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

Paravertebral and erector spinae plane blocks decrease length of stay compared with local infiltration analgesia in autologous breast reconstruction

BACKGROUND

Autologous breast reconstruction is associated with significant pain impeding early recovery. Our objective was to evaluate the impact of replacing surgeon-administered local infiltration with preoperative paravertebral (PVB) and erector spinae plane (ESP) blocks for latissimus dorsi myocutaneous flap reconstruction.

METHODS

Patients who underwent mastectomy with latissimus flap reconstruction from 2018 to 2022 were included in three groups: local infiltration, PVB, and ESP blocks. Block effect on postoperative length of stay (LOS) and the association between block status and pain, opioid consumption, time to first analgesic, and postoperative antiemetic administration were assessed.

RESULTS

122 patients met the inclusion criteria for this retrospective cohort study: no block (n=72), PVB (n=26), and ESP (n=24). On adjusted analysis, those who received a PVB block had a 20-hour shorter postoperative stay (95% CI 11 to 30; p<0.001); those who received ESP had a 24-hour (95% CI 15 to 34; p<0.001) shorter postoperative stay compared with the no block group, respectively. Using either block was associated with a reduction in intraoperative opioids (23 morphine milligram equivalents (MME)), 95% CI 14 to 31, p<0.001; ESP versus no block: 23 MME, 95% CI 14 to 32, p<0.001).

CONCLUSIONS

Replacing surgical infiltration with PVB and ESP blocks for autologous breast reconstruction reduces LOS. The comparable reduction in LOS suggests that ESP may be a viable alternative to PVB in patients undergoing latissimus flap breast reconstruction following mastectomy. Further research should investigate whether ESP or PVB have better patient outcomes in complex breast reconstruction.

A new approach to peripheral nerve block education with the Anatomage Table as a learning adjunct

Human anatomy education serves as a gateway for entering the intricacies of health science. Human cadavers have been the gold standard for learning regional and gross anatomy. However, increasing barriers in acquisition, maintenance, and longevity have pushed anatomy education toward technology-based alternatives such as the Anatomage Table (AT), an interactive, life-sized virtual dissection table with many anatomy education-centric features. The AT has found purchase in various contexts, such as clinical settings, research, outreach, and education. Studies into the efficacy of the AT in teaching settings have been generally positive but limited in its application, particularly in clinical procedure education. In this study, we conducted an informal workshop for second-year Certified Registered Nurse Anesthetist (CRNA) students to aid in being able to identify the important neuraxial landmarks for performing peripheral nerve blocks (PNBs), an anesthetic technique often used before other procedures. In our workshop, we paired the AT with identification of the same neuraxial landmarks on volunteer models with an ultrasound probe to provide students with relevant tactile experience for the procedure. From our pre-/post-surveys of the participants (n = 29), we found that our workshop significantly increased student confidence in identifying the relevant neuraxial landmarks for and in performing PNBs. Our results support the use of the AT in clinical education as a supplement, particularly where other anatomic teaching tools, such as cadaver models, may be too difficult to implement.NEW & NOTEWORTHY We implemented the Anatomage Table (AT) and portable ultrasound to teach neuraxial landmarks for performing peripheral nerve blocks (PNB), an anesthetic technique for Certified Registered Nurse Anesthetist (CRNA) students. The workshop significantly increased student confidence in identifying the relevant neuraxial landmarks for performing PNBs. Our results support the use of the AT in clinical education as a supplement.

Data Science and Geriatric Anesthesia Research: Opportunity and Challenges

With an increase in geriatric population undergoing surgical procedures, research focused on enhancing their perioperative outcomes is of paramount importance. Currently, most of the evidence-based medicine protocols are driven by studies concentrating on adults encompassing all adult age groups. Given the alterations in physiology with aging, geriatric patients respond differently to anesthetics and, therefore, require specific research initiatives to further expound on the same. Large databases and the development of sophisticated analytic tools can provide meaningful insights into this. Here, we discuss a few research opportunities and challenges that data scientists face when focusing on geriatric perioperative research.

