Evaluation of Pectoral Nerve Block in Modified Radical Mastectomy: Comparison of Three Concentrations of Ropivacaine

Efficacy of opioid-free anesthesia in modified radical mastectomy: a cross-sectional observational study

Introduction

Perioperative management of female patients undergoing breast surgeries differs from other patients due to chronic pain and postoperative nausea and vomiting. The anesthesia could consist of opioid-free general anesthesia (OFA) or non-opioid-free general anesthesia (NOFA). OFA relies on multimodal analgesia preoperatively and postoperatively. However, it is not yet established whether OFA could replace NOFA as a standard regimen for the management of breast surgeries. The aim of this study is to evaluate the efficacy of OFA for breast surgeries in female patients.

Materials and methods

Patients undergoing modified radical mastectomy were retrospectively recruited. Two groups were defined: group 1, consisting of treated patients using OFA and group 2, consisting of treated patients using NOFA. Mean time to extubate and mean dose of morphine after recovery were computed. Postoperative morphine and antiemetic use were assessed for up to 24 h. A comparison of the computed data was conducted between both groups.

Results

A total of 116 patients were included with a mean age of 53±13 years. Group 1 consisted of 56 (mean age was 54±14 years). Group 2 consisted of 60 patients (mean age was 51±12 years). Demographic parameters and time to extubate did not yield significant differences. We noticed morphine sparing at T0 and T12 with statistically significant differences P=0.043 and P=0.006, respectively.

Conclusion

OFA could be considered in modified radical mastectomy management in female patients; nerve block seemed to act as morphine sparing in operative and postoperative settings by providing significantly less time to extubate with less postoperative morphine requirement.

Benefits of PECS Block as Part of the Enhanced Recovery After Surgery (ERAS) Protocol for Breast Cancer Surgery in an Asian Institution: A Retrospective Cohort Study

INTRODUCTION

Regional analgesia techniques have been increasingly used for post-operative pain management following mastectomy. We aim to evaluate analgesic benefits of pectoral nerve (PECS2) block incorporated as part of the enhanced recovery after surgery (ERAS) protocol in patients undergoing mastectomy in University Malaya Medical Centre, Malaysia.

MATERIAL AND METHODS

A single centre, cohort study evaluating 335 women who have undergone unilateral mastectomy between January 2017 and March 2020 in Malaysia. Regional anaesthesia were given pre-operatively via ultrasound guided pectoral and intercostal nerves block (PECSII).

RESULTS

Utilization of regional anaesthesia increased from 11% in 2017 to 43% in 2020. Types and duration of surgeries were comparable. Opiod consumption was 3 mg lower in those who had PECS2 block ((27 [24-30] mg), in comparison with those who received general anaesthesia only (30 [26-34] mg), p < 0.001, and length of stay was half a day shorter in the regional anaesthesia group and these were statistically significant. However, pain score (2 [1-3]; 2 [1-3], p=0.719) and post-operative nausea and vomiting (PONV) (32.6-32.5%, p = 0.996) were similar.

CONCLUSION

This study highlights the importance of PECS2 block as a component of ERAS protocol for mastectomy in an Asian hospital. This study also inferred that patients may be safely discharged within 24 h of surgery and therefore, same day surgery may be feasible in selected group of patients undergoing mastectomy and this could imply overall cost benefits.

Postoperative Analgesic Efficacy of Intraoperative Pectoral Nerve Block for Modified Radical Mastectomy: a Double-Blind Prospective Randomised Interventional Study

Severe acute postoperative pain following breast surgery increases the risk of persistent pain and affects the recovery of patients. Recently, pectoral nerve (PECs) block has gained significance as a regional fascial block that can provide adequate postoperative analgesia. This study aimed to evaluate the safety and efficacy of PECs II block, which was given intraoperative under direct vision after performing modified radical mastectomy for breast cancer patients. This prospective randomised study was comprised of a PECs II group (n = 30) and a control group (n = 30). Group A patients received 25 ml of 0.25% bupivacaine for PECs II block intraoperatively after the surgical resection was done. Both groups were compared with respect to the demographic and clinical parameters, total intraoperative fentanyl dose, total duration of surgery, postoperative pain score (Numerical Rating Scale) and the analgesic requirement, postoperative complications, postoperative duration of hospital stay, and the outcome. Intraoperative PECs II block was not associated with any increase in the duration of surgery. The postoperative pain scores were significantly higher in the control group till 24 h after the surgery, and so was the postoperative analgesic requirement. Patients in the PECs group were found to have rapid recovery and decreased postoperative complications. Intraoperative PECs II block is not only safe, time-saving procedure but also significantly reduces the postoperative pain and analgesic requirement in breast cancer surgeries. It is also associated with a faster recovery, decreased postoperative complications, and better patient satisfaction.

