Ultrasound-guided modified serratus anterior plane block for perioperative analgesia in breast oncoplastic surgery: A case series

Analgesic efficacy of superficial versus deep serratus plane block for modified radical mastectomy under general anaesthesia: A randomised comparative study

BACKGROUND AND AIMS

Serratus anterior plane (SAP) blocks can be given either superficial or deep to the serratus anterior muscle to block the branches of intercostal nerves providing analgesia to the anterolateral chest wall. This prospective randomised comparative study aimed to compare the analgesic efficacy of superficial and deep SAP block in breast surgeries.

METHODS

Forty female patients scheduled to undergo elective modified radical mastectomy under general anaesthesia (GA) were randomly assigned to receive ultrasound guided SAP block with 30 ml 0.375% ropivacaine either superficial (group S, n = 20) or deep (group D, n = 20) to the serratus anterior muscle, before the induction of GA. The primary outcome was post operative fentanyl requirement over 24 hours and secondary outcomes were comparison of numerical rating scale (NRS) scores for pain, sensory block mapping, time to perform the block, number of needle attempts, etc.

RESULTS

The post operative 24-hour fentanyl requirement was comparable between group S and D (318.75 ± 80.65 versus 272.5 ± 80.25 μg, P = 0.07). NRS pain scores were comparable between the groups. Sensory block mapping done at various levels showed T3-T7 block in most of the patients with no difference between the groups. Block performance time (6.05 ± 3.27 versus 8.35 ± 3.26 minutes, P = 0.034) and number of needle attempts was significantly lesser in group D.

CONCLUSION

There was no difference in analgesic efficacy when SAP block was given superficial or deep to serratus anterior muscle for modified radical mastectomies. However, deep SAP block required less time and number of attempts to perform than superficial technique.

The Tumor Plastic Surgery Technology versus Traditional Repair Technology on the Repair of Large-Area Skin Defects after Maxillofacial Tumor Resection: A Randomized Controlled Trial

Objective

To explore the effect of tumor plastic surgery on the repair of large-area skin defects after maxillofacial tumor resection.

Methods

90 patients undergoing maxillofacial tumor resection in our hospital from March 2019 to March 2020 were selected and randomized 1 : 1 to receive either tumor plastic surgery (experimental group) or traditional repair (control group). The clinical efficacy and facial cosmetic improvement of the two groups were compared. The Patient and Observer Scar Assessment Scale (POSAS) was used to evaluate the surgical outcomes of the two groups, the Profile of Mood States (POMS) was used to evaluate the patients' psychological status, and the Generic Quality of Life Inventory-74 (GQOLI-74) was used to assess the quality of life of patients.

Results

Total clinical effective rate of the experimental group was significantly higher than that of the control group (p < 0.001). A higher excellent rate of facial cosmetic improvement was observed in the experimental group versus the control group (p < 0.001). Significantly lower POSAS scores of the experimental group than the control group were observed (p < 0.001). The POMS scores of the experimental group after treatment were lower than those of the control group (p < 0.001). Tumor plastic surgery resulted in a remarkably higher GQOLI-74 score in the patients versus traditional repair (p < 0.001).

Conclusion

Tumor plastic surgery is a promising alternative for patients undergoing maxillofacial tumor resection. It can effectively promote the recovery of facial morphology and physiological function of patients, with high clinical efficacy, so it merits promotion and application.

The Role of Maximal Locoregional Block in Autologous Breast Reconstruction

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has become the standard of care in microsurgical breast reconstruction. The current literature provides overwhelming evidence of the benefit of ERAS pathways in improving quality of recovery, decreasing length of hospital stay, and minimizing the amount of postoperative narcotic use in these patients. However, there are limited data on the role of using maximal locoregional anesthetic blocks targeting both the abdomen and chest as an integral part of an ERAS protocol in abdominally based autologous breast reconstruction. The aim of this study is to compare the outcomes of implementing a comprehensive ERAS protocol with and without maximal locoregional nerve blocks to determine any added benefit of these blocks to the standard ERAS pathway.

