PECS Block in Partial Mastectomy for Postoperative Pain Control (PECS)

February 18, 2020 updated by: Kaitlyn Kennard MD, Main Line Health

Use of PECS Block in Partial Mastectomy for Postoperative Pain Control and Mitigation of Narcotic Use- A Randomized Control Trial

The aim of this study is to evaluate patients who are undergoing partial mastectomy or removal of breast tissue and see if a pectoralis nerve block (PECS) can provide a meaningful improvement in postoperative pain control over standard pain medication. The hope is that this will decrease the need for postoperative narcotics. Prior studies have shown improved pain control using a PECS block in patients who undergo a mastectomy. PECS block is a procedure in which local anesthesia, similar to that used by dentists, is injected in the muscles of your chest and arm pit during your surgical procedure while you are asleep. This anesthetizes the nerves in the area which decreases pain. The local anesthetic used is called Marcaine. Marcaine is the brand name for bupivacaine hydrochloride which is an anesthetic known for its long duration in comparison to lidocaine.

It is known that postoperative pain is a risk factor for chronic pain which is tied to increased narcotic use. Due to the opioid epidemic considerable time and research has gone into decreasing opioid use particularly in post-operative period. The PECS block procedure involves injecting local anesthesia between two chest muscles called pectoralis major and pectoralis minor. There is an additional injection between the pectoralis minor and serratus anterior which is another muscle of the chest.

This study will be conducted at Lankenau Medical Center of Main Line Health. You have been selected since you will be undergoing a partial mastectomy (removal of a part of your breast). It is believed that PECS block has the potential to benefit your postoperative pain control. A total of 130 patients will be recruited and 65 will be placed into the treatment arm (receive intraoperative nerve block) and 65 will be placed into the non- treatment arm (no nerve block) for comparison.

Study Overview

Status

Unknown

Conditions

Intervention / Treatment

Detailed Description

Prior investigations have shown that use of intraoperative PECS blocks in patients undergoing a Modified Radical Mastectomy improves postoperative pain control and decreases postoperative narcotic use which will eventually mitigate the issue of dependence on narcotics postoperatively (Kulhari et al, Blanco et al). The aim of this study is to do a prospective randomized control of patients undergoing a Partial Mastectomy at Lankenau Medical Center to see if pectoral nerve block (PECS) provides a meaningful improvement in postoperative pain control over standard pain medication as well as a decrease in postoperative narcotic use.

PECS block as described by Blanco et al has been used safely and effectively used for modified radical mastectomy in multiple studies as reviewed above (Blanco et al, Kumar et al, Kulhari et al). The breast surgeons at Lankenau Medical Center within Main Line Health are currently using the PECS block as part of their partial mastectomy procedure and have been since 5/1/19. The PECS block is currently being used at random when time and resources allow There are not certain subsets or patients who are selected for this procedure. This procedure has been well tolerated by patients and has proved feasible for the surgeons and surgical team to facilitate. Therefore since PECS block for partial mastectomy are within the standard of care at Lankenau Medical Center this study only introduces a risk of randomization rather than the increased risk of the procedure itself.

This is a randomized prospective control study looking at patients at Lankenau Hospital undergoing partial mastectomy from 8/30/19- 8/30/20 after obtaining Institutional Review Board (IRB) approval. The plan is to recruit 130 patients with 65 patients randomized into each cohort. One cohort will receive the PECS II block intraoperatively and one cohort will not. This will be a single blinded randomized control trial in that the surgeon knows who will be receiving the block however the patient will be blinded. Patient must be able to provide their own consent to be included in this study. There will be no advertisement or compensation for this study. The study will be explained to the eligible candidates at time of discussion of their surgery. Patients will be informed that involvement in the study does not affect their ability to seek or receive care at this facility.

A written informed consent will be obtained from all patients. The patients once scheduled for surgery unit will be enrolled in research study by an independent research assistant. The participants will be allocated randomly into two groups according to block randomization schedule shown below. Group one will receive anesthesia only and Group two will receive anesthesia and PECS block. The surgeon who will be performing the intraoperative block will be informed of the random and independent assignment prior to surgery. The patients will be instructed on usage of a 10-mm Visual Analogue Scale (VAS) for pain graded from 0 (no pain) to 10 (most severe pain) before surgery. Patients will be blinded as to whether or not they will be receiving intraoperative PECS block. In both the control and test groups, patients will receive general anesthesia with laryngeal mask airway or endotracheal tube per anesthesiologist discretion. Induction of anesthesia will use fentanyl 1 μg/kg and propofol 1.5-2 mg/kg until loss of verbal response with or without muscle relaxant as needed. Maintenance of anesthesia will be assessed for any intraoperative rise in heart rate and systolic blood pressure more than 20% from pre-induction value. If this occurs fentanyl 0.25 μg/kg can be administered IV. Toradol should be given unless contraindication at the end of the case. No ketamine or dilaudid will be used. Long acting opioids will be avoided. Once anesthesia is instituted prior to prepping and draping a timeout will be called during which patient will be identified and procedures to be performed will be identified.

