A French nationwide survey on the practice of regional anesthesia for breast cancer surgery.

BACKGROUND: The aim of this study was to assess the impact of recent recommendations concerning regional anesthesia for breast cancer surgery, a nationwide practice survey was carried out. METHODS: This cross-sectional electronic survey, conducted in 2021, collected answers from a panel of anesthetists currently working in French practicing centers. It addressed the sets of techniques they practiced for every type of surgical procedure and their perceptions of the difficulties and risks associated with these techniques. RESULTS: The practice of regional anesthesia was generally high (70%), involving all the current types of blocks. Surgeon-done infiltration was popular for lumpectomy only. For the other current procedures, the pectoralis nerve blocks were preferred to the paravertebral block, which was favored for mastectomies, when a lymph node harvesting was planned, or for immediate or delayed pedicle flap. Catheters were mostly used for mastectomies with pedicle flap. The erector spinae plane block was emergent. Whatever the type of block, regional anesthesia was preferentially started before surgery. Despite some deviations such as the adjunction of unlabeled molecules, the practice fitted well with the European recommendations, but training and within-center guidance lacked standardization. For each block, actual practice, perceived difficulty, and risk were inter-correlated, but paravertebral block - either practiced or not - was considered as more difficult and riskier to perform than any other. CONCLUSIONS: These encouraging results do not dispense with the need to improve anesthetic practices both in quantity and quality. Such improvement in the anatomic fit to the procedure and in the timing of blocks will also have to be considered.

Preoperative Paravertebral Block and Chronic Pain after Breast Cancer Surgery: A Double-blind Randomized Trial.

BACKGROUND: The effectiveness of paravertebral block in preventing chronic pain after breast surgery remains controversial. The primary hypothesis of this study was that paravertebral block reduces the incidence of chronic pain 3 months after breast cancer surgery. METHODS: In this prospective, multicenter, randomized, double-blind, parallel-group, placebo-controlled study, 380 women undergoing partial or complete mastectomy with or without lymph node dissection were randomized to receive preoperative paravertebral block with either 0.35 ml/kg 0.75% ropivacaine (paravertebral group) or saline (control group). Systemic multimodal analgesia was administered in both groups. The primary endpoint was the incidence of chronic pain with a visual analogue scale (VAS) score greater than or equal to 3 out of 10, 3 months after surgery. The secondary outcomes were acute pain, analgesic consumption, nausea and vomiting, chronic pain at 6 and 12 months, neuropathic pain, pain interference, anxiety, and depression. RESULTS: Overall, 178 patients received ropivacaine, and 174 received saline. At 3 months, chronic pain was reported in 93 of 178 (52.2%) and 83 of 174 (47.7%) patients in the paravertebral and control groups, respectively (odds ratio, 1.20 [95% CI, 0.79 to 1.82], P = 0.394). At 6 and 12 months, chronic pain occurred in 104 of 178 (58.4%) versus 79 of 174 (45.4%) and 105 of 178 (59.0%) versus 93 of 174 (53.4%) patients in the paravertebral and control groups, respectively. Greater acute postoperative pain was observed in the control group 0 to 2 h (area under the receiver operating characteristics curve at rest, 4.3 ± 2.8 vs. 2.9 ± 2.8 VAS score units × hours, P < 0.001) and when maximal in this interval (3.8 ± 2.1 vs. 2.5 ± 2.5, P < 0.001) but not during any other interval. Postoperative morphine use was 73% less in the paravertebral group (odds ratio, 0.272 [95% CI, 0.171 to 0.429]; P < 0.001). CONCLUSIONS: Paravertebral block did not reduce the incidence of chronic pain after breast surgery. Paravertebral block did result in less immediate postoperative pain, but there were no other significant differences in postoperative outcomes.

Analgesic and opioid-sparing effects of single-shot preoperative paravertebral block for radical mastectomy with immediate reconstruction: A retrospective study with propensity-adjusted analysis.

BACKGROUND: Before radical mastectomy with immediate latissimus dorsi flap reconstruction, single-shot paravertebral block (PVB) can be added to general anesthesia to improve analgesia. As this technique was introduced in 2014 in our centre, our aim was to retrospectively assess its clinical effects. METHODS: Among 175 patients who underwent surgery over four years (40 receiving PVB), we studied the intra-operatively administered doses of opioids and vasopressors, postoperative pain as estimated by a composite score based on the intensity scores for maximum postoperative pain and the amounts of analgesic drugs, and the report of postoperative nausea/vomiting (PONV). The effect of PVB on these outcomes was tested by propensity-matched comparisons, after a propensity score based on the patient's age, body mass index, ASA and Apfel scores, was calculated. Depending on the outcomes, results are expressed as odds ratios (OR) or regression coefficients (RC), with their 95% confidence interval limits. RESULTS: PVB reduced the doses of intraoperative opioids (OR for comparisons between the 2nd and 3rd tercile to the 1st tercile, respectively: 0.39 (0.21; 0.67) and 0.10 (0.05; 0.21)). It increased the doses of intraoperative vasopressors (CR = 1.94 (0.89; 2.93). It reduced the composite score for postoperative pain (CR = -0.80 (-1.04; -0.56), and the occurrence of PONV (OR = 0.21 (0.14; 0.37). CONCLUSIONS: Despite a higher risk of intraoperative hypotension, single-shot PVB seems to markedly improve postoperative analgesia and reduce the amounts of opioids. This could offer many clinical advantages in this type of cancer surgery.

