Paravertebral or serratus anterior plane block combined with PECS I (interpectoral) blocks versus paravertebral block for mastectomy: A cluster-randomized trial of 1507 patients.
Academic Article
Overview
abstract
BACKGROUND: While paravertebral block is a well-established regional anesthetic technique for breast surgery, evidence for fascial plane blocks and combined block approaches is limited. Furthermore, the optimal block approach for mastectomy with expander reconstruction remains unclear. We hypothesized that combining PECS I (interpectoral) nerve blocks with either paravertebral or serratus anterior plane blocks would reduce opioid use after mastectomy with expander reconstruction compared with paravertebral block alone. METHODS: This was a single-center, cluster-randomized, clinically integrated trial. Patients undergoing bilateral mastectomy with immediate expander reconstruction were randomized by month to receive paravertebral, paravertebral plus PECS I, or serratus anterior plane plus PECS I blocks. The primary outcome was postoperative opioid consumption. Secondary outcomes included postoperative pain scores and antiemetic use, discharge time, adverse events, chronic pain, and patient-reported quality of recovery. The primary analysis compared the combined block groups, paravertebral plus PECS I and serratus anterior plane plus PECS I blocks, with the paravertebral block group. RESULTS: 1507 patients were randomized between 2019 and 2023: 492 to paravertebral blocks, 446 to paravertebral plus PECS I blocks, and 568 to serratus anterior plane plus PECS I blocks. Rates of high postoperative opioid use were 26%, 27% and 22% respectively, with a non-significant 1.9% lower rate in patients who received any combination block, paravertebral plus PECS I or serratus anterior plane plus PECS I blocks (95% CI -2.7%, 6.5%, p=0.4). There were no significant differences for any secondary outcomes when accounting for multiple testing. CONCLUSION: Paravertebral or serratus anterior plane blocks combined with PECS I blocks were not superior to paravertebral block alone in reducing high opioid use after bilateral mastectomy with expander reconstruction. All three block approaches are acceptable techniques for this procedure. Choice of block should be based on clinician expertise, patient-specific factors, and safety considerations.
