Impact of Ultrasound-Guided Deep Serratus Anterior Plane Block Combined With Dexmedetomidine as an Adjuvant to Ropivacaine Inpatient Quality of Recovery Scores Undergoing Modified Radical Mastectomy: A Randomized Controlled Trial

Abstract

BackgroundBreast cancer has overtaken lung cancer as the most commonly diagnosed malignancy and is the leading cause of cancer-related death in women. Surgery is the only possible cure for breast cancer, and the incidence of acute postoperative pain (APP) is high in breast surgery. Previous reports suggested that ultrasound-guided deep serratus anterior plane block (dSAPB) provided effective blockade to relieve pain after modified radical mastectomy for breast cancer. In fact, despite the long-acting local anesthetic agents used, the patient’s pain cannot completely be eliminated due to the short duration of anesthesia. Dexmedetomidine as an adjunct to local anesthetics can prolong peripheral nerve block duration. However, no study has investigated the role of dSAPB with dexmedetomidine in the quality of recovery scores undergoing modified radical mastectomy. Thus, this study was conducted aiming at this aspect.Material and MethodsThis single-center, double-blind, randomized clinical trial was conducted at Bethune International Peace Hospital. A total of 88 participants of elective modified radical mastectomy were enrolled from May and November 2021. Ultrasound-guided dSAPB combined with 30 ml of 0.375% ropivacaine or 30 ml of 0.375% ropivacaine with dexmedetomidine (1 μg/kg) was administrated before anesthesia at the fourth to fifth ribs of the axillary midline. The primary outcome was quality of recovery, measured 24 h postoperatively using the QoR-15. Secondary outcomes were the Visual Analogue Scale (VAS) scores at rest and movement at 1, 6, 12, 24, and 48 h after surgery, 48 h sufentanil consumption postoperatively, the incidence of postoperative nausea and vomiting (PONV), length of post-anesthesia care unit (PACU) stay, dizziness, delirium, SAPB-related adverse events, and patient’s satisfaction with pain management.ResultsAmong the 88 participants, 8 did not meet the inclusion criteria; the other 80 were randomized to receive dSAPB combined with ropivacaine (Group R, N=40) and dSAPB combined with ropivacaine plus DEX (Group RD, N=40), of which a total of 7 (4 in Group R and 3 in Group RD) were excluded due to protocol deviation. Eventually,73 participants (36 in Group R and 37 in Group RD) were included for final analysis, with age (SD, years, 54.08[6.28] vs. 54.62[7.44], p=0.740), body mass index (BMI) (SD, 27.96[1.67] vs. 27.57[2.38], p=0.428), and median preoperative global QoR-15 score (interquartile range (IQR), 127[123.25–131] vs. 126[121–130], p=0.662). The median postoperative global QoR-15 score (IQR, 107[103–112] vs. 109.5[107–114], p=0.016), VAS score at rest at 12th hour (IQR, 1[1–2] vs. 1[1–2], p=0.033), VAS score in movement at 12th hour (IQR, 2[1–3] vs. 2[1–3], p=0.014) and at 24th hour (IQR, 3[2–3] vs. 3[2–3], p=0.040), and median sufentanil rescues consumption (IQR, 14[12–17 vs. 14[12–15], p=0.022] of Group RD were significantly lower than those of the Group R. Patient satisfaction score (SD, 8.28[0.70] vs. 8.62[0.59], p=0.024) of Group RD were significantly higher than those of the Group R.ConclusionThe ultrasound-guided dSAPB combined with dexmedetomidine plus ropivacaine may improve the QoR-15 in patients undergoing modified radical mastectomy and indicates that it may be a useful intervention to aid recovery following breast cancer surgery. Furthermore, participants in the ropivacaine with DEX group met the superior pain relief in the early postoperative period, reduced postoperative cumulative opioid consumption, increased patient satisfaction, and no increase in the incidence of complications.

Postoperative recovery after breast cancer surgery

“…25 The mean QoR-15 score at 24 h after surgery in the control group (132.0 AE 12.0) in this trial was higher than that reported previously in patients undergoing breast cancer surgery from China (107 to 120). 26,27 Such a discrepancy may reflect the use of multimodal analgesia (the use of dexmedetomidine and NSAIDs) in the current study. The anxiolytic properties of dexmedetomidine 28 and the anti-inflammatory effects of NSAIDs may also contribute to improved QoR.…”

Effects of Subcostal Anterior Quadratus Lumborum Block with and without Dexmedetomidine on Postoperative Rehabilitation in Patients Undergoing Laparoscopic Renal Surgery: A Prospective Double-Blinded Randomized Controlled Study

“…DEX is a highly selective drug α2-adrenergic receptor agonist with characteristics including sedation, analgesia, antianxiety, inhibition of sympathetic activity, mild respiratory inhibition, and stable hemodynamics. [23][24][25] The mechanism of DEX as an adjuvant to local anesthetics enhances their effect is a multifactorial theory still being controversial, which works mainly through peripheral level, spinal cord level and supraspinal level. [25][26][27][28][29] Furthermore, there is a lack of research about the mechanism of DEX on renal.…”

“…Moreover, DEX reduced postoperative opioids requirements, increase patient satisfaction, and enhance postoperative recovery of gastrointestinal function. [25][26][27][28][29] In addition, DEX appears to have postoperative renal protective effects. 30 Nevertheless, so far, the exact protective mechanism of DEX in the kidney has still not been elucidated, which is thought to act mainly by inhibiting sympathetic activity, attenuating inflammation and reducing ischemic-reperfusion injury.…”

Comparing analgesic efficacy of different block modalities after breast cancer surgery

“…However, the authors did not clearly describe the patient' status when assessing postoperative pain, as performed in other works comparing the postoperative analgesic efficacy of different interventions in the patients undergoing breast cancer surgery. [3][4][5] The available evidence indicates that for patients undergoing breast cancer surgery, postoperative pain is more severe with movement than in a resting state. We argue that this unknown factor would have biased the results of postoperative pain assessment at the different time points.…”

“…Fourth, this study did not observe any outcome variable of enhanced recovery after surgery protocols for breast cancer surgery, such as the time to early mobilization, the incidence of postoperative nausea and vomiting, patient's satisfaction with pain management, the time to hospital discharge, and quality of postoperative recovery. [3][4][5] In fact, these variables are very important for comparing the performance and clinical availability of different interventions for postoperative pain control. 2 Thus, we believe that this study would have provided more useful data comparing clinical values of two block modalities in patients undergoing breast cancer surgery if the design had included the assessment of the outcomes of enhanced recovery after surgery protocols.…”