Procedures The patient will be kept in supine position with ipsilateral arm in abducted position. The skin overlying the ipsilateral breast and adjoining infraclavicular and axillary regions will be disinfected with chloraprep and sterile draping of the area is performed. A linear ultrasound probe of high frequency (6-13 MHz) of a portable ultrasound system (Sonosite, Micromaxx Bothell, Washington USA) is taken. The probe will be covered with a sterile transparent dressing and a sterile conductivity gel will be applied. The imaging depth on the ultrasound screen is set to 4-6 cm. The ultrasound probe will first be placed cephalocaudally in the infraclavicular region and moved laterally to locate vessels directly above the 1st rib. With further lateral and downward movements the 3rd and 4th ribs will be identified. The probe is maneuvered and appropriate anatomical structures including pectoralis major and minor muscles and serratus anterior muscle are identified.

The interface between pectoralis major, pectoralis minor and serratus anterior are identified. A spinal needle 20 gauge and 4 inches in length will be used to instill 10 cc of 0.2% Marcaine between serratus anterior and pectoralis minor. Aspiration is continuously used to confirm that there is no intravenous or intra-arterial injection of local anesthesia. The needle will then be withdrawn slightly, and 10 cc of 0.25% Marcaine is injected between pectoralis major and pectoralis minor under direct ultrasound visualization. Attention is then turned to the axilla of the operative side. A spinal needle under direct visualization is used to deliver 10 cc of 0.25% Marcaine between latissimus dorsi and serratus anterior. The PECS block is finished, and the rest of the procedure is performed according to surgeon discretion. All patients whether or not they receive the PECS block will receive 10 cc of 0.25% Marcaine subcutaneously at incision site.

Study Type

Interventional

Enrollment (Anticipated)

130

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

  • United States
    • Pennsylvania
      • Philadelphia, Pennsylvania, United States, 19147
        • Recruiting
        • Kaitlyn Kennard
        • Contact:
        • Principal Investigator:
          • Kaitlyn Kennard, MD
        • Principal Investigator:
          • Robin Ciocca, MD
        • Principal Investigator:
          • Jennifer Sabol, MD
        • Principal Investigator:
          • Ned Carp, MD

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

Female

Description

Inclusion Criteria:

  • Inclusion criteria are patients are undergoing a partial mastectomy or excisional biopsy. Patients may undergo additional procedures such as sentinel lymph node biopsy or axillary lymph node dissection which will be recorded.

Exclusion Criteria:

  • Chronic Pain, Presence of Breast Implants prior to surgery

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Prevention
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: PECS Block
Group who was randomly selected to receive the intraoperative nerve block.
Procedure: Pectoral Nerve Block
Patients who were given 20 cc of 0.25% Marcaine as part of the pectoralis nerve block
Sham Comparator: Control
Patient who was randomly selected not to receive intraoperative nerve block
Procedure: Surgery without Nerve Block
Patient's underwent indicated procedure without regional pectoralis nerve block

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Postoperative pain
Time Frame: Immediately postoperatively until day 3
Visual Analogue Pain scores scaled from 1-10 with 1 being no pain and 10 being worst pain of one's life. This scale is used to assess postoperative pain. Scores will be compared between the two groups.
Immediately postoperatively until day 3

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Postoperative Narcotic Use
Time Frame: 72 hours
Amount of pain medication in morphine equivalents used after surgery until day 3
72 hours

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Main Line Health

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

September 1, 2019

Primary Completion (Anticipated)

September 1, 2020

Study Completion (Anticipated)

November 1, 2020

Study Registration Dates

First Submitted

September 10, 2019

First Submitted That Met QC Criteria

September 10, 2019

First Posted (Actual)

September 11, 2019

Study Record Updates

Last Update Posted (Actual)

February 20, 2020

Last Update Submitted That Met QC Criteria

February 18, 2020

Last Verified

February 1, 2020

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • R20-3896L

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

No

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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