Impact of Pectoralis Nerve Block (PECS) on postoperative pain in patients submitted to mastectomy with lymphadenectomy

OBJECTIVE

Breast cancer is the most common malignant neoplasm in women worldwide. Surgery has been traditional treatment and, generally, it´s mastectomy with lymphadenectomy, that can causes postoperative pain. Therefore, we seek to study regional anesthesic techniques that can minimize this effect, such as the interpectoral block (PECS).

METHODS

randomized controlled study with 82 patients with breast cancer who underwent mastectomy with lymphadenectomy from January 2020 to October 2021 in oncology hospital.

INTERVENTIONS

two randomized groups (control - exclusive general anesthesia and PECS group - received PECS block with levobupivacaine/ropivacaine and general anesthesia). We applied a questionnaire with Numeric Rating Scale for pain 24h after surgery. We used Shapiro-Wilk, Mann-Whitney and Chi-square tests, and analyzed the data in R version 4.0.0 (ReBEC).

RESULTS

in the PECS group, 50% were pain-free 24h after surgery and in the control group it was 42.86%. The majority who presented pain classified it as mild pain (VAS from 1 to 3) - (42.50%) PECS group and (40.48%) control group (p=0.28). Only 17.50% consumed opioids in the PECS group, similar to the control group with 21.43%. (p=0.65). There was a low rate of complications such as PONV in both groups. In the subgroup analysis, there was no statistical difference between the groups that used levobupivacaine or ropivacaine regarding postoperative pain and opioid consumption.

DISCUSSION

the studied group had a low rate of pain in the postoperative period and it influenced the statistical analysis. There wasn´t difference in postoperative pain in groups.

CONCLUSION

was not possible to demonstrate better results with the association of the PECS block with total intravenous analgesia. Need further studies to assess the efficacy of the nerve block.

A comparative study between ultrasound-guided thoracic paravertebral block, pectoral nerves block, and erector spinae block for pain management in cancer breast surgeries. A randomized controlled study

OBJECTIVES

Achieving adequate perioperative analgesia can be challenging in patients undergoing breast surgeries due to the complex nerve supply of the breast and axilla. The study aims to investigate the efficacy of ESPB in comparison to conventional regional anesthesia techniques (TPVB and PECS).

METHODS

Eighty female patients who were scheduled for elective MRM, with ASA score I-II, and aged between 18 and 60 years, were included in the study. Patients were randomized into four groups, the TPVB, PECS, ESPB, and the control group. All patients in either block groups received 25 ml bupivacaine 0.25% with ultrasound guidance. The control group received only opioids for perioperative pain management. The patients were observed for 48 h after surgery for the duration of analgesia (primary outcome).

RESULTS

ESPB has a shorter duration of analgesia than PECS block with no significant statistical difference compared with group TPVB. Morphine consumption is increased in ESPB compared to the PECS group, with an insignificant difference compared to group TPVB. There was an insignificant difference between the groups concerning hemodynamics and complications, with one pneumothorax case reported in the TPVB group.

CONCLUSION

PECS and ESPB represent a good alternative to TPVB for post-mastectomy analgesia with a superior analgesic effect of PECS block regarding opioid consumption, duration of the analgesia, and VAS score.

Effects of ultrasound-guided erector spinae plane block with dexmedetomidine combined with ropivacaine of the same dose and different concentrations on analgesic effect and rehabilitation quality of patients undergoing thoracoscopic wedge resection of the lung: a prospective, randomized, controlled trial

Objective

To investigate the analgesic effect and rehabilitation quality of patients undergoing thoracoscopic wedge resection of the lung under erector spinae plane (ESP) block with dexmedetomidine combined with the same dose and different concentrations of ropivacaine.

