[Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery]

One year follow-up on a randomized study investigating serratus anterior muscle and pectoral nerves type I block to reduced neuropathic pain descriptors after mastectomy

Breast cancer is the second most common diagnosed type of cancer in women. Chronic neuropathic pain after mastectomy occurs frequently and is a serious health problem. In our previous single-center, prospective, randomized controlled clinical study, we demonstrated that the combination of serratus anterior plane block (SAM) and pectoral nerve block type I (PECS I) with general anesthesia reduced acute postoperative pain. The present report describes a prospective follow-up study of this published study to investigate the development of chronic neuropathic pain 12 months after mastectomy by comparing the use of general anesthesia alone and general anesthesia with SAM + PECS I. Additionally, the use of analgesic medication, quality of life, depressive symptoms, and possible correlations between plasma levels of interleukin (IL)-1 beta, IL-6, and IL-10 collected before and 24 h after surgery as predictors of pain and depression were evaluated. The results showed that the use of SAM + PECS I with general anesthesia reduced numbness, hypoesthesia to touch, the incidence of patients with chronic pain in other body regions and depressive symptoms, however, did not significantly reduce the incidence of chronic neuropathic pain after mastectomy. Additionally, there was no difference in the consumption of analgesic medication and quality of life. Furthermore, no correlation was observed between IL-1 beta, IL-6, and IL-10 levels and pain and depression. The combination of general anesthesia with SAM + PECS I reduced the occurrence of specific neuropathic pain descriptors and depressive symptoms. These results could promote the use of SAM + PECS I blocks for the prevention of specific neuropathic pain symptoms after mastectomy.Registration of clinical trial: The Research Ethics Board of the Hospital Sirio-Libanes/Brazil approved the study (CAAE 48721715.0.0000.5461). This study is registered at Registro Brasileiro de Ensaios Clinicos (ReBEC), and ClinicalTrials.gov, Identifier: NCT02647385.

Comparison of the Effects of Pectoral Nerve Block and Local Infiltration Anesthesia on Postoperative Pain for Breast Reduction Surgery: A Prospective Observational Study

Objective

To evaluate the effects of the Pecs II block on postoperative pain in patients undergoing breast reduction surgery.

Materials and Methods

This prospective, comparative, and observational study was conducted with 53 patients, with American Society of Anesthesiologists I-II, between the ages of 18 and 65, and undergoing bilateral breast reduction surgery. The patients were divided into two groups: Pecs II block with general anesthesia (Pecs group; n = 26) and local infiltration anesthesia with general anesthesia (control group; n = 27). The patients' demographic data, duration of surgery and anesthesia, hemodynamic parameters, perioperative analgesia requirements, postoperative visual analog scale (VAS) scores (at zero, one, three, six, nine, and 12 hours postoperative), the number of patients who needed analgesia at least once, the length of the hospital stay, and block-related complications were recorded.

Results

There was no statistical difference in terms of the duration of surgery and anesthesia and hemodynamic parameters. Intraoperative total fentanyl consumption (128.85 ± 25.19 mcg in the Pecs group and 227.77 ± 44.58 mcg in the control group; P < .001) and postoperative analgesic requirement were significantly lower in the Pecs group (P < .001). The number of patients who needed analgesia at least once in the Pecs group was four (15.3%). Postoperative VAS scores were significantly lower (P < .001) and the length of the hospital stay was significantly shorter in the Pecs group (P < .001). No block-related complications were observed.

Conclusion

Pecs II block with general anesthesia may significantly contribute to reducing intraoperative and postoperative analgesia requirements and provide long-lasting and more effective postoperative pain in breast reduction surgery.

Ultrasound-guided thoracic paravertebral block vs pectoral nerve block for postoperative analgesia after modified radical mastectomy

Background

Thoracic paravertebral block may be used for analgesia after breast surgery. Ultrasound can be used during the whole technique of paravertebral block to increase success rate and decrease its complications. As well, pectoral nerve block is now used for pain relief after modified radical mastectomy with or without axillary clearance.

