ultrasound, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Xuejiao Cai
- Department of Anesthesiology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Jianlin Ge
- Department of Anesthesiology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Boxiang Du
- Department of Anesthesiology, the Second Affiliated Hospital of Nantong University, Nantong, China
| | - Jie Song
- Department of Anesthesiology, the Second Affiliated Hospital of Nantong University, Nantong, China
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16
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Hegazy MA, Awad G, Abdellatif A, Saleh ME, Sanad M. Ultrasound versus thoracoscopic-guided paravertebral block during thoracotomy. Asian Cardiovasc Thorac Ann 2020; 29:98-104. [PMID: 33019807 DOI: 10.1177/0218492320965015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Paravertebral block can be performed with the aid of surgical landmarks, ultrasound, or a thoracoscope. This study was designed to compare ultrasound-guided paravertebral block with the thoracoscopic technique. METHODS This prospective randomized comparative study included 40 adults scheduled for elective thoracic surgery. Study participants were randomized to an ultrasound group or a thoracoscope group. A catheter for paravertebral block was inserted prior to thoracotomy with real-time ultrasound visualization in the ultrasound group, and under thoracoscopic guidance in the thoracoscope group. Total analgesic consumption, visual analogue pain score, technical difficulties, and complications were compared between the 2 groups. RESULTS Total analgesic consumption in the first 24 hours was less in the ultrasound group than in the thoracoscope group (rescue intravenous fentanyl 121.25 ± 64.01 µg in the ultrasound group vs. 178.75 ± 91.36 µg in the thoracoscope group; p = 0.027). Total paravertebral bupivacaine consumption was 376.00 ± 33.779 mg in the ultrasound group and 471.50 ± 64.341 mg in the thoracoscope group (p < 0.001). Technical difficulties and complications in terms of time consumed during the maneuver, more than one needle pass, and pleural puncture were significantly lower in the ultrasound group than in the thoracoscope group. CONCLUSION Ultrasound-guided paravertebral catheter insertion is more effective, technically easier, and safer than the thoracoscope-assisted technique.
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Affiliation(s)
- Mohammed A Hegazy
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Mansoura University, Egypt
| | - Gehad Awad
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Egypt
| | - Amr Abdellatif
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Egypt
| | | | - Mohammed Sanad
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Egypt
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17
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Lepot A, Elia N, Tramèr MR, Rehberg B. Preventing pain after breast surgery: A systematic review with meta-analyses and trial-sequential analyses. Eur J Pain 2020; 25:5-22. [PMID: 32816362 DOI: 10.1002/ejp.1648] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 08/03/2020] [Accepted: 08/13/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE The aim of this systematic review was to indirectly compare the efficacy of any intervention, administered perioperatively, on acute and persistent pain after breast surgery. DATABASES AND DATA TREATMENT We searched for randomized trials comparing analgesic interventions with placebo or no treatment in patients undergoing breast surgery under general anaesthesia. Primary outcome was intensity of acute pain (up to 6 hr postoperatively). Secondary outcomes were cumulative 24-hr morphine consumption, incidence of postoperative nausea and vomiting (PONV), and chronic pain. We used an original three-step approach. First, meta-analyses were performed when data from at least three trials could be combined; secondly, trial sequential analyses were used to separate conclusive from unclear evidence. And thirdly, the quality of evidence was rated with GRADE. RESULTS Seventy-three trials (5,512 patients) tested loco-regional blocks (paravertebral, pectoralis), local anaesthetic infiltrations, oral gabapentinoids or intravenous administration of glucocorticoids, lidocaine, N-methyl-D-aspartate antagonists or alpha2 agonists. With paravertebral blocks, pectoralis blocks and glucocorticoids, there was conclusive evidence of a clinically relevant reduction in acute pain (visual analogue scale > 1.0 cm). With pectoralis blocks, and gabapentinoids, there was conclusive evidence of a reduction in the cumulative 24-hr morphine consumption (> 30%). With paravertebral blocks and glucocorticoids, there was conclusive evidence of a relative reduction in the incidence of PONV of 70%. For chronic pain, insufficient data were available. CONCLUSIONS Mainly with loco-regional blocks, there is conclusive evidence of a reduction in acute pain intensity, morphine consumption and PONV incidence after breast surgery. For rational decision making, data on chronic pain are needed. SIGNIFICANCE This quantitative systematic review compares eight interventions, published across 73 trials, to prevent pain after breast surgery, and grades their degree of efficacy. The most efficient interventions are paravertebral blocks, pectoralis blocks and glucocorticoids, with moderate to low evidence for the blocks. Intravenous lidocaine and alpha2 agonists are efficacious to a lesser extent, but with a higher level of evidence. Data for chronic pain are lacking.
