Ultrasound-guided fascial plane blocks for post-breast surgery pain syndrome

INTRODUCTION

Persistent pain following breast surgery is common and may be challenging to treat. In patients refractory to conservative treatments, ultrasound-guided fascial plane blocks of thoracic nerves can be a useful option.

RESULTS

This type of neuro blockade technique provides advantages in terms of safety and efficacy that are convenient for physicians managing refractory and complex cases of post-breast surgery syndrome.

CONCLUSION

This technical review aims to present an up-to-date summary of the most common ultrasound-guided fascial plane blocks for chronic pain in post-breast surgery patients, provide a detailed technical description of each intervention, and propose preferred injections based on the anatomical location of the pain.

The Effect of Pectoral Nerve Blocks on Opioid Use and Postoperative Pain in Masculinizing Mastectomy: A Randomized Controlled Trial

BACKGROUND

Bilateral masculinizing mastectomy is the most common gender-affirmation operation performed. Currently, there is lack of data regarding intraoperative and postoperative pain control for this population. It is the authors' aim to study the effects of the pectoral nerve (Pecs) I and II regional nerve blocks in patients undergoing masculinizing mastectomy.

METHODS

A randomized, double-blind, placebo-controlled trial was performed. Patients undergoing bilateral gender-affirmation mastectomy were randomized to receive either a Pecs block with ropivacaine or placebo injection. The patient, surgeon, and anesthesia team were blinded to the allocation. Intraoperative and postoperative opioid requirements were collected and recorded as morphine milligram equivalents (MME). Participants recorded postoperative pain scores at specific time points on the day of surgery through postoperative day 7.

RESULTS

Fifty patients were enrolled between July of 2020 and February of 2022. Twenty-seven were randomized to the intervention group and 23 to the control group, with 43 patients undergoing analysis. There was no significant difference in intraoperative MME between the Pecs block group and the control group (9.8 versus 11.1; P = 0.29). In addition, there was no difference in postoperative MME between the groups (37.5 versus 40.0; P = 0.72). Postoperative pain scores were also similar between the groups at each specified time point.

CONCLUSIONS

There was no significant reduction in opioid consumption or postoperative pain scores in patients undergoing bilateral gender-affirmation mastectomy who received a regional anesthetic when compared with placebo. In addition, a postoperative opioid-sparing approach may be appropriate for patients undergoing bilateral masculinizing mastectomy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, I.

Selective Dorsal Scapular Nerve and Long Thoracic Nerve Blocks for Rescue Analgesia in Scapulothoracic Arthrodesis Surgery: A Case Report

Scapulothoracic arthrodesis (STA) surgery is performed to stabilize the scapula in patients with facioscapulohumeral dystrophy (FSHD). Postoperative pain could be a major problem even while using erector spinae plane block (ESPB). We performed a preoperative ESPB with an intraoperative ESPB catheter, but rescue analgesia was needed for pain in the periscapular area in the postoperative period. The patient's pain score was reduced by applying an ultrasound-guided dorsal scapular nerve (DSN) and long thoracic nerve (LTN) block. Selective DSN and LTN blocks can be effective in enhancing postoperative analgesia in STA surgery.

Assessing the Efficacy of the S-PECS Block in Breast Augmentation Surgery: A Randomized, Double-Blind, Controlled Trial

BACKGROUND

Postoperative acute and chronic pain following breast surgery is a common complication that needs resolving to allow for improved patient outcomes. Previously, thoracic epidurals and paravertebral blocks have been the accepted standard administered intraoperatively. However, more recently the introduction of the pectoral nerve block (PECS and PECS-2 blocks) has appeared promising to control the pain more effectively, but further robust analysis is required to prove its efficacy. The authors aim to study the efficacy of a new block, S-PECS, that combines a serratus anterior and a PECS-2 block.

METHODS

In this study, the authors performed a single-center, randomized, controlled, double-blind group trial in 30 female patients undergoing breast augmentation surgery with silicone breast implants and the S-PECS block. Divided into two groups of 15, the PECS group received local anesthetics and the no-PECS control group received a saline injection. All participants were followed up at recovery and at 4, 6, and 12 hours postoperatively.

RESULTS

The authors' results showed that the pain score in the PECS group was significantly less than in the no-PECS group across all time points: recovery, and at 4, 6, and 12 hours. Furthermore, the patients who received the S-PEC block were 74% less likely to request pain medications compared with the no-PECS group ( P < 0.05).

CONCLUSION

Overall, the modified S-PECS block is an effective, efficient, and safe method of controlling pain in patients undergoing breast augmentation surgery, with additional applications yet to be explored.

The analgesic efficacy of pectoral nerve block for breast augmentation: a meta-analysis of randomized controlled studies

BACKGROUND

Many patients suffered from serious pain after breast augmentation, but the analgesic efficacy of pectoral nerve block for these patients was not well established. Thus, this meta-analysis was intended to study the analgesic efficacy of pectoral nerve block for breast augmentation.

METHODS

Several databases including PubMed, EMbase, Web of Science, EBSCO, and Cochrane library databases were searched, and we included randomized controlled trials (RCTs) regarding the analgesic efficacy of pectoral nerve block for breast augmentation.

RESULTS

Six RCTs were ultimately included in this meta-analysis. Compared with control intervention for breast augmentation, pectoral nerve block could significantly reduce pain scores at 1 h (mean difference [MD] = -2.28; 95% confidence interval [CI] = -3.71 to -0.85; P = 0.002), 2 h (MD = -3.08; 95% CI = -3.95 to -2.20; P < 0.00001), 4 h (MD = -2.95; 95% CI = -3.32 to -2.58; P < 0.00001), 6-8 h (MD = -2.68; 95% CI = -3.24 to -2.11; P < 0.00001), 24 h (MD = -2.04; 95% CI = -2.41 to -1.67; P < 0.00001), the number of analgesic requirement (odd ratio [OR] = 0.20; 95% CI = 0.09 to 0.45; P = 0.0001), and the incidence of nausea (OR = 0.21; 95% CI = 0.08 to 0.54; P = 0.001) and vomiting (OR = 0.15; 95% CI = 0.05 to 0.39; P = 0.0001).  Conclusions: Pectoral nerve block may be effective for pain relief after breast augmentation.

