Combined thoracic paravertebral and pectoral nerve blocks for breast surgery under sedation: a prospective observational case series

Ultrasound-Guided Regional Anesthesia Using a Mixture of Dexamethasone, Dexmedetomidine, and 0.2% Levobupivacaine for Bilateral Breast Cancer Surgery Under a Spontaneous Breathing Opioid-Free Anesthesia: A Case Report

Breast cancer is unfortunately the most common cancer in women, although survival rates have greatly increased in recent years. Breast surgery can be very aggressive and therefore highly painful, leading to high rates of acute postsurgical pain and chronic pain. In addition to general anesthesia (GA), ultrasound-guided regional anesthesia (RA) is sometimes performed to help reduce acute postoperative pain and consumption of opioids. Although effective, the main limitation of fascial plane blocks is that they require high volumes of local anesthetics, carrying the risk of local anesthetic systemic toxicity. In this article, we present the case of a 41-year-old woman, who refused GA and was successfully operated on for bilateral breast cancer, under a spontaneous breathing opioid-free sedation and ultrasound-guided RA, based on only 0.2% levobupivacaine with the addition of dexamethasone and dexmedetomidine as adjuvants. Despite this, postoperative analgesia lasted for more than 48 hours, and the patient did not require additional analgesia or opioids.

Interpectoral nerve blocks may lower postoperative narcotic use after mastectomy

BACKGROUND

Pain management following mastectomy is a significant challenge often requiring opioids. Nonopioid pain management utilizing nerve blocks has been shown in other fields to reduce postoperative opioid use and may be effective for postoperative pain in mastectomy patients. The primary purpose of this study was to compare postoperative opioid use, measured in morphine milligram equivalents (MME), between mastectomy patients who underwent interpectoral nerve block (IPNB) and a historical control group. Secondary outcomes included length of stay (LOS) and postoperative pain scores.

METHODS

This is a single-center, retrospective cohort study. The charts of women who underwent mastectomy for cancer without immediate reconstruction from 10/2017-12/2019 were reviewed. Wilcoxon rank sum test was used for unadjusted analysis and multiple linear regression for adjusted analysis.

RESULTS

There were 105 patients included in this study, of which 37 (35%) underwent IPNB. In unadjusted analysis, median MME use was significantly lower in patients that received IPNB compared to the control group (IPNB = 5, controls = 17, p = 0.03). Patients that received IPNB had an observed reduction in LOS and postoperative pain, though these results failed to reach statistical significance. There were no IPNB-related complications.

CONCLUSIONS

IPNB may be an effective strategy to decrease postoperative opioid use in mastectomy patients. Larger, prospective studies are needed to further investigate the effectiveness of IPNB.

Analgesia-nociception index accurately predicts inadequate pectoralis muscle fascia block (PECS) in patients undergoing breast surgery: A prospective observational study

BACKGROUND

Postoperative opioid administration has been largely replaced by regional anesthesia techniques. We aimed to determine whether intraoperative Analgesia-Nociception Index (ANI) can aid in early evaluation of the effectiveness of regional blocks such as the pectoralis muscle fascia block (PECS, pectoserratus and interpectoral plane blocks) and predicting the need for analgesics postoperatively.

METHODS

This prospective observational study enrolled 30 women (age: 20-80 years) undergoing unilateral, non-intubated, breast tumor excision alone or in conjunction with sentinel lymph node biopsy. PECS block was performed following sedation. ANI readings were obtained at 1-min intervals, and polar coordinates were assigned to the distance from the nipple (0.5-cm intervals) and o'clock position (15-min intervals) for each reading. Pain scores were assessed using a numeric rating scale from 0 to 10, and analgesics were administered depending on pain score post-operatively.

RESULTS

8 (27%), 19 (63%), and 3 (10%) patients received morphine, tramadol, and no analgesics, respectively. In total, 954 ANI measurements were obtained. At the proposed cut-off of 50, the sensitivity and specificity of the ANI nadir for need of post-operative opioids were 0.875 and 0.932, respectively. Block effectiveness was most satisfactory in the upper lateral quadrant of the breast with nipple-areolar complex (NAC) sparing effect. Most average ANI measurements for the NAC were <50. No patient experienced postoperative nausea/vomiting, although one reported dizziness.

CONCLUSIONS

The intraoperative ANI nadir <50 was strongly correlated with need for postoperative opioids. The ANI may aid in objectively evaluating the effectiveness of pectoralis muscle fascial blocks and predicting postoperative need for analgesics.