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Affiliation(s)
- Ariane Lepot
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Nadia Elia
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, Institute of Global Health, University of Geneva, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Martin Richard Tramèr
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benno Rehberg
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
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18
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Brenin DR, Dietz JR, Baima J, Cheng G, Froman J, Laronga C, Ma A, Manahan MA, Mariano ER, Rojas K, Schroen AT, Tiouririne NAD, Wiechmann LS, Rao R. Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons. Ann Surg Oncol 2020; 27:4588-4602. [PMID: 32783121 DOI: 10.1245/s10434-020-08892-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.
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Affiliation(s)
- David R Brenin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Jill R Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Baima
- Department of Physical Medicine and Rehabilitation, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gloria Cheng
- Department of Anesthesia, University of Texas Southwestern, Dallas, TX, USA
| | - Joshua Froman
- Department of Surgery, Mayo Clinic, Owatonna, MN, USA
| | | | - Ayemoethu Ma
- Surgery and Integrative Medicine, Scripps Health, La Jolla, CA, USA
| | - Michele A Manahan
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Edward R Mariano
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Kristin Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Anneke T Schroen
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Lisa S Wiechmann
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshni Rao
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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19
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Sessler DI, Pei L, Huang Y, Fleischmann E, Marhofer P, Kurz A, Mayers DB, Meyer-Treschan TA, Grady M, Tan EY, Ayad S, Mascha EJ, Buggy DJ. Recurrence of breast cancer after regional or general anaesthesia: a randomised controlled trial. Lancet 2019; 394:1807-1815. [PMID: 31645288 DOI: 10.1016/s0140-6736(19)32313-x] [Citation(s) in RCA: 217] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/19/2019] [Accepted: 08/07/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Three perioperative factors impair host defence against recurrence during cancer surgery: the surgical stress response, use of volatile anaesthetic, and opioids for analgesia. All factors are ameliorated by regional anaesthesia-analgesia. We tested the primary hypothesis that breast cancer recurrence after potentially curative surgery is lower with regional anaesthesia-analgesia using paravertebral blocks and the anaesthetic propofol than with general anaesthesia with the volatile anaesthetic sevoflurane and opioid analgesia. A second hypothesis was that regional anaesthesia-analgesia reduces persistent incisional pain. METHODS We did a randomised controlled trial at 13 hospitals in Argentina, Austria, China, Germany, Ireland, New Zealand, Singapore, and the USA. Women (age <85 years) having potentially curative primary breast cancer resections were randomised by computer to either regional anaesthesia-analgesia (paravertebral blocks and propofol) or general anaesthesia (sevoflurane) and opioid analgesia. The primary outcome was local or metastatic breast cancer recurrence. The secondary outcome was incisional pain at 6 months and 12 months. Primary analyses were done under intention-to-treat principles. This trial is registered with ClinicalTrials.gov, NCT00418457. The study was stopped after a preplanned futility boundary was crossed. FINDINGS Between Jan 30, 2007, and Jan 18, 2018, 2132 women were enrolled to the study, of whom 24 were excluded before surgery. 1043 were assigned to regional anaesthesia-analgesia and 1065 were allocated to general anaesthesia. Baseline characteristics were well balanced between study groups. Median follow-up was 36 (IQR 24-49) months. Among women assigned regional anaesthesia-analgesia, 102 (10%) recurrences were reported, compared with 111 (10%) recurrences among those allocated general anaesthesia (hazard ratio 0·97, 95% CI 0·74-1·28; p=0·84). Incisional pain was reported by 442 (52%) of 856 patients assigned to regional anaesthesia-analgesia and 456 (52%) of 872 patients allocated to general anaesthesia at 6 months, and by 239 (28%) of 854 patients and 232 (27%) of 852 patients, respectively, at 12 months (overall interim-adjusted odds ratio 1·00, 95% CI 0·85-1·17; p=0·99). Neuropathic breast pain did not differ by anaesthetic technique and was reported by 87 (10%) of 859 patients assigned to regional anaesthesia-analgesia and 89 (10%) of 870 patients allocated to general anaesthesia at 6 months, and by 57 (7%) of 857 patients and 57 (7%) of 854 patients, respectively, at 12 months. INTERPRETATION In our study population, regional anaesthesia-analgesia (paravertebral block and propofol) did not reduce breast cancer recurrence after potentially curative surgery compared with volatile anaesthesia (sevoflurane) and opioids. The frequency and severity of persistent incisional breast pain was unaffected by anaesthetic technique. Clinicians can use regional or general anaesthesia with respect to breast cancer recurrence and persistent incisional pain. FUNDING Sisk Healthcare Foundation (Ireland), Eccles Breast Cancer Research Fund, British Journal of Anaesthesia International, College of Anaesthetists of Ireland, Peking Union Medical College Hospital, Science Fund for Junior Faculty 2016, Central Bank of Austria, and National Healthcare Group.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anesthesia, Conduction/adverse effects
- Anesthesia, Conduction/methods
- Anesthesia, General/adverse effects
- Anesthesia, General/methods
- Anesthetics, Inhalation/adverse effects
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Female
- Follow-Up Studies
- Humans
- Kaplan-Meier Estimate
- Lymphatic Metastasis
- Mastectomy/methods
- Middle Aged
- Neoplasm Grading
- Neoplasm Recurrence, Local/etiology
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Staging
- Nerve Block/methods
- Pain, Postoperative/prevention & control
- Sevoflurane/adverse effects
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Affiliation(s)
- Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Lijian Pei
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China.
