Prevention of Severe Postoperative Pain after Breast Surgery Using Opioid-Sparing Analgesia with Intraoperative and Drain-Based Ropivacaine Infiltration: A Prospective Observational Study

ONE potential adverse outcome from surgery is chronic pain. Analysis of predictive and pathologic factors is important to develop rational strategies to prevent this problem. Additionally, the natural history of patients with and without persistent pain after surgery provides an opportunity to improve the understanding of the physiology and psychology of chronic pain. Ideally, studies of chronic postoperative pain should include (1) sufficient preoperative data (assessment of pain, physiologic and psychologic risk factors for chronic pain); (2) detailed descriptions of the operative approaches used (location and length of incisions, handling of nerves and muscles); (3) the intensity and character of acute postoperative pain and its management; and (4) follow-up at intervals to 1 yr or more. In addition, there would be information about postoperative interventions that may influence pain, such as radiation therapy or chemotherapy. At long-term follow-up visits, patient function, physical signs, and symptoms would be evaluated using a standardized algorithm, including quantitative and descriptive pain assessments. We found no studies that contain all of these data. For this review, we specifically sought population data that reflect the incidence of chronic postoperative pain or predictors (medical, physiologic, and psychologic) of chronic pain. We selected five groups of surgeries (limb amputations, breast surgery, gallbladder surgery, lung surgery, and inguinal hernia surgery). These surgeries were selected because the incidence of pain is known to be high, thus improving the probability of detecting predictive factors. They also represent a range of major surgical procedures.

Postoperative pain relief is of importance to both patients and surgeons. One of the simpler techniques is infiltration of the surgical incision with long acting local anaesthetic. The literature is confusing, with numerous reports attesting to the value of this approach and a similar number disputing the demonstrable benefits. A prospective, 'blinded', randomized trial was undertaken involving 18 females undergoing uncomplicated bilateral sapheno-femoral ligation. They received intraoperative bupivacaine infiltration into one or the other of their groin incisions. Postoperatively these patients were asked to assess a number of variables relating to their postoperative pain, each patient thereby acting as their own control. There was no significant difference in the postoperative pain experience between groins infiltrated with bupivacaine and those not infiltrated. Two patients developed wound infections and both of these occurred on the sides which had been infiltrated with bupivacaine, however this was not statistically significant. There was no difference found in pain experience with respect to pre- versus post-incision infiltration. Intraoperative wound infiltration with bupivacaine is widely employed as a method of minimizing postoperative pain. This study was unable to demonstrate a benefit of employing the technique in terms of a reduction in the patient's perception of pain. By having each patient act as their own control, we have avoided one of the major deficiencies of previous studies, namely, interpatient variability in assessment and perception of pain.

Introduction: The strip method of follicle harvesting (FUT) has great advantages but post-operative pain and the fear of pain are common complaints of this surgery. The severity of post-operative pain is in direct relation to the width of the strip harvested. It is mandatory to reduce post-operative pain to make this method more acceptable for patients. Objective: Our objective was to determine the effect of strip width and ropivacaine (a long-acting local anaesthetic) infiltration on post-operative pain after strip excision (FUT) surgery. Method: Grading was performed by the authors for the severity of post-operative pain and post-operative sleep disturbance. In Study I (control), the initial data, pain severity, and sleep disturbance was collected from patients on whom a 2cm-wide strip was excised centrally and 1.5cm-wide strip was excised laterally. In the test group, post-operatively, ropivacaine 0.5% was infiltrated below the suture line after 2cm-wide strip excision. In Study II, the strip was excised 1.5cm centrally and 1cm laterally. Again in the test group, ropivacaine infiltration was performed post-operatively while in the control group no ropivacaine was infiltrated. Data was collected and analysed. Observation: There was significant pain in patients where the strip width was 2cm centrally as compared to patients where the strip width was 1.5cm centrally. There was significant reduction of pain in those with strip width 1.5cm centrally and infiltration with ropivacaine was done. Conclusion: The severity of pain is directly proportional to the width of strip harvested. The post-operative infiltration of ropivacaine 0.5% along the suture line significantly reduced post-operative pain.