Insignificant influence of the intertransverse process block for major breast cancer surgery: a randomized, blinded, placebo-controlled, clinical trial

INTRODUCTION

The intertransverse process (ITP) block mimics the thoracic paravertebral block and allegedly ameliorates hemithoracic postoperative pain. However, concerning major reconstructive breast cancer surgery the modality has never been tested against placebo in a randomized clinical trial. We aimed to assess the efficacy of the multiple-injection ITP block and hypothesized that the blockade would reduce postoperative opioid consumption.

METHODS

We screened 58 patients with breast cancer scheduled for unilateral subpectoral implant-based primary breast reconstruction, involving mastectomy with complete fascial dissection of the major pectoral muscle. A randomization procedure allowed for the allocation of 36 patients to receive either unilateral multiple-injection active ITP block (0.5% ropivacaine 3×10 mL) or placebo ITP block (isotonic saline 3×10 mL) at T2, T4, T6 in a prospective, blinded, clinical trial. The primary outcome was total opioid consumption within the first 24 postoperative hours. Secondary outcomes included opioid consumption at 4-hour intervals, postoperative pain, patient satisfaction with block application, time to first opioid, ambulation and discharge, opioid-related side effects, and quality of recovery.

RESULTS

Opioid consumption within the first 24 postoperative hours showed no significant reduction when comparing the active and placebo group median (IQR): 75.0 mg (45-135) vs 62.5 mg (30-115), p=0.5, respectively. We did not find any consequential clinically relevant results of the secondary outcomes.

CONCLUSIONS

Following major reconstructive breast cancer surgery, a preoperative multiple-injection ITP block neither reduces 24-hour opioid consumption postoperatively nor promotes substantial clinical positive outcomes.

TRIAL REGISTRATION NUMBER

EudraCT2019-001016-35.

Combined thoracic erector spinae plane and inter-transverse plane blocks for awake breast surgery

Worldwide, breast cancer is the most commonly diagnosed cancer in women. Surgical procedures are typically performed using general anaesthesia, often complemented by regional anaesthesia to manage postoperative pain. However, avoidance of general anaesthesia for breast surgery may be desirable for clinical reasons or patient choice. It is theorised that the use of regional anaesthesia and the avoidance of volatile anaesthetics and opioid analgesia may have beneficial effects on oncological outcomes, and there is some evidence to support this. While many patients successfully undergo awake breast surgery, a limited number of anaesthetists possess direct experience of this approach, despite familiarity with regional anaesthesia techniques. Undertaking regional anaesthesia for awake breast surgery requires patient cooperation and excellent staff teamwork. Here, we present a case of a patient who underwent awake bilateral mastectomy with reconstruction. This was carried out under two 'paravertebral-by-proxy' blocks: the thoracic erector spinae plane and inter-transverse plane blocks, with intravenous sedation.

Enhanced Recovery After Aesthetic Breast Surgery Under Sedation, Intercostal Block and Tumescent Anaesthesia: A Prospective Cohort Study of the Early Postoperative Phase

BACKGROUND

Comfort and recovery are major concerns of patients seeking aesthetic surgery. This study aimed to assess postoperative pain and recovery after outpatient breast surgery under sedation, intercostal block, and local anaesthesia.

METHODS

This prospective cohort study included all consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022. Epidemiological data, anaesthesia, pain, and patients' satisfaction were systematically assessed with standardized self-assessment questionnaires.

RESULTS

Altogether, 48 patients [median (IQR) age: 30 (36-25)] were included. The most frequent surgery was mastopexy. 69% of surgeries involved additional procedures. The mean intercostal block and local anaesthesia time was 15 min. Patients received a median (IQR) of 19 (34-2) mg/kg lidocaine and 2.3 (2.5-2.0) mg/kg ropivacaine. The median (IQR) consumption of propofol and alfentanil was, respectively, 4.89 (5.48-4.26) mg/kg/h and 0.27 (0.39-0.19) µg/kg/min. No conversion to general anaesthesia or unplanned hospital admission occurred. Patients were discharged after a median (IQR) of 2:40 (3:43-1:58) hours. Within the first 24 postoperative hours, 17% required once an antiemetic medication and 38% an opioid. Patients were very satisfied with the anaesthesia and 90% of the patients had not wished more analgesia in the first 24 h.

CONCLUSIONS

Aesthetic breast surgery under sedation, intercostal block, and tumescent anaesthesia can safely be performed as an ambulatory procedure and is associated with minimal intra- and postoperative opioid consumption and high patient satisfaction. These data may be used to inform patients and clinicians and improve the overall quality of care.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Propofol enhances stem-like properties of glioma via GABAAR-dependent Src modulation of ZDHHC5-EZH2 palmitoylation mechanism

Background

Propofol is a commonly used anesthetic. However, its effects on glioma growth and recurrence remain largely unknown.