| | - Edith Fleischmann
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Peter Marhofer
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Andrea Kurz
- Department of Outcomes Research, Anesthesiology Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas B Mayers
- Department of Outcomes Research, Anesthesiology Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Regional Anesthesiology, Anesthesiology Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Martin Grady
- Department of Outcomes Research, Anesthesiology Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Regional Anesthesiology, Anesthesiology Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ern Yu Tan
- Tan Tock Seng Hospital, Singapore, Singapore
| | - Sabry Ayad
- Department of Outcomes Research, Anesthesiology Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Regional Anesthesiology, Anesthesiology Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Edward J Mascha
- Department of Outcomes Research, Anesthesiology Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Anesthesiology Institute and Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Donal J Buggy
- Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
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20
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Sriganesh K, Syeda S, Shanthanna H, Venkataramaiah S, Palaniswamy SR. Comparison of intraoperative fentanyl with dexmedetomidine for perioperative analgesia and opioid consumption during craniotomies: A randomised controlled pilot study with non-inferiority design. Int J Clin Pract 2019; 73:e13338. [PMID: 30829429 DOI: 10.1111/ijcp.13338] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/26/2019] [Accepted: 03/02/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Moderate to severe pain is common despite the use of potent opioids during craniotomies. Non-opioid agents such as dexmedetomidine reduce undesirable opioid effects and are successfully used as primary analgesic during bariatric surgeries. This study assessed the feasibility of conducting a large randomised controlled trial comparing fentanyl with dexmedetomidine for perioperative analgesia during craniotomy. METHODS This was a prospective single-centre randomised controlled feasibility trial. Twenty-four consenting adult patients undergoing supratentorial craniotomy at NIMHANS, Bangalore, India, were recruited after ethical approval in March and April 2018. They received either fentanyl 1 µg kg-1 h-1 (n = 12) or dexmedetomidine 0.5 µg kg-1 h-1 (n = 12) as primary intraoperative analgesic drug. Patient, anaesthesiologist, outcome assessor and data analyst were blinded to the study intervention. Our feasibility outcomes (primary) were recruitment and adherence rates. We also explored the potential efficacy of intervention and adverse events. RESULTS We recruited 24 out of 30 eligible patients and had 100% protocol adherence, thereby demonstrating the feasibility of a larger randomised controlled trial. All 24 patients completed the study. The demographic and clinical parameters were similar between the groups. Compared between fentanyl and dexmedetomidine, there was no difference in the intraoperative fentanyl (top-up) consumption (µg), expressed as median and interquartile range: 25 (0-50) and 0 (0-50); P = 0.844; and no difference in postoperative pain at 15 and 60 minutes. Adverse events were few and similar with fentanyl and dexmedetomidine. CONCLUSIONS A large-scale randomised controlled trial of perioperative dexmedetomidine versus fentanyl is feasible. Dexmedetomidine has the potential to be non-inferior to fentanyl for perioperative analgesia during craniotomies.
