Combined ultrasound-guided Pecs II block and general anesthesia are effective for reducing pain from modified radical mastectomy

Comparison of Analgesic Efficacy of Ultrasound Guided PEC II Block Using Dexamethasone as an Adjuvant to Ropivacaine Versus Plain Ropivacaine in Patients Undergoing Modified Radical Mastectomy: A Double-Blind, Randomized Controlled Trial

INTRODUCTION

 Pain after breast cancer surgery is one of the main reasons for postoperative morbidity and pulmonary complications leading to increased hospital stay. Therefore, effective management of postoperative pain becomes necessary to alleviate patients' suffering and allow early mobilization and hospital discharge. Traditionally, opioids have been used to manage perioperative pain but they are associated with side effects. So, an opioid-sparing multimodal analgesia approach is used nowadays. Ultrasound-guided pectoral type-II (PEC II) block is increasingly being used to address acute postoperative pain after breast cancer surgery. However, to date, not many studies have been done regarding prolonging the duration of analgesia of PEC II blocks for postoperative pain relief in patients undergoing modified radical mastectomy (MRM). So, we undertook this study to compare the analgesic efficacy of PEC II block using dexamethasone as an adjuvant to ropivacaine versus plain ropivacaine in patients undergoing MRM.

METHODS

 After obtaining approval from the institute ethics committee and written informed consent from the patients, this prospective, double-blind, parallel group, randomized controlled study was carried out at All India Institute of Medical Sciences (AIIMS) Raipur, from March 2021 to March 2022. Sixty-four female patients, aged 18 years and above, belonging to the American Society of Anesthesiologists, physical status I, II, and III, undergoing unilateral, elective MRM under general anesthesia, were randomly allocated to two groups A and B, with 32 patients in each to receive 30 mL of 0.25% ropivacaine plus 2 mL (8 mg) of dexamethasone and 30 mL of 0.25% ropivacaine plus 2 mL of normal saline, respectively. The primary outcome measure was total opioid consumption till 12 hours postoperatively. Secondary outcome measures were the difference in pain scores based on the numeric rating scale till 12 hours postoperatively, post-operative sedation scores, the incidence of postoperative nausea vomiting (PONV), and other adverse events (if any).

RESULTS

The mean (SD) of morphine (mg) consumed intraoperatively was 5.50 (1.05) and 5.95 (0.86) with P = 0.033 and that consumed postoperatively was 1.00 (0.00) and 1.69 (0.93) with P <0.001 in group A and B respectively, with morphine consumption being higher in the group. The difference in the NRS score for pain at rest was statistically significant at 2 h (P=0.030), 4 h (P=0.004), 6 h (P=0.002), and, 12 h (P=0.039) time points with the score being higher in group B. The groups were comparable in terms of postoperative sedation score (P > 0.05) and incidence of postoperative nausea and vomiting. None of the patients in group A and 6.2% of the patients in group B had nausea (P = 0.492). None of the patients in either of the groups had vomiting. No other complication occurred during the entire study in either of the groups.

CONCLUSION

In comparison to plain ropivacaine, the addition of dexamethasone as an adjuvant to ropivacaine for PEC II block in patients undergoing MRM significantly reduced perioperative opioid consumption and postoperative NRS scores. No significant change was noted in terms of postoperative sedation score, incidence of PONV, and other side effects between the groups. Therefore, we conclude that the analgesic efficacy of US-guided PEC II block using dexamethasone, as an adjuvant to ropivacaine is superior to that of plain ropivacaine in patients undergoing MRM.

