Pectoral nerve block in anesthesia for modified radical mastectomy

Zhao, Jia; Han, Fang; Yang, Yang; Li, Hangyu; Li, Zinan

doi:10.1097/md.0000000000015423

Cited by 42 publications

(40 citation statements)

References 33 publications

(52 reference statements)

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“…Two meta‐analyses comparing PECS to paravertebral blocks reported similar results on pain reIief and analgesia consumption . A third meta‐analysis also demonstrated the efficacy of PECS blocks to reduce pain and morphine consumption when compared with no block or placebo .…”

Section: Resultsmentioning

confidence: 78%

PROSPECT guideline for oncological breast surgery: a systematic review and procedure‐specific postoperative pain management recommendations

et al. 2020

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Summary 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.

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Section: Resultsmentioning

confidence: 78%

PROSPECT guideline for oncological breast surgery: a systematic review and procedure‐specific postoperative pain management recommendations

et al. 2020

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“…Our review, through indirect comparisons, confirms these findings. Another more recent review (Zhao, Han, Yang, Li, & Li, 2019), comparing PEC block to standard care only, found similar results with a reduction in pain scores and opioid consumption.…”

Section: Discussionmentioning

confidence: 83%

Preventing pain after breast surgery: A systematic review with meta‐analyses and trial‐sequential analyses

Lepot

Elia

Tramèr

et al. 2020

European Journal of Pain

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Background and objective: The aim of this systematic review was to indirectly compare the efficacy of any intervention, administered perioperatively, on acute and persistent pain after breast surgery. Databases and data treatment: We searched for randomized trials comparing analgesic interventions with placebo or no treatment in patients undergoing breast surgery under general anaesthesia. Primary outcome was intensity of acute pain (up to 6 hr postoperatively). Secondary outcomes were cumulative 24-hr morphine consumption, incidence of postoperative nausea and vomiting (PONV), and chronic pain. We used an original three-step approach. First, meta-analyses were performed when data from at least three trials could be combined; secondly, trial sequential analyses were used to separate conclusive from unclear evidence. And thirdly, the quality of evidence was rated with GRADE. Results: Seventy-three trials (5,512 patients) tested loco-regional blocks (paravertebral, pectoralis), local anaesthetic infiltrations, oral gabapentinoids or intravenous administration of glucocorticoids, lidocaine, N-methyl-D-aspartate antagonists or alpha2 agonists. With paravertebral blocks, pectoralis blocks and glucocorticoids, there was conclusive evidence of a clinically relevant reduction in acute pain (visual analogue scale > 1.0 cm). With pectoralis blocks, and gabapentinoids, there was conclusive evidence of a reduction in the cumulative 24-hr morphine consumption (> 30%). With paravertebral blocks and glucocorticoids, there was conclusive evidence of a relative reduction in the incidence of PONV of 70%. For chronic pain, insufficient data were available. Conclusions: Mainly with loco-regional blocks, there is conclusive evidence of a reduction in acute pain intensity, morphine consumption and PONV incidence after breast surgery. For rational decision making, data on chronic pain are needed. Significance: This quantitative systematic review compares eight interventions, published across 73 trials, to prevent pain after breast surgery, and grades their degree of efficacy. The most efficient interventions are paravertebral blocks, pectoralis blocks and glucocorticoids, with moderate to low evidence for the blocks. Intravenous lidocaine and alpha2 agonists are efficacious to a lesser extent, but with a higher level of evidence. Data for chronic pain are lacking.

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“…This hypothesis has been demonstrated by several studies. For example, Zhao et al [ 37 ] found, by meta-analysis of 8 RCTs and 2 cohort studies on breast cancer surgery, the PECS 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 compared with the GA group. This conclusion of PECS block was also demonstrated by the analysis of 13 RCTs.…”

Section: Discussionmentioning

confidence: 99%

Dexmedetomidine as an adjuvant for patients undergoing breast cancer surgery

et al. 2020

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Background: The goal of this study was to comprehensively evaluate the analgesic and antiemetic effects of adjuvant dexmedetomidine (DEX) for breast cancer surgery using a meta-analysis. Methods: Electronic databases were searched to collect the studies that performed randomized controlled trials. The effect size was estimated by odd ratio (OR) or standardized mean difference (SMD). Statistical analysis was performed using the STATA 13.0 software. Results: Twelve published studies involving 396 DEX treatment patients and 395 patients with control treatment were included. Pooled analysis showed that the use of DEX significantly prolonged the time to first request of analgesia (SMD = 1.67), decreased the postoperative requirement for tramadol (SMD = −0.65) and morphine (total: SMD = −2.23; patient-controlled analgesia: SMD = −1.45) as well as intraoperative requirement for fentanyl (SMD = −1.60), and lower the pain score at 1 (SMD = −0.30), 2 (SMD = −1.45), 4 (SMD = −2.36), 6 (SMD = −0.63), 8 (SMD = −2.47), 12 (SMD = −0.81), 24 (SMD = −1.78), 36 (SMD = −0.92), and 48 (SMD = −0.80) hours postoperatively compared with the control group. Furthermore, the risks to develop postoperative nausea/vomiting (PONV) (OR = 0.38) and vomiting (OR = 0.54) were significantly decreased in the DEX group compared with the control group. The pain relief at early time point (2, 6, 12, 24 hours postoperatively) and the decrease in the incidence of PONV were especially obvious for the general anesthesia subgroup ( P < .05) relative to local anesthesia subgroup ( P >.05). Conclusion: DEX may be a favorable anesthetic adjuvant in breast cancer surgery, which could lower postoperative pain and the risk to develop PONV. DEX should be combined especially for the patients undergoing general anesthesia.

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Pectoral nerve block in anesthesia for modified radical mastectomy

Abstract: Supplemental Digital Content is available in the text

Cited by 42 publications

References 33 publications

PROSPECT guideline for oncological breast surgery: a systematic review and procedure‐specific postoperative pain management recommendations

PROSPECT guideline for oncological breast surgery: a systematic review and procedure‐specific postoperative pain management recommendations

Preventing pain after breast surgery: A systematic review with meta‐analyses and trial‐sequential analyses

Dexmedetomidine as an adjuvant for patients undergoing breast cancer surgery

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