The clinical impact of pectoral nerve block in an 'enhanced recovery after surgery' program in breast surgery

Background: Pectoral nerve block (PECS) is increasingly performed in breast surgery. Aim: The study evaluated the clinical impact of these blocks in the postoperative course. Patients & methods: In this case-control study, patients undergoing breast surgery with 'enhanced recovery after surgery' pathways were divided into group 1 (57 patients) in whom PECS was performed before general anesthesia, and group 2 (57 patients) in whom only general anesthesia was effected. Results: Postoperative opioid consumption (p < 0.002), pain at 32 h after surgery (p < 0.005) and the length of stay (p < 0.003) were significantly lower in group 1. Conclusion: Reducing opioid consumption and pain after surgery, PECS could favor a faster recovery with a reduction in length of stay, ensuring a higher turnover of patients undergoing breast surgery.

Pectoral nerve blocks for transvenous subpectoral pacemaker insertion in children: a randomized controlled study

BACKGROUND

Postoperative pain management after pacemaker insertion routinely requires opioid agents, nonsteroidal anti-inflammatory drugs, or paracetamol. However, interest in opioid-sparing multimodal pain management to minimize postoperative narcotic use has increased recently. This study aimed to assess the pectoral nerve (PECS) block versus standard treatment on postoperative pain control and opioid consumption in pediatric patients after transvenous subpectoral pacemaker insertion.

METHODS

In this randomized controlled study, 40 pediatric patients underwent transvenous subpectoral pacemaker insertion with either congenital or postoperative complete heart block. Patients were randomly assigned to two groups: Group C (control) received conventional analgesic care without any block and Group P (pectoral) received a PECS block. Demographics, procedural variables, postoperative pain, and postoperative opioid consumption were compared between the two groups.

RESULTS

In children undergoing transvenous subpectoral pacemaker insertion, the PECS block was associated with a longer procedure time; however, the cumulative dose of fentanyl and atracurium was reduced and the hemodynamic profile was superior in Group P compared with Group C intraoperatively. Postoperatively, the PECS block was associated with lower postprocedural pain scores, which was reflected by the longer interval before the first call for rescue analgesia and lower postoperative morphine consumption, without an increase in the rate of complications.

CONCLUSION

Ultrasound-guided PECS blocks are associated with a good intraoperative hemodynamic profile, reduced postoperative pain scores, and lower total opioid consumption in children undergoing transvenous subpectoral pacemaker placement.

The efficacy of pectoral nerve block for pain control after breast augmentation: A meta-analysis of randomized controlled studies

BACKGROUND

The efficacy of pectoral nerve block for pain control remains unknown in patients undergoing breast augmentation. This meta-analysis aims to explore the analgesic efficacy of pectoral nerve block for breast augmentation.

METHODS

We systematically searched PubMed, Embase, Web of Science, EBSCO, and Cochrane library databases, and included randomized controlled trials reporting pectoral nerve block versus no block for breast augmentation.

RESULTS

Five randomized controlled trials were included in this meta-analysis. Compared with control group after breast augmentation, pectoral nerve block was associated with substantially reduced pain scores at 1 hour (standard mean difference [SMD] = -1.63; 95% confidence interval [CI] = -2.81 to -0.44; P = .007), maximal pain scores at 1 to 6 hours (SMD = -1.72; 95% CI = -2.75 to -0.69; P = .001) and 6 to 24 hours (SMD = -2.06; 95% CI = -3.40 to -0.72; P = .003), rescue analgesic (odd ratio = 0.17; 95% CI = 0.05-0.57; P = .004), nausea (SMD = 0.21; 95% CI = 0.08-0.54; P = .001), and vomiting (odd ratio = 0.15; 95% CI = 0.05-0.39; P = .0001).

CONCLUSIONS

Pectoral nerve block benefits to alleviate pain intensity after breast augmentation.

Impact of Pectoralis Nerve Block (PECS) on postoperative pain in patients submitted to mastectomy with lymphadenectomy

OBJECTIVE

Breast cancer is the most common malignant neoplasm in women worldwide. Surgery has been traditional treatment and, generally, it´s mastectomy with lymphadenectomy, that can causes postoperative pain. Therefore, we seek to study regional anesthesic techniques that can minimize this effect, such as the interpectoral block (PECS).

METHODS

randomized controlled study with 82 patients with breast cancer who underwent mastectomy with lymphadenectomy from January 2020 to October 2021 in oncology hospital.

INTERVENTIONS

two randomized groups (control - exclusive general anesthesia and PECS group - received PECS block with levobupivacaine/ropivacaine and general anesthesia). We applied a questionnaire with Numeric Rating Scale for pain 24h after surgery. We used Shapiro-Wilk, Mann-Whitney and Chi-square tests, and analyzed the data in R version 4.0.0 (ReBEC).

RESULTS

in the PECS group, 50% were pain-free 24h after surgery and in the control group it was 42.86%. The majority who presented pain classified it as mild pain (VAS from 1 to 3) - (42.50%) PECS group and (40.48%) control group (p=0.28). Only 17.50% consumed opioids in the PECS group, similar to the control group with 21.43%. (p=0.65). There was a low rate of complications such as PONV in both groups. In the subgroup analysis, there was no statistical difference between the groups that used levobupivacaine or ropivacaine regarding postoperative pain and opioid consumption.

DISCUSSION

the studied group had a low rate of pain in the postoperative period and it influenced the statistical analysis. There wasn´t difference in postoperative pain in groups.

CONCLUSION

was not possible to demonstrate better results with the association of the PECS block with total intravenous analgesia. Need further studies to assess the efficacy of the nerve block.

[Effect of ultrasound-guided serratus plane block combined with pectoral nerve block I on postoperative analgesia after radical mastectomy]