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Affiliation(s)
- Kamath Sriganesh
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Seham Syeda
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Harsha Shanthanna
- Department of Anaesthesia, McMaster University, Hamilton, ON, Canada
| | - Sudhir Venkataramaiah
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Sangeetha R Palaniswamy
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, India
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Xie Q, Wang S, Zhao Y, Zhang Z, Qin C, Yang X. MicroRNA-216a suppresses the proliferation and migration of human breast cancer cells via the Wnt/β-catenin signaling pathway. Oncol Rep 2019; 41:2647-2656. [PMID: 30864744 PMCID: PMC6448085 DOI: 10.3892/or.2019.7050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 09/05/2018] [Indexed: 12/16/2022] Open
Abstract
The aim of the present study was to investigate the potential anticancer effects of microRNA-216a on the growth of human breast cancer and the possible underlying mechanisms. The results demonstrated that serum microRNA-216a was significantly decreased in patients with breast cancer compared with healthy controls. MicroRNA-216a overexpression led to a decrease in cell proliferation and migration, as well as increases in apoptosis, caspase-3/8 activities, Bax expression and p53 protein expression in MCF-7 cells. It was also revealed that microRNA-216a suppressed Wnt and β-catenin expression in MCF-7 cells. The anticancer effects of microRNA-216a were reversed by anti-microRNA-216a by promoting the Wnt/β-catenin signaling pathway. Inactivation of the Wnt pathway increased the anticancer effects of microRNA-216a in MCF-7 cells. Collectively, the results of the present study indicated that microRNA-216a suppressed the growth of human breast cancer cells by targeting the Wnt/β-catenin signaling pathway.
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Affiliation(s)
- Qing Xie
- School of Basic Medical Sciences, Xinxiang Medical University, Xinxiang, Henan 453003, P.R. China
| | - Shuai Wang
- School of Basic Medical Sciences, Xinxiang Medical University, Xinxiang, Henan 453003, P.R. China
| | - Yue Zhao
- School of Basic Medical Sciences, Xinxiang Medical University, Xinxiang, Henan 453003, P.R. China
| | - Zhenchao Zhang
- School of Basic Medical Sciences, Xinxiang Medical University, Xinxiang, Henan 453003, P.R. China
| | - Chuan Qin
- School of Basic Medical Sciences, Xinxiang Medical University, Xinxiang, Henan 453003, P.R. China
| | - Xianjun Yang
- School of Basic Medical Sciences, Xinxiang Medical University, Xinxiang, Henan 453003, P.R. China
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The Efficacy of Ultrasound-Guided Paravertebral Block in Laparoscopic Cholecystectomy. ACTA ACUST UNITED AC 2018; 54:medicina54050075. [PMID: 30360531 PMCID: PMC6262619 DOI: 10.3390/medicina54050075] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/05/2018] [Accepted: 10/18/2018] [Indexed: 01/22/2023]
Abstract
Background and objectives: Despite its wide use in thoracic procedures, to date, few studies have assessed the effectiveness of paravertebral block (PVB) in laparoscopic cholecystectomy (LC) in an adult population. In these studies, PVB was performed bilaterally using nerve stimulator guidance. To the best of our knowledge, the effectiveness of unilateral preoperative and postoperative ultrasound-guided PVB has not been evaluated in patients undergoing elective LC. The aim of this study was to evaluate the efficacy of single-dose unilateral paravertebral block (PVB) in patients undergoing laparoscopic cholecystectomy (LC) under general anesthesia. Materials and Methods: Patients undergoing LC were randomly separated into control, preoperative block, and postoperative block groups. PVB was performed unilaterally using bupivacaine under ultrasound guidance. Postoperative pain within the first 24 h, side effects, intraoperative opioid and postoperative analgesic requirements were noted. Evaluation was made of a total of 90 patients (25 males, 65 females) with a mean age of 45.78 ± 14.0 years (range, 19–74 years). Results: Opioid and additional analgesic needs and nausea/vomiting rates were significantly reduced in the preoperative block group compared to the other groups (p < 0.05). Visual Analog Scale (VAS) scores were significantly lower in the preoperative and postoperative block groups compared to the control group (p < 0.05 for all). When the VAS scores were compared between the preoperative and postoperative block groups, a significant difference in favor of the preoperative group was observed in terms of the zero minute-, 1st and 2nd h assessments (p < 0.05 for all). Conclusions: Ultrasound-guided PVB is a useful and safe approach for pain management during and after LC. Preoperative block can also reduce the rate of requirement for intraoperative opioid and postoperative analgesia.
