Single shot ultrasound-guided thoracic paravertebral block for opioid-free radical mastectomy: a prospective observational study

Efficacy of bi-level erector spinae plane block versus bi-level thoracic paravertebral block for postoperative analgesia in modified radical mastectomy: a prospective randomized comparative study

BACKGROUND

Postoperative analgesia in breast surgery is difficult due to the extensive nature of the surgery and the complex innervation of the breast; general anesthesia can be associated with regional anesthesia techniques to control intra- and post-postoperative pain. This randomized comparative study aimed to compare the efficacy of the erector spinae plane block and the thoracic paravertebral block in radical mastectomy procedures with or without axillary emptying.

METHODS

This prospective randomized comparative study included 82 adult females who were randomly divided into two groups using a computer-generated random number. Both groups, Thoracic Paraverterbal block group and Erector Spinae Plane Block group (41 patients each), received general anesthesia associated with a multilevel single-shot thoracic paravertebral block and a multilevel single-shot erector spinae plane block, respectively. Postoperative pain intensity (expressed as Numeric Rating Scale), patients who needed rescue analgesic, intra- and post-operative opioid consumption, post-operative nausea and vomiting, length of stay, adverse events, chronic pain at 6 months, and the patient's satisfaction were recorded.

RESULTS

At 2 h (p < 0.001) and 6 h (p = 0.012) the Numeric Rating Scale was significantly lower in Thoracic Paraverterbal block group. The Numeric Rating Scale at 12, 24, and 36 postoperative hours did not show significant differences. There were no significant differences also in the number of patients requiring rescue doses of NSAIDs, in intra- and post-operative opioid consumption, in post-operative nausea and vomiting episodes and in the length of stay. No failures or complications occurred in the execution of techniques and none of the patients reported any chronic pain at six months from the surgery.

CONCLUSIONS

Both thoracic paravertebral block and erector spinae plane block can be effectively used in controlling post-mastectomy pain with no significant differences between the two blocks.

TRIAL REGISTRATION

The study was prospectively registered on Clinicaltrials.gov (trial identifier NCT04457115) (first registration 27/04/2020).

Erector spinae plane block versus thoracic paravertebral block for the prevention of acute postsurgical pain in breast cancer surgery: A prospective observational study compared with a propensity score-matched historical cohort

BACKGROUND

Preventing acute postsurgical pain (PSP) following breast cancer surgery is a major issue. Thoracic paravertebral block (TPVB) has been widely studied for this indication. Erector spinae plane block (ESPB) has been assumed to be effective. We aimed to compare the efficacy and safety of ESPB over TPVB in preventing acute PSP.

METHODS

In this prospective observational study, 120 patients admitted for unilateral major oncologic breast surgery received T2/T3 ESPB (ropivacaine 0.75%, 0.35 ml.kg-1), and 102 were analysed. Then, the ESPB cohort was compared to a TPVB cohort from the experimental arm of a randomized controlled study with the same protocol (NCT02408393) using propensity score matching analysis. The primary outcome was the need for morphine consumption in the PACU. Secondary outcomes were the morphine total dose, the incidence of ESPB and TPVB complications, and discontinuous visual analogue scale measurement trends at rest and at mobilization in the 24 hours after surgery.

RESULTS

A total of 102 patients completed the study between December 2018 and August 2019. Propensity score matching formed 94 matched pairs. The proportion of morphine titration in the PACU was higher in the ESPB group than in the TPVB group (74.5% vs. 41.5%, p<0.001), with a between-group difference of 33.0% (95% CI [19.3%, 46.7%]). No ESPB-related complications were observed.

CONCLUSION

ESPB is less effective in preventing morphine consumption in the PACU than TPVB. Our findings do not support the use of ESPB as the first-line regional anaesthesia for major breast cancer surgery. Randomized trials comparing ESPB and TPVB are needed.