The Pectoral (PECS) Regional Block: A Scoping Review

Among the various surgical procedures, breast surgeries rank as a frequently conducted procedure. Interfacial blocks such as the Pectoral (PECS) block became possible with the currently available knowledge on innervations and ultrasound. Interfacial blocks target the deep fascial planes, which are potential spaces for injecting local anesthetics. The Pectoral I (PECS I) consists of the injection of local anesthetics in the plane between the pectoralis major and minor muscles. The PECS II block, a modified version of the block, is achieved by adding another, deeper injection in the plane between the pectoralis minor and the serratus anterior muscle. We conducted a scoping review using Arkesy and O'Malley's framework, as described by Levac. We identified our research question as the uses of the PECS regional block technique with the choice of local anesthetics, including adjuncts, and its effectiveness in intraoperative and postoperative analgesia in the first 24 hours and incidence of postoperative nausea and vomiting. Subsequently, we identified the relevant studies that met our inclusion criteria and charted the data. Lastly, we summarized and reported the results. The PECS block was used in various breast surgeries, among which radical mastectomies with/without lymph node dissection were the most common. It was found that the PECS block reduced intraoperative opioid consumption in 60% and 24-hour postoperative opioid consumption in 93.3% of the included papers. Various local anesthetics were used such as ropivacaine, bupivacaine, and levobupivacaine. Ultrasound-guided interfacial plane blocks, such as the PECS block, are a recent development in regional anesthesia that offers analgesia for patients undergoing breast surgeries. The authors conclude that PECS block can provide a decrease in intraoperative and postoperative opioid consumption, a decrease in the incidence of nausea and vomiting, and can lead to overall patient satisfaction in terms of lower pain scores compared to systemic analgesia.

The clinical impact of pectoral nerve block in an 'enhanced recovery after surgery' program in breast surgery

Background: Pectoral nerve block (PECS) is increasingly performed in breast surgery. Aim: The study evaluated the clinical impact of these blocks in the postoperative course. Patients & methods: In this case-control study, patients undergoing breast surgery with 'enhanced recovery after surgery' pathways were divided into group 1 (57 patients) in whom PECS was performed before general anesthesia, and group 2 (57 patients) in whom only general anesthesia was effected. Results: Postoperative opioid consumption (p < 0.002), pain at 32 h after surgery (p < 0.005) and the length of stay (p < 0.003) were significantly lower in group 1. Conclusion: Reducing opioid consumption and pain after surgery, PECS could favor a faster recovery with a reduction in length of stay, ensuring a higher turnover of patients undergoing breast surgery.

Comparison of the efficacy of ultrasound guided pectoralis-II block and intercostal approach to paravertebral block (proximal intercostal block) among patients undergoing conservative breast surgery: A randomised control study

Background and Aims

Regional anesthesia techniques have attributed a multimodal dimension to pain management after breast surgery. The intercostal approach to paravertebral block has been gaining interest, becoming an alternative to conventional paravertebral block, devoid of complexities in its approach, being recognized as the proximal intercostal block. Parallel to the widespread acceptance of fascial plane blocks in breast surgery, pectoralis II block has emerged as being non-inferior to paravertebral block. The aim of this study was to evaluate the efficacy of two independent fascial plane blocks, proximal intercostal block and pectoralis II block, in breast conservation surgery.

Material and Methods

This prospective, randomized control, pilot study included 40 patients, randomly allocated among two groups: proximal intercostal block and pectoralis II block.

Results

The pectoralis II block group had significantly lower pain scores at rest in the immediate postoperative period but became comparable with the proximal intercostal block group in the late postoperative period. Pain scores on movement though were lower at 0 h postoperatively and became comparable with the proximal intercostal block group subsequently. Although the pectoralis II group had earlier recovery in the post-anesthesia care unit, the overall time to discharge from the hospital was comparable and not influential. Both groups had high patient satisfaction scores and similar perioperative opioid consumption. Sedation, time to first rescue analgesia, and postoperative nausea vomiting scores were comparable.

Conclusion

Fascial plane blocks in the form of pectoralis II and proximal intercostal block facilitate pain alleviation, early return to shoulder arm exercise, and enhanced recovery, which should render them to be incorporated into multimodal interdisciplinary pain management in breast conservation surgery.

