The analgesic effects of combined pectoral nerve blocks versus combined serratus anterior plane block and pecto-intercostal fascial plane block in breast surgery

Abstract Background Poorly controlled acute pain after breast surgery is associated with a variety of unwanted post-operative consequences, including patient suffering, distress, respiratory complications, prolonged hospital stay and increased likelihood of chronic pain. The analgesic regimen used for postoperative pain control needs to meet the goals of providing safe, effective analgesia, with minimal side effects for the patient. Objective The aim of this study is to compare the intra-operative and the post-operative analgesic effects of the thoracic interfascial plane blocks (serratus anterior plane block in combination with pecto-intercostal fascial plane block) and pectoral nerve blocks (PECS I and II)in patients undergoing non-reconstructive breast surgeries. Patients and Methods The study was conducted on 50 randomly chosen patients in Ain Shams University General Surgery Hospital after approval of the medical ethical committee. They were allocated in two groups of 25 patients each. The two groups were compared regarding analgesic outcome by using the visual analogue scaling system in the first 24 hours postoperative and the patients' satisfaction using verbal rating scale and this was the primary outcome of our study. The amount of fentanyl consumed intra-operative, time for first call for rescue analgesia and the frequency of using it were recorded and compared to achieve the secondary outcome of the study which included reducing opiods requirements and avoiding their side effects. Results The study found that the total amount of intra-operative fentanyl consumption was significantly higher in the SAPB and PIFB group than the Pecs group with the range of 100-150 versus 100-200 micg fentanyl respectively, and the VAS was significantly higher in the combination of serratus anterior plane block and pecto-intercostal fascial plane block compared to Pecs I and II at 8th, 12th and 24th hours post operatively with p value 0.018, 0.022 and 0.032 respectively, also the frequency of administration of rescue analgesia was higher in the SABP and PIFB group with the range of (2 to 3) times in PECS I and II group versus (2 to 5) in SABP/PIFB group. Besides, the first request of post-operative morphine was significantly delayed in the pectoral nerve blocks than the SABP and PIFB group with the p value (0.020). Conclusion The present study found that Pecs I and II group provided superior intra-operative and post-operative analgesic control compared to the serratus and PIFB group in patients undergoing non-reconstructive breast surgeries.

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COMPARISON OF ULTRASOUND GUIDED MODIFIED PECTORAL NERVE BLOCK WITH LOCAL ANAESTHESTIC INFILTRATION FOR ANALGESIA IN BREAST CANCER SURGERY

Pakistan Armed Forces Medical Journal ◽

10.51253/pafmj.v6i6.4110 ◽

2021 ◽

Vol 71 (6) ◽

pp. 1981-84

Author(s):

Usman Saqib ◽

Rashid Iqbal ◽

Sana Usman ◽

Rashid Hanif

Keyword(s):

Nerve Block ◽

Local Anaesthetic ◽

Local Anaesthesia ◽

Breast Surgery ◽

P Value ◽

Nerve Blocks ◽

Pectoral Nerve ◽

Analgesia Requirement ◽

Group A ◽

Group B

Objective: To compare the frequency of pain and mean analgesia requirement after breast surgery under general anaesthesia when comparing pectoral nerve block with local anaesthesia infiltration. Study Design: Comparative prospective study. Place and Duration of Study: Combined Military Hospital, Rawalpindi from Mar 2018 to Sep 2019. Methodology: A total of 60 patients undergoing modified radical mastectomy were included in the study. Group A (n=30) received pectoral nerve blocks while Group B (n=30) received local anaesthetic infiltration. Outcome was assessed at 12 hours after injection of local anaesthetic. Results: Pain in 7 (23.33%) patients in Group A (Pectoral nerve blocks) and in 20 (66.67%) patients in Group B (Local anaesthetic infiltration), p-value of 0.001 which was considered statistically significant. Mean analgesic requirement was found to be 80 ± 33.73 mg in the Group A (pectoral nerve blocks) compared with 141.67 ± 47.50 mg in Group B (Local anaesthesia infiltration) patients with a p-value of <0.001 which was statistically significant. Conclusion: Pectoral nerve block significantly reduces early postoperative pain and analgesia requirement when compared with Local anaesthesia infiltration after breast surgery.

