Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives

Abstract

The management of postoperative pain is of critical importance for women undergoing breast reconstruction after surgical treatment for breast cancer. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Multimodal analgesia pain management strategies with nonopioid analgesics have improved the value of surgical care in patients undergoing various operations but have only recently been reported in reconstructive breast surgery. Regional anesthesia techniques, with paravertebral blocks (PVBs) and transversus abdominis plane (TAP) blocks, and enhanced recovery after surgery (ERAS) pathways have been increasingly utilized in opioid-sparing multimodal analgesia protocols for women undergoing breast reconstruction. The objectives of this review are to 1) comprehensively review regional anesthesia techniques in breast reconstruction, 2) outline important components of ERAS protocols in breast reconstruction, and 3) provide evidence-based recommendations regarding each intervention included in these protocols. The authors searched across six databases to identify relevant articles. For each perioperative intervention included in the ERAS protocols, the literature was exhaustively reviewed and evidence-based recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation system methodology. This study provides a comprehensive evidence-based review of interventions to optimize perioperative care and postoperative pain control in breast reconstruction. Incorporating evidence-based interventions into future ERAS protocols is essential to ensure high value care in breast reconstruction.

Enhanced Recovery With Paravertebral and Transversus Abdominis Plane Blocks in Microvascular Breast Reconstruction

“…Our study is consistent with a recent meta-analysis that found significant improvement in opioid use and length of stay with no increase in complications. 24 , 25 With paravertebral as well as TAP analgesia, our protocol was unique in accomplishing this without continuous infusions, and expensive or high-risk medications. This protocol allowed us to consistently avoid using PCA.…”

Perioperative Blocks for Decreasing Postoperative Narcotics in Breast Reconstruction

“…The Transverse Abdominis Plane (TAP) block is useful in controlling abdominal pain after autologous reconstruction. This nerve block entails anesthetizing T6-L1 anterior rami, and subsequently, the anterior abdominal wall (24). The single-injection TAP block has been reported to be safe and decrease the amounts of opioids used postoperatively (16)(17)(18).…”

Fast Recovery in Esthetic Body Contouring Surgery

“…These symptoms are a common cause of longer hospitalizations [11,23,24]. Among the recommendations for postoperative analgesia, treatment with ketorolac and then with paracetamol, nonsteroidal anti-inflammatory drugs, and gabapentin are recommended [25,26].…”

“…Multimodal management is chosen to act on the different pain mechanisms and thus reduce them in the postoperative period [25]. As preoperative planning, celecoxib (200-400 mg), gabapentin (300-600 mg), and ondansetron (8 mg) are started as premedication one night before surgery and the surgery morning.…”

“…Intraoperatively, dexamethasone (8 mg) and promethazine (25 mg) are added after induction, either intravenously or in suppository [26], in addition to fentanyl and propofol per kilogram of weight [23]. In breast surgery, the protocols also include regional anesthesia by paravertebral blocks [25] and in abdominoplasty the use of liposomal bupivacaine [27] (0.25-0.5%) below the rectus abdominis sheath [25] or transverse abdominal plane block. Ropivacaine as a pain control measure within the breast pocket in breast surgeries has also been reported efficiently by Durán-Vega [28].…”