Feasibility and efficacy of routinary PECs 1 block on perioperative and postoperative pain control in breast surgery: a prospective non-controlled trial in a medium-volume breast unit

Strategies to reduce the postoperative pain in patients undergoing breast cancer surgery include the use of Interpectoral (PECs) block, first described by Blanco in 2011, but its feasibility and efficacy in everyday clinical practice has been debated. The aim of the study was to evaluate the routine feasibility and effectiveness of PECs block added to general anesthesia to reduce postoperative pain and opioids consumption in the Breast Unit's patients. From June to December 2021 all patients undergoing surgery were included to receive PECs1 block before general anesthesia; clinical and outcome data were prospectively collected. Fifty-eight out of 61 patients undergoing major or minor procedures were enrolled. The average time of block execution was 93.56 s (SD 42.45), with only one minor complication reported. Very low doses of intra and postoperative opioids consumption were reported, regardless of the type of surgery. The pain NRS resulted under the median value of 1 point [IQR 3] in the early postoperative period to 0 at 24-48 h, with beneficial effects lasting at least for two weeks, since no opioids consumption in the postoperative period had been reported, only 31% of patients required paracetamol with a dosage of 0.34 g (SD 0.548); comparison between type of surgery and different regimens of general anesthesia were reported. Routine use of PECs block, in addition to general anesthesia, was found to be safe, feasible and effective, resulting in low intraoperative opioids consumption, very low postoperative pain and analgesic requirement, with effects lasting up to two weeks after surgery.

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.

Ultrasound-Guided Interpectoral and Pectoserratus Plane Blocks in Breast Surgery: An Alternative Option to General Anaesthesia in an Elderly Woman with a Complex Medical History

With an incidence of over 1.5 million worldwide per annum, breast cancer continues to be the most common cancer affecting the female population. The main and most effective treatment in over 40% of these patients is a primary neoplasm resection. General anaesthesia, at times in association with loco-regional anaesthetics, is the most commonly used anaesthesia technique for radical mastectomies. Nausea, vomiting, and considerable postoperative pain, which are commonly experienced side effects and complications of general anaesthesia, tend, however, to augment most patients' post-surgical morbidity. A growing body of research has shown that loco-regional anaesthesia often used together with and, in some cases, in the substitution of general anaesthesia can be a safe, effective alternative. This work is a case report regarding a 94-year-old elderly patient who was anaesthetised during a left radical mastectomy using exclusively combined interpectoral and pectoserratus plane blocks.

Effects of Esketamine Combined with Ultrasound-Guided Pectoral Nerve Block Type II on the Quality of Early Postoperative Recovery in Patients Undergoing a Modified Radical Mastectomy for Breast Cancer: A Randomized Controlled Trial

Purpose

To evaluate the effect of esketamine combined with ultrasound-guided pectoral nerve block type II (Pecs II block) on the quality of early postoperative recovery in patients undergoing a modified radical mastectomy (MRM) for breast cancer.

Patients and Methods

A total of 136 female patients undergoing an elective MRM for unilateral breast cancer (UBC) for the first time were randomly divided into the control group (group C, n=68) and the experimental group (PE group, n=68). In group C, sufentanil was used for anesthesia induction and patient-controlled intravenous analgesia (PCIA). Esketamine was used for anesthesia induction and PCIA in the PE group. Ultrasound-guided Pecs II block was performed after anesthesia induction in the two groups. All other anesthetics were administered in the same way. The primary outcome was the 40-item Quality of Recovery (QoR-40) score at discharge. The secondary outcomes were postoperative Observer’s Assessment of Alertness/Sedation Scale (OAA/S) scores, time of anesthesia recovery, Numeric Rating Scale (NRS) scores, serum inflammatory cytokines interleukin-10 (IL-10), interleukin-6 (IL-6), and interleukin-1ß (IL-1ß), Hospital Anxiety and Depression Scale (HADS) scores, length of postoperative Postanesthesia Care Unit (PACU) stay, length of postoperative hospital stay and patient satisfaction score.

