ESRA19-0338\u2005Overcoming divergent surgical opinion to successfully implement an evidence based regional anaesthetic guideline: a marriage of published evidence and consultant preference

Abstract

Background and aims Regional anaesthesia (RA) in breast surgery (BS) reduces post-operative pain,1,2,3 chronic pain4 and possibly risk of malignant recurrence.5,6 However, diversity of surgical opinion, available blocks and absence of any national or local protocol has lead to miscellany of what RA, if any, is offered regardless of its evidence based benefits. Despite such challenges, we devised and successfully implemented a departmental guideline which integrated opposing views with available evidence to enhance the provision of RA in BS. Methods All anaesthetists and surgeons undertaking BS at Surrey and Sussex NHS Trust were invited to give their opinion of RA in BS, preferred blocks and those they feel are problematic. A literature review was conducted and each respondent interviewed in person. The guideline was an amalgamation of these elements. Results Anaesthetists universally preferred PECSI and II blocks for their efficacy, ease and speed. All surgeons reported interference with the surgical field with PECSI and II with one advising the disruption was sufficiently deleterious to precluded axillary dissection. However, on further discussion and explanation was only dissatisfied with PECSI and serratus anterior blocks. Most found preoperative RA unnecessary in most cases and were only agreeable to its routine use in BS when advised of the growing evidence of possible oncological benefit. Conclusions Standardising the practice of RA is challenging in a workplace of conflicting opinion of what, if any, blocks should be employed even in the face of proven value. We have shown that in such circumstances, interprofessional liaison, education and compromise is necessary for successful implementation; evidence alone is insufficient. References Beverly A, Courtney-Evans N, Rudiger J. Analgesia for Breast Surgery: Regional vs. LA infiltration. Poster Presentation ESRA Annual Conference 2017. Moller JF, Nikolajsen L, Rodt SA, et al. Thoracic paravertebral block for breast cancer surgery: a randomized double-blind study. Anesth Analg 2007; 105: 1848–1851. Boughey JC, Goravanchi F, Parris RN, et al. Prospective randomized trial of breast cancer surgery. Am Surg 2009; 198: 720–725. Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: A Cochrane systematic review and meta-analysis. Br J Anaesth 2013; 111: 711–20. Heaney A, Buggy D. Can anaesthetic and analgesic techniques affect cancer recurrence or metastasis? Brit J Anaesth 2012: 109:i17–i28. Garg R. Regional anaesthesia in breast cancer: Benefits beyond pain. Indian J Anaesth 2017: 61: 369–72.