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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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Pawa A, Wight J, Onwochei DN, Vargulescu R, Reed I, Chrisman L, Pushpanathan E, Kothari A, El-Boghdadly K. Combined thoracic paravertebral and pectoral nerve blocks for breast surgery under sedation: a prospective observational case series. Anaesthesia 2018; 73:438-443. [DOI: 10.1111/anae.14213] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2017] [Indexed: 11/29/2022]
Affiliation(s)
- A. Pawa
- Department of Anaesthesia; Guy's and St. Thomas’ NHS Foundation Trust; London UK
| | - J. Wight
- Department of Anaesthesia; Guy's and St. Thomas’ NHS Foundation Trust; London UK
| | - D. N. Onwochei
- Department of Anaesthesia; Guy's and St. Thomas’ NHS Foundation Trust; London UK
| | - R. Vargulescu
- Department of Anaesthesia; Guy's and St. Thomas’ NHS Foundation Trust; London UK
| | - I. Reed
- Department of Anaesthesia; Guy's and St. Thomas’ NHS Foundation Trust; London UK
| | - L. Chrisman
- Department of Anaesthesia; Guy's and St. Thomas’ NHS Foundation Trust; London UK
| | - E. Pushpanathan
- Department of Anaesthesia; Guy's and St. Thomas’ NHS Foundation Trust; London UK
| | - A. Kothari
- Department of Breast Surgery; Guy's and St. Thomas’ NHS Foundation Trust; London UK
| | - K. El-Boghdadly
- Department of Anaesthesia; Guy's and St. Thomas’ NHS Foundation Trust; London UK
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Analgesia nociception index (ani) monitoring in patients with thoracic paravertebral block: a randomized controlled study. J Clin Monit Comput 2017. [PMID: 28631050 DOI: 10.1007/s10877-017-0036-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The goal of the study was to evaluate the effectiveness of analgesia nociception index (ANI) monitoring during intraoperative period for patients with thoracic paravertebral block (TPVB) undergoing breast surgery under general anesthesia. This prospective randomized trial was performed after receiving ethics committee approval in 44 patients who were scheduled to undergo breast surgery under general anesthesia. TPVB was performed in the preoperative period using 20 mL of bupivacaine 0.25% at T4 level. Anesthesia maintenance was provided with sevoflurane in O2: air mixture and remifentanil infusion. Intraoperative concentration of sevoflurane was adjusted according to BIS monitoring keeping the values between 40-60. In a randomized manner patients were divided into two groups. In Group control (n:22) intraoperative remifentanil infusion rate was regulated according to hemodynamic parameters, in Group ANI (n:22) remifentanil infusion rate was titrated to keep ANI monitoring values between 50-70. Total remifentanil consumption was recorded as micrograms. Demographic data, anesthesia and surgery time, intraoperative hemodynamic parameters, post-anesthesia recovery time and requirement of additional analgesic in the recovery drug were recorded. There were no significant difference in demographic data, intraoperative hemodynamic parameters, post-anesthesia recovery time and requirement of additional analgesic drug. There was a statistically significant difference between groups in total remifentanil consumption (Group ANI: 629.6 ± 422.4 mcg, Group control: 965.2 ± 543.6 mcg) (p = 0.027). In patients under general anesthesia ANI monitorisation can help optimisation of opioid consumption and provide data about nociception/antinociception intraoperatively but further experimental and clinical trials in a large scale are needed.
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Abstract
PURPOSE OF REVIEW Cancer pain is often incapacitating and discouraging to patients; is demoralizing to family members and care takers; and is taxing and difficult to subdue for the pain specialists. The consequences of implementing suboptimal treatment are far-reaching; therefore, effective treatment methods are in a great demand. The face of cancer pain management has changed in considerable ways, and interventional procedures have become an integral part of providing multimodal analgesia in cancer pain treatment. The goals of this review are to draw attention to the critical role that regional anesthetic nerve blocks and interventional pain management techniques play in treating malignancy-related pain and emphasize the benefits provided by the aforementioned treatment strategies. RECENT FINDINGS A large proportion of cancer patients continues to struggle with an inadequately treated pain despite a strict adherence to the WHO analgesic step ladder. The previous pain treatment algorithm has been modified to include peripheral neural blockade, neuro-destructive techniques, neuromodulatory device use, and intrathecal drug delivery systems. The accumulated evidence highlights the opioid-sparing qualities and other benefits afforded by these modalities: decreasing medication-induced side effects, reducing economic burden of poor analgesia, and overall improvement in quality of life of the patients afflicted with a painful neoplastic disease. The rising prevalence of cancer-related pain syndromes is paralleled by an unmatched growth of innovative treatment strategies. Modified WHO analgesic ladder represents one of the greatest paradigm shifts within the domain of oncologic pain treatment. The cancer patient population requires a prompt and liberal, albeit judicious, delivery of unorthodox pain treatment options freed from the rigid bonds of conventional guidelines and standard practices.
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