Regional block pilot for microvascular free-flap breast reconstruction.

Abstract

e18646 Background: With increasing focus on improving patient outcomes and decreasing narcotic use, healthcare has prioritized the use of multidisciplinary, multimodal, and evidence-based approaches to perioperative management through enhanced recovery after surgery (ERAS) pathways. Currently, microsurgical breast reconstruction with or without concurrent mastectomy commonly may employ regional anesthesia in the preoperative and intraoperative techniques. To optimize perioperative analgesia, an ERAS protocol was piloted at a quaternary care academic center implementing a pre-operative anesthesia placed regional block with preference for anterior quadratum lumborum blocks. Methods: A total of 161 patients were enrolled in this single center Continuous Quality Improvement (CQI) project. The project consisted of 72 baseline, 20 pilot, and 69 after pilot patients who underwent unilateral (n = 65) or bilateral (n = 96) deep inferior epigastric perforator (DIEP) flap reconstruction either immediately (n = 87) or delayed (n = 74) after mastectomy. In the 20 CQI pilot group, anesthesiologists pre-operatively placed bilateral anterior quadratus lumborum blocks (aQLB) under direct ultrasound guidance. After positively observed metrics, the official ERAS pathway was implemented into clinical practice, allowing for subsequent accrual of 69 additional patients. We compared this after pilot group to 72 baseline patients who underwent a surgeon-placed intraoperative transversus abdominus plane (TAP) block using liposomal bupivacaine. Statistics data was tracked using a dedicated clinical EMR dashboard. Baseline patients were matched to the after pilot cohort based on laterality and timing of DIEP flap reconstruction. Results: The ERAS pathway with anesthesia-placed aQLB was associated with lower post-operative daily opioid consumption from 27.2 MME to 10.2 MME. Average pain scores, post-anesthesia care unit (PACU) length of stay, hospital length of stay, as well as re-admissions and complications were not statistically different before and after the implementation of the ERAS pathway. Conclusions: Anesthesia placed pre-operative aQLB is a safe and effective opioid-reducing pain control modality for DIEP flap reconstruction with or without mastectomy. Prospective and controlled studies will be important for the precise impacts of aQLB in DIEP procedures in an ERAS protocol.[Table: see text]