Objective

To compare thoracic paravertebral block and pectoral nerve block for postoperative analgesia after modified radical mastectomy

Methods

The study was performed over 30 female patients that were randomly divided into 2 groups with 15 patients in group A for thoracic paravertebral block (TPVB) and 15 in group B for pectoral nerve block (PECS) with injection of total 20 ml bupivacaine 0.25% in each block. Outcome measures of the study are postoperative analgesia duration (time to first rescue analgesia (0.5 mg/kg pethidine) after administration of block) and total analgesic dose in 24 h after surgery and postoperative pain which will be assessed using a visual analog scale (VAS, 0–10 as 0 = no pain and 10 = worst imaginable pain). The vital signs and pain score will be recorded at 0, 1, 2, 4, 6, 8, 12, 18, and 24 h after surgery.

Results

Our study showed decrease in systolic blood in PVB group immediately postoperative and in the first 6 h postoperative withpvalue < 0.05. Less time to perform the block in PECS group withpvalue < 0.001. Less VAS score in PECS group with statistically significant difference between groups at 1 h, 2 h, and 4 h. More time is needed for the 1st requested rescue analgesia in PECS group withpvalue < 0.05. Patients in the PECS group received less total dose of pethidine with apvalue < 0.05

Conclusion

The PECS can be effectively and safely used, provides better relief of pain and less hemodynamic changes compared with the TPVB, and reduces postoperative analgesic consumption. Therefore, the PECS can be used safely for postoperative analgesia in patients undergoing breast surgeries with axillary dissection.

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

Background

Pectoral nerve block type I (PECS I Block) and type II (PECS II Block) with ropivacaine are relatively new analgesic methods for breast-cancer surgery. We evaluated the safety and efficacy of different concentrations of ropivacaine given in the same volume for the PECS II Block in patients undergoing modified radical mastectomy (MRM).

Patients and Methods

One hundred and twenty women undergoing elective MRM who met inclusion criteria were divided randomly into four groups of 30: control group without PECS II Block and R_0.2%, R_0.3%, and R_0.4% groups, who received general anesthesia plus the PECS II Block with ropivacaine at 0.2%, 0.3%, and 0.4%, respectively, in a volume of 40 mL.

Results

The postoperative numerical rating scale (NRS) pain score at rest and active was significantly higher in the control group than that in the three ropivacaine groups (P<0.05 for all), and the postoperative NRS score in the R_0.3% group and R_0.4% group at 12, 24, and 48 h postoperatively were significantly lower than that in the R_0.2% group (P<0.05 for all); there was no significant difference between the R_0.3% group and R_0.4% group. The time when pain was first felt after MRM, the total number of complaints during 3, 6, 12, 24, and 48 h after MRM, and the total analgesic requirement (tramadol consumption) during the first 24 h postoperatively in the R_0.3% group and R_0.4% group were significantly lower than those in the control group and R_0.2% group (P<0.05 for all); there was no significant difference between the R_0.3% group and R_0.4% group.

Conclusion

A dose of 0.3% ropivacaine was the optimal concentration for a PECS II Block for patients undergoing MRM because it provided efficacious analgesia during and >48 h after MRM. Increasing the ropivacaine concentration did not improve the analgesia of the PECS II Block significantly.

The role of pectoral nerve blocks in a day-case mastectomy service: A prospective cohort study

Background

It is now recognised that the majority of breast surgery can be safely undertaken as day case procedures. We aimed to evaluate the effect of pectoral nerve (Pecs2) blocks on recovery parameters and day case rates in patients undergoing mastectomy for breast cancer.

Methods

A prospective cohort study was performed in a single NHS Foundation trust between 1st April 2014 and 31st December 2016. Visual analogue scale (VAS) pain scores (0-10) at 4 and 8 h, episodes of post-operative nausea ± vomiting (PONV), opioid use and day case outcome were compared between Pecs2 and no Pecs2 groups.

Results

22 patients underwent general anaesthesia (GA) + Pecs2 block and 30 GA ± local anaesthetic infiltration.Mean pain scores were significantly lower in the Pecs2 (2.5) vs no Pecs2 (4.6) group at 4 h (p = 0.0132) and 8 h, Pecs2 (1.9) vs no Pecs2 (3.6) (p = 0.0038).Episodes of PONV requiring additional anti-emetic were lower and statistically significant in the Pecs2 group (2/22, 9%) than the no Pecs2 group (14/30, 46%), (p = 0.005).Additional opioid use was significantly lower in the Pecs2 group (4/22, 18%) than in the no Pecs2 group (14/30, 46%) (p = 0.0423).18 patients in the Pecs2 group were discharged the same day in contrast to just 3 patients in the no Pecs2 group. This was highly statistically significant (p = 0.0001).

