Postmastectomy analgesia with subcutaneous infiltration of ketamine with lidocaine in surgical wound

Background

Ketamine is an analgesic adjuvant useful in acute pain preventive treatment. However, there are few studies evaluating its efficacy in local administration for postoperative pain management.

Objective

To compare ketamine´s efficacy plus 2% lidocaine versus placebo plus 2% lidocaine infiltrated into surgical wound as postoperative analgesia in patients undergoing mastectomy.

Material and methods

An experimental, randomized, single-blind study was carried out in 18 patients older than 18 years scheduled for mastectomy under general anesthetic technique. The surgical wound was infiltrated before to its closure with 0.5 mg/kg of ketamine plus 10 mL of simple 2% lidocaine volumetric to 20 mL with saline solution (group 1) or 10 mL saline solution + 10 mL of simple 2% lidocaine (group 2). Each patient was randomly assigned to one of the two intervention groups by draw (from which a piece of paper was drawn indicating the group to which they would belong). The pain intensity was assessed by Analog Numerical Scale (ANS) at 2, 8 and 12 hours after surgery and the need for analgesic rescue doses.

Results

The scores on the ANS scale in both groups were similar at leaving (p 0.26) and 2 hours later (p 0.05). The ENA value was lower with 2% ketamine/lidocaine infiltration at 8 hours (ketamine 2.5 [2-3]; placebo 4 [3-7], p 0.01) and 12 hours (ketamine 3 [1-5]; placebo 5 [4-6], p < 0.001).

Conclusions

Ketamine infiltrated into the surgical wound provides superior analgesia and improves ENA scores in the post-surgical period.

Opioid-free mastectomy under thoracic epidural anesthesia-analgesia in a patient with critical tracheal stenosis: a case report

Mastectomy is traditionally performed under general anaesthesia and invasive ventilation, and is often complemented with regional techniques. In this setting, tracheal stenosis can pose a challenge to airway management. The aim of this report is to describe the successful management of a 68-year-old woman with severe subglottic tracheal stenosis undergoing mastectomy due to breast cancer. Surgery was performed without airway instrumentation under an opioid-free regimen consisting of thoracic epidural, propofol and dexmedetomidine perfusion, and non-opioid analgesics. Spontaneous ventilation and adequate perioperative analgesia were achieved. Opioid-free anaesthesia without airway instrumentation, consisting of thoracic epidural anaesthesia and sedation, is a good alternative in patients undergoing mastectomy in whom airway manipulation is best avoided.

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.

Single port endoscopic mastectomy: surgical technique and first case in Mexico

Las innovaciones técnicas han permitido realizar un sinnúmero de cirugías endoscópicas y laparoscópicas, entre ellas la mastectomía preservadora de piel y pezón por puerto único, que ha sido reportada como bien tolerada, con un excelente resultado cosmético y con el mismo pronóstico oncológico que la cirugía tradicional. Esta técnica, común en Asia, presenta diversos retos técnicos y económicos. Presentamos la primera aproximación en nuestro país sobre este abordaje en una paciente con cáncer de mama. Para realizar esta cirugía es preciso el entrenamiento en mínima invasión y en cirugía mamaria, así como una adecuada selección de las pacientes.

Technical innovations and scientific advances have allowed to perform countless endoscopic and laparoscopic surgical procedures. Among these, Single port endoscopic Mastectomy has been reported as well tolerated, with great aesthetic results and the same oncologic prognosis as traditional surgery. This popular approach in Asian countries presents many technical and economic challenges. We present the first endoscopic approach in our country: a female patient with infiltrating ductal carcinoma in the left breast. We understand that to carry out this procedure, adequate patient selection, great minimal invasive and breast surgery skills are necessary.

Major ambulatory surgery in breast diseases

INTRODUCTION

The use of ambulatory surgery (AS) for breast pathology (BP) has increased. The objective of this study is to analyse a group of patients treated surgically for breast pathology in order to evaluate its quality and security in a MAS setting in 2017.

METHODS

A retrospective review of all patients undergoing breast surgery was conducted within an AS programme from January to December 2017 in Consorcio Hospital General Universitario of Valencia (CHGUV). The study analysed the number of patients, exclusion reasons, type of surgical procedures, evolution of substitution rate (SR), rate and causes of conversion to admission, postoperative complications, motives for not being included in the ambulatory programme and the satisfaction rate of the patients treated with ambulatory surgery. This has been compared with a 2013 group.

RESULTS

In 2017, 396 procedures for BP were performed: 170 for benign and 226 for malignant disease. The SR for the global mammary pathology was 72.8%. The SR for benign pathology was 93.4% and the SR for malignant pathology was 57.2%, which has increased in recent years from 45.4% in 2013. The unexpected hospitalization rate (HR) of malignant pathologies was 14.1%, while the HR in benign pathologies was 0.6%. Patients hospitalized for malignant pathologies presented higher complications (17%) than ambulatory patients (8.5%) and benign pathologies (6.5%).

CONCLUSIONS

At the CHGUV, the SR has steadily increased in malignant pathologies. The unexpected hospitalization rate is determined by perioperative sentinel lymph node biopsy results. AS for the treatment of mammary pathology is efficient and safe.

Erector spinae plane block for radical mastectomy: A new indication?

The erector spinae plane block is a technique recently described by Forero et al. in September 2016. It has applications in the control of chronic pain with neuropathic component of the chest wall, and for pain control in thoracoscopic surgery. In this article, we describe the use of this technique as part of a multimodal analgesic approach in a 40-year-old woman, who underwent radical mastectomy due to breast cancer. By performing this block before anesthetic induction, we have achieved an opioid sparing effect, avoiding a possible immunomodulatory effect, although not yet proven in humans. During hospitalization, the patient reported no pain (0/10 in numeric scale), without resorting to rescue analgesia. The easy, fast and safe execution of erector spinae plane block makes it a promising technique in the context of surgical pain during radical mastectomy.

Ultrasound guided nerve block for breast surgery

The breast surgery has undergone changes in recent years, encouraging new initiatives for the anaesthetic management of these patients in order to achieve maximum quality and rapid recovery. The fundamental tool that has allowed a significant improvement in the progress of regional anaesthesia for breast disease has been ultrasound, boosting the description and introduction into clinical practice of interfascial chest wall blocks, although the reference standard is still the paravertebral block. It is very likely that these blocks will change the protocols in the coming years. A review is presented of the anatomy of the breast region, description of nerve blocks and techniques, as well as their indications, all according to published articles and the opinion of the authors based on their experience.