Objective: To study the effect of ultrasonic-guided serratus plane block combined with pectoral nerve block Ⅰ on postoperative analgesia after radical mastectomy. Methods: A total of 30 patients, all female, aged [M (Q₁, Q₃)] 53 (43, 62) years old, who underwent radical mastectomy in Beijing Tongren Hospital from May to August 2021 were selected. The patients were divided into two groups (n=15 in each group) using a random number table: general anesthesia alone+patient controlled intravenous analgesia (PCIA) group (control group) and serratus plane block combined with pectoral nerve block Ⅰ before general anesthesia+PCIA group (combined group). Numerical rating scale (NRS) at rest in both groups were detected in the post anesthesia care unit (PACU) and 4, 8, 12, 24, 36 and 48 h after operation. The time of first pain, the time of first pressing of the automatic analgesic device after the operation, the dosage of remifentanil during operation, cumulative dosages of sufentanil at 24 h and 48 h postoperatively, and the incidence of adverse effects were all recorded. Results: The NRS scores in combined group in the PACU and 4, 8, 12 and 24 h after surgery were (2.1±1.7), (1.7±1.5), (1.5±1.4), (1.5±1.3) and (1.7±1.3), respectively, while the NRS scores in control group at each time points were (4.5±2.0), (3.2±1.4), (2.7±0.9), (2.8±0.9) and (2.4±0.8), respectively, and the NRS scores in combined group were significantly lower than those in control group (all P<0.05). The NRS scores in combined group at 36 and 48 h after surgery were (1.8±1.6) and (1.6±1.2), while the NRS scores in control group were (2.2±0.9) and (2.1±0.8), and the differences between the two groups were not statistically significant (both P>0.05). The time of first pain and the time of the first pressing of the automatic analgesic device in combined group were (573±174) min and (962±313) min, which were significantly longer than those of control group [(13±6) min and (135±41) min] (both P<0.05). The dosage of remifentanil during operation and cumulative dosage of sufentanil at 24 h postoperatively in combined group were (410±129) μg and (14±4) μg, which were lower than those in control group [(580±225) μg and (21±11) μg] (both P<0.05). Cumulative dosage of sufentanil at 48 h postoperatively in combined group was (29±11) μg, while in control group was (36±14) μg, and the difference between the two groups was not statistically significant (P=0.131). The incidence of postoperative dizziness in combined group was 6.7% (1/15), which was lower than that of control group [40.0% (6/15)] (P=0.031). The incidence of nausea and pruritus was 6.7% (1/15) and 0 in combined group, while 20.0% (3/15) and 6.7% (1/15) in control group, with no statistical significance (both P>0.05). Conclusion: Serratus plane block combined with pectoral nerve block Ⅰ can effectively relieve postoperative pain, decrease the need for opioids, and reduce the incidence of adverse effects.

Evaluation of the effect of different block techniques on open-heart surgery in the postoperative period: a prospective observational study

BACKGROUND

Open-heart surgery is associated with severe postoperative pain. Adequate analgesia after open-heart surgery improves patients' early postoperative recovery, extubation, ambulation and early discharge from hospital. Regional anaesthesia techniques are the new hope for adequate postoperative analgesia after cardiac surgery and are widely used for early pain management in the first six hours.

METHODS

A total of 100 patients with the American Society of Anesthesiologists physical status classification I-III, aged 18 years and over, undergoing open-heart surgery with sternotomy for coronary artery bypass grafting or valve replacement under general anaesthesia, were included in this study. For postoperative analgesia, 50 patients with pectoral nerve (PECS II) block and 50 with parasternal (PS) block were consecutively enrolled in one of the groups at the end of the surgery and compared in terms of sedation scores, ventilation duration, pain scores at rest after extubation, block duration, total morphine consumption and complications.

RESULTS

The block duration in the PS group was statistically significantly higher than in the PECS II group (p = 0.001, p < 0.05, respectively). The visual analogue scale scores at rest in the fourth and sixth hours were statistically significantly higher in the PECS II group than in the PS group ( p = 0.001, p = 0.001, p < 0.01). Cumulative morphine consumption in the PECS II group was statistically significantly higher than in the PS group in the fourth, sixth, 12th and 24th hours ( p = 0.001, p = 0.001, p = 0.001, p = 0.001, p = 0.001, p < 0.01, respectively).

CONCLUSIONS

PS block provided longer block duration with lower postoperative pain and sedation scores than the PECS II block, with lower cumulative morphine consumption.

Sternal Gap Syndrome Caused by Improperly Fitted Body Armor: A Preventable Military Injury

Isolated atrophy of the pectoralis major muscle (PMM) secondary to traumatic lesion of the medial pectoral nerve is a known entity in the field of neuromuscular electrodiagnostics. Recent literature has begun describing a Pectoral Gap Phenomenon in which this atrophy occurs bilaterally as an overuse injury, leading to a marked concavity in the central chest wall musculature. While there is limited information in science journals on this topic, social media posts on weight lifting discuss the topic frequently. We report a case in which a soldier's body armor crushed the lateral medial and pectoral nerves against the anterior chest wall causing permanent upper body weakness. To optimize military medical readiness, awareness of this disorder and the pathophysiology causing it should spread so as to mitigate this potential for significant disability.

Efficacy of type-I and type-II pectoral nerve blocks (PECS I and II) in patients undergoing mastectomy: a prospective randomised clinical trial

INTRODUCTION

The benefits of type I/II pectoral nerve blocks (PECS I/II), which can be dose dependent, have been examined in different studies. Nonetheless, few randomised trials have been performed in South America. The present randomised trial examined the efficacy of PECS I/II with a higher dose of the local anaesthetic to manage perioperative pain after mastectomy in Brazil.

MATERIAL AND METHODS

This was a randomised, parallel, single-centre, and single-blind trial. Eighty participants undergoing elective mastectomy were randomised (1 : 1) to receive PECS I/II plus ultrasound-guided ropivacaine (0.5%) or standard general anaesthesia. The primary outcome was pain intensity at rest 24 hours after surgery, assessed with a numerical rating scale. Haemodynamic outcomes, consumption of opioids, anaesthe-tics and antiemetics, and post-anaesthetic recovery times were also recorded.

RESULTS

Sixty participants (75%) completed the study. The mean age was 54 years, with 57% of participants undergoing mastectomy and 43% undergoing quadrantectomy. Median pain intensity (interquartile range) at rest (24 h postoperatively) was lower in the PECS I/II group compared to the control group: 0 (0-1.75) vs. 1 (1-2), P = 0.021. A smaller number of patients in the PECS I/II group required intraoperative fentanyl (23.3% vs. 83.3%; P < 0.001) and postoperative tramadol (20.0 vs. 76.7%; P < 0.001). Mean doses of fentanyl and tramadol were about 4-5 times lower in the PECS I/II group (P < 0.001). PECS I/II significantly reduced sevoflurane consumption during surgery (P = 0.01). No difference was observed regarding adverse effects.

CONCLUSIONS

PECS I/II blockade with high-dose local anaesthetic is efficacious and safe, resulting in lower levels of perioperative pain after mastectomy compared to standard general anaesthesia.