Intercostal nerve block is effective in open biopsies of the anterior mediastinal region: Case report and review

INTRODUCTION AND IMPORTANCE

Anterior mediastinal masses are rare conditions that can become symptomatic through compression of the airways and vascular structures. Fatal or severe complications can occur during anesthesia and surgery. With this review we aim to describe the state of the art in peri-anesthetic management of mediastinal tumors, which we illustrate with a clinical case.

PRESENTATION OF CASE

We report a case of a young female patient suffering from a large anterior mediastinal mass that underwent an open biopsy after intercostal nerve blocks (INB) in six consecutive right intercostal spaces (2nd to 7th). A right anterior mediastinotomy was performed and an excellent analgesic effect was achieved. The patient was awake and did not experience significant pain or cough, having received paracetamol 1 g and returned home later in the day. The diagnosis of non-Hodgkin's lymphoma was later confirmed.

DISCUSSION

Our review showed that anesthesia for mediastinal masses' resection or open biopsy is rare and prone to severe complications. Such complications are more important in children, patients in supine position, under general anesthesia and already symptomatic prior to the procedure. INB presents some advantages against paravertebral block (PVB) and thoracic epidural anesthesia (TEA), is easier to reproduce and has a shorter learning curve. Airway stenting with a rigid bronchoscope can be an alternative.

CONCLUSION

Multilevel medial axillary line INBs are safer and easier to reproduce than PVB, have less hemodynamic repercussion than TEA and can, therefore, be preferable for open anterior mediastinal biopsies or small masses resection.

Intrapandemic regional anesthesia as practice: a historical cohort study in patients undergoing breast cancer surgery

BACKGROUND

The COVID-19 pandemic has markedly increased delays in oncologic surgeries because of the virus's impact on traditional anesthetic management. Novel protocols, developed to protect patients and medical professionals, have altered the ways and instances in which general anesthesia (GA) can be safely performed. To reduce virus exposure related to aerosol-generating procedures, it is now recommended to avoid GA when feasible and promote regional anesthesia instead. At our institution, we observed faster postoperative recovery in patients who received paravertebral blocks for breast cancer surgery instead of GA. This led us to formally evaluate whether regional anesthesia instead of GA helped improve time to hospital discharge.

METHODS

We conducted a historical cohort study to retrospectively analyze two cohorts of patients: prepandemic vs intrapandemic. We obtained approval from our institutional ethics committee to review files of consecutive patients who underwent breast cancer surgery between 30 March 2020 and 30 June 2020 (intrapandemic group; N = 106) and consecutive patients-moving backwards-from 28 February 2020 to 6 December 2019 (prepandemic group; N = 104). The primary outcome was the length of time between the end of surgery to readiness for hospital discharge. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), the need for postoperative analgesia, and the duration of stay in the postanesthesia care unit (PACU).

RESULTS

The median [interquartile range (IQR)] time to readiness for hospital discharge was significantly lower in patients who received paravertebral blocks for breast cancer surgery compared with GA (intrapandemic group, 119 [99-170] min vs prepandemic group, 191 [164-234] min; P < 0.001) as was the incidence of PONV (3% vs 11%; P = 0.03) and median [IQR] PACU durations of stay (29 [21-39] min vs 46 [37-63] min; P < 0.001).

CONCLUSIONS

Patients who received paravertebral blocks for breast cancer surgery in the intrapandemic group were ready for hospital discharge earlier, spent less time in the PACU, and experienced less PONV than those who received GA in the prepandemic group. With growing surgical wait times, concerns related to aerosol-generating procedures, and recommendations to avoid GA when feasible, paravertebral blocks as the principal anesthetic modality for breast cancer surgery offered benefits for patients and medical teams.

Advances in Oncoanaesthesia and Cancer Pain

INTRODUCTION

The growing interest on how peri-‑operative interventions, especially regional anesthesia, during cancer surgery can alter oncological outcome increasing disease free survival is probably responsible for the birth of the new subspecialty called onco-anesthesia. A paradigm shift in the concept of anesthetic management has occurred recently owing to the innumerable diverse revelations from the ongoing research in this field.

