Multimodal Analgesia in Breast Surgical Procedures: Technical and Pharmacological Considerations for Liposomal Bupivacaine Use

Abstract

Enhanced recovery after surgery is a multidisciplinary perioperative clinical pathway that uses evidence-based interventions to improve the patient experience as well as increase satisfaction, reduce costs, mitigate the surgical stress response, accelerate functional recovery, and decrease perioperative complications. One of the most important elements of enhanced recovery pathways is multimodal pain management. Herein, aspects relating to multimodal analgesia following breast surgical procedures are discussed with the understanding that treatment decisions should be individualized and guided by sound clinical judgment. A review of liposomal bupivacaine, a prolonged-release formulation of bupivacaine, in the management of postoperative pain following breast surgical procedures is presented, and technical guidance regarding optimal administration of liposomal bupivacaine is provided.

Figures

Fig. 1.

Multimodal analgesia addresses multiple sources of pain.,– COX-2, cyclooxygenase 2; NMDA, N-methyl-D-aspartate. Adapted with permission from Henrik Kehlet and Jørgen B. Dahl, The value of “multimodal” or “balanced analgesia” in postoperative pain treatment, Anesthesia & Analgesia, volume 77, issue 5, pages 1048–1056, ©1993 by the International Anesthesia Research Society, and from Dave Klemm, Washington, DC, ©2001.

Fig. 2.

Proposed multimodal regimen for controlling postsurgical pain following common breast surgical procedures. COX-2, cyclooxygenase 2; IV, intravenous; Pecs I + II, pectoral nerve block types I and II; PO, oral; POD, postoperative day.

Fig. 3.

Ultrasound images of Pecs I (A) and Pecs II (B). Pecs I and II, pectoral nerve block types I and II; pM, pec major; pm, pec minor; r4, rib 4; sm, serratus muscle. Images courtesy of Jacob Hutchins, MD.

Fig. 4.

Overview of Pecs I and II infiltration (A) internal sagittal view and (B) external anterior view., Pecs I and II, pectoral nerve block types I and II. Images courtesy of Pacira Pharmaceuticals, Inc.

Video Graphic 1.

See video, Supplementary Digital Content 1, which demonstrates Pecs I and II infiltration technique. Pecs I and II, pectoral nerve block types I and II. Video courtesy of Jeffrey C. Gadsden, MD. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A514.

Video Graphic 2.

See video, Supplementary Digital Content 2, which demonstrates Pecs II and serratus plane infiltration (sometimes referred to as Pecs III) technique. Pecs I and II, pectoral nerve block types I and II. Video courtesy of Mark Brzezienski, MD, Chattanooga, TN. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A513.

Fig. 5.

Ultrasound images of TAP infiltration: classic TAP (A) and subcostal TAP (B). EO, external oblique; IO, internal oblique; TA, transversus abdominis. Images courtesy of Jacob Hutchins, MD.

Fig. 6.

Overview of TAP infiltration. Image courtesy of Pacira Pharmaceuticals, Inc.

Video Graphic 3.

See video, Supplementary Digital Content 3, which shows an overview of classic TAP infiltration technique. Video courtesy of Jacob Hutchins, MD. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A516.

Video Graphic 4.

See video, Supplementary Digital Content 4, which demonstrates an overview of subcostal TAP infiltration technique. Video courtesy of Jacob Hutchins, MD. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at http://links.lww.com/PRSGO/A515.