METHODS

Forty consecutive patients who underwent abdominally based autologous breast reconstruction in the period between July 2017 and February 2020 were included in this retrospective institutional review board-approved study. The goal was to compare patients who received combined abdominal and thoracic wall locoregional blocks as part of their ERAS pathway (study group) with those who had only transversus abdominis plane blocks. The primary end points were total hospital length of stay, overall opioids consumption, and overall postoperative complications.

RESULTS

The use of supplemental thoracic wall block resulted in a shorter hospital length of stay in the study group of 3.2 days compared with 4.2 days for the control group (P < 0.01). Postoperative total morphine equivalent consumption was lower at 38 mg in the study group compared with 51 mg in the control group (P < 0.01). Complications occurred in 6 cases (15%) in the control group versus one minor complication in the thoracic block group. There was no difference between the 2 groups in demographics, comorbidities, and type of reconstruction.

CONCLUSION

The maximal locoregional nerve block including a complete chest wall block confers added benefits to the standard ERAS protocol in microvascular breast reconstruction.

The effect of postoperative serratus anterior plane block on postoperative analgesia in patients undergoing breast surgery

Objectives

This study aimed to evaluate the effect of serratus anterior plane block (SAP) on postoperative morphine consumption. We aimed to determine the differences between both similar blocks and evaluate the effect of the methods of application of this block on patients' postoperative pain scores and morphine consumption.

Material and Methods

This study is a single-center, prospective and observational study performed with 40 volunteer patients with American Society of Anesthesiologists (ASA) I-III, who were 18-70 years of age, scheduled for breast surgery. A total of 40 patients who underwent general anesthesia were divided into two groups each with 20 patients. While SAP block was applied to the study group, no block was applied to the control group. SAP block was made by injecting a total of 40 ml of 0.25% bupivacaine between 2 muscles after the test dose was injected with saline. All patients were followed up for 12 hours postoperatively with patient-controlled analgesia (PCA) pump. Morphine consumption, visual analogue score (VAS) values and side effects were recorded at the postoperative 1st, 6th and 12th hours.

Results

There was no significant difference between the two groups in terms of hemodynamic parameters and demographic data. Postoperative morphine consumption and postoperative analgesic requirement were significantly lower in the SAP block group (p <0.001). Postoperative VAS values were significantly lower in the SAP block group (p <0.001). No complication was observed related to the block.

Conclusion

It was found that the SAP block reduced morphine consumption, significantly decreased VAS values, and reduced side effects due to opioids postoperatively.

Practical Review of Abdominal and Breast Regional Analgesia for Plastic Surgeons: Evidence and Techniques

Regional analgesia has been increasing in popularity due to its opioid- sparing analgesic effects and utility in multimodal analgesia strategies. Several regional techniques have been used in plastic surgery; however, there is a lack of consensus on the indications and the comparative efficacy of these blocks. The goal of this review is to provide evidence-based recommendations on the most relevant types of interfascial plane blocks for abdominal and breast surgery. A systematic search of the PUBMED, EMBASE, and Cochrane databases was performed to identify the evidence associated with the different interfascial plane blocks used in plastic surgery. The search included all studies from inception to March 2020. A total of 126 studies were included and used in the synthesis of the information presented in this review. There is strong evidence for using the transversus abdominis plane blocks in both abdominoplasties as well as abdominally-based microvascular breast reconstruction as evidenced by a significant reduction in post-operative pain and opioid consumption. Pectoralis (I and II), serratus anterior, and erector spinae plane blocks all provide good pain control in breast surgeries. Finally, the serratus anterior plane block can be used as primary block or an adjunct to the pectoralis blocks for a wider analgesia coverage of the breast. All the reviewed blocks are safe and easy to administer. Interfascial plane blocks are effective and safe modalities used to reduce pain and opioid consumption after abdominal and breast plastic surgery.