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Combined transverse thoracis plane and pectoral nerve blocks for breast surgery under sedation

Anaesthesia Reports ◽

10.1002/anr3.12097 ◽

2021 ◽

Vol 9 (1) ◽

pp. 28-31

Author(s):

E. J. Helmich ◽

R. J. Van Den Broek ◽

J. G. Bloemen

Keyword(s):

Breast Surgery ◽

Nerve Blocks ◽

Pectoral Nerve

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By Ultrasonic-Guided Erector Spinae Block, Thoracic Paravertebral Block versus Serratus Anterior Plane Block by Articaine with Adrenaline during Breast Surgery with General Anesthesia: A Comparative Study of Analgesic Effect Post-Operatively: Double Blind Randomized, Controlled Trial

Open Journal of Anesthesiology ◽

10.4236/ojanes.2019.94008 ◽

2019 ◽

Vol 09 (04) ◽

pp. 68-82 ◽

Cited By ~ 1

Author(s):

Ayman Mohamady Eldemrdash ◽

El-Sayed Mohamed Abdelzaam

Keyword(s):

Randomized Controlled Trial ◽

Analgesic Effect ◽

Breast Surgery ◽

Controlled Trial ◽

Erector Spinae ◽

Serratus Anterior ◽

Double Blind ◽

Thoracic Paravertebral Block ◽

Randomized Controlled ◽

Anterior Plane

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Refining a great idea: the consolidation of PECS I, PECS II and serratus blocks into a single thoracic fascial plane block, the SAP block

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2019-100745 ◽

2019 ◽

pp. rapm-2019-100745 ◽

Cited By ~ 2

Author(s):

Carlo D Franco ◽

Konstantin Inozemtsev

Keyword(s):

Brachial Plexus ◽

Chest Wall ◽

Mechanism Of Action ◽

Sensory Innervation ◽

Common Mechanism ◽

Nerve Blocks ◽

Intercostal Nerves ◽

Lateral Branches ◽

Fascial Plane Block ◽

Fascial Plane

The popularity of ultrasound-guided nerve blocks has impacted the practice of regional anesthesia in profound ways, improving some techniques and introducing new ones. Some of these new nerve blocks are based on the concept of fascial plane blocks, in which the local anesthetic is injected into a plane instead of around a specific nerve. Pectoralis muscles (PECS) and serratus blocks, most commonly used for post op analgesia after breast surgery, are good examples. Among the nerves targeted by PECS/serratus blocks are different branches of the brachial plexus that traditionally have been considered purely motor nerves. This unsubstantiated claim is a departure from accepted anatomical knowledge and challenges our understanding of the sensory innervation of the chest wall. The objective of this Daring Discourse is to look beyond the ability of PECS/serratus blocks to provide analgesia/anesthesia of the chest wall, to concentrate instead on understanding the mechanism of action of these blocks and, in the process, test the veracity of the claim. After a comprehensive review of the evidence we have concluded that (1) the traditional model of sensory innervation of the chest wall, which derives from the lateral branches of the upper intercostal nerves and does not include branches of the brachial plexus, is correct. (2) PECS/serratus blocks share the same mechanism of action, blocking the lateral branches of the upper intercostal nerves, and so their varied success is tied to their ability to reach them. This common mechanism agrees with the traditional innervation model. (3) A common mechanism of action supports the consolidation of PECS/serratus blocks into a single thoracic fascial plane block with a point of injection closer to the effector site. In a nod to transversus abdominus plane block, the original inspiration for PECS blocks, we propose naming this modified block, the serratus anterior plane block.