Wound infiltration with local anaesthetics is commonly used during breast surgery in an attempt to reduce post-operative pain and opioid consumption. The aim of this review was to evaluate the effect of wound infiltration with local anaesthetics compared with a control group on post-operative pain after breast surgery. A systematic review was performed by searching PubMed, Google Scholar, the Cochrane database and Embase for randomised, blinded, controlled trials of wound infiltration with local anaesthetics for post-operative pain relief in female adults undergoing breast surgery. The analgesic effect was evaluated in a qualitative analysis by assessment of significant difference between groups (P < 0.05) in pain scores and supplemental analgesic consumption. Ten trials including 699 patients were included in the final analysis. Three trials investigated mastectomy, four trials partial or segmental mastectomy, and three trials breast reduction, excision of benign lump and unspecified breast surgery, respectively. Six trials demonstrated a small and short-lasting, but statistically significant reduction of post-operative pain scores, and four trials observed a statistically significant reduction in post-operative, supplemental opioid consumption that was, however, of limited clinical relevance. Wound infiltration with local anaesthetics may have a modest analgesic effect in the first few hours after surgery. Pain after breast surgery is, however, generally mild to moderate, and other non-invasive analgesic methods may be preferable in this surgical population.

INTRODUCTION: The importance of breast surgeries can be observed in the current context in which the increasingly growing number of restorative procedures and plastic surgeries in Brazil. To perform the various surgeries, several anesthesic techniques are used as general anesthesia, thoracic epidural or more recently, thoracic paravertebral block. Thus, it is essential to know about the safety of each anesthesic technique in these surgeries, which led to the realization of this review. OBJECTIVES: Analyze the benefits and complications of general anesthesia, thoracic epidural and paravertebral block in breast surgery. MATERIAL AND METHODS: We used the keywords “breast surgery general anesthesia”, “breast surgery thoracic epidural anesthesia” and “breast surgery thoracic paravertebral block” to draw up this systematic review of literature. The databases searched were PubMed, SciELO, MEDLINE, LILACS and Cochrane Library. The articles were selected using the following inclusion criteria: Medical journals from 1995 to 2011, in the languages English, Spanish and Portuguese, in order of relevance and study design of randomized controlled trials and cohort. The pre-selected articles were assessed individually by two reviewers and evaluated on their methodological quality by the Jadad scale, and were scored according to the criteria of randomization, blinding and accountability of all patients, including withdrawals. RESULTS: Fifteen articles were included in this review. The benefits of thoracic epidural anesthesia were better quality of postoperative analgesia, lower length hospitalization and the consumption of analgesics was also lower than general anesthesia. Hypotension and bradycardia were reported as possible complications. General anesthesia was more frequent reported with nausea, hypertension and vomiting. When associated with thoracic paravertebral block, promoted analgesia and anesthesia with lower complications than when applied as single anesthesic technique, as lower intensity of postoperative pain, less nausea and vomiting and less anesthesic recovery time. There are no studies that prove the effectiveness of paravertebral block when used without general anesthesia association. CONCLUSION: The epidural technique, despite its complications, remains the best option for regional block, and with general anesthesia, are the most commonly anesthesic techniques performed in breast surgeries, since evidence is lacking to prove the effectiveness of using thoracic paravertebral block in a patient who is not sedated. More research on the effectiveness of such techniques not associated with general anesthesia should be performed.

Quadrantectomy is a surgical procedure traditionally performed under general anaesthesia with intraoperative and postoperative opioid-based analgesia. The use of locoregional anaesthesia techniques in breast surgery has become widespread and allows excellent management of intraoperative and postoperative pain with reduced opioid consumption. We chose thoracic paravertebral block as regional anaesthesia technique in breast surgery to investigate the possibility of carrying out this surgery with the patient awake. A prospective observational study on 50 patients was designed. The primary outcome for this study was the possibility to carry out the surgery with only the paravertebral block associated with mild sedation without general anaesthesia. Forty minutes before the start of the surgery, an ultrasound-guided thoracic paravertebral block was performed at two thoracic levels, and for each level, 7 mL of ropivacaine 0.7% was injected. Sedation was obtained with target-controlled infusion of propofol. Forty-nine patients underwent the operation awake; in one case, we had to place an I-gel and perform general anaesthesia. No patient needed intraoperative or postoperative opioids. The numeric rating scale, recorded at 0, 2, 6, 12, 24, and 36 hours, was greater than 3 in only five patients. We believe that if in the future we try to make quadrantectomy an intervention in which the anaesthesia is exclusively regional, therefore with a patient awake and collaborating, it will not be possible to ignore the use of thoracic paravertebral block.