Continuous Wound Infiltration With Ropivacaine After Mastectomy: A Randomized Controlled Trial.

BACKGROUND: To evaluate the efficacy of continuous wound infiltration with ropivacaine to reduce acute postoperative pain in patients undergoing mastectomy for carcinoma of the breast. MATERIALS AND METHODS: A randomized, double-blind, placebo-controlled trial was conducted. One hundred fifty patients were randomly assigned to receive continuous ropivacaine (0.2%) (group A, n = 74) or saline solution (0.9%) (group B, n = 76) at 10 mL/h for 48 h through a multilumen catheter placed during the surgical procedure. Postoperative morphine consumption and visual analog scale (VAS) pain scores were recorded. A quality of life score (Quality of life questionnaire Core 30) and a VAS score were obtained at 1, 3, and 6 mo after surgery. RESULTS: The difference in mean morphine consumption between the two groups was close to significance during the first 48 h postsurgery (P = 0.056; 10.8 ± 16.5 versus 4.8 ± 10.4 mg). At day 1, patients in the ropivacaine-infusion group had lower morphine consumption than the control group (P = 0.0026). The link between local ropivacaine infiltration and a decrease in mean postoperative VAS scores reached significance for the first 24 h postsurgery (P = 0.039). No significant difference was found between the two arms for VAS pain scores (P = 0.36) or for quality of life (overall QLQ-C30 score, P = 0.09) at 1, 3, or 6 mo. CONCLUSIONS: Continuous wound infiltration with ropivacaine is efficacious in reducing postoperative pain. Quality of life and chronic pain at 1, 3, and 6 mo were not improved by ropivacaine wound infiltration.

A French Nationwide Survey on Anesthesiologist-Perceived Barriers to the Use of Epidural and Paravertebral Block in Thoracic Surgery.

OBJECTIVES: To explore the barriers to the use of epidural block (EDB) or paravertebral block (PVB) for thoracotomy or thoracoscopy. DESIGN: Cross-sectional ancillary study. SETTING: French nationwide practice survey. PARTICIPANTS: Lead anesthesiologists at centers practicing thoracic surgery completed an online questionnaire. INTERVENTIONS: A 9-item electronic questionnaire regarding perceived barriers to the use of EDB and PVB was developed, including technical factors, nursing factors (training and supervision), and reluctance of non-anesthesiologist colleagues (eg, surgeons, nurses and hospital managers). Descriptive and factorial analyses were conducted, including the current use of the techniques in the model. MEASUREMENTS AND MAIN RESULTS: The questionnaire was answered by 84 of 103 (82%) centers. For both techniques, the most frequently cited barriers were the 4 technical ones and lack of nursing supervision. There was a high rate of do not know/no opinion responses regarding barriers to paravertebral block. The type of center did not influence the responses, but paravertebral block was used more often in university hospitals. Colleague reluctance and time consumption (for both techniques), nursing barriers (for epidural block), and perception of risk and complexity (for paravertebral block), were correlated inversely with actual use. Perception of cost had no influence on practice. CONCLUSIONS: This survey suggested that the use of epidural or paravertebral block to provide analgesia for thoracic surgery might be increased by multimodal actions focused on improved communication with surgical and managerial teams. Paravertebral block, as an emerging technique, still is insufficiently recognized in France.

Lung postmortem autopsy revealing extramedullary involvement in multiple myeloma causing acute respiratory distress syndrome.

Pulmonary involvement with multiple myeloma is rare. We report the case of a 61-year-old man with past medical history of chronic respiratory failure with emphysema, and a known multiple myeloma (Durie and Salmon stage III B and t(4;14) translocation). Six months after diagnosis and first line of treatment, he presented acute dyspnea with interstitial lung disease. Computed tomography showed severe bullous emphysema and diffuse, patchy, multifocal infiltrations bilaterally with nodular character, small bilateral pleural effusions, mediastinal lymphadenopathy, and a known lytic lesion of the 12th vertebra. He was treated with piperacillin-tazobactam, amikacin, oseltamivir, and methylprednisolone. Finally, outcome was unfavourable. Postmortem analysis revealed diffuse and nodular infracentimetric infiltration of the lung parenchyma by neoplastic plasma cells. Physicians should be aware that acute respiratory distress syndrome not responding to treatment of common causes could be a manifestation of the disease, even with negative BAL or biopsy and could be promptly treated with salvage therapy.

Low Molecular Weight Heparin Induced Skin Necrosis without Platelet Fall Revealing Immunoallergic Heparin Induced Thrombocytopenia.

Low molecular weight heparins (LMWH) are commonly used in the ICU setting for thromboprophylaxis as well as curative decoagulation as required during renal replacement therapy (RRT). A rare adverse event revealing immunoallergic LMWH induced thrombopenia (HIT) is skin necrosis at injection sites. We report the case of a patient presenting with skin necrosis witnessing an HIT after RRT, without thrombocytopenia. The mechanism remains unclear. Anti-PF4/heparin antibodies, functional tests (HIPA and/or SRA), and skin biopsy are of great help to evaluate differential diagnosis with a low pretest probability 4T's score.