Efficacy and Safety of Pectoral Nerve Block (Pecs) Compared With Control, Paravertebral Block, Erector Spinae Plane Block, and Local Anesthesia in Patients Undergoing Breast Cancer Surgeries: A Systematic Review and Meta-analysis

OBJECTIVE

We aimed to compare the safety and efficacy of pectoral nerve block (Pecs) I and II with control or other techniques used during breast cancer surgeries such as local anesthesia, paravertebral block, and erector spinae plane block (ESPB).

METHODS

We searched 4 search engines (PubMed, Cochrane Library, Scopus, and Web of Science) for relevant trials, then extracted the data and combined them under random-effect model using Review Manager Software.

RESULTS

We found 47 studies, 37 of them were included in our meta-analysis. Regarding intraoperative opioid consumption, compared with control, a significant reduction was detected in Pecs II (standardized mean difference [SMD]=-1.75, 95% confidence interval [CI] [-2.66, -0.85], P=0.0001) and Pecs I combined with serratus plane block (SMD=-0.90, 95% CI [-1.37, -0.44], P=0.0002). Postoperative opioid consumption was significantly lowered in Pecs II (SMD=-2.28, 95% CI [-3.10, -1.46], P<0.00001) compared with control and Pecs II compared with ESPB (SMD=-1.75, 95% CI [-2.53, -0.98], P<0.00001). Furthermore, addition of dexmedetomidine to Pecs II significantly reduced postoperative opioid consumption compared with Pecs II alone (SMD=-1.33, 95% CI [-2.28, -0.38], P=0.006).

CONCLUSION

Pecs block is a safe and effective analgesic procedure during breast cancer surgeries. It shows lower intra and postoperative opioid consumption than ESPB, and reduces pain compared with control, paravertebral block, and local anesthesia, with better effect when combined with dexmedetomidine.

Endometriosis: a guide to investigations and treatment in the emergency department

Endometriosis is an oestrogen-dependent disorder where endometrial tissue forms lesions outside the uterus, causing chronic inflammation and scarring. Women who have endometriosis may experience a highly variable range of non-specific signs and symptoms, including pelvic pain. Endometriosis is often misdiagnosed, partly because its signs and symptoms can easily be attributed to more common conditions that cause pelvic pain in women, resulting in delayed diagnosis and treatment. This article describes the pathophysiology, aetiology, risk factors for, and signs and symptoms of endometriosis. It also outlines how endometriosis should be investigated and treated in the emergency department (ED). Its aim is to support nurses to deliver effective care to women of reproductive age presenting to the ED with severe pelvic pain.

Winged scapula: an overview of pathophysiology, diagnosis and management

Patients commonly present to the emergency department (ED) with shoulder injuries and shoulder pain. Winged scapula is one potential underlying cause of shoulder pain which is often forgotten or ill-defined. This non-traumatic skeletal condition typically presents as a prominent protrusion of the medial border of the bone from its normal position in the back. It often results from damage to and/or compression of the long thoracic nerve, which innervates the serratus anterior muscle. History taking, physical examination and imaging are needed to correctly diagnose winged scapula. Conservative management is often sufficient to resolve the condition. However, in some cases further investigations and more invasive treatment modalities are needed. This article provides an overview of the pathophysiology of winged scapula and its diagnosis and management in the ED.

Scapula alata: diagnosis and treatment by nerve surgery and tendon transfers

Scapula alata, also known as winged scapula, can lead to severe upper limb impairment. The shoulders' function is altered because the scapula, which supports the upper limb, is no longer stable. Typical scapula alata is described for serratus anterior palsy; however, any scapulothoracic muscle impairment may lead to scapular winging, particularly trapezius palsy, which is easy to miss, thus needed to be considered as a differential diagnosis. The diagnosis is difficult and based on various clinical tests and a thorough examination as well as electroneuromyography and MRI. The treatment ranges from conservative treatments for spontaneous recovery, nerve surgery including neurolysis, nerve transfers and nerve grafts for acute cases, to tendon transfers for more chronic cases and when nerve procedures are no longer feasible. Tendon transfers in serratus anterior palsy produce excellent results with a high rate of patient satisfaction and are described with the sternal or clavicular head of the pectoralis major; we describe our preferred technique in this article. Tendon transfers in trapezius palsy are performed with the levator scapulae, rhomboid minor and major muscles. Our preferred method is the Elhassan triple transfer. Scapula alata is a frequent and often misdiagnosed condition. Appropriate management can yield excellent results. Patients should be referred right away to specialized centers for surgery if recovery is not spontaneous.

The Efficacy of Pectoralis Nerve Blockade in Breast Reductions: A Prospective Randomized Trial

BACKGROUND

Pectoralis nerve (Pecs) blocks have been shown to reduce perioperative opioid consumption in patients undergoing mastectomies, but the effectiveness of these blocks in breast reductions has not been established. This trial aims to evaluate the efficacy of Pecs blocks (I and II) on perioperative pain management in patients undergoing breast reductions.

METHODS

Thirty-six patients were enrolled in the randomized controlled trial divided into 2 groups. The treatment group (n = 16) received general anesthesia plus postinduction ultrasound-guided Pecs blocks. The control group (n = 20) received general anesthesia alone. The primary outcomes measured were perioperative narcotic requirements, need for postoperative antiemetics, pain scores, and length of time in the operating room (OR). We measured patient and procedural risk factors including pedicle/skin excision patterns, concurrent liposuction, weight of resection, and additional local anesthesia. Risk factors as well as outcomes were analyzed using Fischer exact and t tests.

RESULTS

No statistically significant difference was shown between the group receiving the Pecs blocks and the control with regard to narcotic requirements, pain scores, and need for antiemetics. Patients undergoing Pecs blocks had a significantly higher OR time before incision (P = 0.0073). Patient and procedural risk factors were well balanced (P > 0.41).

CONCLUSIONS

Pectoralis nerve blocks may be a valuable component of a multimodality pain regimen; however, when performed as a solitary adjunct, they do not seem to decrease perioperative narcotic requirements, pain scores, or the need for antiemetic medication in patients undergoing breast reductions. In addition, postinduction Pecs blocks significantly increase OR times.

The Analgesic Efficacy of Pecto-Intercostal Fascial Block Combined with Pectoral Nerve Block in Modified Radical Mastectomy: A Prospective Randomized Trial

BACKGROUND

Pectoral nerve (Pecs) block is one of the most promising regional analgesic techniques for breast surgery. However, Pecs II block may not provide analgesia of the medial aspect of the breast or the entire nipple-areolar complex.