Paravertebral blockade (PVB) has been advocated as a useful technique for breast surgery. We prospectively compared the efficacy of PVB via a catheter technique with the efficacy of general anesthesia (GA) for minor breast surgery. Thirty patients were randomized into two groups to receive either PVB or GA. Variables of efficacy were postoperative pain measured on a visual analog scale, postoperative nausea and vomiting (PONV), recovery time, and patient satisfaction. Postoperative visual analog scale scores in the PVB group were significantly lower in the early postoperative period (maximum, 12 vs 45 mm; P < 0.01). In both groups, PONV was nearly absent. There was no difference in recovery time. Patient satisfaction was better in the PVB group (2.8 vs 2.3; scale, 0-3; P < 0.01). There was one inadvertent epidural block and one inadvertent pleural puncture in the PVB group. Although PVB resulted in better postoperative pain relief, the advantages over GA were marginal in this patient group because postoperative pain was relatively mild and the incidence of PONV was small. Considering that the technique has a certain complication rate, we conclude that at present the risk/benefit ratio of PVB does not favor routine use for minor breast surgery. This study confirms the previously reported superior pain relief after paravertebral blockade (PVB) for breast surgery. However, considering the relatively mild postoperative pain and therefore the limited advantage of PVB for these patients, the risk/benefit ratio does not favor the routine use of PVB for minor breast surgery.

Wound infiltration with ropivacaine and fentanyl: effects on postoperative pain and PONV after breast surgery

This study aimed to investigate the trajectories of acute postoperative pain intensity during the initial 5days after abdominal surgery, and to analyze their association with the risk of developing chronic postsurgical pain (CPSP). We enrolled patients with elective abdominal surgery with pain measurements taken across postoperative days 1 through 5. Since postoperative pain is often unavoidable and its initial intensity is closely related to the invasiveness of the surgery, focusing on the overall pain trajectory may be more meaningful than evaluating pain at a single time point. Therefore, the primary outcome of this study was to identify distinct pain trajectories. Secondary outcome was the incidence of CPSP between differences pain trajectories. Lastly, mediation analyses were performed to explore the mediating role of the quality of recovery and subacute pain on the studied associations. The final analysis encompassed 1170 patients (36.75% female) with a median age of 55years. Two distinct clusters were identified: with movement (high: 533 [45.56%]; low: 637 [54.44%]) and at rest (high: 363 [31.03%]; low: 807 [68.97%]). Patients in the high pain trajectory group (during movement [odds ratio [OR] 2.04, 95% CI 1.56-2.68] or at rest [OR 1.90, 95% CI 1.44-2.53]) exhibited nearly doubled risk of CPSP. Moreover, these patients exhibited a significantly poorer recovery quality. Mediation analyses revealed that the poor recovery quality at postoperative 5days (17.62%-18.57%) and higher subacute pain at postoperative 1month (29.46%-32.75%) were significant mediators in the association between adverse postoperative acute pain trajectory patterns and CPSP. This study highlights the clinical significance of postoperative pain trajectory profiles in predicting the risk of CPSP, emphasizing postoperative acute pain trajectory as a critical indicator and subacute pain as a significant mediator. The findings underscore the potential for tailored pain management strategies targeting acute pain trajectories to reduce such risk.

