Perioperative Blocks for Decreasing Postoperative Narcotics in Breast Reconstruction.

CONTEXT: High rates of mortality and chemical dependence occur following the overuse of narcotic medications, and the prescription of these medications has become a central discussion in health care. Efforts to curtail opioid prescribing include Enhanced Recovery After Surgery (ERAS) guidelines, which describe local anesthesia techniques to decrease or eliminate the need for opioids when used in a comprehensive protocol. Here, we review effective perioperative blocks for the decreased use of opioid medications post-breast reconstruction surgery. EVIDENCE ACQUISITION: A comprehensive review was conducted using keywords narcotics, opioid, surgery, breast reconstruction, pain pump, nerve block, regional anesthesia, and analgesia. Papers that described a local anesthetic option for breast reconstruction for decreasing postoperative narcotic consumption, written in English, were included. RESULTS: A total of 52 papers were included in this review. Local anesthetic options included single-shot nerve blocks, nerve block catheters, and local and regional anesthesia. Most papers reported equal or even superior pain control with decreased nausea and vomiting, length of hospital stay, and other outcomes. CONCLUSIONS: Though opioid medications are currently the gold standard medication for pain management following surgery, strategies to decrease the dose or number of opioids prescribed may lead to better patient outcomes. The use of a local anesthetic technique has been shown to reduce narcotic use and improve patients' pain scores after breast reconstruction surgery.

Additives to local anesthetics for peripheral nerve blocks: Evidence, limitations, and recommendations.

PURPOSE: The therapeutic rationale, clinical effectiveness, and potential adverse effects of medications used in combination with local anesthetics for peripheral nerve block therapy are reviewed. SUMMARY: A wide range of agents have been tested as adjuncts to peripheral nerve blocks, which are commonly performed for regional anesthesia during or after hand or arm surgery, neck or spine surgery, and other procedures. Studies to determine the comparative merits of nerve block adjuncts are complicated by the wide variety of coadministered local anesthetics and sites of administration and by the heterogeneity of primary endpoints. Sodium bicarbonate has been shown to speed the onset of mepivacaine nerve blocks but delay the onset of others. Epinephrine has been shown to prolong sensory nerve blockade and delay systemic uptake of local anesthetics, thus reducing the risk of anesthetic toxicity. Tramadol, buprenorphine, dexamethasone, and clonidine appear to be effective additives in some situations. Midazolam, magnesium, dexmedetomidine, and ketamine cannot be routinely recommended as nerve block additives due to a dearth of supportive data, modest efficacy, and (in the case of ketamine) significant adverse effects. Recent studies suggest that administering additives intravenously or intramuscularly can provide many of the benefits of perineural administration while reducing the potential for neurotoxicity, contamination, and other hazards. CONCLUSION: Some additives to local anesthetics can hasten the onset of nerve block, prolong block duration, or reduce toxicity. On the other hand, poorly selected or unnecessary additives may not have the desired effect and may even expose patients to unnecessary risks.