Ketamine or Neostigmine for Serratus Anterior Plane Block in Modified Radical Mastectomy
Condition: Postoperative Pain
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      The aim of this study is to Investigate the analgesic efficacy of adding ketamine compared to
      neostigmine to local anesthetic in Ultrasound guided Serratus anterior plane block for
      patients undergoing Modified Radical Mastectomy.
    

Detailed description: 
      Breast cancer is the most common malignancy among females with incidence of 18,660 patients
      each year in Egypt. Modified Radical Mastectomy is considered the main surgical management
      for breast cancer accounting for 31% of all breast surgery cases.

      Ultrasound guided Serratus anterior plane block provides analgesia for breast and lateral
      thoracic wall surgeries by blocking nerves that are located in a compartment between the
      serratus anterior and the latissimus dorsi muscles ( the intercostobrachial nerve, lateral
      cutaneous branches of the intercostal nerves (T3-T9), long thoracic nerve and thoracodorsal
      nerve).

      A previous study demonstrated the analgesic efficacy of ketamine in patients undergoing
      modified pectoral nerve block in breast cancer surgery as evidenced by prolonged time to
      first rescue analgesia and reduced total opioid consumption.

      Neostigmine has been used as an additive to local anesthetics to prolong the analgesic
      effect. Although there is good evidence for a spinal action of neostigmine, its analgesic
      efficacy as an adjuvant to local anesthetic is still unclear.

      The aim of this study is to Investigate the analgesic efficacy of adding ketamine compared to
      neostigmine to local anesthetic in Ultrasound guided Serratus anterior plane block for
      patients undergoing Modified Radical Mastectomy.
    

Intervention name(s): Serratus Anterior Plane Block Technique; General anesthesia; bupivacaine +ketamine; bupivacaine + neostigmine; bupivacaine +saline
Intervention type(s): Procedure; Procedure; Drug; Drug; Drug
Intervention description(s): The patient will be placed in Lateral Decubitus with a surgical side upwards with arm abduction. A linear ultrasound transducer (6-13 MHz) will be placed on the patient's midaxillary line in the transverse plane, at the level of the fifth rib, with the indicator oriented toward the operator's left. With the rib, pleural line, and overlying serratus anterior and latissimus dorsi muscles visualized, local infiltration of the skin and subcutaneous tissue will be applied by 2-3ml of lidocaine 2%. Then, using ultrasound guidance, A 38-mm 22-gauge regional block needle will be advanced in-plane at an angle of approximately 45 degrees towards the fifth rib. The expecting depth for this block is 1-4 cm. After aspiration, injection 30ml local anesthetic mixture will be injected anteriorly to the rib and deep to the serratus anterior muscle.; Induction of general anaesthesia will be performed using a regimen of IV 2 μg/kg fentanyl and propofol IV 2 mg /kg. Tracheal intubation will be facilitated using 0.5 mg/kg IV of rocuronium.
Anaesthesia will be maintained with inhaled sevoflurane 2-2.5% in oxygen enriched air (FiO2=0.5). Maintenance doses of rocuronium 0.1 m\kg will be provided every 30 minutes.
The residual neuromuscular blockade will be reversed using neostigmine (0.05 mg/kg) and atropine (0.02 mg/kg), and extubation will be performed after complete recovery of the airway reflexes.; 30 ml bupivacaine 0.25% + 1 ml ketamine (50mg) in Serratus Anterior Plane Block.; 30 ml bupivacaine 0.25% + 1 ml neostigmine (500 μg)in Serratus Anterior Plane Block.; 30 ml bupivacaine 0.25% + 1 ml normal saline in Serratus Anterior Plane Block.
Other intervention name(s): ketamine; neostigmine; saline
Intervention MeSH terms: Ketamine; Bupivacaine; Neostigmine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Treatment