Methods

The effect of propofol on glioma growth was demonstrated by a series of in vitro and in vivo experiments (spheroidal formation assay, western blotting, and xenograft model). The acyl-biotin exchange method and liquid chromatography-mass spectrometry assays identified palmitoylation proteins mediated by the domain containing the Asp-His-His-Cys family. Western blotting, co-immunoprecipitation, quantitative real-time polymerase chain reaction, co-immunoprecipitation, chromatin immunoprecipitation, and luciferase reporter assays were used to explore the mechanisms of the γ-aminobutyric acid receptor (GABA_AR)/Src/ZDHHC5/EZH2 signaling axis in the effects of propofol on glioma stem cells (GSCs).

Results

We found that treatment with a standard dose of propofol promoted glioma growth in nude mice compared with control or low-dose propofol. Propofol-treated GSCs also led to larger tumor growth in nude mice than did vector-treated tumors. Mechanistically, propofol enhances the stem-like properties of gliomas through GABA_AR to increase Src expression, thereby enhancing the palmitoylation of ZDHHC5-mediated EZH2 and Oct4 expression.

Conclusion

These results demonstrate that propofol may promote glioma growth through the GABA_AR-Src-ZDHHC5-EZH2 mechanism and are helpful in guiding the clinical use of propofol to obtain a better patient prognosis after the surgical resection of tumors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-022-03087-5.

Use of ultrasound guided single shot costotransverse block (intertransverse process) in breast cancer surgery: a prospective, randomized, assessor blinded, controlled clinical trial

BACKGROUND

Ultrasound guided costotransverse block (CTB) is a relatively new "peri-paravertebral" block that has been described recently. It has been previously reported that CTB, administered with a single high-volume injection, provides effective analgesia in breast conserving surgery. In this study we evaluated the effect of CTB when used in breast cancer surgery.

METHODS

Seventy patients due to undergo breast cancer surgery were included in this blinded, prospective, randomized, efficiency study. Patients were randomized into two equal groups (CTB group and control group) using the closed envelope technique. All patients underwent general anesthesia. In addition to standard analgesia methods, patients in group CTB also received CTB block while the remaining (control group) did not. Numeric rating (pain) scores and opioid consumption was compared between the two groups.

RESULTS

Opioid consumption in all time frames and pain scores at 1st and 3rd hours only were found to be significantly lower in Group CTB when compared to the control group.

CONCLUSIONS

Ultrasound guided CTB improves analgesia quality in breast cancer surgery.

TRIAL REGISTRATION

Clinicaltrials Registration ID: NCT04197206 , Registration Date: 13/12/2019.

Anesthesia With Propofol Sedation Reduces Locoregional Recurrence in Patients With Breast Cancer Receiving Total Mastectomy Compared With Non-Propofol Anesthesia

Purpose

We examined locoregional recurrence (LRR) in patients with breast invasive ductal carcinoma (IDC) receiving total mastectomy (TM) under propofol-based paravertebral block-regional anesthesia (PB-RA) versus sevoflurane-based inhalational general anesthesia (INHA-GA) without propofol. All-cause death and distant metastasis were secondary endpoints.

Patients and Methods

Patients with breast IDC receiving TM were recruited through propensity score matching and categorized into INHA-GA with sevoflurane and PB-RA with propofol groups. Cox regression analysis was performed to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

In the multivariate Cox regression analysis, the adjusted HR (aHR; 95% CI) of LRR for the PB-RA with propofol group was 0.52 (0.28–0.96) compared with the INHA-GA with sevoflurane group. The aHRs of LRR for differentiation grade II, grade III, the American Joint Committee on Cancer clinical stage II, stage III, pathological tumor (pT) stage 2, pT stage 3–4, pathological nodal (pN) stage 1, and pN stage 2–3 were 1.16 (1.04–2.08), 1.28 (1.07–2.12), 3.71 (1.82–7.59), 4.67 (1.65–13.18), 1.09 (1.02–1.21), 1.17 (1.03–2.16), 1.10 (1.03–1.33), and 1.22 (1.06–2.41), respectively, compared with differentiation grade I, clinical stage I, pT1, and pN0. The aHR of LRR for adjuvant RT was 0.88 (0.64–0.94) compared with that for no adjuvant RT.

Conclusion

PB-RA with propofol might be beneficial for reducing LRR in women with breast IDC receiving TM compared with INHA-GA without propofol.

