Thoracic Wall Nerve Blocks for Perioperative Breast Cancer Surgery Analgesia

Abstract

Purpose: The purpose of this quality improvement (QI) project was to enhance certified registered nurse anesthesiologist (CRNA) and physician anesthesiologist knowledge, skills, and utilization of the erector spinae plane block (ESPB) and pectoral nerve block I/II (PECS I/II) for breast cancer surgery analgesia.Background: There were approximately 270,000 new cases of breast cancer diagnosed in women and men in 2019 (American Cancer Society [ACS], 2019). Improved screening tools, earlier detection, and better cancer treatment modalities make it increasingly important to optimize long-term patient outcomes and minimize the adverse effects of oncology treatment and surgery (ACS, 2019). Utilization of thoracic wall nerve blocks as adjuncts to anesthesia and analgesia is associated with decreased opioid consumption, superior pain control, decreased incidence of PPSP, decreased opioid-related adverse effects, and decreased hospital length of stay (Cali et al., 2017). Methods: Although there’s considerable evidence supporting utilization of regional anesthesia for breast cancer surgery analgesia, the implementation site lacked standards for managing breast cancer surgery pain. This QI project included the development of an evidence-based site-specific educational presentation, informational handout, and hands-on training for anesthesia providers and surgeons. Following the intervention, participants were asked to complete a one-time post-/pre-survey assessing their knowledge, skills, and attitudes towards the selected blocks. Data were collected, analyzed, and appraised to determine the effectiveness of the QI project. Results: Fifteen CRNAs responded to the post-/pre-survey. The educational presentation, informational material, and hand-on training were rated “very useful” by 100% of the participants. Participants reported statistically significant improvements in their ability to perform, select medications, and identify anatomy for both blocks. Following the intervention, participants were 70% more likely to perform the ESPB and 53% more likely to perform the PECS I/II block on patients undergoing breast cancer surgery. Conclusions: Overall, results from the surveys, feedback from anesthesia providers, and an increase in block use in the weeks following the intervention support significant provider buy-in and the effectiveness of the intervention. There was positive interest in expanding the use of ultrasound-guided regional anesthesia among anesthesia providers and there’s potential for further implementation, dissemination, and sustainability of this initiative at the site.