Too Deep or Not Too Deep?: A Propensity-Matched Comparison of the Analgesic Effects of a Superficial Versus Deep Serratus Fascial Plane Block for Ambulatory Breast Cancer Surgery

Ultrasound-guided Bilateral Serratus Anterior Plane Block for Postoperative Analgesia in Ear Reconstruction after Costal Cartilage Harvest: A Randomized Controlled Trial

BACKGROUND

Costal cartilages harvest for ear reconstruction is accompanied by severe pain in chest. However, there is no perfect solution for reducing this chest pain.

OBJECTIVE

Evaluate the efficacy and safety of analgesia using ultrasound-guided bilateral serratus anterior plane block (SAPB) in children receiving costal cartilage harvest for ear reconstruction.

METHODS

Sixty children undergoing ear reconstruction using costal cartilage were randomized to an SAPB group (SAPB with 3 mg/kg 0.25% ropivacaine) or an incision infiltration (II) group (II with 3 mg/kg 0.75% ropivacaine), and 29 in each group completed the study. All children received patient-controlled intravenous analgesia (PCIA). The primary outcomes were numerical rating scale (NRS) scores of pain while rest and coughing at 1, 6, 12, 24, and 48 h after surgery. The secondary outcomes were sufentanil use within 24 h, duration of analgesia, use of oral rescue analgesics, first time out of bed, and incidence of treatment-related adverse effects.

RESULTS

The SAPB group had lower rest and coughing NRS scores at 6 and 12 h after surgery (all P < 0.001), but the scores were similar at other times. The SAPB group used less sufentanil within 24 h, but had a longer duration of analgesia (both P < 0.001). The II group used more oral rescue analgesics within 48 h, had a longer time until first time out of bed, and had more opioid-related side effects (all P < 0.01). There were no SAPB-related complications.

CONCLUSION

Ultrasound-guided SAPB can provide safe and effective regional pain relief after costal cartilage harvest for ear reconstruction.

LEVEL OF EVIDENCE II

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The Effect of Ultrasound-Guided Low Serratus Anterior Plane Block on Analgesia and Quality of Recovery After Robot-Assisted Thymectomy via Subxiphoid Approach: Study Protocol for a Randomized Controlled Trial

Purpose

Study Design and Methods

Discussion

Ultrasound-guided superficial serratus plane block for persistent post-mastectomy pain: four case reports

BACKGROUND

Persistent post-mastectomy pain (PPMP) is common after surgery. Although multiple modalities have been used to treat this type of pain, including medications, physical therapy, exercise interventions, cognitive-behavioral psychology, psychosocial interventions, and interventional approaches, managing PPMP may be still a challenge for breast cancer survivors. Currently, serratus plane block (SPB) as a novel regional anesthetic technique shows promising results for controlling chronic pain.

METHODS

We report four cases of patients with PPMP that were treated using superficial serratus plane block (SSPB) at our clinic. A retrospective review of effect of pain relief was collected through postprocedure interviews.

RESULTS

We found that two of our patients were successfully treated with SSPB for pain after treatment for breast cancer. The third patient had an intercostobrachial nerve block that produced incomplete pain relief but had adequate pain relief with a SSPB. However, the fourth patient reported no pain relief after SSPB.

CONCLUSION

These cases illustrate that the patients with PPMP could benefit from SSPB. Particularly, we find patients with a subjective sense of "tightness" relating to reconstructive surgeries may be a good candidate for SSPB. Further studies are warranted to evaluate this block for PPMP, as it is low risk and relatively simple to perform.

Analgesic Effect of Serratus Anterior Plane Block After Thoracoscopic Surgery: A Randomized Controlled Double-Blinded Study

Purpose

Fast-track surgery is a developing trend in medical care. It is a core challenge for clinical anesthesia to reasonably reduce the dosage of opioids and relieve postoperative pain. Serratus anterior plane block (SAPB) is a novel analgesic technique with such advantages as easy operation, good safety, and few side effects.

Patients and Methods

In total, 60 patients aged 18 to 65 years who were diagnosed with lung cancer and scheduled for thoracoscopic resection were randomly assigned to receive SABP or local infiltration anesthesia. We analyzed the time within 48 hrs after operation to visual analogue scale (VAS) pain score of 4 or higher and the number of patients requiring additional analgesics at 6 hrs and 12 hrs after operation.