Conclusions

Pecs2 blocks can significantly reduce post-operative pain, nausea and vomiting in patients undergoing mastectomy. Their use can enable units to achieve high day-case mastectomy rates.

Are single-injection erector spinae plane block and multiple-injection costotransverse block equivalent to thoracic paravertebral block?

BACKGROUND

Thoracic paravertebral block (TPVB) is considered the gold standard for hemithoracic regional anaesthesia. Erector spinae plane block (ESPB) is a new posterior thoracic wall block. Multiple-injection costotransverse block (MICB) mimics TPVB but with injection points within the thoracic intertransverse tissue complex and posterior to the superior costotransverse ligament. We aimed to compare the spread of injectate into the thoracic paravertebral space (TPVS) resulting from single-injection ESPB and MICB, respectively, with TPVB.

METHODS

Ten soft-embalmed cadavers were utilised. In five cadavers, the right hemithorax was randomly allocated either to ultrasound-guided single-injection ESPB or single-injection TPVB; vice versa on the other side. In another five cadavers, the right hemithorax was randomly allocated either to ultrasound-guided MICB or multiple-injection TPVB. About 20 mL of dye was injected in each hemithorax with all techniques.

RESULTS

With TPVB, the dye was consistently present in the TPVS with concomitant epidural spread in the majority of cases. The injectate spread into the TPVS with ESPB (60%) and MICB (100%). MICB consistently stained the ventral rami (T1-7), communicating rami and thoracic sympathetic trunk without epidural spread. Dissection after MICB revealed dye spread into the TPVS via the costotransverse foramina and along the dorsal branches of the posterior intercostal veins.

CONCLUSIONS

Consistent spread of dye into the TPVS colouring the ventral rami, the communicating rami, and the sympathetic trunk was observed with MICB; in this respect equivalent to TPVB. ESPB exhibited only partial success and was not equivalent to TPVB. No epidural spread was found with neither MICB nor ESPB.

The usefulness of interpectoral block as an analgesic technique in breast cancer surgery

OBJECTIVE

To compare the analgesic efficacy of continuous interpectoral block (CIPB) compared to intravenous analgesia (IV) after breast surgery.

MATERIAL AND METHOD

A prospective, comparative and randomised study of women aged from 18-75years, ASAI-III, operated for breast cancer. In group1 (CIPB) after general anaesthetic, an ultrasound-guided interpectoral catheter was placed and 30mL of 0.5% ropivacaine was administered through it. In the event of an increase in heart rate and blood pressure >15% after the surgical incision, intravenous fentanyl 1μg·kg^-1 was administered, repeating the dose as necessary. In the postoperative period, perfusion of ropivacaine 0.2% 5mL·h^-1; with PCA bolus 5mL/30minutes was administered through the catheter for 24hours and rescue analgesia prescribed with 5mg subcutaneous morphine chloride. In group2 (IV), after induction of general anaesthesia, intravenous fentanyl was administered in the same way as in the other group. The patients received metamizole 2g with dexketoprofen 50mg and ondansetron 4mg postoperatively followed by perfusion of metamizole 4%, tramadol 0.2% and ondansetron 0.08% 2ml·h^-1; with PCA bolus 2mL/20min for 24hours. The same rescue analgesia was prescribed. The principal variables recorded were pain at rest and during movement, according to a simple verbal scale (VAS 0-10) and the rescue analgesia required on discharge from recovery, at 12 and at 24hours.

RESULTS

137 patients were included: 81 in group1 (59.12%) and 56 in group2 (40.87%). No significant differences were observed in the analgesia between either group, but differences were observed in the dose of intraoperative fentanyl (P<.05). Differences that were not significant were observed in the rescue analgesia required on recovery (10% fewer on group1).

CONCLUSIONS

Both techniques provided effective postoperative analgesia, but the CIPB group required significantly less intraoperative fentanyl.

Efficacy of Pectoral Nerve Block using Bupivacaine with or without Magnesium Sulfate

Background:

Worldwide, breast cancer is the main common cancer among females. In the United States, it affects one in eight women during their lifespan. In breast cancer surgery, chronic pain can be developed from poorly managed acute postoperative pain. The aim of the study was to use a safe, easy, and less complicated method of regional block for reducing the postoperative pain after mastectomy, which will reduce the incidence of chronic postmastectomy pain.