Ultrasound-guided multiple-injection costotransverse block for mastectomy and primary reconstructive surgery. A study protocol

BACKGROUND

Post-operative pain amelioration following breast cancer surgery is inconsistent. The novel multiple-injection costotransverse block (MICB) mimics the thoracic paravertebral block by possible anaesthetising the ventral rami of the thoracic spinal nerves and the sympathetic trunk. Proof of concept has been determined in a cadaveric study and needs further clinical testing.

METHODS

This double-blinded, randomised and placebo-controlled study investigates the efficacy of the ultrasound-guided MICB versus placebo in 36 patients undergoing unilateral mastectomy and primary subpectoral reconstruction surgery. Oral pre-operative medicine is standardised for all patients. Active group is pre-operatively administered MICB with three injections of each 10 ml of ropivacaine (5 mg/ml). The placebo group is pre-operatively administered three injections of each 10 ml of saline (0.9%). Standard general anaesthesia is induced and 30 min before emergence 0.2 μg/kg total body weight sufentanil IV, 1 g of paracetamol IV and 4 mg of ondansetron IV (post-operative nausea and vomiting, PONV, prophylaxis) will be administered. All patients are provided with a patient-controlled analgesia pump with morphine. The primary aim is total morphine consumption in the first 24 post-operative hours. Secondary aims are pain intensity, duration of the block, patient satisfaction, side effects, time to ambulation, time to discharge, and quality of recovery.

DISCUSSION

Recruitment began in November 2019 and is expected to finish ultimo 2021. Results are expected to be published in an international peer-reviewed medical journal. The results will hopefully provide a substantial contribution to the knowledge of these new 'intertransverse process blocks' providing regional anaesthesia of the thoracic wall.

Paravertebral block in regional anesthesia with propofol sedation reduces locoregional recurrence in patients with breast cancer receiving breast conservative surgery compared with volatile inhalational without propofol in general anesthesia

PURPOSE

We examined locoregional recurrence (LRR) in patients with breast invasive ductal carcinoma (IDC) receiving breast conservative surgery (BCS) under propofol-based paravertebral block-regional anesthesia (PB-RA) versus sevoflurane-based inhalational general anesthesia (INHA-GA) without propofol. All-cause death and distant metastasis were secondary endpoints.

PATIENTS AND METHODS

Patients with breast IDC receiving BCS were recruited through propensity score matching and categorized into INHA-GA with sevoflurane and PB-RA with propofol groups. Cox regression analysis was performed to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

In the multivariate Cox regression analysis, the adjusted HR (aHR; 95% CI) of LRR for the PB-RA with propofol group was 0.67 (0.46-0.99) compared with the INHA-GA with sevoflurane group. The aHRs of LRR for differentiation grade II, grade III, the American Joint Committee on Cancer clinical stage II, stage III, pathological tumor (pT) stage 2, pT stage 3-4, pathological nodal (pN) stage 2-3, and Her-2 positivity were 1.87 (1.03-3.42), 2.31 (1.20-4.44), 1.67 (1.09-2.56), 2.43 (1.18-4.97), 1.17 (1.03-1.19), 1.28 (1.13-2.24), 1.20 (1.05-2.22), and 1.59 (1.01-2.51), respectively, compared with those for differentiation grade I, clinical stage I, pT1, pN0, and HER-2 negativity. The aHR of LRR for adjuvant radiotherapy was 0.60 (0.38-0.97) compared with that for no adjuvant radiotherapy.

CONCLUSION

PB-RA with propofol might be beneficial for reducing LRR in women with breast IDC receiving BCS compared with INHA-GA without propofol.

Trends in Peripheral Nerve Block Usage in Mastectomy and Lumpectomy: Analysis of a National Database From 2010 to 2018

BACKGROUND

Compared to general anesthesia, regional anesthesia confers several benefits including improved pain control and decreased postoperative opioid consumption. While the benefits of peripheral nerve blocks (PNB) have been well studied, there are little epidemiological data on PNB usage in mastectomy and lumpectomy procedures. The primary objective of our study was to assess national trends of the annual proportion of PNB use in breast surgery from 2010 to 2018. We also identified factors associated with PNB use for breast surgery.

METHODS

We identified lumpectomy and mastectomy surgical cases with and without PNB between 2010 and 2018 using the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (AQI NACOR). We modeled the nonlinear association between year of procedure and PNB use with segmented mixed-effects logistic regression clustered on facility identifier. The association between PNB use and year of procedure, age, sex, American Society of Anesthesiologists physical status (ASA PS), facility type, facility region, weekday, and tissue expander use was also modeled using mixed-effects logistic regression.

