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ORIGINAL ARTICLE
Year : 2018  |  Volume : 12  |  Issue : 2  |  Page : 440-445  

Efficacy of pectoral nerve block using bupivacaine with or without magnesium sulfate


Department of Anesthesia, Faculty of Medicine, Menoufya University, Shibin Al Kawm, Egypt

Date of Web Publication14-Jun-2018

Correspondence Address:
Dr. Ahmed A Abdelaziz Ahmed
29 El-Essawy Street, Sidi Beshr, P. O. 21611, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_37_18

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   Abstract 

Background: Worldwide, breast cancer is the main common cancer among females. In the United States, it affects one in eight women during their lifespan. In breast cancer surgery, chronic pain can be developed from poorly managed acute postoperative pain. The aim of the study was to use a safe, easy, and less complicated method of regional block for reducing the postoperative pain after mastectomy, which will reduce the incidence of chronic postmastectomy pain. Materials and Methods: Ninety adult female patients with American Society of Anesthesiologists Physical Status I, II, and III were allocated randomly into three groups: Group C had general anesthesia; Group B had ultrasound-guided pectoral nerve block (PECS block) (28mL 0.25% bupivacaine+2mL normal saline) plus general anesthesia; and Group M had ultrasound-guided PECS block (total 28 mL of Bupivacaine 0.25%+2mL of magnesium sulfat 50%) plus general anesthesia. Results: The intraoperative fentanyl (μg) used was significantly lower in Group B (110.4 ± 26.3) and Group M (108.7 ± 14.1) than in Group C (214.3 ± 20.1) and also the same as regards the total postoperative pethidine (mg) in Group C (220 ± 25.5), Group B (100.6 ± 24.3), and Group M (52.3 ± 12.3). The Group M was the least group suffered from postoperative pain at all times of measurement. Conclusion: The Group M was the least group suffered from postoperative pain at all times of measurement.

Keywords: Magnesium sulfate, pectoral nerve, ultrasound


How to cite this article:
Abdelaziz Ahmed AA. Efficacy of pectoral nerve block using bupivacaine with or without magnesium sulfate. Anesth Essays Res 2018;12:440-5

How to cite this URL:
Abdelaziz Ahmed AA. Efficacy of pectoral nerve block using bupivacaine with or without magnesium sulfate. Anesth Essays Res [serial online] 2018 [cited 2019 Aug 25];12:440-5. Available from: http://www.aeronline.org/text.asp?2018/12/2/440/230455


   Introduction Top


Worldwide, breast cancer is the main common cancer among females. In the United States, it affects one in eight women during their lifespan.[1] As the community alertness becomes high toward breast cancer, breast surgery increases so much nowadays.[2] In breast cancer surgery, chronic pain can be developed from poorly managed acute postoperative pain. Forty percent of women will have severe acute postoperative pain after this surgery, potentially upsetting the quality postoperative recovery quality.[3] The complications during recovery can occur due to inadequate pain control including impaired respiratory and immune functions with an increased danger of ileus, thromboembolic manifestations, and myocardial troubles. These subsequently can delay hospital discharge and increase the cost of healthcare.[4] Usually, analgesia for different breast surgeries including soft-tissue excision, mastectomy, or implants includes a multimodal approach, i.e. paracetamol, nonsteroidal anti-inflammatory drugs, and narcotics, with or without local anesthetic infiltration. Patients with intercostal drain are often a complaint of pain.[5] Surgeries for breast cancer can be done under thoracic paravertebral block (TPVB), which is used for anesthesia and managing of their postoperative pain, as not all anesthesiologists are familiar with this invasive technique in breast cancer surgery. A less invasive new technique described by Blanco et al. is the pectoral nerve (PECS) block, where local anesthetic is injected into the plane between the two pectoralis muscles, pectoralis major and pectoralis minor muscles (PMm and Pmm), (PECS-I block) and between the Pmm and the serratus anterior muscle at the third rib (PECS-II block).[6],[7]

The aim of the study

This study aimed to compare the intraoperative demand of narcotics, postoperative analgesia, postoperative sedation, and postoperative side effects of the PECS procedure with and without magnesium sulfate.


   Materials and Methods Top


The study was done at Menoufia University Hospital over the period from June 23, 2015, to November 16, 2016. After obtaining the Ethics Committee's approval, 90 adult female patients aged 20–65 years with American Society of Anesthesiologists (ASA) Physical Status I, II, and III undergoing modified radical mastectomy with axillary clearance who had consented were included for the study. Exclusion criteria included refusal of the patients, contraindications to regional anesthesia (including coagulopathy and local infection, fungating breast cancer), history of allergy to the medications used in the study, morbidly obese patients, and patients with a history of drug abuse, prior breast surgery except for diagnostic biopsies, and history of treatment for a chronic pain condition and/or psychiatric disorder.

Preoperatively, patients were taught how to express the severity of their pain using the visual analog scale (VAS), scored from 0 to 10 (where 0 = no pain and 10 = worst pain imaginable).

Patients were allocated randomly into three groups using a randomization computer program.

  • Group C had general anesthesia
  • Group B had PECS (bupivacaine only) block plus general anesthesia
  • Group M had PECS (bupivacaine plus magnesium sulfate) plus general anesthesia.