OBJECTIVES

The aim of the present study was to investigate the efficacy of combining the pecto-intercostal fascial block (PIFB) and Pecs II block for perioperative analgesia following modified radical mastectomy (MRM).

STUDY DESIGN

A prospective randomized study.

SETTING

An academic medical center.

METHODS

Sixty women undergoing unilateral MRM were randomly divided into 2 groups. The Pecs II group received Pecs II block using 20 mL bupivacaine 0.25% between the serratus anterior and the external intercostal muscles, and 10 mL bupivacaine 0.25% between the pectoralis major and minor muscles, together with sham PIFB using 15 mL normal saline solution in the interfascial plane between the pectoralis major muscle and the external intercostal muscle. PIFB-Pecs II group received the same Pecs II block combined with PIFB using 15 mL bupivacaine 0.25%.

RESULTS

The median (interquartile range [IQR]) time to the first morphine dose was significantly longer in the PIFB-Pecs II group (327.5 [266.3-360.0] minutes) than the Pecs II group (196 [163.8-248.8] minutes) (P < 0.001, 95% confidence interval [CI] 79.98, 150.00).The median (IQR) cumulative morphine consumption was higher in the Pecs II group (14.0 [11.0-18.0] mg) than the PIFB-Pecs II group (8.0 [7.0-9.0] mg) (P < 0.001; CI, 4.0-8.0). Intraoperative consumption of fentanyl was significantly lower in PIFB-Pecs II group with a median (IQR) of 0 (0-15 mu g) than the Pecs II group median 57.5 (0-75 mu g) (P = 0.022, CI; 0-60). The Visual Analog Scale scores for the first 12 postoperative hours were lower in the PIFB-Pecs II group than the Pecs II group at rest and on moving the ipsilateral arm (P < 0.001). The dermatomal block on the lateral chest wall was comparable between the 2 studied groups. PIFB-Pecs II provided extensive sensory block on the anterior chest wall, whereas Pecs II block failed to achieve any sensory block.

LIMITATIONS

This study was limited by its small sample size.

CONCLUSIONS

The combination of Pecs II and PIFB provide better perioperative analgesia for MRM than Pecs II alone.

Computed Tomography-Guided Percutaneous Coblation of the Thoracic Nerve Root for Treatment of Postherpetic Neuralgia

BACKGROUND

Postherpetic neuralgia (PHN) is one of the most intractable pain disorders and often does not respond to medication, physical, and interventional procedures. Coblation technology has been demonstrated to have potential for neuralgia, but there are rare reports of the efficacy and security of coblation for PHN. The thoracic segment is the most common predilection part of PHN, so we conducted this long-term study to investigate the results of coblation for the treatment of thoracic PHN.

OBJECTIVES

The aim of this study was to determine the efficacy and security of computed tomography (CT)-guided coblation of the thoracic nerve root for treatment of PHN.

STUDY DESIGN

Self before-after controlled clinical assessment.

SETTING

Department of Pain Management, Xuanwu Hospital, Capital Medical University.

METHODS

Seventy-seven patients with thoracic PHN sustained for at least 6 months and refractory to conservative therapy were identified. Patients underwent CT-guided percutaneous coblation to ablate the thoracic nerve root for thoracic PHN. The therapeutic effects were evaluated using a Visual Analog Scale (VAS), medication doses, and pain-related quality of life (QoL) scale before coblation, and at 1 week, and at 1, 3, and 6 months after the procedure. Patients who achieved more than 50% pain relief were defined as responders. In addition, adverse effects were also recorded to investigate the security of this procedure.

RESULTS

The VAS score significantly decreased from 7.22 ± 1.15 before the coblation to 3.51 ± 1.12 (P = 0.01), 3.02 ± 1.21 (P = 0.006), 3.11 ± 2.15 (P = 0.014), and 2.98 ± 2.35 (P = 0.008) at 1 week, and at 1, 3, and 6 months after the procedure, respectively. The number of responders were 56 (77.78%), 54 (75%), 55 (76.39%), and 54 (75%) at 1 week, and at 1, 3, and 6 months after the procedure, respectively. The doses of anticonvulsants and analgesics were decreased significantly at all time points after the procedure compared with before treatment (P < 0.05). Patient responses on the Brief Pain Inventory Short Form indicated mean scores that were significantly lower than baseline across all domains of pain interference with QoL at all evaluations (P = 0.001). Most of the patients had mild numbness and it did not affect the daily activities after the procedure. No other severe adverse events occurred during or after the procedure.

LIMITATIONS

A single-center study, relatively small number of patients, short duration of review of medical record, and the retrospective study.

CONCLUSIONS

CT-guided percutaneous thoracic nerve root coblation is an effective and safe method for the treatment of thoracic PHN, and the procedure can also significantly improve the QoL in patients with PHN.

Clinical analgesic efficacy of pectoral nerve block in patients undergoing breast cancer surgery: A systematic review and meta-analysis

BACKGROUND

Breast cancer is the most commonly diagnosed cancer in women, and more than half of breast surgery patients experience severe acute postoperative pain. This meta-analysis is designed to examine the clinical analgesic efficacy of Pecs block in patients undergoing breast cancer surgery.

METHODS

An electronic literature search of the Library of PubMed, EMBASE, Cochrane Library, and Web of Science databases was conducted to collect randomized controlled trials (RCTs) from inception to November 2018. These RCTs compared the effect of Pecs block in combination with general anesthesia (GA) to GA alone in mastectomy surgery. Pain scores, intraoperative and postoperative opioid consumption, time to first request for analgesia, and incidence of postoperative nausea and vomiting were analyzed.

RESULTS

Thirteen RCTs with 940 patients were included in our analysis. The use of Pecs block significantly reduced pain scores in the postanesthesia care unit (weighted mean difference [WMD] = -1.90; 95% confidence interval [CI], -2.90 to -0.91; P < .001) and at 24 hours after surgery (WMD = -1.01; 95% CI, -1.64 to -0.38; P < .001). Moreover, Pecs block decreased postoperative opioid consumption in the postanesthesia care unit (WMD = -1.93; 95% CI, -3.51 to -0.34; P = .017) and at 24 hours (WMD = -11.88; 95% CI, -15.50 to -8.26; P < .001). Pecs block also reduced intraoperative opioid consumption (WMD = -85.52; 95% CI, -121.47 to -49.56; P < .001) and prolonged the time to first analgesic request (WMD = 296.69; 95% CI, 139.91-453.48; P < .001). There were no statistically significant differences in postoperative nausea and vomiting and block-related complications.