RESULTS

Of the 189,854 surgical cases from 2010 to 2018 that met criteria, 86.2% were lumpectomy cases and 13.8% were mastectomy cases. The proportion of lumpectomy cases with PNB was <0.1% in 2010 and increased each subsequent year to 1.9% in 2018 (trend P < .0001). The proportion of mastectomy cases with PNB was 0.5% in 2010 and 13% in 2018 (trend P < .0001). The year 2014 was the breakpoint selected for segmented regression. Before 2014, the odds of PNB among the mastectomy cases was not significantly different from year to year. After 2014, the odds of PNB increased by 2.24-fold each year (95% confidence interval [CI], 2.00-2.49; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. Similar trends were seen in the lumpectomy cases, where after 2014, the odds of PNB increased by 2.03-fold (95% CI, 1.81-2.27; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. In the mastectomy cohort, year of procedure ≥2014, female sex, facility region, and tissue expander use were associated with higher odds of PNB. For lumpectomy cases, year of procedure ≥2014 and facility region were associated with higher odds of PNB use.

CONCLUSIONS

We found increased annual utilization of PNB for mastectomy and lumpectomy since 2010, although absolute prevalence is low. PNB use was associated with year of procedure for both lumpectomy and mastectomy, particularly post-2014.

Fascial plane blocks: a narrative review of the literature

Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As 'new' FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.

Ultrasound-Guided Regional Anesthesia Under Sedation for Radical Mastectomy in an SAS Patient: A Case Report

Radical mastectomy is commonly performed under general anesthesia, and regional block is often used as assisted or postoperative analgesia. We herein report a case of successful radical mastectomy with severe aortic stenosis (SAS) by using ultrasound-guided regional anesthesia under sedation. A 66-year-old female with an American Society of Anesthesiology physical status IV; limited functional capacity with <4 metabolic equivalents; a lump (10 cm × 8 cm) in the right breast with skin breakage and infection; and a history of hypertension, diabetes, atrial fibrillation, and SAS, underwent lump-resection and rapid pathological examination by biopsy. Considering a high-risk of significant mortality, we used ultrasound-guided regional block to avoid general anesthesia. We performed the right thoracic paravertebral nerve block (TPVB), subclavicular brachial plexus block, and pectoralis plane block (PECS 1). Patient tolerated the procedure well with no significant hemodynamic changes. Nevertheless, when the axillary lymph nodes were wiped, discharge was observed from the patient’s upper limbs. We inserted the laryngeal mask airway combined with low-dose sevoflurane inhalation sedation. The operation was successfully completed, and the patient was revived with steady hemodynamics and good prognosis. In the present case, radical mastectomy with SAS was performed successfully using ultrasound-guided regional anesthesia under sevoflurane sedation. Despite some potential limitations, this case report can serve as a reference for other anesthetists.

A systematic review and meta-analysis of the effects of general anesthesia combined with continuous paravertebral block in breast cancer surgery and postoperative analgesia

Background

This study aimed to compare the effects of general anesthesia (GA) combined with continuous paravertebral block (CPVB) in breast cancer surgery via systematic review and meta-analysis, in order to provide a theoretical basis for the clinical use of CPVB surgical analgesia.

Methods

A search of the PubMed, Embase, Medline, Ovid, Springer, and Web of Science databases was conducted to screen clinical trials on GA + CPVB for breast cancer surgery published before December 31, 2020. The Cochrane Handbook for Systematic Reviews of Intervention 5.0.2 was adopted for bias risk assessment, and Review Manager 5.3 software (RevMan, The Cochrane Collaboration, http://tech.cochrane.org/revman) was applied for meta-analysis of the literature.

Results

A total of 15 studies that satisfied the requirements were included, involving a total of 1,435 research subjects. The results of our meta-analysis showed the following: the visual analogue scale (VAS) score of the observation group (group A) was significantly reduced [mean difference (MD) =-0.68; 95% confidential interval (CI): -1.04 - -0.33; Z=3.80; P=0.0001]; the level of monocyte chemoattractant protein -1 (MCP-1) was notably decreased (MD =-18.64; 95% CI: -29.68 - -7.61; Z=3.31; P=0.0009); the level of tumor necrosis factor-α (TNF-α) was markedly lower (MD =-1.89; 95% CI: -2.66 - -1.13; Z=4.87; P<0.00001); the interleukin-6 (IL-6) level was obviously reduced (MD =-12.10; 95% CI: -19.22 - -4.99; Z=3.33; P=0.0009); and the incidence of postoperative adverse reactions was substantially decreased (MD = 0.16; 95% CI: 0.07-0.36; Z=4.47; P<0.00001). Compared with group B, the differences of the above five indicators showed statistical significance. In addition, the heart rate (HR) (MD =-1.56; 95% CI: -6.20 - 3.08; Z=0.66; P=0.51), mean arterial pressure (MAP) (MD = 4.66; 95% CI: -0.12 -9.43; Z=1.91; P=0.06), Ramsay score (MD =0.44; 95% CI: -0.06-0.93; Z=1.73; P=0.08) of patients in group A showed no statistical differences compared to group B.