Methods

Seventy patients undergoing thoracoscopic wedge resection were randomly divided into groups A (n = 35) and B (n = 35). To perform ESP block, the groups were administered dexmedetomidine (0.5 μg/kg) combined with 30 mL of 0.33% ropivacaine or 20 mL of 0.5% ropivacaine, respectively, half an hour before general anesthesia induction. We compared the onset time of anesthesia, the block level, and the duration of the block between the two groups. The number of compressions of the analgesic pump within 24 h and 48 h postoperatively and the time of the first compression were noted. The visual analog scale (VAS) scores of static and cough at 0.5 h, 6 h, 12 h, 24 h, and 48 h postoperatively were noted. Furthermore, the 40-item quality of recovery questionnaire (QoR-40) score was recorded at 24 h postoperatively. In addition, we noted the time taken to get out of the bed for the first time, the length of hospital stay, analgesia satisfaction, and the occurrence of related adverse reactions and complications within 48 h postoperatively.

Results

The range of ESP block was wider in Group A than in Group B (P < 0.05). Group B had a significantly shorter onset time (P < 0.05) and lower static and cough VAS scores at 6 h and 12 h postoperatively (P < 0.05); this was associated with significantly fewer compressions of the analgesic pump within 24 h and 48 h postoperatively and significantly more time until the first compression of the analgesic pump was required (P < 0.05). Group B was associated with significantly superior QoR-40 scores 24 h postoperatively and significantly shorter time to get out of the bed for the first time than Group A (P < 0.05).

Conclusion

Dexmedetomidine combined with 0.5% ropivacaine for ESP block is better than 0.33% ropivacaine for overall analgesia and postoperative rehabilitation of patients undergoing thoracoscopic wedge resection.

Trial registration

ChiCTR2200058114, Date of registration: 30/03/2022.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

DATA SOURCE

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

ELIGIBILITY CRITERIA

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

PROSPERO (CRD4202125065).

Analgesia and stress attenuation of ultrasound-guided modified pectoral nerve block type-II with different volumes of 0.3% ropivacaine in patients undergoing modified radical mastectomy for breast cancer: A prospective parallel randomized double-blind controlled clinical trial

WHAT IS KNOWN AND OBJECTIVE

A previous randomized clinical trial concluded that an optimal concentration of 0.3% ropivacaine could provide satisfactory analgesia for breast cancer patients undergoing modified radical mastectomy. We wondered if a smaller volume (30 ml vs. 40 ml) of 0.3% ropivacaine could still provide adequate analgesia in an ultrasound-guided PECS II block in modified radical mastectomy.

METHODS

We performed a prospective parallel randomized double-blind controlled clinical trial. Eligible patients were assigned to either the P₃₀ or P₄₀ group (30 or 40 ml of 0.3% ropivacaine, respectively). The skin area of hypoesthesia, anaesthetic plane determined with ultrasound, pain visual analogue scale (VAS), anaesthetic dosages, and complications were recorded. Serum levels of interleukin-1β and interleukin-6 were measured postoperatively.

RESULTS AND DISCUSSION

A total of 40 patients completed the trials, with 20 patients in each group. Although the skin area of hypoesthesia and the anaesthetic planes were significantly larger in the P₄₀ group compared with the P₃₀ group (p < 0.05), the VAS, analgesic and opioid doses, serum cytokine levels, anaesthetic toxicity, and complications had no significant differences between the two groups.

WHAT IS NEW AND CONCLUSION

Compared with 40 ml, 30 ml of 0.3% ropivacaine could provide adequate analgesia and reduce surgical stress in patients undergoing modified radical mastectomy for breast cancer.