Materials and Methods:

Ninety adult female patients with American Society of Anesthesiologists Physical Status I, II, and III were allocated randomly into three groups: Group C had general anesthesia; Group B had ultrasound-guided pectoral nerve block (PECS block) (28mL 0.25% bupivacaine+2mL normal saline) plus general anesthesia; and Group M had ultrasound-guided PECS block (total 28 mL of Bupivacaine 0.25%+2mL of magnesium sulfat 50%) plus general anesthesia.

Results:

The intraoperative fentanyl (μg) used was significantly lower in Group B (110.4 ± 26.3) and Group M (108.7 ± 14.1) than in Group C (214.3 ± 20.1) and also the same as regards the total postoperative pethidine (mg) in Group C (220 ± 25.5), Group B (100.6 ± 24.3), and Group M (52.3 ± 12.3). The Group M was the least group suffered from postoperative pain at all times of measurement.

Conclusion:

The Group M was the least group suffered from postoperative pain at all times of measurement.

Postoperative pain management in the postanesthesia care unit: an update

Acute postoperative pain remains a major problem, resulting in multiple undesirable outcomes if inadequately controlled. Most surgical patients spend their immediate postoperative period in the postanesthesia care unit (PACU), where pain management, being unsatisfactory and requiring improvements, affects further recovery. Recent studies on postoperative pain management in the PACU were reviewed for the advances in assessments and treatments. More objective assessments of pain being independent of patients' participation may be potentially appropriate in the PACU, including photoplethysmography-derived parameters, analgesia nociception index, skin conductance, and pupillometry, although further studies are needed to confirm their utilities. Multimodal analgesia with different analgesics and techniques has been widely used. With theoretical basis of preventing central sensitization, preventive analgesia is increasingly common. New opioids are being developed with minimization of adverse effects of traditional opioids. More intravenous nonopioid analgesics and adjuncts (such as dexmedetomidine and dexamethasone) are introduced for their opioid-sparing effects. Current evidence suggests that regional analgesic techniques are effective in the reduction of pain and stay in the PACU. Being available alternatives to epidural analgesia, perineural techniques and infiltrative techniques including wound infiltration, transversus abdominis plane block, local infiltration analgesia, and intraperitoneal administration have played a more important role for their effectiveness and safety.

Ultrasound-Guided Continuous Interpectoral Block for Patient Undergoing Mastectomy and Axillary Clearance

Using a single dose of local anaesthetics has some disadvantages and provides limited analgesia depending on the pharmacokinetic characteristics of the local anaesthetic used. Nevertheless, the use of continuous perineural infusions allows sustained pain control. Ultrasound-guided interpectoral block followed by the placement of catheters in patients undergoing mastectomies with or without lymph node axillary dissections can result in sufficient pain control. We present a case of a 58-year-old woman undergoing mastectomy and axillary clearance who received ultrasound-guided continuous interpectoral block for postoperative analgesia. After the induction of general anaesthesia, interpectoral ultrasound block was performed and levobupivacaine was administered through a catheter placed between the pectoralis minor and pectoralis major muscles using an ultrasound-guided technique. We used an elastomeric pump containing the 0.125% levobupivacaine anaesthetic solution, with an infusion rate of 5 mL h^-1 for 48 h. Excellent postoperative pain control was observed. Local anaesthetic- and catheter-related side-effects were not observed. The ideal infusion rate for interpectoral block in patients under mastectomy has not been determined. More randomised studies are needed to confirm whether interpectoral techniques are appropriate for routine clinical practice.

Paravertebral Block Plus Thoracic Wall Block versus Paravertebral Block Alone for Analgesia of Modified Radical Mastectomy: A Retrospective Cohort Study

BACKGROUND AND OBJECTIVES

Paravertebral block placement was the main anesthetic technique for modified radical mastectomy in our hospital until February 2014, when its combination with blocks targeting the pectoral musculature was initiated. We compared the analgesic effects of paravertebral blocks with or without blocks targeting the pectoral musculature for modified radical mastectomy.

METHODS

We retrospectively collected data from a single surgeon and anesthesiologist from June 1, 2012, to May 31, 2015. Intraoperative sedatives and analgesic requirements, time to the first analgesic request, postoperative analgesic doses, patient satisfaction, and complications were compared.