Conclusions

GA + CPVB applied to breast cancer surgery for analgesia can reduce the levels of MCP-1, TNF-α, and IL-6 in patients, thereby providing good postoperative analgesia. Therefore, GA + CPVB could effectively reduce the incidence of pain and adverse reactions in patients, and is effective for analgesia in breast cancer surgery.

Post-mastectomy pain syndrome: A timely review of its predisposing factors and current approaches to treatment

Background:

Post-mastectomy pain syndrome (PMPS) has been reported to occur in 25–60% of patients following surgeries for breast cancer, the highest occurring cancer in women worldwide. There has been much research interest due to this high prevalence. However, there is still a lack of incorporation of PMPS prevention strategies in standard perioperative plans, and our understanding of this condition is still incomplete.

Objectives:

This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and treatment and potential directions for future treatment and research.

Methods:

A PubMed search with the relevant keywords was done for articles published in the last 10 years.

Results:

The incidence of PMPS can be reduced by early recognition and management of modifiable risk factors as well as the perioperative use of analgesics and regional nerve blocks. These also have a significant role in the management of established PMPS together with surgical interventions and physical therapy.

Conclusions:

PMPS is still poorly defined and hence underdiagnosed and undertreated at this point. Perioperative peripheral nerve blocks have a very promising role as preventive analgesia to reduce the risk of developing PMPS, but large-scale randomised controlled studies will need to be done to evaluate their comparative efficacy. There is a need to prioritise PMPS prevention as a standard inclusion into the perioperative plans of mastectomy patients.

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.

Combined transverse thoracis plane and pectoral nerve blocks for breast surgery under sedation

The pectoral nerves 2 (pecs 2) block is widely used as adjunct to general anaesthesia for breast surgery. There are a few case reports and a single case series that describe regional anaesthesia as a single technique or supplemented by light to moderate sedation. Here we describe the management of a 91-year-old ASA physical status 4 patient who presented with a T4 breast malignancy. She was considered unfit for general anaesthesia due to significant valvular heart disease. A wide local excision was successfully performed under a pecs 2 block and a transverse thoracis plane block, supplemented with light sedation. We consider this technique to be a good option for selected patients who are considered unfit for general anaesthesia.

Laparoscopic Sleeve Gastrectomy under Awake Paravertebral Blockade Versus General Anesthesia: Comparison of Short-Term Outcomes

AIMS

This study aimed at comparing the pre-, intra-, and early postoperative outcomes, between patients who underwent PVB vs general anesthesia (GA) during LSG. Follow-up of weight loss at least 1 year postoperatively was also evaluated.

METHODS

A cohort study was conducted by selecting all patients who underwent LSG under PVB and GA at Makassed General Hospital between 2010 and 2016. Demographic, social, pre-op health status, body mass index (BMI), operative time, postoperative pain and pain medication consumption, postoperative complications and length of hospital stay, all were studied. Follow-up weight loss was collected up to 5 years postoperatively. Data entry, management, and descriptive and inferential statistics were performed using SPSS.

RESULTS

A total of 210 participants were included in this study of which 48 constituted the PVB group and 162 patients composed the GA group. Both groups were similar in baseline demographic factors, with patients in PVB suffering from higher number and advanced stage of comorbidities than the GA group. Mean operative time was similar in between the two groups with 80 ± 20 min for PVB and 82 ± 18 min for GA group. Intraoperative complications were scarce among both study groups. GA group requested a second dose of analgesia earlier than PVB group. After at least 1 year postoperatively, the mean percentage of excess weight loss was 81.35 ± 15.5% and 77.89 ± 14.3% for the PVB and GA groups, respectively, P value 0.45.

CONCLUSION

Outcomes of LSG under both types of anesthesia (PVB alone and GA alone) were found to be comparable. However, the need for analgesia was significantly less in the PVB group compared to GA group.