Assessment of cardiotoxicity and plasma ropivacaine concentrations after serratus intercostal fascial plane block in an experimental model

Serratus intercostal fascial plane block (SIFPB) has emerged as an alternative to paravertebral block in breast surgery. It involves the administration of high volumes and doses of local anesthetics (LA) that can potentially reach toxic levels. Ropivacaine is widely used in thoraco-fascial blocks; however, there is no information on the plasma concentrations attained after SIPFB and whether they are associated with cardiotoxicity. Plasma concentrations of ropivacaine and its electrophysiological effects were evaluated in eight pigs after bilateral SIFPB with ropivacaine in doses of 3 mg/kg. Plasma concentrations, electrophysiological and hemodynamic parameters were measured sequentially for the following 180 min until the end of the study. The area under the curve, the maximum plasma concentration (C_max) and the time to reach C_max (t_max) were calculated. The median arterial ropivacaine concentration C_max was, 2.34 [1.40 to 3.74] µg/ml. The time to reach the highest concentration was 15 [10 to 20] min. Twenty-five percent of the animals had arterial concentrations above the lower limit concentration of ropivacaine for LA systemic toxicity (3.4 µg/ml). No alterations were observed in the electrophysiological or electrocardiographic parameters except for a prolongation of the QTc interval, from 489 ± 30 to 544 ± 44 ms (Δ11.38 ± 6%), P = 0.01. Hemodynamic parameters remained in the physiological range throughout the study. SIFPB with ropivacaine in doses of 3 mg/kg has reached potentially toxic levels, however, it has not been associated with adverse electrophysiological or hemodynamic effects.

Anesthetic Practice Trends and Perceptions Toward Postoperative Delirium: A Mixed-Methods Analysis

BACKGROUND

Delirium is the most common postoperative complication in older adults, though anesthesiologist awareness of delirium prevention guidelines-and associated practice trends-remains unknown.

METHODS

This was a convergent mixed-methods study, which simultaneously analyzed quantitative and qualitative data to determine delirium guideline awareness among anesthesiologists and practice patterns based on guideline recommendations. Quantitative data were abstracted from the Multicenter Perioperative Outcomes Group database for noncardiac surgery patients (2009-2020) aged 65 years and older. Linear trends were reported for select guideline-based delirium prevention recommendations via regression modeling. Anesthesiologists (n = 40) from a major academic center without a structured delirium reduction program on hospital wards were then surveyed regarding knowledge and practices with respect to postoperative delirium. For qualitative data, 3 focus groups were held to further discuss guideline awareness and identify challenges with delirium prevention.

RESULTS

Quantitative results demonstrated a significant decline in the proportion of cases with midazolam between 2009 and 2020, with the largest decrease observed with urologic surgeries (-3.9%/y; 95% confidence interval [CI], -4.2 to -3.6; P < .001). Use of regional anesthesia increased over this period, particularly with gynecologic surgeries (+2.3%/y; 95% CI, 1.2-3.4; P = .001). Anesthesiologist survey results revealed variable guideline awareness, as 21 of 39 (54%) respondents reported being aware of guidelines for anesthetic management of older adults. Importantly, unawareness of delirium management guidelines was the most frequently cited challenge (17 of 37, 46%) when caring for older adults. Finally, focus group participants were largely unaware of postoperative delirium guidelines. However, participants conveyed key barriers to delirium identification and prevention, including the unclear pathophysiology, nonmodifiable risk factors, and system-based hospital challenges. Participants also expressed a desire for decision-support systems, integrated within the perioperative workflow, that provide evidence-based recommendations for reducing delirium risk.

CONCLUSIONS

Perioperative practice trends are indicative of an improving environment for postoperative delirium. However, delirium guideline awareness remains variable among anesthesiologists, and key barriers continue to exist for identifying and preventing postoperative delirium.

The Comparison of Postoperative Analgesic Efficacy of Ultrasound-Guided Paravertebral Block and Mid-Point Transverse Process Pleura Block in Mastectomy Surgeries: A Randomized Study

PURPOSE/AIM OF THE STUDY

The purpose of this triple-blind randomized study is to compare the postoperative analgesic efficacy of Mid-Point Transverse Process Pleura Block (MTP) and Paravertebral Block (PVB) in patients undergoing breast surgery.

MATERIALS AND METHODS

The study was retrospectively registered on ClinicalTrials.gov (NCT05332028). A total of 64 patients undergoing unilateral simple mastectomy operation due to breast cancer were included in the study. Before the anesthesia procedure, participants were randomly assigned to one of two groups: Group 1: Participants undergoing PVB or Group 2: Participants undergoing MTP block. All block applications were performed using 20 mL of 0.25% bupivacaine. Routine general anesthesia protocol was performed on all patients. In the postanesthetic care unit, fentanyl infusion was given to all patients postoperatively via a patient-controlled analgesia device. Postoperative fentanyl consumption, time to the first request for analgesia, VAS score values at rest and in motion, and blocked dermatome areas were recorded.