Results

Compared with group C, the PE group had higher QoR-40 scores at discharge (P<0.05), decreased IL-6 levels at 24 h after surgery (P<0.05), lower anxiety and depression scores (P<0.05) and higher patient satisfaction scores at discharge (P<0.05). No significant difference was found in the NRS score postoperatively between the two groups (P>0.05). There was no significant difference in the postoperative OAA/S score, time of anesthesia recovery, length of postoperative PACU and hospital stays between the two groups (P>0.05).

Conclusion

Esketamine combined with Pecs II block can be used for anesthesia in MRM for breast cancer, thus, improving patient quality of early postoperative recovery.

Regional anesthesia for breast cancer surgery: which block is best? A review of the current literature

Breast cancer is the most common type of cancer worldwide. Fortunately, continual advances in diagnosis and treatment are resulting in increased survival rates. Earlier detection and treatment, to include surgical resection, can greatly improve patients outcomes. However, due to the complex innervation of the breast, management of postoperative pain has proven difficult in the past. Approximately, half of all women who undergo breast cancer surgery report postoperative pain syndrome. The paravertebral block has long been the anesthesiologist's choice for mitigating pain during and after the procedure. Newer techniques such as the pectoral nerve block and erector spinae plane block may prove to have some additional benefits. This literature review compares the risks, benefits and specific uses of these three regional nerve blocks in women undergoing breast cancer surgery. It aims to better inform anesthesiologists when they are choosing which technique is best for their patients.

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).

Comparing Effect of Adding Ketamine versus Dexmedetomidine to Bupivacaine in Pecs-ⅠⅠ Block on Postoperative Pain Control in Patients Undergoing Breast Surgery

BACKGROUND

Pecs-II block has previously and successfully demonstrated a good quality of perioperative analgesia for breast surgery.

OBJECTIVE

This study aimed to compare the quality of postoperative pain control when adding either ketamine or dexmedetomidine to bupivacaine 0.25% for Pecs-II block.

METHODS

This prospective randomized double-blind study was conducted on 159 female patients with American society of anesthesiologist (ASA) physical status class I-III scheduled to have modified radical mastectomy. Patients were randomly assigned into three groups. Each group included 53patients to receive ultrasound guided Pecs-II blocks with either 32 mL of 0.25% bupivacaine added to ketamine hydrochloride 1 mg/kg (BK group), 32 mL of 0.25%bupivacaine added to dexmedetomidine 1 ug/kg (BD group) or 32 mL of 0.25% bupivacaine only (B group).The primary outcome of this study was the total postoperative morphine consumption for the first 24 hours postoperatively. The time of the first request of analgesia, the pain scores at rest of ipsilateral arm, and the intra-operative fentanyl requirements, were the secondary outcome measures. Any side effects occurred were recorded.

RESULTS

The total postoperative morphine consumption was significantly lower in patients received bupivacaine with addition of either ketamine (BK group), (10.3±2.6 mg), or dexmedetomidine (BD group), (3.8±0.2 mg) respectively, versus patients received only bupivacaine (B group), (16.9±5.3 mg). Both ketamine (BK group) and dexmedetomidine (BD group) added to bupivacaine significantly prolonged the time to first analgesic request (16.7±4.5 h), (21.6±1.6 h) in both groups respectively compared to patients received bupivacaine alone (B group), (11.5±1.2 h).The pain score was variable between the three groups over different times during the first 24 hours postoperatively. There was no significant difference in perioperative hemodynamics, O2 saturation, sedation scores or side effects observed between the three groups. Patient satisfaction was reported to be the best in patients received dexmedetomidine added to bupivacaine than the other patients who received ketamine as an additive or those who received bupivacaine alone.

CONCLUSION

Adding dexmedetomidine to bupivacaine provides more effective postoperative pain control than adding ketamine during Pecs-II blocks for breast cancer surgery.

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

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.