RESULTS

Fifty-four patients received a paravertebral block alone (PECS 0), and 46 received a paravertebral block combined with blocks targeting the pectoral musculature (PECS 1). The highest intraoperative effect-site concentration of propofol was significantly lower in the PECS 1 group than in the PECS 0 group [2.3 (1.5, 2.8) vs 2.5 (1.5, 4) μg/mL, p = 0.0014]. The intraoperative rescue analgesic dose was significantly lower in the PECS 1 group [0 (0, 25) vs 0 (0, 75) mg of ketamine, p = 0.0384]. Furthermore, the PECS 1 group had a significantly longer time to the first analgesic request [636.5 (15, 720) vs 182.5 (14, 720) min, p = 0.0001]. After further adjustment for age, body mass index, American Society of Anesthesiologists Physical Status classification, chronic pain history, incidence of a superficial cervical plexus block placement, and operation duration, blocks targeting the pectoral musculature were determined to be the only significant factor (hazard ratio, 0.36; 95% confidence interval, 0.23-0.58; p < 0.0001). Very few patients used potent analgesics including morphine and ketorolac; the cumulative use of morphine or ketorolac was similar in the study groups. However, the incidence of all analgesic use, namely morphine, ketorolac, acetaminophen, and celecoxib, was significantly lower in the PECS 1 group [3.5 (0, 6) vs 5 (0, 12), p < 0.0001].

CONCLUSIONS

Compared with the placement of a paravertebral block alone, combining blocks targeting the pectoral musculature with a paravertebral block for modified radical mastectomy reduced the sedative and analgesic requirements during operation and provided more effective postoperative analgesia.

A review of postoperative analgesia for breast cancer surgery

An online database search with subsequent article review was performed in order to review the various analgesic modalities for breast cancer surgery. Of 514 abstracts, 284 full-length manuscripts were reviewed. The effect of pharmacologic interventions is varied (NSAIDS, opioids, anticonvulsants, ketamine, lidocaine). Likewise, data from high-quality randomized, controlled studies on wound infiltration (including liposome encapsulated) and infusion of local anesthetic are minimal and conflicting. Conversely, abundant evidence demonstrates paravertebral blocks and thoracic epidural infusions provide effective analgesia and minimize opioid requirements, while decreasing opioid-related side effects in the immediate postoperative period. Other techniques with promising – but extremely limited – data include cervical epidural infusion, brachial plexus, interfascial plane and interpleural blocks. In conclusion, procedural interventions involving regional blocks are more conclusively effective than pharmacologic modalities in providing analgesia to patients following surgery for breast cancer.

Anaesthetic considerations for pectus repair surgery

Repair of pectus is one of the most common congenital abnormality for which patient presents for thoracic surgery. In recent years, innovative minimally invasive techniques involving video assisted thoracoscopy for pectus repair have become the norm. Similarly, anaesthetic techniques have evolved to include principles of enhanced recovery, multimodal analgesia and innovative ultrasound guided neuraxial and nerve blocks. Adequate anaesthetic set up and monitoring including the use of real time intraoperative monitoring with transesophageal echocardiography (TOE) has enabled the anaesthetist to enhance patient safety by providing instantaneous imaging of cardiac compression and complications during surgery. In this review article we aim to provide non-systematic review and institutional experience of our anaesthetic strategy to provide effective peri-operative care in this patient group.

Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery

OBJECTIVE

The Pecs block (pectoral nerves block) is an easy and reliable superficial block inspired by the infraclavicular block approach and the transversus abdominis plane blocks. Once the pectoralis muscles are located under the clavicle the space between the two muscles is dissected to reach the lateral pectoral and the medial pectoral nerves. The main indications are breast expanders and subpectoral prosthesis where the distension of these muscles is extremely painful.

MATERIAL AND METHODS

A second version of the Pecs block is described, called "modified Pecs block" or Pecs block type II. This novel approach aims to block at least the pectoral nerves, the intercostobrachial, intercostals III-IV-V-VI and the long thoracic nerve. These nerves need to be blocked to provide complete analgesia during breast surgery, and it is an alternative or a rescue block if paravertebral blocks and thoracic epidurals failed. This block has been used in our unit in the past year for the Pecs I indications described, and in addition for, tumorectomies, wide excisions, and axillary clearances.

RESULTS AND CONCLUSIONS

The ultrasound sequence to perform this block is shown, together with simple X-ray dye images and gadolinium MRI images to understand the spread and pathways that can explain the benefit of this novel approach.