RESULTS

Postoperative total opioid consumption, the number of patients given rescue analgesia, the time requiring postoperative supplemental analgesia, postoperative pain scores at rest and in motion, and blocked dermatome areas at both anterior and posterior lower and upper limits were not different between groups (p > 0.05, for all).

CONCLUSIONS

It was concluded that ultrasound-guided PVB and MTP blocks have similar postoperative analgesic efficacy in patients undergoing breast surgery. The MTP block may be preferred as an alternative to PVB for breast surgeries with less risk of complications.

Racial Disparities in the Use of Peripheral Nerve Blocks for Postoperative Analgesia After Total Mastectomy: A Retrospective Cohort Study

BACKGROUND

Peripheral nerve blocks (PNBs) are used to provide postoperative analgesia after total mastectomy. PNBs improve patient satisfaction and decrease postoperative opioid use, nausea, and vomiting. Few studies have examined whether there is racial-ethnic disparity in the use of PNBs for patients having total mastectomy. We hypothesized that non-Hispanic Asian, non-Hispanic Black, non-Hispanic patients of other races, and Hispanic patients would be less likely to receive a PNB for postoperative analgesia compared to non-Hispanic White patients having total mastectomy. Secondarily, we hypothesized that PNBs would be associated with reduced odds of major complications after total mastectomy.

METHODS

We performed a retrospective cohort study using National Surgical Quality Improvement Program (NSQIP) data from 2015 to 2019. Patients were included if they underwent total mastectomy under general anesthesia. Unadjusted rates of PNB use were compared between race-ethnicity groups. Multivariable logistic regression was performed to determine whether race-ethnicity group was independently associated with receipt of a PNB for postoperative analgesia. Secondarily, we calculated crude and risk-adjusted odds ratios for major complications in patients who received a PNB.

RESULTS

There were 64,103 patients who underwent total mastectomy and 4704 (7.3%) received a PNB for postoperative analgesia. Patients who received a PNB were younger, more commonly women, were less likely to have diabetes and hypertension, and had less disseminated cancer (all P < .05). In our regression analysis, the odds of receiving a PNB differed significantly by race-ethnicity group (P < .001). Non-Hispanic Asian and non-Hispanic Black patients had reduced odds of receiving a PNB compared to non-Hispanic White patients (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.33-0.49 and OR, 0.37 [0.32-0.44]), respectively. Non-Hispanic patients of other races, including American Indian, Alaskan Native, and Pacific Islander, also had reduced odds of receiving a PNB (OR, 0.73 [95% CI, 0.64-0.84]) compared to non-Hispanic White patients, as did Hispanic patients (OR, 0.62 [0.56-0.69]). Patients who received a PNB did not have reduced odds of major complications after mastectomy (crude OR, 0.83 [0.65-1.08]; P = .17 and adjusted OR, 0.85 [0.65-1.10]; P = .21).

CONCLUSIONS

Significant disparity exists in the use of PNBs for postoperative analgesia in patients of different race-ethnicity who undergo total mastectomy in the United States. Continued efforts are needed to better understand the causes of disparity and to ensure equitable access to PNBs.

Single-injection regional analgesia techniques for mastectomy surgery: A network meta-analysis

BACKGROUND

Patients undergoing mastectomy surgery experience severe postoperative pain. Several regional techniques have been developed to reduce pain intensity but it is unclear, which of these techniques is most effective.

OBJECTIVES

To synthesise direct and indirect comparisons for the relative efficacy of different regional and local analgesia techniques in the setting of unilateral mastectomy. Postoperative opioid consumption at 24 h, postoperative pain at extubation, 1, 12 and 24 h, postoperative nausea and vomiting were collected.

DESIGN

Systematic review with network meta-analysis (PROSPERO:CRD42021250651).

DATA SOURCE

PubMed, Scopus, the Cochrane Central Register of Controlled Trials (from inception until 7 July 2021).

ELIGIBILITY CRITERIA

All randomised controlled trials investigating single-injection regional and local analgesia techniques in adult patients undergoing unilateral mastectomy were included in our study without any language or publication date restriction.