A novel approach to spinal anaesthesia to avoid aerosol-generating procedures in a patient with COVID-19 presenting for laser prostate surgery

General anaesthesia involves aerosol-generating procedures which, in the context of the coronavirus 2019 (COVID-19) pandemic, increases the risk of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) transmission from patients to staff. This risk can be minimised by performing spinal or regional anaesthesia instead of general anaesthesia where possible. We report the successful management of a patient utilising spinal anaesthesia in a patient with COVID-19 undergoing urgent holmium laser enucleation of prostate for symptomatic benign prostatic hyperplasia. A combination of bupivacaine, diamorphine and midazolam was administered intrathecally which provided adequate anaesthesia despite the prolonged surgical duration. Nebulised lidocaine was also given to prevent coughing during the procedure. This report demonstrates that it is possible and safe to use spinal anaesthesia to perform prolonged surgical procedures that are normally conducted under general anaesthesia using a combination of intrathecal adjuncts to facilitate effective block duration. In addition, the novel use of nebulised lidocaine for its antitussive effects in a patient with COVID-19 is highlighted.

Ultrasound-Guided Multilevel Thoracic Paravertebral Block and Its Efficacy for Surgical Anesthesia During Primary Breast Cancer Surgery

Purpose

Thoracic paravertebral block (TPVB), in conjunction with intravenous sedation, is reported to provide surgical anesthesia for primary breast cancer surgery (PBCS). Although ultrasound-guided (USG) TPVB has been described, there are no reports of USG multilevel TPVB for surgical anesthesia during PBCS. The aim of this prospective observational study was to determine the feasibility of performing USG multilevel TPVB, at the T1–T6 vertebral levels (6m-TPVB), and to evaluate its efficacy in providing surgical anesthesia for PBCS.

Patients and Methods

Twenty-five female patients undergoing PBCS received an USG 6m-TPVB for surgical anesthesia. Four milliliters of ropivacaine 0.5% (with epinephrine 1:200,000) was injected at each vertebral level. Dexmedetomidine infusion (0.1–0.5 µg.kg⁻¹.h⁻¹) was used for conscious sedation. Success of the block, for surgical anesthesia, was defined as being able to complete the PBCS without having to resort to rescue analgesia or convert to GA.

Results

The USG 6m-TPVB was successfully performed on all 25 patients but it was effective as the sole anesthetic in only 20% (5/25) of patients. The remaining 80% (20/25) reported pain during separation of the breast from the pectoralis major muscle and its fascia. Surgery was successfully completed using small doses of intravenous ketamine (mean total dose, 38.0±20.5 mg) as supplementary analgesia.

Conclusion

USG 6m-TPVB is technically feasible but does not consistently provide complete surgical anesthesia for PBCS that involves surgical dissection on the pectoralis major muscle and its fascia. Our data suggest that the pectoral nerves, which are not affected by a 6m-TPVB, are involved with afferent nociception.

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.

The Efficacy and Safety of Paravertebral Block Combined with Parecoxib During Video-Assisted Thoracic Surgery: A Randomized Controlled Trial

Background

Although video-assisted thoracoscopic surgery (VATS) is increasingly used, the optimal analgesia strategy is still unknown. We explore the efficacy and safety of preemptive ultrasound-guided paravertebral block (PVB) combined with parecoxib during VATS.

Methods

Seventy-four patients were divided into two groups. PVBs were performed before anesthesia induction under real-time ultrasound guidance. Visual analog scale (VAS) score with coughing at 48 h after surgery, postoperative sufentanil consumption and level of sedation (LOS) at 1, 4, 8, 12, 24, and 48 h postoperatively, intraoperative hemodynamics, satisfaction scores of patients and surgeons, remedial measures, time to chest tube removed and mobilization, adverse effects and hospital stay length were recorded. We also recorded inflammatory markers, respiratory function and the prevalence of chronic pain after surgery.

Results

VAS scores at rest and with coughing during the first 24 h after surgery were significantly lower in the P group (P<0.05). Consumption of sevoflurane, remifentanil, and dexmedetomidine was all significantly reduced in the P group (P<0.05). The consumption of sufentanil within 48 h after surgery, time to first dose and total dose of rescue ketorolac was significantly lower in the P group (P<0.05). The FEV1/FVC ratio was significantly higher in the P group at 1 and 3 d after surgery (P<0.05). Times to chest tube removal and mobilization were significantly shorter in the P group (P<0.05). Compared with the C group, the level of both ACTH and cortisol was significantly reduced in the P group at 1 and 3 d after surgery (P<0.05).

Conclusion

PVB combined with parecoxib was associated with better pain relief, decreased sufentanil and ketorolac consumption, less hemodynamic instability, and a lower surgery-related stress response. However, the incidences of chronic pain 3 and 6 months after surgery and the risk of complication except urinary retention were not significantly different between groups.

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.

Pectoral nerve blocks and postoperative pain outcomes after mastectomy: a meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVES

Several studies have evaluated the effect of pectoral nerve blocks to improve postoperative analgesia following breast cancer surgery resulting in contradictory findings. The aim of this study was to examine the effect of Pecs blocks on postoperative analgesia in women following mastectomies.

