Implementation of Pecs I and Pecs II Blocks as Part of Opioid-Sparing Approach to Breast Surgery

unique within British Columbia in that we have a core regional anesthesia service staffed daily by an attending regional anesthesiologist dedicated to performing regional blocks and perineural catheter insertions, many outpatient orthopedic patients continue to receive sPNBs. Somewhat ironically, this in part is due to our regional anesthesia program's success and increasing popularity among surgeons and patients. Hence, despite the allocation of dedicated anesthesia personnel, growing clinical demands and time constraints in the face of resource limitations have made it necessary to prioritize the placement of perineural home catheters (eg, for patients with a history of chronic pain syndromes, those undergoing complex foot and ankle surgery, or individuals scheduled for painful shoulder or elbow surgery). That said, as Dr Bansal and colleagues are alluding to, other (and less resourceintensive as well as simpler) approaches to the extension of postoperative analgesia warrant consideration. For example, in our current practice, we, like others, indeed use dexamethasone as a local anesthetic adjunct “off label” in many of our blocks in order to prolong pain relief. Consistent with the literature, our own routine clinical follow-up interviews with these patients have consistently shown longlasting analgesia, and we are frequently observing block durations beyond 24 hours. For example, a recent informal internal practice audit of 26 patients who received single-shot popliteal sciatic nerve blocks with 0.75% ropivacaine (median volume, 25 mL) showed that adjuvant dexamethasone (2–4 mg) prolonged the mean block duration from 21.8 hours (n = 17) to 32.6 hours (n = 9; 95% confidence interval of difference betweenmeans, 0.6–20.9 hours; P = 0.388; unpublished data). In our opinion, the available data with adjuvant dexamethasone for sPNBs collectively raise the possibility that in many patients analgesic outcomes could be produced that are similar to those with home catheters, while at the same time avoiding problems associated with the latter such as catheter dislodgement or leakage. Clearly, room exists for future research to test this hypothesis. Lastly, we continue to be of the opinion that the provision of clear verbal and written postoperative patient instructions and a multimodal protocol-based approach to oral postdischarge analgesia are of paramount importance. Since the completion of our QI project, these perioperative care components have been overhauled at our center for significant enhancement of the former and improved standardization of the latter. We believe that this initiative has played the most important role