Efficacy and Safety of Pectoral Nerve Block (Pecs) Compared With Control, Paravertebral Block, Erector Spinae Plane Block, and Local Anesthesia in Patients Undergoing Breast Cancer Surgeries: A Systematic Review and Meta-analysis

OBJECTIVE

We aimed to compare the safety and efficacy of pectoral nerve block (Pecs) I and II with control or other techniques used during breast cancer surgeries such as local anesthesia, paravertebral block, and erector spinae plane block (ESPB).

METHODS

We searched 4 search engines (PubMed, Cochrane Library, Scopus, and Web of Science) for relevant trials, then extracted the data and combined them under random-effect model using Review Manager Software.

RESULTS

We found 47 studies, 37 of them were included in our meta-analysis. Regarding intraoperative opioid consumption, compared with control, a significant reduction was detected in Pecs II (standardized mean difference [SMD]=-1.75, 95% confidence interval [CI] [-2.66, -0.85], P=0.0001) and Pecs I combined with serratus plane block (SMD=-0.90, 95% CI [-1.37, -0.44], P=0.0002). Postoperative opioid consumption was significantly lowered in Pecs II (SMD=-2.28, 95% CI [-3.10, -1.46], P<0.00001) compared with control and Pecs II compared with ESPB (SMD=-1.75, 95% CI [-2.53, -0.98], P<0.00001). Furthermore, addition of dexmedetomidine to Pecs II significantly reduced postoperative opioid consumption compared with Pecs II alone (SMD=-1.33, 95% CI [-2.28, -0.38], P=0.006).

CONCLUSION

Pecs block is a safe and effective analgesic procedure during breast cancer surgeries. It shows lower intra and postoperative opioid consumption than ESPB, and reduces pain compared with control, paravertebral block, and local anesthesia, with better effect when combined with dexmedetomidine.

Pectoral nerve blocks for breast surgery: A meta-analysis

BACKGROUND

Pectoral nerve blocks (PECS block) might be an interesting new regional anaesthetic technique in patients undergoing breast surgery.

OBJECTIVE

The aim of this meta-analysis was to investigate postoperative pain outcomes and adverse events of a PECS block compared with no treatment, sham treatment or other regional anaesthetic techniques in women undergoing breast surgery.

DESIGN

We performed a systematic review of randomised controlled trials (RCT) with meta-analysis and risk of bias assessment.

DATA SOURCES

The databases MEDLINE, CENTRAL (until December 2019) and clinicaltrials.gov were systematically searched.

ELIGIBILITY CRITERIA

All RCTs investigating the efficacy and adverse events of PECS compared with sham treatment, no treatment or other regional anaesthetic techniques in women undergoing breast surgery with general anaesthesia were included.

RESULTS

A total of 24 RCTs (1565 patients) were included. PECS (compared with no treatment) block might reduce pain at rest [mean difference -1.14, 95% confidence interval (CI), -2.1 to -0.18, moderate quality evidence] but we are uncertain regarding the effect on pain during movement at 24 h after surgery (mean difference -1.79, 95% CI, -3.5 to -0.08, very low-quality evidence). We are also uncertain about the effect of PECS block on pain at rest at 24 h compared with sham block (mean difference -0.83, 95% CI, -1.80 to 0.14) or compared with paravertebral block (PVB) (mean difference -0.18, 95% CI, -1.0 to 0.65), both with very low-quality evidence. PECS block may have no effect on pain on movement at 24 h after surgery compared with PVB block (mean difference -0.56, 95% CI, -1.53 to 0.41, low-quality evidence). Block-related complications were generally poorly reported.

CONCLUSION

There is moderate quality evidence that PECS block compared with no treatment reduces postoperative pain intensity at rest. The observed results were less pronounced if patients received a sham block. Furthermore, PECS blocks might be equally effective as PVBs. Due to mostly low-quality or very low-quality evidence level, further research is warranted.

PROTOCOL REGISTRATION

CRD42019126733.