Controlling postoperative pain after spinal surgery is important for rehabilitation and patient satisfaction. Wound infiltration with local anesthetics may improve postoperative pain, but true multimodal approaches for achieving analgesia after spinal surgery remain unknown. In this randomized, controlled, double-blind trial after lumbar interbody fusion, we asked: (1) Does multimodal analgesia reduce VAS pain scores by a clinically important amount? (2) Does this analgesic approach reduce the amount of morphine patients consume after surgery? (3) Is this approach associated with fewer opioid-related side effects after surgery? This study included 80 adult patients undergoing lumbar interbody fusion who were randomized into two groups: A control group (n = 40) who received infiltration of the surgical incision at the end of the procedure with an injection of 0.5% bupivacaine 100 mg (20 mL) and epinephrine 0.5 mg (0.5 mL), and the multimodal group (n = 40), who received wound infiltration with the same approach but with different medications: 0.5% bupivacaine 92.5 mg (18.5 mL), ketorolac 30 mg (1 mL), morphine 5 mg (0.5 mL), and epinephrine 0.5 mg (0.5 mL). There were no between-group differences in the proportion of patients who were male, nor in the mean age, height, weight, preoperative pain score, or surgical time. All treatments were administered by one surgeon. All patients, the surgeon, and the researchers were blinded to the allocation of patients to each group. Pain at rest was recorded using the VAS. Postoperative morphine consumption (administered using a patient-controlled analgesia pump) and opiod-associated side effects including nausea/vomiting, pruritus, urinary retention, and respiratory depression were assessed; this study was analyzed according to intention-to-treat principles. No loss to follow-up or protocol deviations were noted. We considered a 2-cm change on a 10-cm scale on the VAS as the minimum clinically important difference (MCID). Differences smaller than this were considered unlikely to be important. At no point were there between-group differences in the VAS scores that exceeded the MCID, indicating no clinically important reductions in pain associated with administering multimodal injections. The highest treatment effect was observed at 3 hours that showed only a -1.3 cm mean difference between the multimodal and the control groups (3.2 ± 1.8 versus 4.5 ± 1.9 [95% CI -1.3 to -0.3]; p < 0.001), which was below the MCID. Morphine consumption was very slightly higher in the control group than in the multimodal group (2.8 ± 2.8 versus 0.3 ± 1.0, mean difference 2.47; p < 0.001). The percentage of patients reporting opioid-related side effects was lower in the multimodal group than in the control group. The proportions of nausea and vomiting were higher in the control group (30% [12 of 40] than in the multimodal group (3% [1 of 40]; p = 0.001). All of these side effects were transient and none was severe. Multimodal wound infiltration with an NSAID and morphine did not yield any clinically important reduction in pain or opioid consumption. Since no substantial benefit of adding these drugs to a patient's aftercare regimen was achieved, and considering the potential risks of administering opioids and NSAIDs (such as, polypharmacy in older patients, serious adverse effects of NSAIDs), we recommend against routine use of this approach in clinical practice. Level I, therapeutic study.

IntroductionCosmetic breast surgery is commonly performed in the United States; 520,000 procedures of the total 1.8 million cosmetic surgical procedures performed in 2018 were breast related. Postoperative chronic pain, defined as lasting 3 or more months, has been reported in a wide variety of breast surgical procedures including breast augmentation, reduction mammaplasty, mastectomy, and mastectomy with reconstruction. Patient characteristics associated with the development of postoperative chronic pain following cosmetic breast surgery include a younger age, larger BMI, smaller height, postoperative hyperesthesia, and elevated baseline depression, anxiety, and catastrophizing scores. The anatomical distribution of chronic pain following breast augmentation procedures is dependent upon incision site placement; pectoral and intercostal nerves have been implicated. The purpose of this review is to provide an update on the current literature addressing the pathophysiology, clinical presentation, and treatment of patients presenting with chronic postoperative pain following cosmetic breast surgery.MethodsA comprehensive literature review was performed in MEDLINE, PubMed, and Cochrane databases from 1996 to 2019 using the terms “cosmetic surgery”, “breast surgery”, “postoperative pain”, and “chronic pain”.ResultsCosmetic breast surgery can have a similar presentation as post-mastectomy pain syndrome and thus have overlapping diagnostic criteria. Seven domains are identified for a diagnosis of PBSPS: Pain after breast surgery, neuropathic in nature, at least a moderate intensity of pain, as defined as within the middle one-third of the selected pain scale, pain for at least 6 months, symptoms occurring for 12 or more hours a day for a minimum of 4 days each week, pain in at least one of the following sites: breast, chest wall, axilla, or arm on the affected side, pain exacerbated by movement. Patient risk factors and surgical risk factors may influence the development of chronic post-cosmetic surgery breast pain. Improved perioperative analgesia including preoperative regional nerve anesthesia and postoperative catheter infusion have been shown to improve chronic postoperative pain outcomes.ConclusionsThe present review provides a discussion of clinical presentation, pathophysiology, and treatment and preventative strategies for chronic breast pain following cosmetic surgery. This review provides evidence from multiple randomized controlled trials (RCTs) and systematic reviews of efficacy and effectiveness. While chronic postoperative breast pain remains challenging to treat, various preventative strategies have been described to improve postoperative pain outcomes.