METHODS

We performed a quantitative systematic review in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Articles of randomized controlled trials that compared Pecs block (types I and II) to a control group in patients undergoing mastectomy were included. The primary outcome was total opioid consumption 24 hours after surgery. Secondary outcomes included pain scores and side effects. Meta-analysis was performed using the random effect model.

RESULTS

7 randomized controlled trials with 458 patients were included in the analysis. The effect of pectoral nerve blocks on postoperative opioid consumption compared with control revealed a significant effect, weighted mean difference (WMD) (95% CI) of --4.99 (-7.90 to -2.08) mg intravenous morphine equivalents (p=0.001). In addition, postoperative pain compared with control was reduced at 6 hours after surgery: WMD (95% CI) of -0.72 (-1.37 to -0.07), p=0.03, and at 24 hours after surgery: WMD (95% CI) of -0.91 (-1.81 to -0.02), p=0.04.

DISCUSSION

This quantitative analysis of randomized controlled trials demonstrates that the Pecs block is effective for reducing postoperative opioid consumption and pain in patients undergoing mastectomy. The Pecs block should be considered as an effective strategy to improve analgesic outcomes in patients undergoing mastectomies for breast cancer treatment.

Mid-point transverse process to pleura block for surgical anaesthesia

The use of ultrasound in regional anaesthesia has expanded our understanding of regional anaesthesia techniques and allowed for the development of novel strategies to achieve blockade of the trunk. Several alternatives to paravertebral block have recently been proposed, but none of these new techniques have yet been shown to provide surgical anaesthesia equivalent to a paravertebral block. This case report describes the successful use of the mid-point transverse process to pleura (MTP) block as the sole anaesthetic technique for a patient undergoing breast surgery.

Opioid-free anesthesia for breast cancer surgery: A comparison of ultrasound guided paravertebral and pectoral nerve blocks. A randomized controlled trial

Background and Aims:

Pectoral block (PECS)-based anesthesia without opioids decreases analgesic requirement, pain scores and post-operative nausea vomiting (PONV) compared to conventional opioid-based general anesthesia in patients undergoing modified radical mastectomy and axillary dissection (MRM-AD). We compared PECS versus Paravertebral Block (PVB) in providing an opioid free, nerve block-based regimen. Outcomes of interest were post-operative analgesic requirement, duration of analgesia, PONV and patient and surgeon satisfaction.

Material and Methods:

This randomised controlled study involved 58 adult ASA I-III patients posted for MRM-AD. After randomization patients were induced with propofol and maintained on spontaneous ventilation with isoflurane (0.8-1.0 MAC) through i-gel. Ultrasound-guided PECS or PV blocks (30 ml of 0.1% lignocaine + 0.25% bupivacaine + 1 μg/kg dexmedetomidine) were administered. Post-operative pain scores, non-opioid analgesic requirement over 24 hours, PONV, satisfaction of surgeon and patient were measured.

Results:

Between the two groups, there was no difference in demographics, ASA status, location and volume of breast tumour excised or the duration of surgery. The time from block to incision was significantly longer in the PV group (P = 0.01). There was no difference between the two groups in terms of intra and post-operative parameters, and the median VAS scores for pain at rest or during shoulder abduction were similarly low in both the groups.

Conclusion:

Both blocks result in equally prolonged analgesia and preclude requirement of opioid analgesics intra and post-operatively. PECS block is associated with lesser time to allow incision. Complications are low in both the groups. Routine use of these blocks to avoid opioids may be studied further.

A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine

Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.

Local anesthetic systemic toxicity: current perspectives

Local anesthetic systemic toxicity (LAST) is a life-threatening adverse event that may occur after the administration of local anesthetic drugs through a variety of routes. Increasing use of local anesthetic techniques in various healthcare settings makes contemporary understanding of LAST highly relevant. Recent data have demonstrated that the underlying mechanisms of LAST are multifactorial, with diverse cellular effects in the central nervous system and cardiovascular system. Although neurological presentation is most common, LAST often presents atypically, and one-fifth of the reported cases present with isolated cardiovascular disturbance. There are several risk factors that are associated with the drug used and the administration technique. LAST can be mitigated by targeting the modifiable risk factors, including the use of ultrasound for regional anesthetic techniques and restricting drug dosage. There have been significant developments in our understanding of LAST treatment. Key advances include early administration of lipid emulsion therapy, prompt seizure management, and careful selection of cardiovascular supportive pharmacotherapy. Cognizance of the mechanisms, risk factors, prevention, and therapy of LAST is vital to any practitioner using local anesthetic drugs in their clinical practice.