Effect of adding dexamethasone to ropivacaine for ultrasound-guided serratus anterior plane block in patients undergoing modified radical mastectomy: A preliminary trial

BACKGROUND AND AIMS

Ultrasound-guided serratus anterior plane (SAP) block is a field block with high efficacy. We studied the analgesic effect of the addition of dexamethasone to ropivacaine in SAP block for modified radical mastectomy (MRM).

METHODS

Sixty patients undergoing MRM were randomised into two groups. Patients in Group P (n = 30) received 0.375% ropivacaine (0.4 ml/kg) with normal saline (2 ml) and those in group D (n = 30) received 0.375% ropivacaine (0.4 ml/kg) with 8 mg of dexamethasone (2 ml) in ultrasound-guided SAP block. The primary objective was to compare the time to first rescue analgesia and the secondary objectives were to compare the intraoperative fentanyl requirement, total diclofenac and tramadol requirements, and occurrence of nausea and vomiting in 24 hours, postoperatively. The statistical analysis was done using Mann-Whitney U-test, Chi-square test, Fisher's exact test, and Kaplan Meier survival estimates.

RESULTS

More patients required rescue analgesia in 24 hours in group P (33%) than group D (10%, P = 0.04). The probability of a pain free-period was significantly higher in group D than group P (P = 0.03, log-rank test). Intra-operative fentanyl requirement and postoperative diclofenac and tramadol requirements were comparable in both the groups. The incidence of postoperative nausea and vomiting was significantly more in Group P than Group D.

CONCLUSION

Addition of dexamethasone to ropivacaine for SAP block increases the time to first rescue analgesic in the postoperative period.

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.

Perioperative Analgesic Modalities for Breast Cancer Surgeries: A Prospective Randomized Controlled Trial

Purpose

Various analgesic modalities are adopted for perioperative analgesia in breast cancer surgeries. This study aimed to compare the efficacy of intravenous morphine versus serratus anterior plane block (SAPB) and erector spinae plane block (ESPB) in breast cancer surgeries.

Patients and Methods

Seventy-five breast cancer patients undergoing modified radical mastectomy from January 2020 to June 2020 were randomly allocated into 3 groups; the morphine group received morphine 0.1 mg/kg, the SAPB group received ultrasound-guided SAPB with 25 mL bupivacaine 0.25% and the ESPB group received ultrasound-guided ESPB with 25 mL bupivacaine 0.25%. A visual analogue scale (VAS) 0–10 was used to evaluate pain postoperatively, where 0 denotes no pain and 10 worst pain. If any patient in the 3 studied groups reported breakthrough pain with VAS ≥ 4 then a bolus of 3 mg morphine was given.

Results

There was no difference in VAS scores between the 3 groups postoperatively. Morphine consumption was higher in the morphine group (9.19 ± 2.32 mg) than the SAPB group (4.00 ± 1.55 mg) and the ESPB group (4.20 ± 1.64 mg), respectively. First time to receive postoperative morphine was significantly longer for the ESPB and SAPB groups than the morphine group (20.40 ± 4.98 hours), (19.00 ± 5.9 hours), (5.00 ± 4.62 hours), respectively. Intraoperative hemodynamics and fentanyl consumption showed no difference between groups, whereas postoperative mean arterial blood pressure values at 2 and 4 hours were higher in the morphine group. Ramsay sedation score and postoperative nausea and vomiting values in the post anesthesia care unit were higher for the morphine group compared to the SAPB and ESPB groups. No complications related to the blocks were reported.

Conclusion

SAPB and ESPB can be used as an effective and safe alternative to opioids with fewer side effects in breast cancer patients undergoing modified radical mastectomy.

Trial Registration

This trial was prospectively registered at Clinical Trials.gov on 22 January 2020 with registration number NCT04248608 (https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0009JS5&selectaction=Edit&uid=U0004LIG&ts=7&cx=−81xkwa).