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

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

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

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

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

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

Impacto do Bloqueio Peitoral (PEC) na dor pós-operatória em pacientes submetidos a mastectomia com linfadenectomia

RESUMO Introdução: o câncer de mama é a neoplasia maligna mais comum em mulheres no mundo. A cirurgia tem sido o tratamento tradicional e, geralmente consiste em mastectomia com linfadenectomia, podendo causar dor pós-operatória. Por isso, buscamos estudar técnicas anestésicas regionais que possam minimizar esse efeito, como o bloqueio interpeitoral (PEC). Métodos: estudo controlado randomizado com 82 pacientes com câncer de mama submetidos à mastectomia com linfadenectomia de Janeiro de 2020 a Outubro de 2021, em hospital oncológico. Intervenções: dois grupos randomizados (controle - anestesia geral exclusiva e grupo PECS - anestesia geral e bloqueio PEC com levobupivacaína/ropivacaína). Aplicou-se um questionário com Escala Visual Analógica da dor 24h pós-cirurgia. Utilizamos os testes de Shapiro-Wilk, Mann-Whitney e Quiquadrado e analisamos os dados em R versão 4.0.0. Estudo registrado em Ensaios Clínicos Brasileiros (REBec). Resultados: no grupo PEC, 50% não apresentava dor 24 horas após a cirurgia enquanto no grupo controle, 42,86% negava quadro álgico. A maioria que apresentou dor classificou-a como dor leve (EVA de 1 a 3) - (42,50%) grupo PEC e (40,48%) controle (p=0,28). Apenas 17,50% consumiram opioides no grupo PEC, semelhante ao grupo controle com 21,43%. (p=0,65), (17,50%) grupo PEC e (21,43%) grupo controle (p=0,65). Houve baixo índice de complicações como PONV (náuseas, vômitos, cefaleia) em ambos os grupos. Na análise de subgrupo, não houve diferença estatística entre os grupos que usaram Levobupivacaína ou Ropivacaína quanto a dor pós-operatória e o consumo de opioides. Discussão: o grupo estudado apresentou baixa taxa de dor no pós-operatório e isso influenciou na análise estatística. Não houve diferença estatística quanto a dor pós-operatória entre grupos. Conclusão: não foi possível demonstrar melhores resultados com a associação do bloqueio PEC com analgesia intravenosa total. São necessários novos estudos para avaliar a eficácia do bloqueio anestésico no intraoperatório e pós-operatório.

The impact of dexamethasone as a perineural additive to ropivacaine for PECS II blockade in patients undergoing unilateral radical mastectomy - A prospective, randomized, controlled and double-blinded trial

STUDY OBJECTIVE

Dexamethasone is commonly used as an adjuvant to local anesthetics to prolong duration of peripheral nerve blocks with minimal side-effects. The present study investigates the efficacy of dexamethasone added to ropivacaine 0.2% as compared to ropivacaine 0.2% alone for pectoral nerves block II (PECS II) in unilateral radical mastectomy.

DESIGN

A prospective, randomized, controlled and double-blinded trial.

SETTING

The study was performed at Innsbruck Medical University Hospital, Austria, between January 2019 and October 2020.

PATIENTS

Sixty female patients with an American Society of Anesthesiologists Score I-II (18-90 years, BMI 18-35) scheduled for unilateral radical mastectomy without one-stage immediate autologous breast reconstruction were randomly assigned to receive PECS II block with ropivacaine 0.2% with or without dexamethasone 8 mg.

INTERVENTIONS

Patients were randomly assigned to receive PECS II block with ropivacaine 0.2% with or without dexamethasone 8 mg.

MEASUREMENTS

Primary outcome parameter was the cumulative opioid consumption during the first 72 postoperative hours. Secondary outcome parameters were the duration of analgesia and the course of the visual analogue scale (VAS) and the area under the curve VAS (AUC-VAS).

MAIN RESULTS

There was no difference in cumulative opioid consumption after 72 h between the ropivacaine 0.2% plus dexamethasone group and the ropivacaine 0.2% plus placebo group (11.89 vs 11.90 morphine milligram equivalent, respectively; p 0.831). Duration of analgesia also did not differ significantly between the ropivacaine 0.2% plus dexamethasone group and the ropivacaine 0.2% plus placebo group (12.75 versus 8.75 h, respectively; p 0.680). There also was no difference in the course of VAS and AUC-VAS.

CONCLUSIONS

Dexamethasone 8 mg when added to ropivacaine 0.2% for PECS II block in unilateral radical mastectomy was not found to reduce total opioid consumption over 72 postoperative hours or to prolong duration of analgesia as compared to pure ropivacaine 0.2%.

Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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