Influence of anaesthetic and analgesic techniques on outcome after surgery

Purpose:To identify factors contributing to persistent postoperative pain in patients treated surgically for idiopathic scoliosis.Methods:In total, 280 patients aged ten through 25 years at surgery, were identified in the Swedish Spine registry; all having preoperative and postoperative visual analogue scale (VAS) for back pain scores. The patients were divided into a high and low postoperative pain group based on the reported postoperative VAS for back pain scores (by using 45 mm on the 0 mm to 100 mm VAS scale as a cut-off). The patient-reported questionnaire included VAS for back pain, the 3-level version of EuroQol 5-dimensional (EQ-5D-3L) instrument, the EuroQol VAS (EQ-VAS) and the Scoliosis Research Society 22r instrument (SRS-22r). Predictors of postoperative back pain were searched in the preoperative data.Results:The 67 (24%) patients that reported high postoperative VAS back pain (> 45 mm) also reported lower postoperative EQ-5D-3L, EQ-VAS and SRS-22r than patients with low postoperative VAS back pain (all p < 0.001). Two preoperative variables were independently associated with postoperative pain; each millimetre increase in preoperative VAS back pain (on the 0 mm to 100 mm scale) was associated with a higher risk of being in the high postoperative back pain group (odds ratio (OR) 1.03; 95% confidence interval (CI) 1.02 to 1.05) and each 1 point decrease on the preoperative SRS-22r mental health (scale from 1 to 5) was associated with a higher risk of being in the high postoperative back pain group (OR 1.68; 95% CI 1.03 to 2.73).Conclusion:High preoperative back pain and low preoperative mental health are independent predictors of back pain after surgery for idiopathic scoliosis.Level of Evidence:III

Effective management of postoperative pain remains a significant challenge after breast surgery. Among the available strategies, regional nerve blocks play a key role in alleviating surgical pain in these patients. This study was aimed to evaluate and compare the analgesic efficacy of two regional techniques-erector spinae plane block (ESPB) and serratus posterior superior intercostal plane block (SPSIPB)-in patients undergoing breast surgery. This study included 50 female patients aged 18 to 65 years, classified as ASA physical status I-III, with a body mass index ranging from 18 to 35kg/m², who were scheduled to undergo unilateral breast cancer surgery. Based on random group allocation, either ESPB or SPSIPB was administered before the induction of general anesthesia. Postoperative analgesia was provided using a tramadol-based patient-controlled analgesia (PCA) system. Pain intensity was assessed with the visual analog scale (VAS) at specific predetermined time points: immediately postoperatively (0h), and at 1, 4, 8, 12, and 24h. The primary outcome was postoperative pain intensity assessed using the VAS at predetermined time points. Secondary outcomes included total opioid consumption via PCA, requirement for rescue analgesia, incidence of postoperative nausea/vomiting (PONV), block performance time, side effects, and patient satisfaction. There were no significant differences in VAS scores at rest or during coughing between the two groups at any of the assessed postoperative time points (0, 1, 4, 8, 12, and 24h) (p > 0.05). A statistically significant difference in postoperative tramadol consumption was observed between the groups, with the ESPB group receiving 137.6 ± 124mg and the SPSIPB group receiving 82.4 ± 102mg via PCA, corresponding to an average reduction of 55.2mg in the SPSIPB group (p = 0.044). The difference in consumption was due to the difference in consumption between 4 and 8h. In the ESPB group, the average tramadol consumption during this period was 75.2mg, while in the SPSIPB group, it was 36.8mg (p = 0.007). No significant differences were found between the groups regarding PONV, side effects, patient satisfaction, and duration of blocks. The SPSIPB may provide postoperative analgesia that is comparable in efficacy to the ESPB technique in breast surgery. Based on the findings of this study, SPSIPB provided postoperative analgesia comparable to ESPB and was associated with lower opioid consumption within the first 24h after surgery. Furthermore, the ESPB group experienced pain relief earlier after surgery compared to the SPSIPB group, while pain relief in the SPSIPB group occurred later and lasted longer.

Efficacité des techniques d'analgésie locorégionale après chirurgie du sein : une méta-analyse