Serratus anterior plane block in modified radical mastectomy surgery: a case series

Background

Postoperative breast pain may lead to poorer outcome if left untreated. Common analgesia modalities for postoperative breast pain include opioids and regional anesthesia. However, both of these modalities can cause significant side effects or complications. Serratus anterior plane (SAP) block is a new procedure that is relatively easier to perform and safer, compared with other modalities. Previous studies have reported its usefulness in reducing the need for both intraoperative and postoperative opioids.

Case

We reported 2 patients that underwent SAP block combined with general anesthesia in modified radical mastectomy (MRM). Patient 2 was given rescue analgesia during the intraoperative period. The administration of postoperative opioids did not exceed 24 h in both patients. Pain assessment using numeric rating scale (NRS) showed minimal postoperative pain. No side effects were found during 24-h monitoring period.

Conclusion

SAP block can be used as one of the modalities in managing the pain of MRM surgery.

Ultrasound-Guided Serratus Anterior Plane Block for Rib Fracture-Associated Pain Management in Emergency Department

CONTEXT

Traumatic Rib fractures are common and painful conditions to present in the emergency department. Ultrasound-guided serratus anterior plane block (SAPB) is a newer technique which is being used for managing postthoracotomy, thoracoscopic surgery, or post mastectomy pain by the anesthetists. However, we have recently started utilizing this novel technique in our emergency department for rib fracture patients with severe pain.

SETTINGS AND METHODS

We present a case series of 10 patients of multiple rib fractures (MFRs) with persistent Defense and Veterans Pain Rating Scale 7 or more even after intravenous analgesics where this block was applied by trained emergency physicians (EP).

RESULTS

Following SAPB median (± IQR) pain score reduction was 5 (±4) at 30 min and 7.5 (±2) after 60 min of administering the block. There were no incidences of block failure or block-related complications in our series.

CONCLUSIONS

Ultrasound-guided SAPB can be used safely by trained EP in the emergency department to relieve acute severe analgesic-resistant pain in MFR patients.

Effects of Ropivacaine Concentration on Analgesia After Ultrasound-Guided Serratus Anterior Plane Block: A Randomized Double-Blind Trial

Purpose

Serratus anterior plane (SAP) block is effective for analgesia after breast surgery. Whether a higher local anesthetic concentration prolongs sensory block duration and improves postoperative analgesia remains unclear. The aim of this study was to compare the analgesic effects of SAP block with different concentrations of ropivacaine.

Patients and Methods

Sixty patients scheduled for breast surgery were enrolled in this randomized double-blind trial. SAP block was induced with 20 mL of 0.375%, 0.5%, or 0.75% ropivacaine in Group R0.375, Group R0.5, and Group R0.75, respectively. The primary endpoint was the area under the curve (AUC) of numerical rating scale (NRS) pain intensity scores at rest over time. The secondary endpoints were AUC of NRS pain intensity scores on movement over time, active sensory block duration, tramadol consumption, and the elapsed time between completion of surgery and the first administration of rescue analgesia.

Results

The AUC of NRS pain intensity scores at rest of Group R0.375 was significantly higher than that of Groups R0.5 and R0.75 (P=0.025, and P=0.001). The AUC of NRS pain intensity scores on movement of Group R0.375 was also significantly higher than that of Groups R0.5 and R0.75 (both P<0.001). At higher ropivacaine concentrations, the duration of SAP sensory block increased (P<0.001). Tramadol consumption and the elapsed time between completion of surgery and the first administration of rescue analgesia were similar in the three groups (P>0.05).

Conclusion

A comparison of 0.5% and 0.75% ropivacaine showed no significant difference in postoperative analgesia, but both were superior to 0.375% ropivacaine, although higher ropivacaine concentration lengthened the duration of SAP block. Therefore, SAP block with 0.5% ropivacaine is recommended for postoperative analgesia in breast surgery.