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Efficacy of Ultrasound-Guided Serratus Anterior Plane Block for Postoperative Analgesia in Patients Undergoing Breast Surgery: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Pain Research and Management ◽

10.1155/2021/7849623 ◽

2021 ◽

Vol 2021 ◽

pp. 1-12

Author(s):

Nian-Qiang Hu ◽

Qi-Qi He ◽

Lu Qian ◽

Ji-Hong Zhu

Keyword(s):

Randomised Controlled Trials ◽

Breast Surgery ◽

Meta Analysis ◽

Oral Morphine ◽

Mean Difference ◽

Serratus Anterior ◽

Randomised Controlled ◽

Oral Morphine Equivalent ◽

Anterior Plane ◽

Morphine Equivalent

Objective. Serratus anterior plane block (SAPB) provides effective thoracic analgesia. This systematic review and meta-analysis was conducted to assess the safety and efficacy of SAPB for postoperative analgesia after breast surgery. Methods. A systematic literature search was performed using Embase, PubMed, Web of Science, and the Cochrane Library for eligible randomised controlled trials. The primary outcomes involved the administration of intraoperative and postoperative opioids. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used for rating the quality of evidence for making recommendations. Results. Overall, 13 studies comprising 826 patients met the inclusion criteria (412 in the SAPB group and 414 in the control group). Patients treated with SAPB exhibited a significantly lower postoperative opioid consumption (mean difference, −38.51 mg of oral morphine equivalent; 95% confidence interval (CI), −60.97 to −16.05; P < 0.01 ; I2 = 100%), whereas no difference was observed in the intraoperative opioid consumption (mean difference, −9.85 mg of oral morphine equivalent; 95% CI, −19.52 to −0.18; P = 0.05 ; I2 = 94%). In addition, SAPB significantly decreased the occurrence of postoperative nausea and vomiting (risk ratio, 0.32; 95% CI, 0.19–0.55; P < 0.05 ;I2 = 38%) and reduced pain scores during the postoperative period (1 h: standardised mean difference (SMD), −1.23; 95% CI, −2.00 to −0.45; I2 = 92%; 2 h: SMD, −0.71; 95% CI, −1.00 to −0.41; I2 = 48%; 4 h: SMD, −1.52; 95% CI, −2.77 to −0.27; I2 = 95%; 6 h: SMD, −0.80; 95% CI, −1.51 to −0.08; I2 = 81%; 8 h: SMD, −1.12; 95% CI, −1.98 to −0.27; I2 = 92%; 12 h: SMD, −0.78; 95% CI, −1.21 to −0.35; I2 = 83%; and 24 h: SMD, −0.71; 95% CI, −1.20 to −0.23; I2 = 87%; P < 0.05 for all). Conclusion. SAPB was safe and effective after breast surgery to relieve postsurgical pain. However, additional well-developed trials are required to validate these findings.

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Pectoral nerve blocks for breast surgery

European Journal of Anaesthesiology ◽

10.1097/eja.0000000000001403 ◽

2020 ◽

Vol Publish Ahead of Print ◽

Author(s):

Michael Meißner ◽

Ece Austenfeld ◽

Peter Kranke ◽

Peter K. Zahn ◽

Esther M. Pogatzki-Zahn ◽

...

Keyword(s):

Breast Surgery ◽

Nerve Blocks ◽

Pectoral Nerve

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Evaluation of Serratus Anterior Plane Block for Pain Relief in Patients Undergoing MIDCAB Surgery

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/1556984520908962 ◽

2020 ◽

Vol 15 (2) ◽

pp. 148-154 ◽

Cited By ~ 1

Author(s):

Sujeet Gautam ◽

Shantanu Pande ◽

Anil Agarwal ◽

S. K. Agarwal ◽

Amit Rastogi ◽

...

