Procedure-specific postoperative pain management awareness survey for oncologic breast surgery

Authors

Abstract

Aim It was aimed to investigate the compliance and attitudes of senior anesthesia assistants, specialist physicians, and faculty members in Türkiye with PROSPECT recommendations for oncological breast surgery (OBS).
Materials and Methods The survey, consisting of 24 questions, was sent to participants electronically. The answers to the questions were evaluated according to the PROSPECT recommendations for OBS.
Results In general pain management, the faculty members tend to prefer regional methods, while the specialists and the assistants tend to prefer IV analgesics. Physicians had similar attitudes among the medical career groups regarding the administration of acetaminophen, NSAIDs, gabapentin, dexamethasone, and opioids. While the faculty members had attitudes more compatible with the PROSPECT recommendations in recommended regional methods such as local anesthetic infiltration, paravertebral block, and PECS block, the faculty members and the assistants had attitudes incompatible with the PROSPECT recommendations in retrolaminar block, erector spinae plan block, and transvers thoracic plan block, for which there are no recommendations yet.
Discussion This study revealed the compliance levels of anesthesia and reanimation physicians, including senior anesthesia residents in Türkiye, with the PROSPECT recommendations in the OBS. Compliance with the PROSPECT recommendations of specialists and anesthesia assistants can be increased through postgraduate practical training programs with the provision of an organized multidisciplinary approach by authorized institutions.

Keywords

Introduction

Oncologic breast surgery (OBS) is related to postoperative pain, whether acute or chronic [1]. A study was conducted in collaboration with PROSPECT in 2006 [2]. Subsequently, due to advances in pain management, an updated systematic review on pain management was carried out again in OBS in 2020. This guideline provides clinicians with evidence-based recommendations for pain management following OBS [3].
PROSPECT recommends that basic analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), etc.) be administered preoperatively or intraoperatively and maintained postoperatively in OBS. Additionally, preoperative gabapentin and dexamethasone are also recommended. In OBS, it is reported that regional anesthesia techniques (paravertebral block (PVB), pectoral nerve block (PECS), and local anesthetic wound infiltration (LAI), etc.) can be taken into account additionally for pain relief, and PVB can be maintained by making use of postoperative catheter techniques. Opioids are recommended as rescue analgesics in the postoperative period. Finally, PROSPECT reports that research is required to appreciate the role of new regional analgesic techniques such as erector spinae plane block (ESP), transverse thoracic plane block (TTP), or retrolaminar plane block (RLP) [3].
Currently, no study has been found in the literature on physicians’ compliance with PROSPECT recommendations in OBS and practice preferences among physicians of the relevant branch. The purpose of this study is to investigate the compliance and attitudes of senior anesthesia assistants, specialists, and faculty members in Türkiye towards PROSPECT recommendations for OBS.

Materials and Methods

This study was conducted between January 15, 2024, and June 15, 2024. Survey data collection was carried out via an electronic data form. The survey was sent electronically to 1200 senior anesthesia assistants (AR-A), anesthesiology and reanimation specialists (AR-S), and anesthesia and reanimation faculty members (AR-T). It was also communicated directly to the participants at the Mustafa Kemal University congress held in 2024.
Since online responses were expected from all individuals in the population in this study, it was concluded that the sample size should be 190 doctors with 95% confidence, considering the highest rate (50%) in the response distribution and predicting a tolerable error of 7%. The survey form was composed of a total of 24 questions evaluating the participants’ personal information, basic approaches to pain management, and compliance with PROSPECT recommendations for OBS. The survey was prepared as a Google Form and presented to the participants in a virtual environment. Participation in the study was provided on a voluntary basis. Consent to participate in the survey was obtained along with the survey, and the identities of the participants were kept confidential. “Senior anesthesia assistants” were defined as anesthesiology and reanimation specialist students who had completed their 3rd year.
Statistical Analysis
In this study, data were evaluated with the SPSS 25 (Armonk, NY: IBM Corp.) program. According to the answers given to the survey, descriptive statistics such as frequency, percentage, mean, standard deviation, median, and interquartile range were used. The relationship between categorical variables was examined utilizing the chi-square test. Student’s t-test and Mann-Whitney U test were utilized for continuous variables. For all calculations, the significance limit was set as p < 0.05.
Ethical Approval
This study was approved by the Ethics Committee of Mustafa Kemal University School of Medicine (Date: 2023-12-25, No: 10/21).

