Abstract: The Effect of Intraoperative Nerve Blocks on Patient-Centered Outcomes after Tissue Expander Breast Reconstruction: A Prospective, Double-Blinded, Randomized Controlled Clinical Trial

Abstract

INTRODUCTION: Our study represents the first level I evidence to assess whether intraoperative nerve blocks improve the quality of recovery from immediate tissue expander/implant (TE/I) breast reconstruction. METHODS: A prospective, randomized, double-blinded, placebo–controlled, clinical trial was conducted in which patients undergoing immediate TE/I breast reconstruction were randomized to either: 1) intraoperative intercostal and pectoral nerve blocks with 0.25 % bupivacaine with 1:200,000 epinephrine and 4 mg dexamethasone or 2) sham nerve blocks with normal saline. Surgeon, patient and researchers collecting postoperative data were blind to group allocation. Quality of recovery (QoR 40), pain score, and opioid use in the postoperative period were compared between groups using the Mann-Whitney’s U test. Fisher’s exact test was used between categorical variables. Power analysis ensured 80% power to detect a 10-point (clinically significant) difference in QoR 40. RESULTS: 47 patients were enrolled. Age, BMI, laterality, mastectomy type, and lymph node dissection were similar between groups. There were no statistical differences in quality of recovery, pain burden as measured by visual analog scale, or opioid consumption between groups at 24 hours following surgery. Mean global QoR scores were 169 (range: 155–182) for the treatment arm and 165 (range: 143 to 179) for the placebo arm (p = 0.36), indicating a relatively high quality of recovery in both groups. There was less total narcotic required by the treatment group compared to placebo in both PACU (8 v. 17 morEq, p = 0.26) and on the inpatient unit (92 vs. 114, p = 0.31), though these differences were not statistically or clinically significant. Ten patients in the placebo group and six patients in the treatment group required anti-emetic use postoperatively, P= 0.56. Length of hospital stay averaged 1 day in both groups. There were no adverse events or injection-related complications. CONCLUSION: While intraoperative nerve blocks can be a safe and effective adjunct to a comprehensive post-surgical recovery regimen, our results indicate no difference in quality of recovery between patients who received intraoperative intercostal and pectoral nerve blocks with bupivacaine and dexamethasone compared to those who received sham placebo injections.