Results

The estimated median time to VAS ≥4 was 4 hrs (1.32 to 6.68) in the control group and 11 hrs (6.71 to 15.29) in the SAPB group (log-rank test: P=0.008). The number of patients requiring additional analgesics at 6- and 12 hrs after operation was significantly lower in the SAPB group than that in the control group (P<0.05).

Conclusion

Compared with local infiltration, SAPB provided extended postoperative analgesia after thoracoscopic surgery with reduced consumption of additional analgesics in the early postoperative stage.

A randomised controlled comparison of serratus anterior plane, pectoral nerves and intercostal nerve block for post-thoracotomy analgesia in adult cardiac surgery

BACKGROUND AND AIMS

Enhanced recovery after cardiac surgery is centred around multimodal analgesia which is becoming increasingly feasible with the advent of safer regional analgesic techniques such as fascial plane blocks. We designed this prospective, single-blind, randomised controlled study to compare the efficacy of serratus anterior plane block (SAPB), pectoral nerves (Pecs) II block, and intercostal nerve block (ICNB) for post-thoracotomy analgesia in cardiac surgery.

METHODS

100 adults posted for cardiac surgery through a thoracotomy were randomly allocated to one of the three groups: SAPB, Pecs II or, ICNB wherein the patients received 2.5 mg/kg of 0.5% ropivacaine for ultrasound-guided block after completion of surgery. Postoperatively, intravenous (IV) paracetamol was used for multimodal and fentanyl was employed as rescue analgesia. Visual analogue scale (VAS) was evaluated at 2, 4, 6, 8, 10 and 12 hours post-extubation.

RESULTS

The early mean VAS scores at 2, 4 and 6 hours were comparable in the 3 groups. The late mean VAS (8, 10 and 12 hours) was significantly lower in the SAPB and Pecs II group compared with that of the ICNB group (P value <0.05). The cumulative rescue fentanyl dose was significantly higher in ICNB group compared to SAPB and Pecs II group (P value <0.001). The SAPB group had the highest time to 1st rescue analgesic requirement in contrast to the other groups.

CONCLUSION

SAPB and Pecs II blocks are simple single-shot effective alternatives to ICNB with a prolonged analgesic duration following thoracotomy and can potentially enhance pain-free recovery after cardiac surgery.

A Prospective Randomised Study to Assess the Analgesic Efficacy of Serratus Anterior Plane (SAP) Block for Modified Radical Mastectomy Under General Anaesthesia

Objective

Breast cancer is the most common malignancy among women and often requires surgery for the removal of the tumour. Uncontrolled pain after breast surgeries is a common problem. Serratus anterior plane (SAP) block is a recently designed technique to block the lateral cutaneous branches of the ventral rami of thoracic intercostal nerves and may cover the area of surgical dissection for modified radical mastectomy (MRM). The primary objective of this study was to evaluate the effect of SAP block on the time to first rescue analgesic in the post-operative period in patients undergoing MRM.

Methods

A randomised, single-blind, parallel group trial was conducted in a single teaching hospital. A total of 100 patients undergoing MRM were randomised in a 1:1 ratio into 2 groups: MRM under general anaesthesia (GA) alone (group G, n=50) or GA with SAP block (group S, n=50). Blocks were performed under ultrasound guidance at the level of the 5^th rib in the midaxillary line with 0.4 mL kg⁻¹ of 0.375% ropivacaine.

Results

The time to request of first rescue analgesia was significantly prolonged in group S compared with group G (p=0.008). Median (interquartile range) for time to rescue analgesia in group S was 120 (60–300) min, whereas in group G, it was 60 (15–120) min. Post-operative pain scores and the number of patients requiring intra-operative additional fentanyl were significantly less in group S. No technique-related adverse events were observed.

Conclusion

SAP block improved perioperative analgesia in patients undergoing MRM.

