<p>Perioperative Analgesic Modalities for Breast Cancer Surgeries: A Prospective Randomized Controlled Trial</p>

Abstract

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 ).

Analgesic efficacy and safety of erector spinae plane block in breast cancer surgery: a systematic review and meta-analysis

“…Among these 11 trials, 9 [ 16 – 22 , 24 , 26 ] of them included modified radical mastectomy, with sentinel lymph node biopsy in two trials [ 16 , 18 ] and axillary lymph node dissection in three trials [ 16 , 18 , 20 ]. Except for the study by Elsabeeny et al [ 17 ], the rest of the included studies showed that ESPB was performed by ultrasound before the induction of general anesthesia with or without preoperative sedation. Most trials [ 17 – 26 ] received a single-level technique at the T4 or T5 vertebral level, and only one trial [ 16 ] used at bi-level (T2-T4) block technique.…”

“…Except for the study by Elsabeeny et al [ 17 ], the rest of the included studies showed that ESPB was performed by ultrasound before the induction of general anesthesia with or without preoperative sedation. Most trials [ 17 – 26 ] received a single-level technique at the T4 or T5 vertebral level, and only one trial [ 16 ] used at bi-level (T2-T4) block technique. The control group of one trial was treated with 0.9% physiological saline as sham block [ 26 ], the other control groups were received no intervention.…”

“…Assessment of sensory block was performed for mapping the block area in three trials, all blocks performed in these studies were successful [ 23 – 25 ]. In most studies, postoperative pain was provided by patient-controlled intravenous analgesia with morphine, while three trials [ 17 , 20 , 22 ] used morphine and flurbiprofen axetil as single-dose rescue analgesic. There were no complications associated with nerve block reported in any trials, such as vascular puncture, pneumothorax, or local anesthesia toxicity.…”

“…Three studies [ 17 , 22 , 25 ] included 250 patients measured the intraoperative opioid consumption (converted to Intravenous fentanyl equivalents). Patients receiving ESPB showed a significant reduction in fentanyl consumption compared with the GA group (MD: –22.12; 95%CI: − 31.21 to − 13.03; P < 0.01) (Fig.…”

“…Four studies [ 17 , 22 – 24 ] included 250 patients reported postoperative rescue analgesia. The number of patients who received rescue analgesia in the ESPB group was significantly lower than that in GA group (RR = 0.26, 95% CI [0.11to 0.60], P = 0.002) (Fig.…”