Analgesic Effect of Erector Spinae Versus Serratus Anterior Plane Block for Thoracoscopic Sympathectomy

Study Overview
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Brief Summary
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Thoracic incisions are painful and associated with chronic post-surgical pain and inadequate analgesia is associated with poorer postoperative outcomes. Recent progress has been made in the field of thoracic anesthesia by improving analgesic modalities such as PECS 1 and PECS 2, intercostal plane block, paravertebral regional anesthesia, ultrasound-guided erector spinae and serratus anterior plane block. Administered of the local anesthetic in erector spinae plane block is in the interfascial plane between the transverse process of the vertebra and the erector spinae muscles, spreading to multiple paravertebral spaces. It affects both the ventral and dorsal rami and leading to blockage of both visceral and somatic pain. Ultrasound-guided serratus anterior plane block is a facial plane block that provides analgesia by blocking of lateral branches of intercostal nerves above or below the serratus plane muscle. We hypothesize that the ultrasound-guided erector spinae plane block may have better quality than the serratus anterior plane block for patients undergoing thoracoscopic sympathectomy as erector spinea plane blocks visceral and somatic pain.

Detailed Description
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Primary palmar hyperhidrosis (PPH) refers to the excessive secretion of exocrine glands on the palms, which is often accompanied by the head, face, or plantar hyperhidrosis. PPH demonstrates no obvious organic cause; however, some patients may feel distressed because their palms sweat more than normal, and such a situation may lead to severe psychological, social, and occupational dysfunction. Endoscopic thoracic sympathectomy abolishes eccrine sweating in all areas supplied by the postganglionic fibers with its complications which include post-sympathetic neuralgia which is the most important, wound infection, hemorrhage, pneumothorax, horner syndrome, no response to the operation and compensatory hyperhidrosis in non-denervated areas. Forero described ultrasound-guided erector spinae plane block for treatment of thoracic neuropathic pain and explained it as a peri-paravertebral regional anesthesia technique that has been used for prevention of postoperative pain in various surgeries. Ultrasound-guided serratus anterior plane block is a facial plane block which provides analgesia by blocking of lateral branches of intercostal nerves above or below the serratus plane muscle. There are few cases and studies in the literature reporting successful analgesia provided by serratus anterior plane block

Official Title
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A Comparative Study of the Analgesic Effect of Ultrasound-guided Erector Spinae Plane Block Versus Serratus Anterior Plane Block for Thoracoscopic Sympathectomy Surgeries

Conditions
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Thoracic Sympathectomy

Intervention / Treatment
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* Procedure: Erector spinae plane block
* Procedure: Serratus anterior plane block


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: American Society of Anesthesiologists grade I or II physical status Exclusion Criteria: Patients who had coagulopathies local infections neuropathies neuromuscular disease psychiatric disease history of thoracic surgery history of allergy to local anesthetics. receiving chronic analgesic therapy drug abusers

Ages Eligible for Study
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Minimum Age: 21 Years
Maximum Age: 40 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Erector spinae plane block (ESP)<br>Patients would receive erector spinae plane block | Procedure: Erector spinae plane block<br>* Erector Spinae Group (Group E) will receive bilateral ultrasound-guided erector spinae plane block using 30 ml hyperbaric bupivacaine 0.25% will be injected between erector spinae muscle and transverse process of T4<br>|
| Experimental: Serratus anterior plane block (SAP)<br>Patients would receive serratus anterior plane block | Procedure: Serratus anterior plane block<br>* Serratus anterior Group (Group S) will undergo bilateral ultrasound-guided serratus anterior plane block with 30 ml hyperbaric bupivacaine 0.25% will be injected above or below serratus anterior muscle at the level of 4th and 5th rib on the midaxillary line<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The total analgesic consumption | cumulative consumption of opioids during the first postoperative day | 1st 24 hours after surgery | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Postoperative severity of the pain | Visual analogue scale (0-100),where 0 point is equal to no pain and 100 indicate the worst possible pain | every 2 hours for 12hours and then at 16, 20 and 24 hours postoperatively | 
| The total amount of fentanyl consumption | cumulative consumption of fentanyl during the first postoperative day | 1st 24 hours after surgery | 
| The total amount of paracetamol consumption | cumulative consumption of paracetamol during the first post operative day | 1st 24 hours after surgery | 
| Duration of analgesia | from the end of block till the time for the first analgesic requirement (ketorolac) | within 24 hours after surgery | 
| Nausea | number of patients with nausea | 1st 24 hours after surgery | 
| Vomiting | number of patients with vomiting | 1st 24 hours after surgery | 
| Patient Satisfaction | evaluated as 5:excellent, 4:very good, 3:good, 2: fair, 1:poor | After 12 and 24 hours after surgery | 
| Heart rate | changes in heart rate | Intraoperative (every 10 minutes till the end of surgery) | 
| Peripheral oxygen saturation | changes in Peripheral oxygen saturation as measured with pulse oximetry | Intraoperative (every 10 minutes till the end of surgery) | 
| End-tidal carbon dioxide tension | changes in end-tidal carbon dioxide tension as measured with capnography | Intraoperative (every 10 minutes till the end of surgery) | 
| systolic blood pressure | changes in systolic blood pressure | Intraoperative (every 10 minutes till the end of surgery) | 
| diastolic blood pressures | changes in diastolic blood pressure | Intraoperative (every 10 minutes till the end of surgery) | 
| mean blood pressures | changes in mean arterial blood pressure | Intraoperative (every 10 minutes till the end of surgery) |