U/S Guided SAB VS U/S Guided SAB With Modified Pectoral Nerve Block in Modified Radical Mastectomy
Condition: U/S Guided SAB VS U/S Guided SAB Combined With Modified Pectoral Nerve Block
Study type: Interventional

Summary: 
      We hypothesize that ultrasound guided serratus anterior plane block Combined With Modified
      Pectoral Nerve Block is going to be more effective than Ultrasound guided Serratus anterior
      plane block alone in patients undergoing MRM as modified Pecs block involves the block of
      medial and lateral pectoral nerves which are spared in case of serratus block alone,
      resulting in reducing myofascial pain and opioid consumption.
    

Detailed description: 
      Ultrasound guided Serratus anterior plane block was introduced in 2013 for analgesia of
      breast and lateral thoracic wall surgery. At the axillary fossa, the intercostobrachialis
      nerve, lateral cutaneous branches of the intercostal nerves (T3-T9), long thoracic nerve, and
      thoracodorsal nerve are located in a compartment between the serratus anterior and the
      latissimus dorsi muscles, between the posterior and midaxillary lines at this plane local
      anesthetic will be injected . Complications of serratus anterior plane block include local
      anesthetic toxicity and pneumothorax , unfortunately medial and lateral pectoral nerves are
      preserved which are responsible for the myofacial pain .

      The pectoral nerves (Pecs) block types I and II (Modified Pectoral block) , is less invasive
      technique described by Blanco et al where local anesthetic is deposited into the plane
      between the pectoralis major muscle(PMm) and the pectoralis minor muscle (Pmm) (Pecs I
      block)and above the serratus anterior muscle at the third rib (Pecs IIblock).,Blocking
      intercostobrachial, third to sixth intercostals the long thoracic nerves in addition to
      medial and lateral pectoral nerves.

      Addition of Modified Pecs block to Serratus anterior plane block will enhance the control of
      pain as it block the medial and lateral pectoral nerves which are responsible for the
      myofacial pain and which are spared in case of Serratus block alone .
    

Intervention name(s): Serratus Anterior Plane Block
Intervention type(s): Procedure
Intervention description(s): SAPB Technique; U/S probe will be placed on the patient's midaxillary line in the transverse plane, at the level of the fifth rib, Then, using U/S guidance, A 38-mm 22-gauge regional block needle is advanced in-plane at an angle of approximately 45 degrees towards the fifth rib. After aspiration to avoid IV injection 30ml of levobupivacaine 0.25% is injected anteriorly to the rib and deep to the serratus anterior muscle.
SAPB combined with Modified Pectoral Nerve Block :
SAPB with injection of 20 ml levobupivacaine 0.25% as discussed before. Modified Pectoral Nerve Block:After identification of the axillary vessels, the U/S probe will turned inferolaterally till the serratus anterior and the two pectoralis muscles are detected in one plane. 10 ml of levobupivacaine 0.25%was injected between the two pectoralis muscles. After that,10 mL of levobupivacaine 0.25%is injected above this muscle.
Other intervention name(s): Serratus Anterior Plane Block SAPB combined with Modified Pectoral Nerve Block
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: To determine the analgesic effect of ultrasound guided Serratus anterior block combined with modified pectoral nerve block compared to ultrasound guided Serratus Anterior block in patients undergoing modified radical mastectomy regarding the following :
1-Post-operative opioid (morphine) consumption in the 1st 24 hours 2- Post-operative Numeric Pain Rating Scale.
3. Effect on hemodynamics:
Mean arterial blood pressure and Heart rate.
4. Intraoperative fentanyl consumption.
5. Duration of analgesic effect
Masking: Double (Participant, Investigator)
Primary purpose: Supportive Care