Pretreatment with Pectoral Nerve Block II Is Effective for Reducing Pain in Patients Undergoing Thoracoscopic Lobectomy: A Randomized, Double-Blind, Placebo-Controlled Trial

Background

Although video-assisted thoracoscopy has a smaller incision than traditional surgery, the postoperative pain is still severe. Ultrasound-guided pectoral nerve block (PECS) II is a new technique that can reduce pain in patients, and it had not been reported in the analgesia after thoracoscopic lobectomy.

Methods

40 patients scheduled for thoracoscopic lobectomy were randomly divided into two groups. Patients in the PECS II group received 0.5% ropivacaine 25 ml before the general anesthesia, while patients in the placebo group received 0.9% saline. Thirty minutes after the block was performed, a pin-prick test was used to analyze the sense of pain of T2-T6 segments. The primary endpoint was the total consumption of fentanyl. Data were collected in the postanesthesia care unit (PACU) and in the ward within 24 hours after operation.

Results

The total consumption of fentanyl and the consumption of fentanyl in the intravenous analgesia pump within 24 hours after the operation were significantly lower in the PECS II group compared to the placebo group (p < 0.05). The implementation rate of rescue analgesia during operation and in PACU in the PECS II group was significantly lower than that in the placebo group (p < 0.05). The numerical rating scale (NRS) in 1 and 4 h after operation was lower in the PECS II group (p < 0.05). Mean arterial pressure (MAP) and heart rate (HR) of the PECS II group at chest entering (T1) were significantly lower than those in the placebo group (p < 0.05).

Conclusion

Preconditioning of PECS II can stabilize the intraoperative circulation and significantly reduce pain and the consumption of opioids after operation.

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.

Comparison of PECS II and erector spinae plane block for postoperative analgesia following modified radical mastectomy: Bayesian network meta-analysis using a control group

The present study compared the effects of pectoral nerve block II (PECS II) and erector spinae plane (ESP) block for postoperative analgesia in patients who underwent modified radical mastectomy by performing a network meta-analysis (NMA) using indirect comparison with systemic analgesia. Studies comparing the analgesic effects of PECS II and ESP block were searched on MEDLINE, PubMed, EMBASE and the Cochrane Library. The primary outcome of this study was cumulative opioid consumption for 24 h postoperatively. Pain score during this period was also assessed. NMA was performed to compare the postoperative analgesic effects of plane blocks and systemic analgesia. A search of databases identified 17 studies, with a total of 1069 patients, comparing the analgesic efficacies of PECS II block, ESP block, and systemic analgesia. Compared with systemic analgesia, mean difference of opioid consumption was - 10 mg (95% credible interval [CrI] - 15.0 to - 5.6 mg) with PECS II block and - 5.7 mg (95% CrI - 11.0 to - 0.7 mg) with ESP block. Relative to systemic analgesia, PECS II block showed lower pain scores over the first postoperative 24 h, whereas ESP block did not. PECS II block showed the highest surface under the cumulative ranking curves for both opioid consumption and pain score. Both PECS II and ESP blocks were shown to be more effective than systemic analgesia regarding postoperative analgesia following modified radical mastectomy, and between the two blocks, PECS II appeared to have favorable analgesic effects compared to ESP block.

Anesthetic effect of ultrasound-guided multiple-nerve blockade in modified radical mastectomy in patients with breast cancer

INTRODUCTION

Routine anesthesia modality for modified radical mastectomy (MRM) includes general anesthesia (GA), epidural blockade-combined GA and nerve blockade-combined GA. However, GA has been associated with postoperative adverse effects such as vertigo, postoperative nausea and vomiting and requirement for postoperative analgesia, which hinders recovery and prognosis. Moreover, combined blockade of thoracic paravertebral nerves or intercostal nerves and adjuvant basic sedation for massive lumpectomy provided perfect anesthesia and reduced opioid consumption, whereas the excision coverage did not attain the target of MRM. Regional anesthesia strategies involving supplementation of analgesics in ultrasound-guided multiple nerve blocks have garnered interests of clinicians. Nevertheless, the precise effects of intercostal nerves, brachial plexus and supraclavicular nerves in MRM in patients with breast cancer remain obscure.