DISCUSSION

Long lasting but reversible epigenetic changes can occur due to surgical stress and perioperative anesthetic medications. The exact relationship between these factors and tumor biology is being studied further. A popular topic under research now is the influence of regional anesthesia on cancer recurrence. Combining nerve blocks with total intravenous anesthesia (TIVA) brings down the requirement of opioids and volatile anesthetic agents implicated in cancer recurrence. The study of mechanism of pain at the molecular level has led to the discovery of novel modes of prevention of chronic post-surgical pain. Newer combination aggressive treatment therapies -intraoperative chemotherapy and radiotherapy, isolated limb perfusion, photodynamic therapy and robotic surgery require specialized anesthetic management. The COVID pandemic introduced new guidelines for safe management of oncosurgical patients .Use of genomic mapping to personalize pain management will be the breakthrough of the decade.

CONCLUSION

The discovery that anesthetic strategy could have significant oncological sequel is a quantum leap forward. Avoiding some anesthetic medications may decrease cancer recurrence. Comprehensive cancer care and translational research will pave the way to uncover safe anesthetic practices.

Analgesic effects of erector spinae plane block for patients after breast surgery: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis investigated the analgesic effects of erector spinae plane block (ESPB) in patients undergoing breast surgery.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched from database establishment to January 31, 2020. Two reviewers independently extracted the data. The primary outcomes were pain scores and opioid consumption during the first 24 hours after surgery. The risk of bias of the included studies was assessed according to the Cochrane Handbook.

RESULTS

Six randomized controlled trials of 415 patients were included. Compared with the control value, the pain score was significantly lower in the ESPB group at different time points postoperatively. Patients who underwent ESPB required lower opioid consumption (standardized mean difference = -2.02, 95% confidence interval [CI] = -2.85 to -1.20, I²= 91%. The rates of postoperative nausea (risk ratio [RR] = 0.79, 95% CI = 0.48-1.30, I² = 47%) and postoperative vomiting (RR = 0.76, 95% CI = 0.30-1.96, I² = 33%) did not differ between the groups. The quality of evidence was low or very low.

CONCLUSIONS

ESPB significantly alleviated pain and reduced opioid consumption after breast surgery. Further research is needed to expand its clinical application.PROSPERO registration number CRD42020167900.

Anatomic Landmark Technique Thoracic Paravertebral Nerve Block as a Sole Anesthesia for Modified Radical Mastectomy in a Resource-Poor Setting: A Clinical Case Report

Mastectomy is mostly performed as definitive management for resectable breast cancer. Implementing paravertebral nerve block for patients with metastasis features of cancer to lungs and other organs, patients with co-morbidity, geriatrics, and malnourished individuals will eliminate the risks and complications of general anesthesia. Though thoracic paravertebral block is an established technique as postoperative pain management for breast surgery, there is no conclusive evidence on its use as a sole anesthetic for modified radical mastectomy. In this case report, we present a 33-year-old woman who underwent a successful modified radical mastectomy for stage IIIb breast cancer associated with clinical and radiological features of metastasis to the lung under a multiple injection landmark technique paravertebral nerve block. We believe that the anatomic landmark technique paravertebral nerve block can be used as an alternative anesthetic technique for modified radical mastectomy in a resource-limited setting for patients who are expected to have a high risk of perioperative complications under general anesthesia.

Paravertebral block for the prevention of chronic postsurgical pain after breast cancer surgery