Clinical trial registry number

CTRI/2017/11/010424. (http://ctri.nic.in/Clinicaltrials/regtrial.php?modid=1&compid=19&EncHid=45912.14862)

Ultrasound-guided serratus plane block as an effective adjunct to systemic analgesia in four dogs undergoing thoracotomy

Background

Ultrasound-guided serratus plane block (UGSPB) is a loco-regional anesthesia technique designed to desensitize the thoracic wall. It is a compartmental block, where local anesthetic is delivered to the fascial, inter-muscular plane. Since its original description in humans, two cadaveric veterinary studies, redefining the technique, have been performed. Taking into account the successful use of the UGSPB in human medicine, we employed the veterinary description to perform this block in four dogs undergoing thoracotomy. The case series described below aims to share our experience of the clinical application of this new loco-regional anesthesia technique in dogs.

Case Description

Four dogs, with different underlying medical conditions underwent cranial lateral thoracotomy. The analgesia protocol consisted of intravenous methadone and UGSPB performed half an hour before the beginning of the procedure. The cardiovascular system was closely monitored for any signs of nociception. Fentanyl, although available as rescue analgesia, was not required in any of these cases as no signs of nociception were present.

Conclusion

To the authors' knowledge, this is the first veterinary clinical report using the UGSPB as a part of a multimodal analgesia protocol in dogs undergoing thoracotomy. Based on this observation, UGSPB has the potential to prevent nociception and reduce the intraoperative opioid requirements in dogs undergoing thoracotomy. A prospective randomized clinical trial is required to confirm these promising results.

Operation, Effectiveness, and Limitations of Continuous Serratus Anterior Plane Blocks for Thoracoscopic Surgery in Adults

Purpose

This randomized, double-blind study evaluated the effectiveness and limitations of continuous serratus anterior plane block (cSAPB) by comparing the effect of cSAPB to patient-controlled intravenous analgesia (PCIA) on postoperative acute pain after thoracoscopic surgery in adults.

Patients and Methods

Sixty-six patients who underwent elective video-assisted thoracoscopic surgery (VATS) were randomly allocated to cSAPB or PCIA groups (n=33 per group) after surgery. For the cSAPB group, patients were treated by an initial does of 20 mL ropivacaine (0.375%), followed by continuous infusion at a rate of 5 mL/h of ropivacaine (0.2%) and a patient-controlled bolus of 5 mL ropivacaine (0.2%). PCIA started with an initial does of 0.03 µg/kg sufentanil, followed by a basal infusion of 0.03 µg/kg/h sufentanil and a patient-controlled bolus of 0.03 µg/kg sufentanil. Visual analog scale (VAS) and other items were examined postoperatively. The area under the curve of VAS-time (AUC_VAS-time) at rest and on coughing in the first 24 hours postoperatively were primary outcomes.

Results

At the first 24 hours postoperatively, patients in the cSAPB group exhibited a smaller AUC_VAS-time at rest (44.0±17.1 vs 68.9±11.8 cm·h, P<0.001) and AUC_VAS-time on coughing (67.1±8.8 vs 78.0±12.5 cm·h, P<0.001) compared with those in the PCIA group. The differences in means of VAS score at rest were more than 1.0 cm between the two groups, however, on coughing they were less than 1.0 cm at each observation point. Additionally, patients in the cSAPB group had a longer time to first patient-controlled bolus (15.8±7.6 vs 10.6±8.6 hours, P=0.011). Furthermore, a higher rank of satisfaction was recorded with patients in the cSAPB group.

Conclusion

cSAPB using PCA devices might be superior to traditional intravenous continuous analgesia, particularly with an advantage of pain relief at rest following VATS operation. Meanwhile, cSAPB lacks a satisfactory analgesic effect on cough.

Erector Spinae Plane Block and Paravertebral Block for Breast Surgery: A Retrospective Propensity-Matched Noninferiority Trial

Purpose

Thoracic paravertebral block (TPVB) is an established analgesic technique for breast surgery although it is technically challenging. Erector spinae plane block (ESPB) requires less technical expertise and may be an alternative to TPVB. However, whether ESPB has similar analgesic effects to TPVB for breast surgery is still inconclusive. Moreover, information on sensory blockade of ESPB is scarce. Accordingly, we conducted this retrospective propensity-matched study to see if ESPB could provide comparable analgesic effects to TPVB in patients undergoing breast surgery. We also compared cutaneous sensory block levels after the two techniques.

