Comparing Effect of Adding Ketamine Versus Dexmedetomidine to Bupivacaine in Pecs-ⅠⅠ Block on Postoperative Pain Control in Patients Undergoing Breast Surgery

Abstract

Background: Pectoralis and serratus plane blocks (Pecs-II block) has successfully demonstrated a good quality of perioperative analgesia for breast surgery.Objective: This study aimed to compare the quality of postoperative pain control when adding either ketamine or dexmedetomidine to bupivacaine 0.25% for Pecs-II block.Methods: This prospective randomized double-blind study was conducted on 159 female patients with American Society of Anesthesiologist (ASA) physical status class I-III scheduled to have modified radical mastectomy. Patients were randomly assigned into 3 groups. Each group included 53 patients to receive ultrasound guided Pecs-II blocks with either 32 mL of 0.25% bupivacaine added to ketamine hydrochloride 1 mg/kg (BK group), 32 mL of 0.25% bupivacaine added to dexmedetomidine 1 ug/kg (BD group) or 32 mL of 0.25% bupivacaine only (B group). The primary outcome was the total postoperative morphine consumption for the first 24 hours postoperatively. The time of the first request of analgesia, the pain scores at rest of ipsilateral arm, and the intraoperative fentanyl requirements, were the secondary outcome measures. Any side effects occurred were recorded.Results: The total postoperative morphine consumption was significantly lower in patients received bupivacaine with addition of either ketamine (BK group), (10.3 ± 2.6 mg), or dexmedetomidine (BD group), (3.8 ± 0.2 mg) respectively, versus patients received only bupivacaine (B group), (16.9 ± 5.3 mg). Both ketamine (BK group) and dexmedetomidine (BD group) added to bupivacaine significantly prolonged the time to first analgesic request (16.7 ± 4.5 h), (21.6 ± 1.6 h) in both groups respectively compared with patients received bupivacaine alone (B group) (11.5 ± 1.2 h). The pain score was variable between the 3 groups during the first 24 hours postoperatively. There were no statistically significant differences in perioperative hemodynamics, O 2 saturation, sedation scores, or side effects observed between the 3 groups. Patient satisfaction was reported to be the best in patients received dexmedetomidine added to bupivacaine compared to the patients who received ketamine as an additive or those who received bupivacaine alone. Conclusion:Adding dexmedetomidine to bupivacaine provides more effective postoperative pain control than adding ketamine during Pecs-II blocks for breast cancer surgery.

Comparison of Dexmedetomidine and Ketamine in Serratus Anterior Plane Block for Postoperative Pain Control in Thoracotomy Patients: A Randomized Clinical Trial

“…Based on the results of Yazigi et al, no reduction in acute pain score and supplemental morphine consumption following thoracotomy was observed in patients receiving the combination of ketamine and intercostal block ( 21 ). In contrast to the results of the present study, Hefni et al showed that the addition of dexmedetomidine to bupivacaine provides more effective postoperative analgesia than the addition of ketamine during pectoralis blocks in breast cancer surgery ( 22 ). However, in another study, adding 1 mg/kg of ketamine to 0.25% bupivacaine in an intercostal block in breast cancer surgery was shown to be useful, consistent with the results of the present study.…”

Dexmedetomidine as an Adjuvant to Nerve Block for Cancer Surgery: A Systematic Review and Meta-Analysis

“…This study selection process is summarized in the PRISMA flow chart ( Figure 1 ). According to Cochrane’s Risk of Bias 2 (RoB2) assessment, seventeen RCTs [ 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ] were considered to be low-risk and three RCTs [ 30 , 31 , 32 ] had some concerns. Moreover, the quality of the included studies is summarized in Supplementary Materials (Table S2) .…”

“…Five studies into breast cancer surgery reported on 24 h postoperative morphine consumption [ 13 , 16 , 18 , 21 , 31 ]. The meta-analysis of those studies concluded that total 24 h morphine consumption in the dexmedetomidine group was lower than that of the control group (SMD = −1.99 [95% CI −3.01 to −0.98], p = 0.0001, I2 = 91%, random effects) ( Figure 2 ).…”

“…In breast cancer surgery, the time until the first use of rescue morphine analgesia was mentioned in three RCTs [ 13 , 14 , 16 ]. The meta-analysis showed that dexmedetomidine treatment prolonged the requirement for morphine rescue analgesia (SMD = 2.98 [95% CI 0.01 to 5.95], p = 0.05, I2 = 98%, random effects).…”

Effects of Adding Dexamethasone Plus Ketamine to Bupivacaine for Ultrasound-guided Serratus Plane Block as Analgesia in Major Breast Surgery: A Randomized, Double-blind Trial

“…We supposed that ketamine addition to the dexamethasone bupivacaine combination would induce the same effect if bupivacaine was used alone. A previous study [9] reported an increase in analgesia duration of 5.2 h by adding ketamine to the LA, with a pooled standard deviation of 2.8. Based on these findings, 29 patients in each group were required to reject the null hypothesis at an alpha level of 0.05 and a power of 80%.…”