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Intraoperative Nerve Blocks for Tissue Expander Breast Reconstruction: Results of a Prospective, Double-Blind, Randomized, Placebo-controlled Trial
Steven T. Lanier, MD, Mark C. Kendall, MD, Kevin C. Lewis, B.S., Brittany L. Vieira, B.S., John YS Kim, MD, Mohammed Alghoul, MD.
Northwestern University, Chicago, IL, USA.

Purpose: We investigate whether intraoperative nerve blocks improve the quality of recovery from immediate tissue expander/implant breast reconstruction. No current Level I or II evidence addresses this question.
Methods: A prospective, randomized, double-blinded, placebo–controlled, clinical trial was conducted in which patients undergoing immediate tissue expander/implant based 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. The 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.
Results: 45 total subjects were enrolled. There were no statistically significant differences in quality of recovery, pain burden, or opioid consumption between groups at 24 hours following surgery. The difference in overall QoR 40 score approached clinical significance, and data trended towards reduced total opioid consumption and better pain control in PACU in the treatment group.1 Both groups had a good quality of recovery. There were no injection-related complications.
Conclusions: Intraoperative nerve blocks can be a safe and effective adjunct to a comprehensive regimen to improve quality of recovery and pain control following tissue expander/implant breast reconstruction.
Table: Quality of Recovery and opioid consumption during hospital stay0.25 % bupivacaine + 4 mg dexamethasone injection
(n=23)
Placebo
(n=22)
P
Quality of recovery (QOR-40)a
Physical Comfort
Emotional State
Physical independence
Psychological support
Pain
Global
51 (47 to 55)
40 (35 to 42)
19 (16 to 22)
34 (31 to 35)
29 (26 to 31)
169 (155 to 182)
49 (44 to 54)
38 (35 to 41)
18 (15 to 21)
35 (32 to 35)
29 (24 to 31)
165 (143 to 179)
0.36
0.21
0.70
0.86
0.63
0.36
Opioid consumption received in post-anesthesia care unit (mg morEq)*8 (0 to 20)17 (0 to 30)0.26
Total opioid consumption 24 h (mg morEq) ††92 (44 to 142)114 (69 to 161)0.31
Pain Score post-surgery
(NRS 0-10)
Upon arrival to PACU
3 h
6 h
12 h
24 h
3 (0 to 6)
4 (4 to 6)
4 (3 to 6)
5 (3 to 6)
4 (3 to 6)
5 (2 to 7)
5 (3 to 7)
5 (2 to 7)
4 (3 to 6)
4 (2 to 6)
0.15
0.33
0.87
0.98
0.45
Pain burden† at 24 h
(score·hours)
61 (43 to 76)64 (42 to 70)0.89
Length of hospital stay, d1 (1 to 1)1 (1 to 1)0.41
Data presented as median (interquartile range). a= quality of recovery assessed using a (QoR-40) questionnaire at 24 hours following surgery (range 40 is very bad recovery to 200 which is outstanding recovery). * = IV Fentanyl/Dilaudid given in PACU converted to mg morphine equivalents when NRS pain score was ≥ 4 out of 10 as assessed by nursing personnel. ††Total opioid consumption starting from phase 2 discharge from PACU to 24hr post-surgery. †Area under the curve pain scores at rest calculated using the trapezoid method. PACU = post-anesthesia care unit, NRS = pain numeric rating scale, where 0 means “no pain at all” and 10 is the “worst pain imaginable.”

1.
Anesthesiology. 2016 Jul;125 (1):39-45.


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