CONCLUSIONS

Adding Pecs block to GA procedure results in lower pain scores, less opioid consumption and longer time to first analgesic request in patients undergoing breast cancer surgery compared to GA procedure alone.

Efficacy of pectoral nerve block type II versus thoracic paravertebral block for analgesia in breast cancer surgery

OBJECTIVE

The aim: to compare the efficacy of pectoral nerve block type II and thoracic paravertebral block for analgesia during and after breast cancer surgery.

PATIENTS AND METHODS

Materials and methods: Sixty adult women were undergoing unilateral radical mastectomy or quadrantectomy with axillary dissection. Patients were randomized to receive either pectoral nerve block with ropivacaine 0.375% 30 ml or thoracic paravertebral block with ropivacaine 0.5% 20 ml. Evaluated variables included pain intensity at 0, 2, 4, 6, 12, 18 and 24 hours, intraoperative fentanyl, 24-hour postoperative opioid (promedol) and nonopioid (ketoprofen) consumption, the time to first rescue analgesia.

RESULTS

Results: There were no statistically significant differences between pectoral block and paravertebral block groups in intraoperative fentanyl consumption 2,2 (1,81-2,81) vs 1,9 (1,63-2,25) mcg/kg/hour (Р>0,05) and in the pain intensity during the first 24 hours after operation. The mean postoperative 24-hour promedol and ketoprofen consumption was 4,0 (±8,14) mgvs 5,0 (±8,85) mg (Р>0,05) and 66,7 (±66,09) mgvs 95,8 (±90,78) mg (Р>0,05) in the pectoral and paravertebral block groups respectively. Time to the first analgesia request was longer in pectoral block group - 540 (455,0-600,0) min vs 515 (265,0-650,0) min (Р>0,05). There were no complications after pectoral blocks and 2 complications after paravertebral blocks.

CONCLUSION

Conclusions: in breast cancer surgery pectoral nerve blocktype II can provide postoperative analgesia comparable to thoracic paravertebral block with lower complications rate.

Pulsed Radiofrequency on Thoracic Dorsal Root Ganglion Versus Thoracic Paravertebral Nerve for Chronic Postmastectomy Pain, A Randomized Trial: 6-Month Results

BACKGROUND

Pharmacologic treatment is not successful in all cases of postmastectomy pain syndrome (PMPS). Some patients continue suffering pain while taking their medications, and others cannot tolerate the side effects of antineuropathic analgesics. Radiofrequency technology has provided promising results in the management of chronic neuropathic pain.

OBJECTIVES

Considering that affection of intercostobrachial nerves are the main reason behind PMPS, we aimed to evaluate and compare the analgesic efficacy of pulsed radiofrequency (PRF) when delivered either on thoracic dorsal root ganglion (DRG) of intercostobrachial nerves (thoracic DRG 2, 3, and 4) or their corresponding thoracic paravertebral nerves (PVNs).

STUDY DESIGN

Prospective randomized-controlled clinical trial.

SETTINGS

Interventional pain unit, tertiary center, university hospital.

METHODS

Sixty-four patients complaining of PMPS were randomized to either group DRG (n = 32) that received PRF on thoracic DRG, or group PVN (n = 32) that received PRF on thoracic PVN. The outcome variables were that the patients showed > 50% reduction in their visual analog scale (VAS) pain score; the VAS pain score and global perceived effect (GPE) was evaluated during a 6-month follow-up period.

RESULTS

The percentage of patients who showed > 50% reduction of their VAS pain score was significantly higher in group DRG compared with group PVN, assessed at 4 and 6 months postprocedure (23/29:79.3% vs. 13/29:44.8%; P = 0.007) and (22/29:75.9% vs. 7/29:24.1%; P < 0.001), respectively, however, the 2 groups did not significantly differ at 1, 2, and 3 months postprocedure (DRG vs. PVN), (21/29: 72.4% vs. 21/29: 72.4%; P = 0.542), (24/29: 82.8% vs. 23/29: 79.9%; P = 0.778), and (24/29: 82.8% vs. 19/29: 65.5%; P = 0.136), respectively. There was a statistically significant reduction of VAS pain score at 4 and 6 months (DRG vs. PVN, mean ± standard deviation, 2.9 ± 2 vs. 3.9 ± 1.5; mean difference (95% confidence interval), 1 (0.06:1.9); P = 0.038; 3 ± 1.94 vs. 5.1 ± 1.5; mean difference (95% confidence interval), 1.9 (1:2.9); P < 0.001, respectively), however, the 2 groups did not significantly differ at 1, 2, and 3 months postprocedure. With regard to the patient's satisfaction (i.e., GPE), assessed at 3 and 6 months postprocedure, there was a significantly higher satisfaction in group DRG compared with group PVN (median [interquartile range (IQR)], 6 (5:7) vs. 3 (2:4);P < 0.001), however, the patient's satisfaction was similar between groups at 3 months postprocedure: median (IQR), 6 (4:7) vs. 6 (5:6); P = 0.327.

LIMITATIONS

The study follow-up period is limited to 6 months only.

CONCLUSIONS

PRF of both the thoracic DRG and the thoracic PVN are effective treatments for PMPS; however, PRF of DRG provided a better long-term analgesic effect. Nevertheless, given the inherent risk of performing thoracic foraminal interventions and the technical difficulty of targeting thoracic DRG, we recommend that PRF of DRG should be reserved for cases that failed to gain adequate response to PRF of thoracic PVN in conjunction with medical treatment.

KEY WORDS

Postmastectomy pain syndrome, radiofrequency, dorsal root ganglion, paravertebral nerve.

Ultrasound-Guided Pectoral Nerve Block I and Serratus-Intercostal Plane Block Alleviate Postoperative Pain in Patients Undergoing Modified Radical Mastectomy

BACKGROUND

Simultaneous application of pectoral nerve block and serratus-intercostal plane block (SPB) is one of the most desirable multimodal analgesic strategies, with wide implementation of the enhanced recovery after surgery pathway for modified radical mastectomy (MRM).

OBJECTIVES

The aim of the present study was to investigate the efficacy and safety of ultrasound-guided pectoral nerve block I (PECS I) and SPB for postoperative analgesia following MRM.