Patients and Methods

In this retrospective cohort study, we analyzed data saved in our database and compared the two techniques using a propensity matching method. The data of patients who underwent unilateral breast surgery under general anesthesia with the addition of either TPVB or ESPB were identified. We considered that the analgesic efficacy of ESPB was noninferior to TPVB if both postoperative fentanyl consumption and area under the curve (AUC) for pain scores within 24 h were within 50 µg and 240 mm･h margins, respectively. Cutaneous sensory block levels, additional analgesic requirements, and complications were also compared between the two groups.

Results

Among 93 patients, 30 patients for each group were matched. Both postoperative fentanyl consumption and AUC for pain scores after ESPB were noninferior to those after TPVB. ESPB did not produce sensory blockade consistently, and the number of dermatomes was smaller after ESPB [1 (0–3)] [median (interquartile range)] than after TPVB [4 (2–5)] (P=0.002). No serious complications related to blocks were observed.

Conclusion

ESPB and TPVB provided comparable postoperative analgesia for 24 h in patients undergoing breast surgery. Dermatomal sensory blockade was, however, less apparent and narrower after ESPB than after TPVB.

Evaluation of postoperative pain in patients undergoing modified radical mastectomy with pectoralis or serratus-intercostal fascial plane blocks

Background

Regional nerve blocks are an integral part of multimodal analgesia and should be chosen based on their efficacy, convenience, and minimal side effects. Here, we compare the use of pectoral (PEC II) and serratus-intercostal fascial plane (SIFP) blocks in breast carcinoma cases undergoing modified radical mastectomy in terms of the postoperative analgesic efficacy and shoulder mobility.

Methods

The primary outcome of this prospective controlled study was to compare the postoperative static and dynamic pain scores, and the secondary outcome was to assess the shoulder pain, range of shoulder joint motion, and hemodynamic parameters. Sixty patients were randomly allocated to three groups and given general anesthesia. All patients received paracetamol, diclofenac, and rescue doses of tramadol based on the institute's acute pain service policy. No block was performed in group C (control), whereas groups P and S received PEC II and SIFP blocks, respectively, before surgical incision.

Results

The groups were comparable in terms of age, weight, height, and body mass index distribution. Dynamic pain relief was significantly better 12 and 24 h postoperatively in groups P (P = 0.034, P = 0.040 respectively) and S (P = 0.012 and P = 0.017, respectively) compared to group C. Shoulder pain relief and shoulder mobility were better in group S, while the hemodynamic parameters were more stable in group P.

Conclusions

Both SIFP and PEC blocks have comparable dynamic and static pain relief with better shoulder pain scores in patients receiving SIFP.

Serratus Anterior Plane Block for Post-Thoracotomy Analgesia: a Novel Technique for the Surgeon and Anaesthetist

Post-thoracotomy pain is one of the most severe forms of post-operative pain. Anaesthetists usually manage post-thoracotomy pain with an epidural or paravertebral block. However, both of these techniques have their limitations. Ultrasound-guided interfascial plane block like serratus anterior plane block is a new concept and is proposed to provide analgesia to the hemithorax. We report our experience with 10 thoracotomy cases where this block was used as a post-operative analgesic technique. Patients undergoing pulmonary metastasectomy or lobectomy received ultrasound-guided serratus anterior plane block between the serratus anterior and the external intercostal muscles with 0.25% ropivacaine, and a catheter was inserted. Post-operatively, 0.125% ropivacaine with fentanyl (1 mcg/ml) was given as infusion at 5-7 ml/h. Other analgesics were paracetamol and diclofenac. Fentanyl infusion at 0.25 mcg/kg/h was the rescue analgesic if pain persisted. Four out of 10 patients required fentanyl infusion. Uncontrolled pain in two of these patients was at the intercostal drain site; in the third patient, two ribs were resected; and in the 4th patient, there was poor drug spread and the catheter could not be placed in the desired plane due to poor muscle mass. The catheter was kept in situ for a minimum of 48 h to a maximum of 6 days after surgery. Serratus anterior block could be an attractive option for post-thoracotomy analgesia. Further studies can take the help of the surgeon for catheter placement in the desired plane at the time of wound closure to ensure adequate drug spread.