Buxhoeveden, Michael

Dhillon, Sabrina

Li, Jialiu D.

Nguyen, Yvonne, MD

English

VCU Scholars Compass

Virginia Commonwealth University VCU Scholars Compass Graduate Medical Education (GME) Resident and Fellow Research Day Posters VCU Health 2020 Erector Spinae Plane Block and Improved Perioperative Outcomes in Breast Brachytherapy Jialiu D. Li Virginia Commonwealth University Yvonne Nguyen MD Virginia Commonwealth University Michael Buxhoeveden Virginia Commonwealth University Sabrina Dhillon Virginia Commonwealth University Follow this and additional works at: https://scholarscompass.vcu.edu/gme_posters  Part of the Medicine and Health Sciences Commons  © The Author Downloaded from https://scholarscompass.vcu.edu/gme_posters/29 This Clinical Science Research is brought to you for free and open access by the VCU Health at VCU Scholars Compass. It has been accepted for inclusion in Graduate Medical Education (GME) Resident and Fellow Research Day Posters by an authorized administrator of VCU Scholars Compass. For more information, please contact libcompass@vcu.edu. Erector Spinae Plane Block and Improved Perioperative Outcomes in Breast BrachytherapyBreast cancer is the leading cause of both cancer and cancer-related death in females in the United States [1]. Breast brachytherapy has emerged as an adjunct and monotherapy in this population. Studies have found improved outcomes with adjuvant brachytherapy with decreased mortality and reduction in recurrence [2, 3]. With the growing implementation of breast brachytherapy, anesthetic management of these patients needs to be optimized. This patient population often requires multiple hospital visits for treatments and may have multiple comorbidities that increase the risk of perioperative complications. Regional anesthesia is commonly used as the principal technique for brachytherapy gynecologic and urologic cases, but data is lacking on the efficacy of adjuvant use of regional anesthesia for breast brachytherapy procedures [4]. BackgroundA retrospective pilot study was completed with patients that underwent breast brachytherapy interventions in an ambulatory setting. As per institutional guidelines, this study was reviewed by Virginia Commonwealth University (VCU) Health Medical Center IRB board, and it is exempt from IRB review requirements as per Virginia Commonwealth University’s (VCU) Office of Research and Innovation policy as the study is devoid of patient identifiable information and consists of a population not generalizable outside of VCU.Materials and MethodsESP blocks have been well documented in providing analgesia for rib fracture patients as well as larger breast reconstruction and mastectomy surgeries; however, there has been little to no data for its utilization in breast brachytherapy or in ambulatory care centers. Our literature review revealed that use of ESP blocks in elective, inpatient, breast cancer surgery could reduce postoperative opioid use by as much as 65% in the first 24 hours [5, 6]. Our study, while limited in number of subjects, showed a similar trend in reduction of postoperative opioid use after breast brachytherapy treatment. With the prevalence of breast brachytherapy as part of treatment of breast cancer, our data analysis shows promise for further expansion of this regional technique. Given that this is a novel approach to anesthesia management in breast brachytherapy, our study was limited with a small sample size as a pilot study. In the future, having a more robust study size with additional quality metrics would allow for a more complete characterization of this approach to anesthesia management in breast brachytherapy.DiscussionFrom a group of 49 patients, we randomly selected 11 patients without perioperative ESP blocks as a control group and 3 patients with perioperative ESP blocks for a total of 14 participants. Patient demographic information was collected including age (years), body mass index (BMI) and American Society of Anesthesiology Class (ASA 1-4).Upon arrival to the preoperative assessment area, eligible patients were identified and after discussion with the patient and surgeon, ESP blocks were offered to appropriate patients. Patients in the ESP cohort received an ultrasound-guided erector spinae plane block either unilaterally or bilaterally depending on the laterality of the procedure. These patients received 0.25% ropivacaine as a single shot injection under continuous ultrasound guidance with sterile technique. Study participants proceeded under general anesthesia or monitored sedation depending on the anesthetic plan appropriate for each patient for their surgical procedure.After