STUDY DESIGN

A randomized, prospective study.

SETTING

An academic medical center.

METHODS

A total of 61 women undergoing MRM were randomly divided into 2 groups. The control group (group C, n = 32) received general anesthesia only, whereas the PECS I + SPB treated group (group PS, n = 29) received a combination of pectoral nerve block and SPB in addition to general anesthesia.

RESULTS

Pain scores on a visual analog scale, opioid consumption, the duration at the postanesthesia care unit, and the incidence of adverse events were lower in group PS, compared with that of the group C. Moreover, PECS I together with SPB contributed to better sleep quality and higher patient satisfaction of pain relief.

LIMITATIONS

This study was limited by its sample size.

CONCLUSIONS

These results suggest that the combination of PECS I and SPB provide superior perioperative pain relief in breast cancer surgery.

KEY WORDS

Pectoral nerve block, serratus-intercostal plane block, postoperative analgesia, modified radical mastectomy.

Pectoral nerve block in anesthesia for modified radical mastectomy: A meta-analysis based on randomized controlled trials

BACKGROUND

Many types of regional nerve blocks have been used during anesthesia for modified radical mastectomy. In recent years, the use of pectoral nerve (PECS) block has gained importance in postoperative analgesia, but there are still controversies regarding its efficacy. There is especially no consensus on the optimal type of PECS block to be used. Herein, we attempt to evaluate the analgesic efficacy of the PECS block after radical mastectomy.

METHODS

We searched PubMed, EMBASE, and the Cochrane library for randomized controlled trials (RCTs) for studies regarding PECS versus general anesthesia (GA) that were published prior to May 31, 2018. Outcome measures such as intra- and postoperative consumption of opioids, postoperative nausea and vomiting (PONV), need for postoperative rescue analgesia, and pain scores were analyzed. After quality evaluation and data extraction, a meta-analysis was performed using Review Manager 5.3 software, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used for rating the quality of evidence.

RESULTS

A total of 8 RCTs and 2 cohort studies involving 993 patients were eligible. Compared with the GA group, the PECS block group effectively reduced the intraoperative and postoperative use of opioid drugs, incidence of PONV, need for postoperative rescue analgesia, and pain scores within 0 to 6 hours after surgery. However, subgroup analysis showed that PECS I block did not have a significant advantage in reducing the intra- and postoperative consumption of opioids. Results for each outcome indicator were confirmed as having a high or moderate level of evidence.

CONCLUSIONS

Even considering the limitations (evaluations of efficacy in different age groups and for chronic pain were not carried out) of this meta-analysis, it can be concluded that the PECS II block is an effective anesthetic regimen in modified radical mastectomy that can effectively reduce the intra- and postoperative consumption of opioids, postoperative PONV, and the need for postoperative rescue analgesia and can alleviate early pain (0-6 hours) after surgery.

The Efficacy of Different Volumes on Ultrasound-Guided Type-I Pectoral Nerve Block for Postoperative Analgesia After Subpectoral Breast Augmentation: A Prospective, Randomized, Controlled Study

BACKGROUND

PECS type-1 block, a US-guided superficial interfacial block, provides effective analgesia after breast surgery. Aesthetic breast augmentation is one of the most common surgical procedures in plastic surgery. Subpectoral prostheses cause severe pain. The aim of this study was to investigate the effect of different volumes of the solution on the efficacy of PECS type-I block for postoperative analgesia after breast augmentation surgery.

METHODS

Ninety ASA status I-II female patients aged between 18 and 65 years who scheduled breast augmentation surgery under general anesthesia were included in this study. The patients were randomly divided into three groups of 30 patients each (Group 20 = 20 ml of anaesthetic solution, Group 30 = 30 ml anaesthetic solution, and Group K = Control group). Postoperative assessment was performed using the VAS score. The VAS scores were recorded postoperatively at 1, 2, 4, 8, 16 and 24 h.

RESULTS

Fentanyl consumption was statistically significantly lower in Group 20 and Group 30 compared to the Control group (p < 0.05). There was no statistically significant difference in fentanyl consumption between Group 20 and Group 30. The right and left VAS scores were statistically significantly lower in Groups 20 and 30 than in the Control group (p < 0.05). There was no statistical difference in terms of VAS scores between Group 20 and Group 30. The use of rescue analgesia was statistically lower in Groups 20 and 30.

CONCLUSIONS

PECS type-1 block using 20 ml of 0.25% bupivacaine can provide effective analgesia after breast augmentation surgery.

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 .

Pectoral nerve block as a single anesthetic technique for breast surgery and sentinel lymph node investigation

Breast cancer surgery is usually performed under general anesthesia or, more recently, combined with conventional regional techniques. Pectoral nerves (PECs) block appears as an analgesic alternative in these procedures, but few studies refer to it as a single anesthetic technique^1-3. In this case report, we describe a 56-year-old female patient, BMI 31kg/m², ASA IV, admitted for elective tumorectomy of the left upper quadrant of the breast and sentinel node investigation. Given the multiple comorbidities and the high anesthetic and surgical risk, the anaesthetic plan consisted in ultrasound guided PECs II block as a single anesthetic technique. The authors report a successful anesthetic and pain management without complications in breast surgery. PECs block, as a single anesthetic technique, may be safe, advantageous and effective with haemodynamic stability and few side effects in high risk cardiac patients.

Application of lower limb nerve block combined with slow induction of light general anesthesia and tracheal induction in elderly hip surgery

BACKGROUND

This study aims to evaluate the effectiveness and safety of lower limb nerve block combined with slow induction of light general anesthesia and tracheal intubation in hip surgery in the elderly.

METHODS

Thirty elderly patients who underwent hip surgery under the lower limb nerve block were randomly divided into 2 groups: slow induction of light general anesthesia and tracheal intubation group (group M), and laryngeal mask light general anesthesia group (group H). After undergoing total intravenous anesthesia without muscle relaxants, all patients received sciatic nerve, lumbar plexus, and paravertebral nerve blocks. The hemodynamic situations, dosage of anesthetics, time for awakening and extubation (or laryngeal mask removal), and incidence of respiratory adverse reactions in the induction period were recorded.

RESULTS

Compared with baseline levels, the difference in mean arterial pressure (MAP) value at each time point after intubation/laryngeal mask removal in both groups was not statistically significant (P > .05). Furthermore, the time for awakening and extubation/laryngeal mask removal, and anesthetic dosage were significantly decreased in group M, when compared with group H (P < .05). For the incidence of adverse reactions, the incidence of poor sealing and hypoxia was significantly lower in group M than in group H (P < .05), and the incidence of sore throat was significantly lower in group H than in group M (P < .05).

