Comparison of pectoralis plane blocks with ketamine-dexmedetomidine adjuncts and opioid-based general anaesthesia in patients undergoing modified radical mastectomy

Abstract

Background and Aims: Regional anaesthesia attenuates surgical stress-response, provides superior analgesia, reduces recovery time with early mobilisation and is opioid-sparing [addresses post-operative nausea vomiting (PONV), constipation, immunosuppression and cancer-progression concerns with opioids]. Hence, we studied pectoralis (PECS) blocks for modified radical mastectomy (MRM). Methods: A prospective, interventional, double-blind, randomised, parallel-arm, active-controlled study comparing two anaesthetic techniques for post-operative pain relief in70 adult American Society of Anesthesiologists grade I/II carcinoma breast patients undergoing MRM was conducted. Patients were randomised to Group-O (opioids, sevoflurane) and Group-P (PECS-block, pre-incisional intravenous (IV) ketamine (0.5 mg/kg), pre-incisional IVdexmedetomidine (1 μg/kg over 10 min, then 0.6 μg/kg/h). Data were subjected to statistical analysis using the Statistical Package for Social Sciences, version-23 and independent sample t -test/Welch test for equality of means and expressed as dotted box-whisker plots. Nominal categorical intergroup data was compared using Chi-squared test/Fisher's exact test. P<0.05 was considered statistically significant. Clinical significance was calculated. Results: Higher Visual Analogue Scale (VAS)-scores were recorded in Group-O versus Group-P, immediately post-extubation [mean (SD) 3.6 ± 1.5 and 0.76 ± 0.6] and at 1h (3.1 ± 1.2 and1.4 ± 0.5), 2h (2.5 ± 0.9 and 1.2 ± 0.6) and 4h (2.2 ± 0.5 and 1.7 ± 0.9) respectively. At 8h and 24h post-surgery VAS was comparable. Cumulative-VAS was lower in Group-P. Intraoperative haemodynamics were comparable. Incidence of PONV and constipation was higher in Group-O where each patient received average 27.46 mg morphine-equivalents of opioids. Time to discharge from surgical intensive care unit was 2h shorter in Group-P. Conclusion: Pre-emptive PECS-blocks supplemented with low-dose ketamine and dexmedetomidine comprise a practical and useful alternative technique to the standard opioid-based general anaesthetic technique for MRM.

Total opioid‐free general anaesthesia can improve postoperative outcomes after surgery, without evidence of adverse effects on patient safety and pain management: A systematic review and meta‐analysis

“…For dichotomous outcomes, the number of events was quantified. If a study provided insufficient data, raw data were requested from the corresponding author (two 26,27 out of eleven [26][27][28][29][30][31][32][33][34][35][36] while continuous outcomes were reported as mean difference (MD), with a 95% confidence interval (CI). 19 Heterogeneity among studies was assessed using the I 2 coefficient.…”

“…None of the included studies had regional anaesthesia as sole treatment. The studies were conducted in South Ko rea, 28,31,32,[40][41][42][43] Turkey, 26,27,[44][45][46][47] Egypt, 33,[48][49][50] India, 36,51 Canada, 29 Denmark, 30 France, 52 Japan, 53 Republic of Macedonia, 35 Thailand, 34 and USA. 54 Half of the studies involved laparoscopic surgery 2 7-29,32,33,35,43,46,48,49,51,52,54 where the most common surgical procedures were different gynaecological interventions 28,32,34,43,46,48 and upper gastrointestinal surgery (cholecystectomy and bariatric surgery), 27,29,33,35,49,54 followed by breast surgery.…”

Advancing, strengthening and reshaping obstetric critical care with Point-of-Care Ultrasound (POCUS)

“…Apart from the usual and new blocks for limb surgeries being performed under vision,[ 4 5 6 7 8 9 ] with the diminishing size of the machine and better resolution, a whole armamentarium of fascial plane blocks and surrogate central neuraxial blocks such as paravertebral[ 10 11 12 ] and erector spinae plane blocks[ 13 14 15 16 17 ] are now available to the anaesthesiologists. Spinal,[ 18 19 ] epidural[ 20 21 22 ] and even caudal blocks[ 23 ] can now be performed under vision, especially in paediatrics.…”

“…In addition to that, the chest wall (pectoralis,[ 15 16 17 ] serratus anterior plane blocks[ 24 25 ]) and abdominal wall[ 26 ] (transversus abdominis,[ 27 28 29 ] quadratus lumborum,[ 30 31 ] rectus sheath blocks) plane blocks are now being routinely performed.…”

Neural blocks at the helm of a paradigm shift in enhanced recovery after surgery (ERAS)

“…The use of ultrasound-guided nerve blocks has emanated in reduction in acute postoperative pain scores, opioid consumption, improvised patient satisfaction scores, hastened recovery and dramatically reduced length of hospital stay with significant cost-effectiveness and reduction of morbidity and mortality. [ 20 21 22 23 24 25 26 27 28 29 ]…”