Background & Aims
Pain after modified radical mastectomy (MRM) greatly affects the psychophysiology as well as the early recovery of the patient. There are some methods that we can apply to management the pain after MRM such as: epidural anesthesia, paravertebral block, pectoralis and serratus plane nerve blocks, PCA morphine, etc. However, erector spinae plane block (ESP) appeared as a new technique of pain management that having advantages for postoperative analgesia after MRM: safety, good postoperative analgesia, limited side effects of pain killer drugs (opioids, NSAIDs). Our study aims to evaluate the effectiveness of analgesia after MRM with ESP block with levobupivacaine under ultrasound guidance and adverse efects of this method.
Methods
Twenty ASA 1&2 patients, undergoing MRM under general anesthesia were studied. Just before extubation, a catheter was inserted to erector spinae plane under ultrasound guidance, a point just to the depth of the erector spinae muscle and superficial to the 4th transverse process. Patients received automated intermittent bolus regiment of levobupivacaine 0.125% (loading dose 20 mL, continuous rate 0.0 mL, intermittent dose: 20mL every 6 hours, PCA dose: 10 mL, PCA lockout 120 minutes, maximum dose 30 mL/h) using an ambulatory electronic device. 1mg morphine was used by nurses to rescue whenever VAS score ? 4 (after PCA dose of levobupivacaine 10 minutes). All catheters were removed on the third postoperative day. Postoperative VAS score (resting and moving) at extubation time, 1, 6, 12, 18, 24, 48, 72 postoperative hours, the highest VAS score on day 1- 3 postoperation, the total dose of morphine used to rescue, the patient satisfaction and adverse effects were recorded.
Results
The resting and moving VAS scores were less than 4 at all the time points of survey. The mean highest VAS scores were 2.7, 1.9, 1.4 on day 1, day 2, day 3 postoperation, respectively. The rate of satisfied and completely satisfied patient were very high (30% and 70%, respectively). The mean of total dose of morphine used to rescue was 0.75±0.79 mg. The adverse effect was misalignment of catheter position that occupied 5%.
Conclusions
ESP block with levobupivacaine 0.125% administered in automated intermittent boluses and patient-controlled dose supplementation provided safe and effective pain management with minimal opioid requirements after modified radical mastectomy. Further investigation involving randomized controlled trials is indicated to determine the optimal dosing strategies for the ESP block and other clinical benefit of ESP block for MRM and other thoracic surgeries.
References
1. El Ghamry, M.R., et al., Role of erector spinae plane block versus paravertebral block in pain control after modified radical mastectomy. A prospective randomised trial. 2019. 63(12): p. 1008.
2.Gürkan, Y., et al., Erector spinae plane block and thoracic paravertebral block for breast surgery compared to IV-morphine: a randomized controlled trial. 2020. 59: p. 84-88.
3.Kinjo, S., et al., Continuous lumbar erector spinae plane block for postoperative pain management in revision hip surgery: a case report. 2019. 69: p. 420-422.
4.Singh, S., et al., Ultrasound-guided erector spinae plane block for postoperative analgesia in modified radical mastectomy: a randomised control study. 2019. 63(3): p. 200.
Presenting Author
Pham Thi Lan
Poster Authors
Lan Pham
PhD
Thai Nguyen University of Medicine and Pharmacy
Lead Author
Topics
- Treatment/Management: Interventional Therapies – Injections/Blocks