CONCLUSION

Lower limb nerve block combined with slow induction of light general anesthesia and tracheal intubation was associated with smaller anesthetic dosage, and shorter duration of anesthesia induction and extubation/laryngeal mask after surgery.

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.

Pectoral nerve blocks to improve analgesia after breast cancer surgery: A prospective, randomized and controlled trial

STUDY OBJECTIVE

To evaluate the analgesic efficacy of ultrasound guided combined pectoral nerve blocks I and II in patients scheduled for surgery for breast cancer.

DESIGN

Prospective, randomized, control trial.

SETTING

Operating rooms in a tertiary care hospital of Northern India.

PATIENTS

Sixty American Society of Anesthesiologists status I to II adult women, aged 18-70years were enrolled in this study.

INTERVENTIONS

Patients were randomized into two groups (30 patients in each group), PECS (P) group and control (C) group. In group P, patients received both general anesthesia and ultrasound guided combined pectoral nerve blocks (PECS I and II). In group C, patients received only general anesthesia.

MEASUREMENTS

We noted pain intensity at rest and during abduction of the ipsilateral upper limb, incidence of postoperative nausea and vomiting; patient's satisfaction with postoperative analgesia and maximal painless abduction at different time intervals in both groups.

MAIN RESULTS

There was significant decrease in the total amount of fentanyl requirement in the in P group {(140.66±31.80μg) and (438±71.74μg)} in comparison to C group {(218.33±23.93μg) and (609±53.00μg)} during intraoperative and post-operative period upto 24h respectively. The time to first analgesic requirement was also more in P group (44.33±17.65min) in comparison to C group (10.36±4.97min) during post-operative period. There was less limitation of shoulder movement (pain free mobilization) on the operative site at 4h and 5h after surgery in P group in comparison to C group. However there was no difference in the incidence of post-operative nausea and vomiting (22 out of 30 patients in group P and 20 out of 30 patients in group C) but patients in group P had a better satisfaction score with postoperative analgesia than C group having a p value of <0.001(Score 1; 5 VS 20; Score 2; 12 VS 9; Score 3; 13 VS 1).

CONCLUSIONS

Ultrasound guided combined pectoral nerve blocks are an effective modality of analgesia for patients undergoing breast surgeries during perioperative period.

CLINICAL TRIAL REGISTRATION

CTRI/2015/12/006457.

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.

Neurophysiological assessment of sympathetic cardiovascular activity after loss of postganglionic neurons in the anesthetized rat

The goal of this study was to determine the degree of sympathetic postganglionic neuronal loss required to impair cardiovascular-related sympathetic activity. To produce neuronal loss separate groups of rats were treated daily with guanethidine for either 5days or 11days, followed by a recovery period. Sympathetic activity was measured by renal sympathetic nerve activity (RSNA). Stereology of thoracic (T13) ganglia was performed to determine neuronal loss. Despite loss of more than two thirds of neurons in T13 ganglia in both treated groups no effect on resting blood pressure (BP) or heart rate (HR) was detected. Basal RSNA in rats treated for 5days (0.61±0.10μV∗s) and 11days (0.37±0.08μV∗s) was significantly less than vehicle-treated rats (0.99±0.13μV∗s, p<0.05). Increases in RSNA by baroreceptor unloading were significantly lower in 5-day (1.09±0.19μV∗s) and 11-day treated rats (0.59±0.11μV∗s) compared with vehicle-treated rats (1.82±0.19μV∗s, p<0.05). Increases in RSNA to chemoreceptor stimulation were significantly lower in 5-day treated rats (1.54±0.25μV∗s) compared with vehicle-treated rats (2.69±0.23μV∗s, p<0.05). Increases in RSNA in 11-day treated rats were significantly lower (0.75±0.15μV∗s, p<0.05) compared with both vehicle-treated and 5-day treated rats. A positive correlation of neurons to sympathetic responsiveness but not basal activity was detected. These data suggest that diminished capacity for reflex sympathetic responsiveness rather than basal activity alone must be assessed for complete detection of neurophysiological cardiovascular impairment.

[Winged scapula, a condition for the surgical area?]

The winged scapula secondary to long thoracic nerve injury is an uncommon condition. It is most frequently reported in the literature associated with surgical activities, either due to poor positioning during anesthesia or by an iatrogenic traumatic event during surgical procedures. We expose 3 cases and a brief etiological and literature review, to present the multiple origins of this injury, which are not always related to this area of activity, as these are not the only causes of this injury.

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

INTRODUCTION

Major breast surgery was usually performed under general anaesthesia until the first patient series with thoracic paravertebral block was published. This block was introduced into our Hospital, and with the purpose of obtaining a more comfortable perioperative period, it was combined with blocking the pectoral nerves. In this study, both anaesthetic techniques are compared, as regards control of postoperative pain, incidence of postoperative nausea and vomiting, and sedation requirements.

MATERIAL AND METHODS

An observational study was conducted with 60 patients scheduled for breast surgery with subpectoral implants (augmentation and /or prosthesis). Two groups were studied. The first (Group I) was randomly selected from a patient records data base to have thoracic paravertebral block and sedation. In the second (Group II), a pectoral nerve block was performed combined with a thoracic paravertebral block.

RESULTS

In Group I, 33.3% of the patients had a score of ≤ 3 on the visual analogue scale (VAS) at 8 hours, and 66.7% had a VAS score of ≥ 4 at 24h, compared to 80% of the Group II patients who had a VAS score of ≤ 3 at 8 hours and 20% with a VAS score ≥ 4 at 24h. The mean difference in the VAS scores at 8 hours between the two groups was statistically significant: mean VAS score at 8 hours in Group I, 4.23 ± 2.4 compared to 1.77 ± 2.2 in Group II. There was no difference in the VAS scores at 24 hours. No statistically significant differences were found between the two groups in the incidence of postoperative nausea and vomiting. The need for intra-operative sedation supplements with propofol boluses was less in Group II, 40% compared to 90% in Group II.

CONCLUSIONS

Pectoral nerve block is a technique that improves the results obtained with thoracic paravertebral block in reconstructive breast surgery, with better post-operative analgesic control in the immediate post-operative period and a lower requirement for sedation.