METHODS

Eighty female patients with breast cancer scheduled for MRM were recruited in the present trial between May, 2019 and Dec., 2019 in our hospital. The patients ranged from 30 to 65 years of age and 18∼30 kg/m2 in body-mass index, with the American Society of Anesthesiologists I or II. The patients were randomized to ultrasound-guided multiple nerve blocks group and GA group. The patients in multiple nerve blocks group underwent ultrasound guided multiple intercostal nerve blocks, interscalene brachial plexus and supraclavicular nerve blocks, (local anesthesia with 0.3% ropivacaine: 5 ml for each intercostal nerve block, 8 ml for brachial plexus block, 7 mL for supraclavicular nerve block) and basic sedation and intraoperative mask oxygen inhalation. The variations of hemodynamic parameters such as mean arterial pressure, heart rate (HR) and pulse oxygen saturation were monitored. The visual analog scale scores were recorded at postoperative 0 hour, 3 hour, 6 hour, 12 hour and 24 hour in resting state. The postoperative adverse effects, including vertigo, postoperative nausea, and vomiting, pruritus, and urinary retention and so on, as well as the analgesic consumption were recorded.

CONCLUSIONS

The ultrasound guided multiple intercostal nerve blocks, brachial plexus and supraclavicular nerve blocks could provide favorable anesthesia and analgesia, with noninferiority to GA and the reduced incidence of adverse effects and consumption of postoperative analgesics.

Practical Review of Abdominal and Breast Regional Analgesia for Plastic Surgeons: Evidence and Techniques

Regional analgesia has been increasing in popularity due to its opioid- sparing analgesic effects and utility in multimodal analgesia strategies. Several regional techniques have been used in plastic surgery; however, there is a lack of consensus on the indications and the comparative efficacy of these blocks. The goal of this review is to provide evidence-based recommendations on the most relevant types of interfascial plane blocks for abdominal and breast surgery. A systematic search of the PUBMED, EMBASE, and Cochrane databases was performed to identify the evidence associated with the different interfascial plane blocks used in plastic surgery. The search included all studies from inception to March 2020. A total of 126 studies were included and used in the synthesis of the information presented in this review. There is strong evidence for using the transversus abdominis plane blocks in both abdominoplasties as well as abdominally-based microvascular breast reconstruction as evidenced by a significant reduction in post-operative pain and opioid consumption. Pectoralis (I and II), serratus anterior, and erector spinae plane blocks all provide good pain control in breast surgeries. Finally, the serratus anterior plane block can be used as primary block or an adjunct to the pectoralis blocks for a wider analgesia coverage of the breast. All the reviewed blocks are safe and easy to administer. Interfascial plane blocks are effective and safe modalities used to reduce pain and opioid consumption after abdominal and breast plastic surgery.

Association of race and ethnicity in the receipt of regional anesthesia following mastectomy

BACKGROUND

Regional anesthetic techniques have become increasingly used for the purpose of pain management following mastectomy. Although a variety of beneficial techniques have been described, the delivery of regional anesthesia following mastectomy has yet to be examined for racial or ethnic disparities. We aimed to examine the association of race and ethnicity on the delivery of regional anesthesia in patients undergoing surgical mastectomy using a large national database.

METHODS

We used the American College of Surgeons-National Surgical Quality Improvement Program database to identify adult patients aged ≥18 years old who underwent mastectomy from 2014 to 2016. We reported unadjusted estimates of regional anesthesia accordingly to race and ethnicity and examined differences in sociodemographic characteristics and health status. Multivariable logistic regression was used to report the association of race and ethnicity with use of regional anesthesia.