Results

Demographic characteristics of the participants are listed in Supplementary Table S1. In general pain management, faculty members tend to favour regional methods, while the specialists and assistants tend to prefer IV analgesics. The faculty members’ follow-up level of PROSPECT recommendations was high.
Preoperative and intraoperative pain management preferences (Supplementary Table S2):
-The rate of participants’ “pre- or intraoperative use of paracetamol and NSAIDs or selective COX-2 inhibitors in OBS (minor and major)” was 92.6%, and no significant difference was found between the medical career groups (p = 0.127).
-The rate of participants’ “pre- or intraoperative gabapentin use in OBS (minor and major)” was 4.7%, and no significant difference was found between the medical career groups (p = 0.404).
-The rate of participants’ “pre- or intraoperative single-dose dexamethasone use in OBS (minor and major)” was 29.5%, and no significant difference was found between the medical career groups (p = 0.853).
-The rate of participants’ “use of pre- or intraoperative LA infiltration in OBS (minor)” was 47.9%, and a significant difference was found between the medical career groups (p = 0.009).
When examined according to medical career, a significant difference was found between the AR-A and AR-T groups and between the AR-T and AR-S groups (p = 0.024 and p = 0.007, respectively). The faculty members (63.1%) were more consistent with PROSPECT recommendations than the assistants (56.8%) and specialists (37.6%).
-The rate of participants’ “first choice use of preoperative PVB in OBS (major)” was 11.6%, and a significant difference was observed between the medical career groups (p = 0.031).
When examined according to medical career, a significant difference was observed between the AR-T and AR-S groups (p = 0.011). Furthermore, the faculty members (23.6%) demonstrated a higher degree of adherence to the PROSPECT recommendations than the specialists (7.9%).
-The rate of participants’ “intraoperative continuous PVB use if a PVB catheter was inserted in OBS (major)” was 15.3%, and no significant difference was found between the medical career groups (p = 0.098).
-The participants’ rate of “use of PECS block if PVB was contraindicated in OBS (major) or axillary lymph node dissection was not performed” was 56.8%, and a significant difference was observed between the medical career groups (p = 0.0001).
When examined according to the medical career, a significant difference was observed between the AR-A and AR-S groups and between the AR-T and AR-S groups (p = 0.0001 and p = 0.0001, respectively). The faculty members (78.9%) and assistants (76.4%) demonstrated a higher degree of adherence to the PROSPECT recommendations than the specialists (38.6%).
-The rate of participants “using LAI for T1 dermatome if pre- or intraoperative regional anesthesia techniques were used in OBS (major)” was 25.3%, with a significant difference between the medical career groups (p = 0.006). When examined according to the medical career, a significant difference was observed between the AR-T and AR-S groups (p = 0.001). The faculty members (44.7%) were more compatible with the PROSPECT recommendations than the specialists (15.8%).
Postoperative pain management preferences (Supplementary Table S2):
-The rate of participants’ “use of postoperative paracetamol and NSAIDs or selective COX-2 inhibitors, if not contraindicated in OBS (minor and major)” was 92.6%, and no significant difference was found between the medical career groups (p = 0.419).
-The rate of participants’ “postoperative opioid use in OBS (minor and major)” was 76.8%, and no significant difference was found between the medical career groups (p = 0.127).
-The rate of participants’ “continuous postoperative use of PVB if a PVB catheter was inserted in the OBS” was 25.8%, and a significant difference was observed between the medical career groups (p = 0.016).
When examined according to the medical career, a significant difference was observed between the AR-T and AR-S groups (p = 0.003). The faculty members (44.7%) were more compatible with the PROSPECT recommendations than the specialists (16.8%).
Pain management preferences not recommended in the guideline (Supplementary Table S3):
- The rate of participants’ “intraoperative RLP block use in OBS (minor and major)” was 3.2%, and a significant difference was observed between the medical career groups (p = 0.023).
When examined according to the medical career, a significant difference was observed between the AR-A and AR-S groups and between the AR-T and AR-S groups (p = 0.004 and p = 0.02, respectively). The specialists (0%) were more compatible with PROSPECT recommendations than the faculty members (5.2%) and assistants (7.8%).
-The rate of participants’ “use of intraoperative ESP block in OBS (minor and major)” was 34.2%, and a significant difference was observed between the medical career groups (p = 0.001). When examined according to the medical career, a significant difference was found between the AR-A and AR-S groups and between the AR-T and AR-S groups (p = 0.009 and p = 0.001, respectively). The specialists had a compatibility rate of 22.7% with the PROSPECT recommendations, which was lower compared to the faculty members at 52.6% and assistants at 43.1%.
The rate of participants’ “use of adjuvant agents in addition to LA in intraoperative blocks in OBS (minor and major)” was 36.8%, and no significant difference was found between the medical career groups (p = 0.768).
-The rate of participants’ “use of postoperative TTP block in OBS (minor and major)” was 16.8%; a significant difference was observed between the medical career groups (p = 0.0001). When examined according to the medical career, a significant difference was observed between the AR-A and AR-S groups and between the AR-T and AR-S groups (p = 0.0001 and p = 0.0001, respectively). The specialists (5.9%) were more compatible with PROSPECT recommendations than the faculty members (28.9%) and assistants (29.4%).