RESULTS

Sixty-two included studies randomising 4074 patients and investigating nine techniques entered the analysis. All techniques were associated with less opioid consumption compared with controls The greatest mean difference [95% confidence interval (CI)] was associated with deep serratus anterior plane block: mean difference -16.1 mg (95% CI, -20.7 to -11.6). The greatest reduction in pain score was associated with the interpectoral-pecto-serratus plane block (mean difference -1.3, 95% CI, -1.6 to - 1) at 12 h postoperatively, and with superficial serratus anterior plane block (mean difference -1.4, 95% CI, -2.4 to -0.5) at 24 h. Interpectoral-pectoserratus plane block resulted in the greatest statistically significant reduction in postoperative nausea/vomiting when compared with placebo/no intervention with an OR of 0.23 (95% CI, 0.13 to 0.40).

CONCLUSION

All techniques were associated with superior analgesia and less opioid consumption compared with controls. No single technique was identified as superior to others. In comparison, local anaesthetic infiltration does not offer advantages over multimodal analgesia alone.

TRIAL REGISTRATION

PROSPERO (CRD4202125065).

The Effect of Sugammadex on Time of Sciatic Block by Perineural Bupivacaine in Rats

OBJECTIVES

We aimed to investigate the effect of sugammadex on the motor, sensory and deep sensory block in the sciatic nerve created by bupivacaine in rats.

MATERIALS AND METHODS

18 Sprague-Dawley adult male rats treated with unilateral sciatic nerve block by bupivacaine (0.2 ml) were randomly divided into three groups. Control group (Group C, n = 6, 1.5 mL saline) perineural sugammadex group (Group PNS, n = 6, 16 mg/kg) and intraperitoneal sugammadex group (Group IPS, n = 6, 16 mg/kg) Motor, sensory, and deep sensory functions were evaluated every 10 minutes by a blind researcher. 6 tissue samples each belonging to the sciatic nerve, 1.5 cm in length and 0.2 cm in diameter, were taken from paraffin blocks. Sections of 3-4 micrometers were stained with Hematoxylin + Eosin, Masson Trichrome dyes and examined under a light microscope.

RESULTS

There was no statistically significant difference between 3 groups in terms of the time to return to normal motor, sensory and deep sensory function. There was also no significant difference in edema, extracellular matrix, and myelin. Inflammatory cells were seen in all groups, mainly epineurium, epineurium, and perineurium.

CONCLUSION

There are findings of no histological effects or effects on local block of sugammadex in rats undergoing sciatic nerve block.

An Overview of Commonly Used Data Sources in Observational Research in Anesthesia

Anesthesia research using existing databases has drastically expanded over the last decade. The most commonly used data sources in multi-institutional observational research are administrative databases and clinical registries. These databases are powerful tools to address research questions that are difficult to answer with smaller samples or single-institution information. Given that observational database research has established itself as valuable field in anesthesiology, we systematically reviewed publications in 3 high-impact North American anesthesia journals in the past 5 years with the goal to characterize its scope. We identified a wide range of data sources used for anesthesia-related research. Research topics ranged widely spanning questions regarding optimal anesthesia type and analgesic protocols to outcomes and cost of care both on a national and a local level. Researchers should choose their data sources based on various factors such as the population encompassed by the database, ability of the data to adequately address the research question, budget, acceptable limitations, available data analytics resources, and pipeline of follow-up studies.

Big Data in Studying Acute Pain and Regional Anesthesia

The digital transformation of healthcare is advancing, leading to an increasing availability of clinical data for research. Perioperative big data initiatives were established to monitor treatment quality and benchmark outcomes. However, big data analyses have long exceeded the status of pure quality surveillance instruments. Large retrospective studies nowadays often represent the first approach to new questions in clinical research and pave the way for more expensive and resource intensive prospective trials. As a consequence, the utilization of big data in acute pain and regional anesthesia research has considerably increased over the last decade. Multicentric clinical registries and administrative databases (e.g., healthcare claims databases) have collected millions of cases until today, on which basis several important research questions were approached. In acute pain research, big data was used to assess postoperative pain outcomes, opioid utilization, and the efficiency of multimodal pain management strategies. In regional anesthesia, adverse events and potential benefits of regional anesthesia on postoperative morbidity and mortality were evaluated. This article provides a narrative review on the growing importance of big data for research in acute postoperative pain and regional anesthesia.