Comparison of Thoracic Paravertebral Block , Pectoral Nerve Block to Serratus Anterior Plane Block in Breast Surgery, A Randomized Controlled Study
Condition: Comparison of Thoracic Paravertebral Block to Serratus Anterior Plane Block in Breast Surgery
MeSH terms: Aortic Dissection
Study type: Interventional

Summary: 
      The investigators hypothesize that the analgesic efficacy of ultrasound-guided serratus
      anterior plane block will provide better analgesia with fewer complications in comparison to
      ultrasound guided thoracic paravertebral block
    

Detailed description: 
      •The blocks techniques:

        -  Group I: Thoracic paravertebral block group (TPVB group n=15) These patients will
           receive single ipsilateral ultrasound-guided thoracic paravertebral block. TPVB will be
           performed with the patient in the sitting position at the level of the 4th thoracic
           vertebra under complete aseptic precaution with the probe in a vertical position
           approximately 2.5-3 cm lateral to the midline. The midpoint of the transducer is to be
           placed in a longitudinal paramedian plane between two transverse processes. Both
           transverse processes should be visualized, with the superior costo-transverse ligament
           and the pleura visible in between .An 18-20 gauge Tuohy needle will be introduced in a
           cephalad direction. The tip of the needle will be advanced under direct visualization
           until it pierces the superior costo-transverse ligament. the investigators will inject
           small aliquots of normal saline intermittently as the investigators advance the needle
           to confirm the position of the tip. When the needle tip is located immediately above the
           pleura, the needle is aspirated to confirm the absence of blood or air. After this,
           15-20 cc of bupivacaine 0.25% will be injected. Spread of local anaesthetic with
           depression of the pleura will be clearly visualized. The extent of local anaesthetic
           spread should be evaluated by moving the ultrasound probe superiorly and inferiorly.

        -  Group II :Serratus anterior plane block group (SAP group n= 15) These patients will
           receive serratus anterior plane block. The SAP block will be performed while the patient
           is in the supine position by using a linear US probe of high frequency (6-13 MHz) after
           sheathing. The probe will be placed over the mid-clavicular region of the thoracic cage
           in a sagittal plane. The ribs will be counted inferiorly and laterally, until the 5th
           rib is identified in the midaxillary line. The latissimus dorsi (superficial and
           posterior), teres major (superior) and serratus muscles (deep and inferior) will be then
           easily identifiable by ultrasound overlying the fifth rib. The needle (Stimuplex, B
           Braun, Germany 22-G, 50-mm) will be introduced in-plane with respect to the ultrasound
           probe from supero-anterior to postero-inferior. Under continuous ultrasound guidance,
           the investigators will inject 20 cc of bupivacaine 0.25%. The sensory level will be
           tested with pin prick and ice pack before induction of general anesthesia
    

Intervention name(s): Thoracic paravertebral block(TPVB) group
Intervention type(s): Procedure
Intervention description(s): Thoracic paravertebral block group (TPVB) group: The midpoint of the transducer is to be placed in a longitudinal paramedian plane between two transverse processes.Tuohy needle will be introduced in a cephalad direction. The tip of the needle will be advanced under direct visualization until it pierces the superior costo-transverse ligament. When the needle tip is located immediately above the pleura, the needle is aspirated to confirm the absence of blood or air.
Serratus anterior plane block group (SAP) group: The US probe will be placed over the mid-clavicular region of the thoracic cage in a sagittal plane. The ribs will be counted until the 5th rib is identified in the midaxillary line. The latissimus dorsi, teres major and serratus muscles will be then easily identifiable by US overlying the fifth rib. The needle will be introduced in-plane with respect to the US probe from supero-anterior to postero-inferior
Other intervention name(s): Serratus anterior plane block( SAP) group
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Although thoracic epidural analgesia is the gold standard technique after breast surgery paravertebral block (PVB) has become a potential alternative approach. However, both techniques may be associated with serious complications such as pneumothorax, total spinal anaesthesia and inadvertent intravascular injection. Recently since the advent of ultrasound (US) in anaesthetic practice several interfascial plane blocks have been described. Serratus plane block is a novel interfascial plane block which can provide analgesia after breast surgery.
The serratus anterior plane block is an interfascial plane block where the local anaesthetics are injected superficial to serratus anterior at the 5th rib level in the mid axillary line. The serratus plane block is a progression from Blanco's et al work with the Pecs I and II blocks by making the technique easier in its application using single injection and to lower the potential side-effects
Masking: Double (Participant, Care Provider)
Primary purpose: Supportive Care