Discussion

In this study, physicians’ compliance and attitudes towards PROSPECT recommendations, which include optimal analgesic regimens in patients undergoing OBS, were investigated. In addition, physicians’ general pain management tendencies and their attitudes about methods not recommended for pain management in OBS were also investigated.
In OBS, PROSPECT recommends preoperative or intraoperative administration of analgesics (acetaminophen and NSAIDs, etc.), as well as continuing postoperatively unless contraindicated. In addition, preoperative or intraoperative gabapentin and a single dose of dexamethasone are recommended. While PVB is considered the gold standard in major surgery, PECS block is suggested as an alternative to PVB. Opioids are recommended as rescue medication only when other analgesic techniques cannot provide effective pain control.
According to the PROSPECT initiative, basic analgesia (acetaminophen and NSAIDs, etc.) should be administered preoperatively or intraoperatively and maintained postoperatively unless there are contraindications [3]. Compliance with this recommendation was very high when all physicians were considered, and there was no difference between the medical career groups. This very high compliance suggests that this is due to the basic and traditional nature of these drugs.
According to the PROSPECT approach, preoperative gabapentin is recommended since it reduces postoperative pain scores and opioid consumption [3]. Compliance with this recommendation was very low when all physicians were considered, and no difference was found between the medical career groups. This may be due to the wide dose range of this drug in clinical studies, the lack of documented dose-response effects, and the fact that side effects such as giddiness, blurred vision, or sedation are concerns in outpatients at high doses [4]. However, in this study, the reasons for the approach to the prospect proposal were not questioned.
Dexamethasone (iv) administration is recommended for the reason that it provides additional analgesic effect and also reduces postoperative nausea and vomiting [5]. Compliance with this recommendation was 29.5% when all physicians were considered, and there was no difference between the medical career groups.
LAI to the surgical incision site is recommended for patients scheduled for minor to moderately invasive surgical procedures (partial mastectomy, etc.), but provides limited-duration postoperative analgesia. Postoperative pain after these procedures is usually mild to moderate and decreases in intensity during the first few days postoperatively [3]. A high level of compliance with this recommendation was observed among all physicians, and when examined by medical career, the faculty members had the highest compliance rate, with a rate of 63.1%.
PVB is recommended for major breast surgery [3]. PVB is related to lower postoperative pain scores, less systemic analgesia intake, less postoperative nausea and vomiting, and shorter hospitalization. Additionally, some studies report that continuous use of PVB is associated with improved functional outcomes and less severe chronic pain [6, 7, 8, 9]. In this study, firstly, compliance with the recommendation “use of preoperative PVB as the first choice in OBS (major)” was low when all physicians were considered (11.6%), yet when examined in terms of the medical career, the faculty members demonstrated the highest level of adherence, achieving a rate of 23.6%. Secondly, the compliance rate with the recommendation of “continuous intraoperative use of PVB if a PVB catheter was inserted” was 15.3%, and no significant difference was observed between the medical career groups. Finally, the compliance rate with the recommendation of “continuous postoperative use of PVB if a PVB catheter was inserted” was 25.8%, and the faculty members (44.7%) were more compliant with the PROSPECT recommendations. These results suggest that PVB is a complex regional method and requires experience and skill. Therefore, there may be the potential to close this gap with post-graduate applied training programs.