RESULTS

A total of 81 345 patients who underwent mastectomy were included, 14 887 (18.3%) of whom underwent regional anesthesia. The unadjusted rate of use of regional anesthesia was 18.9% for white patients, 16.8% for black patients, 15.6% for Asian patients, 16.5% for Native Hawaiian/Pacific Islander patients, 17.8% for American Indian or Alaska Native and 17.4% for unknown race (p<0.001). With respect to ethnicity, the unadjusted rate of regional anesthesia use was 18.4% for non-Hispanic patients vs 16.1% for Hispanic patients vs 18.6% for the unknown ethnicity cohort (p<0.001). On multivariable logistic regression analysis, the odds of receipt of regional anesthesia was 12% lower in black patients and 21% lower in Asian patients compared with white patients (p<0.001). The odds of regional anesthesia use were 13% lower in Hispanic compared with non-Hispanic patients (p<0.001).

CONCLUSION

Black and Asian patients had lower odds of undergoing regional anesthesia following mastectomy compared with white counterparts. In addition, Hispanic patients had lower odds of undergoing regional anesthesia than non-Hispanic counterparts. These differences underlie the importance of working to deliver equitable healthcare irrespective of race or ethnicity.

Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons

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.

PROSPECT guideline for oncological breast surgery: a systematic review and procedure-specific postoperative pain management recommendations

Analgesic protocols used to treat pain after breast surgery vary significantly. The aim of this systematic review was to evaluate the available literature on this topic and develop recommendations for optimal pain management after oncological breast surgery. A systematic review using preferred reporting items for systematic reviews and meta-analysis guidance with procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Seven hundred and forty-nine studies were found, of which 53 randomised controlled trials and nine meta-analyses met the inclusion criteria and were included in this review. Quantitative analysis suggests that dexamethasone and gabapentin reduced postoperative pain. The use of paravertebral blocks also reduced postoperative pain scores, analgesia consumption and the incidence of postoperative nausea and vomiting. Intra-operative opioid requirements were documented to be lower when a pectoral nerves block was performed, which also reduced postoperative pain scores and opioid consumption. We recommend basic analgesics (i.e. paracetamol and non-steroidal anti-inflammatory drugs) administered pre-operatively or intra-operatively and continued postoperatively. In addition, pre-operative gabapentin and dexamethasone are also recommended. In major breast surgery, a regional anaesthetic technique such as paravertebral block or pectoral nerves block and/or local anaesthetic wound infiltration may be considered for additional pain relief. Paravertebral block may be continued postoperatively using catheter techniques. Opioids should be reserved as rescue analgesics in the postoperative period. Research is needed to evaluate the role of novel regional analgesic techniques such as erector spinae plane or retrolaminar plane blocks combined with basic analgesics in an enhanced recovery setting.

Pectoral Nerve (PECs) block for postoperative analgesia-a systematic review and meta-analysis with trial sequential analysis

BACKGROUND AND OBJECTIVE

Pectoral Nerve (PECs) block is a fascial plane block first described by Blanco et al. for postoperative analgesia in breast surgery. The procedure is now widely used, and several small clinical trials have been published and reported favorably on the analgesic efficacy of PECs block. In this systematic review and meta-analysis, we will summarize the current evidence on the efficacy of PECs block.

METHODS

We identified and analyzed 19 randomized control trials from PubMed, Central, EMBASE, CINAHL, Web of Science citation index, US clinical trials register and Google Scholar. The primary outcome was 24-hour opioid requirement, and secondary outcomes included pain scores, postoperative nausea and vomiting and other complications.

RESULTS

Compared to systemic analgesia, PECs block was associated with reduced 24 hours opioid requirement [mean difference (MD) = -10.66 mg], lower pain score [9-12 hours postoperatively: MD = -1.18; 24 hours postoperatively: MD = -0.79] and less frequent PONV [risk ratio (RR) = 0.37, numbers needed to treat (NNT) = 5]. While the failure rate of PECs block was not well defined, several studies reported significant intraoperative opioid requirement despite PECs block. Lastly, trial sequential analysis indicated that no more clinical trials are needed to demonstrate the opioid sparing effect of PECs block.

CONCLUSION

When compared to general anesthesia with systemic opioids, PECs block was associated with significantly better perioperative pain control. There are currently insufficient data on the complication and failure rate of PECs block in clinical practice.