Erector Spina Plane Block Versus Deep Serratus Anterior Plane Block for Post Mastectomy Analgesia

Study Overview
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Brief Summary
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Breast cancer surgery like Mastectomy and modified radical mastectomy are associated with significant postoperative pain, and management depends largely on patient controlled analgesia with intravenous Morphine or other opioids equivalents. Respiratory depression, Ileus, sedation, nausea and vomiting are some of the potential side effect of opioid treatment which prolonged hospital length of stay and increase the coast. Recent advance in ultrasound guided regional anesthesia has led to the development of two novel regional anesthesia techniques specific to chest wall analgesia; Erector spina plain block and Serratus anterior plain block, with its potential to reduce or eliminate the need for opioids to manage post-operative pain.

Detailed Description
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Experimental: erector spinae plain block After giving general anesthesia, patient is positioned in lateral decubitus with the surgical side up, and prepping para-spinous area with antiseptic solution. Ultrasound high frequency linear transducer is positioned in a para-sagittal plane at the level of fifth thoracic vertebra. Scanning of interested structures from superficial to deep planes, Trapezius muscle, Rhomboid major muscle, Erector spina muscle and transverse process of fifth thoracic vertebra. Comparator: serratus anterior plane block After giving general anesthesia, patient is positioned in lateral decubitus, with the surgical side up. The upper arm is abducted and elevated above the head level. Under sterile aseptic technique, a linear ultrasound transducer (6-15 MHz) is placed in a sagittal oblique plane over the fourth and fifth ribs at the mid-axillary line. The following muscles are identified overlying the fourth/ fifth rib: the latissimus dorsi (superficial) and serratus anterior muscle (deep) overlying the ribs.

Official Title
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Erector Spina Plane Block Versus Deep Serratus Anterior Plane Block for Post Mastectomy Analgesia

Conditions
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MASTECTOMY

Intervention / Treatment
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* Procedure: Erector spina plain block for mastectomy analgesia
* Procedure: Deep serratus anterior plane block


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: ASA I-III patients age 18 to 75 years undergoing unilateral breast surgery Exclusion Criteria: Patients refusal History of amide local anesthetics allergy Alcohol or drug abuse Chronic opioid intake Language barriers Patient with psychiatric disorders Contraindications for regional anesthesia BMI > 40 Kg/m2 Obstructive sleep apnea that preclude PCA opioids

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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Female

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: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: ESPB GROUP<br>Erector spina plane block group | Procedure: Erector spina plain block for mastectomy analgesia<br>* After giving general anesthesia, patient is positioned in lateral decubitus with the surgical side up, An erector Spina plain block is performed with inserting block needle (Pajunk, Geisingen, Germany) in-plane under ultrasound control until needle tip hits the transverse process, a volume of 0.3 ml/kg of bupivacaine 0.25% (Marcaine, Astra Zeneca Pharmaceuticals) is injected. Pain management assessment and analgesic consumption will be provided through patient-controlled analgesia (PCA) for 24 hours. The PCA pump is programmed to deliver 1 mg morphine bolus per press with a lockout interval of 10 min. Pain scores will be measured using eleven points numerical rating scale NRS (0 to 10) and opioids consumption will be documented at 0, 1, 4, 8 and 24 hours. Time of admission to post-anesthesia care unit PACU is considered 0 hours. Any opioid equivalents given during the first 24 hours to manage breakthrough pain will be documented<br>|
| Active Comparator: SAPB group<br>Deep Serratus anterior plane block group | Procedure: Deep serratus anterior plane block<br>* After giving general anesthesia, the patient is positioned in lateral decubitus, with the surgical side up. The upper arm is abducted and elevated above the head level. A block needle is introduced in-plane, targeting the plane deep to the serratus anterior muscle, and a bolus of 0.3 ml/kg bupivacaine 0.25% is injected through ultrasound guidance. Pain management assessment and analgesic consumption will be provided through patient-controlled analgesia PCA for 24 hours. The PCA pump is programmed to deliver 1 mg morphine bolus per press with a lockout interval of 10 min. Pain scores will be measured using eleven points numerical rating scale NRS (0 to 10), and opioids consumption will be documented at 0, 1, 4, 8 and 24 hours. Time of admission to PACU is considered 0 hours. Any opioid equivalents given during the first 24 hours to manage breakthrough pain will be documented<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Cumulative Opioid consumption in the first 24 hours. | Post- operative morphine consumption measured from patient controlled analgesia pump (PCA machine) | 0 hours post- operative( 0 time is considered time to admission to post anesthesia care unit) | 
| Cumulative Opioid consumption in the first 24 hours. | Post- operative morphine consumption measured from patient controlled analgesia pump (PCA machine) | 1 hour post-operative | 
| Cumulative Opioid consumption in the first 24 hours. | Post- operative morphine consumption measured from patient controlled analgesia pump (PCA machine) | 4 hours post-operative | 
| Cumulative Opioid consumption in the first 24 hours. | Post- operative morphine consumption measured from patient controlled analgesia pump (PCA machine) | 8 hours post-operative | 
| Cumulative Opioid consumption in the first 24 hours. | Post- operative morphine consumption measured from patient controlled analgesia pump (PCA machine) | 24 hours post-operative | 
| Post-operative pain intensity | pain intensity is measured by ( 11 point numerical scale from 0 to 10), where 0 is considered no pain, 10 is the worst pain | pain at 0 hour, 0 time is considered time to admission to post anesthesia care unit | 
| Post-operative pain intensity | pain intensity is measured by ( 11 point numerical scale from 0 to 10), where 0 is considered no pain, 10 is the worst pain | pain at 1 hour post operative | 
| Post-operative pain intensity | pain intensity is measured by ( 11 point numerical scale from 0 to 10), where 0 is considered no pain, 10 is the worst pain | pain at 4 hours post operative | 
| Post-operative pain intensity | pain intensity is measured by ( 11 point numerical scale from 0 to 10), where 0 is considered no pain, 10 is the worst pain | pain at 8 hours post operative | 
| Post-operative pain intensity | pain intensity is measured by ( 11 point numerical scale from 0 to 10), where 0 is considered no pain, 10 is the worst pain | pain at 24 hours post operative | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time to patient mobilization | Recording first time patient is able to mobilize without assistance | First 24 hours post operative( 0 time is considered time to admission to post anesthesia care unit) |