الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Effective pain management helps to reduce postoperative complications and leads to early mobilization and faster recovery, thereby increasing patient satisfaction and decreasing the cost of care. Analgesia in breast surgeries can be delivered orally, intravenously, intramuscularly, neuroaxial or via regional nerve blocks.
Intravenous opioids are mainly administered for acute post mastectomy pain but it developed many side effects such as sedation, nausea, vomiting and respiratory depression. Thoracic epidural analgesia and paravertebral block become the gold standard techniques for breast surgery but they associated with serious complications such as pneumothorax and total spinal anesthesia.
Recently, the application of ultrasound in anesthetic practice led to description of several interfascial plane blocks recently. Interfascial plane block can reduce the requirement for use of opioids postoperatively thereby decreasing opioids-related side effects. Pecs blocks in breast surgeries performed under ultrasound guidance are a viable alternative to other more invasive, regional anesthetic techniques which carry an increased side effect.
The aim of this study was to:
- Evaluate intra- and postoperative analgesic effect of ultrasound-guided PEC II block in comparison to PEC II block without PEC I block following unilateral non reconstructive breast surgeries with axillary clearance.
After the approval of the ethical committee of Alexandria Faculty of Medicine and Medical Research Institute (MRI) and informed written consent, the present study was carried out on 90 patients, ASA physical status II, aged between 30-60 years, scheduled to undergo unilateral non reconstructive breast surgery with axillary clearance under general anesthesia in the Medical Research Institute hospital. This sample size was according to the recommendation of the Department of Statistics, High Institute of Health, Alexandria University. The patients were randomly divided into two equal groups using closed envelope method
All patients were trained to use visual analogue scale to express their pain. All patients arrived to the block room 30 minutes before the operation. The blocks were done after insertion of peripheral intravenous line and attached to the multichannel monitor for monitoring of the vital signs. All patients received sedating dose of midazolam (0.05 mg/kg) prior to the block. All patients were moved to the operation room 20 min after performing the block.
Pec II block group: they received preoperative Pec II blocks followed by general anesthesia. The patient laid in supine position and the hemithorax of the site of the operation was prepared with iodine 2%. A high frequency linear probe with 5-13 Hz frequency was positioned in below and perpendicular to lateral half of the clavicle. The pectoral branch of the thoracoacromial artery was identified between pectoralis major and pectoralis minor muscles using color Doppler, with an in-plane needle approach medial-to-lateral and 10 ml of levobupavicane (0.25%) plus adrenaline 1:200,000 (5ug/ml) was injected into the inter-pectoral plane with intermittent aspiration to avoid intravascular injection. Then the probe was placed caudal to the lateral third of the clavicle to locate the axillary vessels under the pectoralis major and the subclavius muscle, and the first rib was identified. The probe was moved distally toward the axilla until the third rib was encountered. At this position, the pectoralis minor was above the serratus anterior with an in-plane needle approach medial-to-lateral and cephalad-to-caudal 20 mL of levobupavicane (0.25%) plus adrenaline 1:200,000 (5ug/ml) was injected between pectorals minor and serratus anterior at the 3rd rib level after aspiration to avoid intravascular injection.
Pec II block without Pec I group: they received preoperative Pec II block without Pec I block followed by general anesthesia. The patient laid in supine position and the hemithorax of the site of the operation was prepared with iodine 2%. Pec II block was done as mentioned before without Pec I block
After assessing the efficacy of the block by sensory block scale, standard general anesthesia was induced in both groups using intravenous fentanyl (1ug/kg), propofol (2 mg/kg) and cisatracurium (0.15 mg/kg). Anesthesia was maintained with isoflurane (1.2%) in 100% oxygen. Incremental doses of cisatracurium (0.03 mg/kg) was given intraoperatively guided by nerve stimulator keeping TOF at 2. fentanyl (25 μg) was given when heart rate and/or mean arterial blood pressure increased more than 20% above pre-induction levels.
At the end of surgery, anaethesia was discontinued, residual neuromuscular block was antagonized by atropine 0.01 mg/kg and neostigmine 0.04 mg/kg, then the oral secretions was suctioned and the trachea was extubated and patients were transferred to the postoperative anaesthesia care unit (PACU) for the next 24 hours.
The following data were measured:
Age and weight of the patients were recorded
Onset of Sensory block was assessed by ice pack every 5 min for 20 min preoperative at T4 (the time of occurrence of partial loss of cold sensation). Dermatomal level was examined bilaterally at (T2 to T6) dermatomes to examine the extent of the block after 20 minutes. Degree of sensory block was measured by a scale (1-3) at T4 dermatome preoperative and every 4 hours for 24 hours postoperatively.
Motor assessment was done by cross arm adduction once pre-induction then every 4 hours for 24 hours postoperatively.
Vital signs: heart rate (beats/min) and mean arterial blood pressure (mmHg) and were recorded pre-induction then intraoperative every 15 minutes. Postoperative heart rate (beats/min) and mean arterial blood pressure (mmHg) were recorded at arrival to the PACU, after 30 minutes then every 4 hours for 24 hours.
Number of patients consumed intraoperative fentanyl and the total dose, number of patients consumed postoperative morphine, first time of request of post-operative morphine and post-operative 24 hours morphine consumption were recorded.