Keyword(s):

Postoperative Pain ◽

Pain Relief ◽

Controlled Trial ◽

Artery Bypass ◽

Primary Outcome Measure ◽

Secondary Outcome ◽

Control Group ◽

P Value ◽

Serratus Anterior ◽

Anterior Plane

Objective The minimally invasive direct coronary artery bypass (MIDCAB) surgery is associated with severe chest pain in the first 2 to 3 postoperative days; this may delay the patient recovery. In this randomized controlled trial we evaluated the role of serratus anterior plane (SAP) block for postoperative pain relief in patients undergoing MIDCAB surgery. Methods Patients undergoing MIDCAB surgery were randomized into 2 groups of 25 each; SAP group received 20 mL of 0.2% ropivacaine with 1 μg/mL fentanyl as bolus followed by infusion at 8 mL/h; control group received saline for both bolus and infusion. Primary outcome measure was postoperative pain when supine, and during deep inspiration, coughing, and patient movement; secondary outcome measures were requirement of postoperative intravenous fentanyl and opioid-related side effects. All patients were followed at 6-hourly intervals for 48 hours in the postoperative period. Results were analyzed by the Student’s t -test, χ 2 test, Mann–Whitney U-test and Kruskall–Wallis test. A P-value <0.05 was considered significant. Results The 2 groups were similar with respect to patient characteristics. Static and dynamic pain visual analog scale scores were significantly reduced in the SAP group as compared to the control group at most of the time points of assessment ( P < 0.05). Patient-controlled fentanyl requirements were reduced in the SAP group as compared to control group on the second postoperative day ( P < 0.05). Conclusions SAP block reduced the postoperative pain scores and opioid requirements in patients undergoing MIDCAB surgery.

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Serratus anterior plane versus paravertebral nerve blocks for postoperative analgesia after non-mastectomy breast surgery: a randomized controlled non-inferiority trial

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2021-102785 ◽

2021 ◽

pp. rapm-2021-102785

Author(s):

Rodney A Gabriel ◽

Matthew W Swisher ◽

Jacklynn F Sztain ◽

Brian P Curran ◽

Engy T Said ◽

...

Keyword(s):

Postoperative Analgesia ◽

Recovery Room ◽

Rating Scale ◽

Breast Surgery ◽

Statistical Significance ◽

Numeric Rating Scale ◽

Opioid Consumption ◽

Dramatic Improvement ◽

Serratus Anterior ◽

Nerve Blocks

BackgroundParavertebral and serratus plane blocks are both used to treat pain following breast surgery. However, it remains unknown if the newer serratus block provides comparable analgesia to the decades-old paravertebral technique.MethodsSubjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection serratus or paravertebral block in a subject-masked fashion (ropivacaine 0.5%; 20 mL unilateral; 16 mL/side bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room with serratus blocks (measurement: Numeric Rating Scale), and (2) opioid consumption would be non-inferior with serratus blocks in the operating and recovery rooms. In order to claim that serratus blocks are non-inferior to paravertebral blocks, both hypotheses must be at least non-inferior.ResultsWithin the recovery room, pain scores for participants with serratus blocks (n=49) had a median (IQR) of 4.0 (0–5.5) vs 0 (0–3.0) for those with paravertebral blocks (n=51): 0.95% CI −3.00 to −0.00; p=0.001. However, the difference in morphine equivalents did not reach statistical significance for superiority with the serratus group consuming 14 mg (10–19) vs 10 mg (10–16) for the paravertebral group: 95% CI −4.50 to 0.00, p=0.123. Since the 95% CI lower limit of −4.5 was less than our prespecified margin of −2.0, we failed to conclude non-inferiority of the serratus block with regard to opioid consumption.ConclusionsSerratus blocks provided inferior analgesia compared with paravertebral blocks. Without a dramatic improvement in safety profile for serratus blocks, it appears that paravertebral blocks are superior to serratus blocks for postoperative analgesia after non-mastectomy breast surgery.Trial registration numberNCT03860974.

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