Interfascial plane blocks have positive effects in providing postoperative analgesia [10]. However, the available data on the utilization of these blocks is restricted, and the selection of the suitable block for OBS (PECS 1, 2, and serratus plane blocks) has not yet been validated. Furthermore, it is stated that neither PECS nor PVB can reliably provide adequate analgesia to the axilla (T1 dermatome, intercostobrachial nerve) for anatomical reasons [11]. As a result, additional LAI to the wound site may be beneficial for these cases. In this study, the participants’ “use of PECS block when PVB was contraindicated in OBS (major) or axillary lymph node dissection was not performed” was 56.8%, and no significant difference was found between the medical career groups. The faculty members (78.9%) and assistants (76.4%) were more compliant with the PROSPECT recommendations than the specialists (38.6%). In addition, the rate of participants’ “use of LAI for T1 dermatome if pre- or intraoperative regional anesthesia techniques were used in OBS (major)” was 25.3%, and no significant difference was observed between the medical career groups. When examined according to the medical career, the faculty members (44.7%) were more compatible with the PROSPECT recommendations. These results are also parallel to the level of follow-up of the faculty members on the PROSPECT recommendations.
RLP block, Serratus plan block, and ESP block are alternative interfascial plane blocks described in recent literatüre [12, 13, 14]. Although the ESP block is also used in mastectomy, studies on the LA volume used are ongoing. The ESP block has been compared with other interfascial blocks (PECS block) in a limited number of studies, and conflicting results have been obtained [15]. However, there are limited studies on the RLP block in breast surgery [12]. These blocks should be compared with PVB and PECS blocks to be included in pain management strategies in the context of OBS [3]. In this study, the rate of participants’ “use of intraoperative RLP, ESP and TTP block in OBS (minor and major)” was 3.2%, 34.2% and 16.8%, respectively, and the faculty members (RLP: 5.2%, ESP: 52.6%, TTP: 28.9%) and assistants (RLP: 7.8%, ESP: 43.1%, TTP: 29.4%) differ from the specialists (RLP: 0%, ESP: 22.7%, TTP: 5.9%) in terms of employ these methods, which are not recommended. These findings may have arisen from the dynamic process of research and development in education.

Limitations

Firstly, the single-center (national) nature of the study may limit the broad applicability of the findings. Secondly, this study carries a risk of bias due to the subjectivity of physicians’ evaluations of themselves and their practices. Finally, the cross-sectional plan of the study limits the capability to detect cause-and-effect relationships and does not allow for causal interpretation of the results.

Conclusion

In conclusion, this study revealed the compliance levels of anesthesia and reanimation physicians in Türkiye, with the PROSPECT recommendations in the OBS. Compliance with the PROSPECT recommendations of specialists and anesthesia assistants can be increased through postgraduate practical training programs with the provision of an organized multidisciplinary approach by authorized institutions.

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