Title: Adopting a Multimodal Approach to Breast Cancer Surgery Analgesia: Shift in Departmental Practice & Overall Decrease in Perioperative Opioid Requirements, A Retrospective Study
Acute postoperative pain is a predictable response and when left untreated can lead to chronic pain, prolonged rehabilitiation, and other complications after breast surgery.2 Pectoral nerve block (PECSB) has been recently reported as an analgesic method for BCS. In recent literature, it is evident that PECSB significantly reduced intraoperative opioid usage, postoperative pain, PONV, and postoperative opioid requirements. PECSB is an interfascial plane block where local anesthetic is deposited into the plane between the pectoralis major muscle and the pectoralis minor muscle (PECS-I block) and above the serratus anterior muscle at the third rib (PECS-II block); blocking the pectoral, intercostobrachial, third to sixth intercostals, and the long thoracic nerves.2, 10, 11 PECSB is thought to be less invasive, can be performed in supine position, and patients can undergo mastectomies after induction of general anesthesia. In Bashandy & Abbas’ 2015 randomized clinical trial, postoperative PECSB (n=60) was able to reduce intraoperative fentanyl requirement, postoperative pain, postoperative morphine consumption, postoperative nausea and vomiting (PONV), and PACU and hospital stays in patients undergoing BCS compared to the control group (n=60). 1
Introduction of ultrasound in regional anesthesia practice influenced the practice and choice of blocks for any given surgery. At Aventura Hospital and Medical Center, a dynamic shift in practice has occurred when approaching breast cancer surgery patients. Prior to 2016, not a single mastectomy patient received preoperative or postoperative regional anesthesia. In June 2016, all anesthesiologists and residents were trained to perform PECS block in the preoperative setting.6,12 NYSORA and ASRA resources were used to assist in the standardized training of all providers.
We conducted a retrospective study consisting of 2 groups: (1) ropivacaine block (n = 20), (2) no block (control, n= 20) to determine if there was a significant difference between the groups in intraoperative, PACU, and post-operative (within 24h of surgery) regarding opioid requirements. The number of times the patient requested pain medication was recorded in both the PACU and throughout the duration of their hospital admission following surgery. The data that followed a normal distribution pattern were analyzed using t test for equality of means. This is a retrospective study approved by our Institutional Review Board.
There was a statistical difference observed in the PECs block group compared with the NO BLOCK group in both the PACU as well as the postoperative period (P < 0.05). The patients in the PECs block group requested pain medication less frequently in both the PACU and postoperative setting.
The PECSB produce excellent analgesia and exhibit synergistic effects in preventing or treating acute pain in patients undergoing breast cancer surgery. They are simple, easy-to-learn techniques, having easily identifiable landmarks based on good anatomical and ultrasound knowledge, making them an excellent alternatives or adjuncts to opioids and have been shown to decrease overall opioid requirements, ultimately decreasing the side effect profile. It is evident that all providers can be trained to perform PECSB preoperatively. Within the department there has been an ultimate shift in practice resulting in better patient outcomes as well increased patient and surgeon satisfaction.