the surgical procedure, patients were monitored in the Radiation Oncology recovery area, where pain scores were documented by nursing staff with verbal quantitative values (scale 0-10, 0 being no pain and 10 being the worst pain). Opioid use was documented intraoperatively in the anesthesia charting and postoperatively by nursing staff, and these values were converted to average morphine equivalents to evaluate pain control. Time from the patient’s procedure to discharge were recorded. Unpaired t-test analyses were done to compare the control group versus the sample population to look for statistical significance in pain scores in the postoperative period, overall opioid use and length of stay after procedures.Materials and Methods ContinuedLi J., Nguyen Y., Buxhoeveden M., Dhillon S. Department of Anesthesiology, Virginia Commonwealth University Health System, Richmond, VA1. “Cancer Today.” Edited by GLOBOCAN Project, Global Cancer Observatory, International Association of Cancer Registries, World Health Organization, Mar. 2019, gco.iarc.fr/today/fact-sheets-cancers.2. Early Breast Cancer Trialists’ Collaborative Group (EBCTG), S Darby, P McGale, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: Meta-analysis of individual patient data on 10,801 women in 17 randomised trials. Lancet, 378 (2011), pp. 1707-17163. Shah, Chirag, et al. “Modern Approaches for Breast Brachytherapy.” Seminars in Radiation Oncology, vol. 30, no. 1, 2020, pp. 61–67., doi:10.1016/j.semradonc.2019.08.004.4. Benrath, J, et al. “Anaesthesia for Brachytherapy—5½ Yr of Experience in 1622 Procedures.” British Journal of Anaesthesia, vol. 96, no. 2, 2006, pp. 195–200., doi:10.1093/bja/aei301.5. Aksu, C. (2019). Analgesic Effect of Bi-Level Injection Erector Spinae Plane Block After Breast Surgery: A Randomized Controlled Trial. Ağrı - The Journal of The Turkish Society of Algology. doi: 10.14744/agri.2019.61687ReferencesESP Block GroupControl GroupAge 59 60BMI 40.7 29.4ASA 2.67 2.1Table 1: Patient DemographicsThis study aimed to evaluate the efficacy of erector spinae plane (ESP) blocks for perioperative pain management in respect to overall pain scores, opioid usage and length of stay in breast brachytherapy cases. We hypothesized that the use of ESP blocks would be associated with reduced postoperative pain scores, decrease opioid requirements and length of stay.PurposePostoperative morphine equivalent consumption was significantly lower in the ESP group compared to the control group (mean of 0 vs. 1.82, respectively; p = 0.02; Graph 1). Average immediate postoperative pain score was significantly lower for the ESP group compared to the control group (mean of 1.67 vs. 4.64, respectively; p = 0.025, Graph 2). Average pain score at time of discharge was lower for the ESP group compared to the control group but not statistically significant (mean of 1.67 vs. 2.73, respectively; p = 0.23). Lastly, length of stay was significantly lower in the ESP group compared to the control group (mean of 3.67 vs. 5.36, respectively, p= 0.036, Graph 3).ResultsFigure 1: Cancer Related Mortality Rates in Females Worldwide Figure 2: Incidence of Cancer in Females in USImage 1 & 2: Ultrasound approach to ESPGraph 1: Postoperative Morphine Equivalent Use; Average postoperative equivalent use was significantly lower in study group (0) versus control group (1.82); p = 0.02.Graph 2: Immediate Postoperative Pain Score; . Average immediate postoperative pain score was significantly lower in study group (1.67 out of 10) versus control group (4.64 out of 10); p = 0.02.Graph 3: Length of Postoperative Stay; Average hours of postoperative stay was significantly lower in study group (3.67 hours) versus control group (5.36 hours); p = 0.03.The use of erector spinae plane block in the setting of breast brachytherapy is a novel technique that can help significantly reduce opioid use in the postoperative setting as well as reduce the length of recovery in the post-anesthesia recovery unit. Anesthesia management and regional techniques for breast brachytherapy require further research as an increasing number of patients are enrolling in this treatment modality. Erector spinae plane blocks appear to be an effective means of pain management, but additional research is required to determine if it becomes a staple technique for breast brachytherapy cases.Conclusions

Erector Spinae Plane Block and Improved Perioperative Outcomes in Breast Brachytherapy

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Erector Spinae Plane Block and Improved Perioperative Outcomes in Breast Brachytherapy

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