Patients frequently report chronic postsurgical pain (CPSP) after breast cancer surgery (BCS). The paravertebral block (PVB) is an effective technique to reduce acute postoperative pain after BCS, but its efficacy in preventing CPSP is unclear. This meta-analysis evaluates the efficacy of PVB in preventing CPSP after BCS. We searched Medline, Embase, CENTRAL, Database of Abstracts of Reviews of Effects, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform for studies comparing PVB with control for CPSP prevention after BCS, from inception to April 2020. The primary outcome was CPSP at 6 months, and the secondary outcomes were CPSP at 3 and 12 months, chronic postsurgical neuropathic pain (CPSNP) at 6 months, and PVB-related complications. Data were pooled and analyzed with a random-effects model, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate the certainty of evidence. A total of 12 studies were included in the study; data for the 6-month time point from 7 studies (2161 patients) were analyzed, and no difference was found between PVB and control in terms of efficacy in preventing CPSP after BCS (risk ratio (RR) 0.82 (95% CI 0.62 to 1.08)), with a moderate quality of evidence according to the GRADE system. Similar results were obtained at 3 and 12 months (RR 0.78 (95% CI 0.57 to 1.06), RR 0.45 (95% CI 0.14 to 1.41), respectively). Data for the 12-month time point from seven studies (2087 patients) were analyzed and showed that PVB protected against CPSNP, with low quality of evidence (RR 0.51 (95% CI 0.31 to 0.85)). In conclusion, CPSP was not found significantly prevented by PVB after BCS despite the limits in the included studies; nevertheless, PVB could prevent CPSNP by impacting the transition from acute to chronic pain.

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.

Comparative randomized study of continuous serratus anterior plane block versus continuous paravertebral block in post-mastectomy pain

Background

Many analgesic methods have been used to control post-mastectomy pain. Both thoracic paravertebral and serratus anterior blocks are recent regional techniques with promising results. The aim of this study was to compare safety and analgesic efficacy of both techniques in controlling post-mastectomy pain.

Methods

The study was conducted from January 1, 2019, till January 10, 2019, on 60 female patients ASA class ≤ 2 undergoing modified radical mastectomy. After induction of balanced general anesthesia patients received either continuous thoracic paravertebral block (group P) or continuous serratus anterior block (group S). Twenty milliliters of levobupivacaine 0.25% were injected in each technique under ultrasound guidance followed by continuous infusion of 5 ml/h levobupivacaine 0.125% through a 22-gage catheter. IV morphine was given postoperatively by patient-controlled analgesia. In both groups, we measured time to first dose morphine, total 24 and 48 h morphine consumption, vital signs, visual analog scale, and side effects of each technique.

Results

The demographic data (age, body mass index, and duration of surgery) were comparable in both groups. The time for first dose of morphine was significantly longer in group P (368 ± 36 min) than group S (270 ± 37.65 min) with P value < 0.001. Total morphine consumption in milligram at both 24 and 48 h were significantly less in group P (8.1 ± 0.8, and 11.5 ± 1 respectively) than in group S (10.1 ± 1.3 and 14.2 ± 1.4), with limited side effects in both groups.

Conclusion

Both continuous paravertebral and serratus anterior plane blocks are safe good alternatives to control post-mastectomy pain. However continuous paravertebral block provides better analgesic profile.

A possible future for anaesthesia in breast surgery: thoracic paravertebral block and awake surgery. A prospective observational study

INTRODUCTION

Quadrantectomy is a surgical procedure traditionally performed under general anaesthesia with intraoperative and postoperative opioid-based analgesia. The use of locoregional anaesthesia techniques in breast surgery has become widespread and allows excellent management of intraoperative and postoperative pain with reduced opioid consumption. We chose thoracic paravertebral block as regional anaesthesia technique in breast surgery to investigate the possibility of carrying out this surgery with the patient awake.

METHODS

A prospective observational study on 50 patients was designed. The primary outcome for this study was the possibility to carry out the surgery with only the paravertebral block associated with mild sedation without general anaesthesia. Forty minutes before the start of the surgery, an ultrasound-guided thoracic paravertebral block was performed at two thoracic levels, and for each level, 7 mL of ropivacaine 0.7% was injected. Sedation was obtained with target-controlled infusion of propofol.

RESULTS

Forty-nine patients underwent the operation awake; in one case, we had to place an I-gel and perform general anaesthesia. No patient needed intraoperative or postoperative opioids. The numeric rating scale, recorded at 0, 2, 6, 12, 24, and 36 hours, was greater than 3 in only five patients.

CONCLUSIONS

We believe that if in the future we try to make quadrantectomy an intervention in which the anaesthesia is exclusively regional, therefore with a patient awake and collaborating, it will not be possible to ignore the use of thoracic paravertebral block.