On arrival to the anesthesia room, intravenous (i.v.) line was inserted in the contralateral arm to the surgery side; the patients were attached to pulse oximetry for measuring oxygen saturation (SaO2) and noninvasive blood pressure (BL P) and electrocardiography (ECG); then, the patient received metoclopramide 10 mg and dormicum 0.05 mg/kg i.v. Then, we sent the patients of the control group to the operative room (OR), where general anesthesia was induced. The other two groups received the PECS block first and then left for 15 min before sending them to OR. PECS block was done using a broadband (5–12 MHz) linear array probe (Sonoscape Portable Ultrasound Machine, Model A5 with high frequency 7.5–12 MHz, A5, Sonoscape Medical Corp., Shenzhen, China) with an imaging depth of 4–6 cm. After cleaning the infraclavicular and axillary regions with betadine 10%, the probe was placed below the lateral third of the clavicle, similar to what is done when performing infraclavicular brachial plexus block.

After identification of the appropriate anatomical structures, we infiltrated the skin puncture point with 2% lignocaine; then, using a 20-gauge blunt needle, the block was done. The needle was advanced to the tissue plane between the PMm and Pmm at the vicinity of the pectoral branch of the acromiothoracic artery, and 10 mL of the mixture (28 mL 0.25% bupivacaine +2 mL normal saline) was injected in Group B, and in Group M, 10 mL of this mixture (total 28 mL of bupivacaine 0.25% +2 mL of magnesium sulfate 50%) was injected at the third rib, the serratus anterior, deep, and covering ribs 2–4.

The PECS-II block was done by advancing a needle in-plane between serratus anterior and Pmm. In a similar manner, in Group B, 20 mL of the mixture (28 mL 0.25% bupivacaine +2 mL normal saline) was injected between serratus anterior and Pmm, while in Group M, 20 mL of the mixture (total 28 mL of bupivacaine 0.25% +2 mL of magnesium sulfate 50%) was injected. After 15 min and after making sure that the block was working using ice bag, the patients were sent to the OR, where general anesthesia was induced by giving propofol 2–3 mg/kg, fentanyl 1 μg/kg, and cisatracurium 0.12 mg/kg and maintained with 2% sevoflurane in 50% O2 with air. Additional boluses of fentanyl were administered to maintain BLPand/or heart rate (HR) values within 20% of the baseline values. BL P, pulse, SaO2, and EtCO2, every 5 min till the end of the operation, continues ECG monitoring. At the end of the operation, closure of inhalational anesthesia and neostigmine 0.03 mg/kg with atropine 0.01 mg/kg were administered i.v. for reversal of the neuromuscular blockade. After responding of the patient to verbal command in the OR, patients were extubated and then transferred to the Postoperative anesthesia care unit(PACU). Patients were transferred to the female surgical ward when a score of 10 was reached in the modified Aldrete scoring.[8]

Measured parameters

  1. The demographic data (age, weight, ASA status, and duration of surgery) were recorded
  2. The parametersHR and mean arterial BL P (MAP) were assessed at baseline, after induction, and every 15 min till the end of the operation.
  3. The total fentanyl dose used intraoperatively
  4. In the PACU, the VAS [9] for pain score was assessed on arrival to PACU and on arrival to PACU, 1, 2, 3, 6, 12, and 24 h in the surgical ward. When the reported VAS score was 3 or greater, 50 mg pethidine was administered through i.v. route slowly
  5. The first time of analgesia and the number of patients who require analgesia in the first 6 h were assessed
  6. The total amount of pethidine used during the first 24 h
  7. Ramsay sedation score [10] was assessed in PACU and the ward at the same times of the pain score (1 = anxious and fully awake, 2 = fully awake, 3 = conscious but drowsy, 4 = asleep but reactive to verbal commands, 5 = asleep but responsive to palpable stimulus, and 6 = asleep and not responsive to any stimulus)
  8. The unpleasant effects in PACU also were assessed: hypotension (decrease in basal MAP >20%) and treated with i.v. fluid and incremental dose of ephedrine 6 mg/kg, bradycardia (decrease in basal HR by >20%) and treated by i.v. atropine 0.1–0.2 mg/kg), respiratory depression (the SaO2<92% and need O2 supplementation).


Data analyses

The mean ± standard deviation (SD) was presented as data for continuous variables, while data for categorical or ordinal variables, as well as data that did not obey the normal distribution, were presented as the median and range. Data for continuous variables and data that obeyed the normal distribution were analyzed by paired t-tests or one-way analysis of variance. Kruskal–Wallis test is used to analyze data for categorical variables or data that did not obey the normal distribution. All statistical analyses were performed using Microsoft Excel 2011 for Macintosh (Microsoft, Redmond, WA, USA) with a statistical macro (XLSTAT2014; Addinsoft, NY, USA). Differences with P < 0.05 were considered statistically significant.


   Results Top


As regards the age, height, weight, ASA score, and the time of surgical procedure, there were insignificant differences between the three groups, while there was a high significant difference between the PECS groups and the control one with no significant difference between Group B and Group M in the intraoperative fentanyl dose [Table 1] and [Table 2]. As regards the total postoperative pethidine, there was a significant difference between the three groups and also between Group M and Group B. There was a significant difference between Group C and the Groups B and M as regards the HR and BL P, intraoperatively, on arrival to PACU, 1, 2, 3, and 6 h postoperatively [Figure 1] and [Figure 2]. There was a significant difference between Group C and Groups B and M. As regards the postoperative pain scores, the pain was significantly lower in both Group B and Group M in comparison with Group C on admission to PCAU and after 1, 2, 3, 6, 12, 24 h from admission with a significant difference between Group B and Group M at 6, 12, and 24 h from admission to PACU [Table 3]. Furthermore, the study showed that the difference between Group C and Groups B and M as regards the first time for analgesia and the number of patients who required analgesia was significantly high. Furthermore, it was significant between Group B and Group M as regards the first time for analgesia [Table 4]. As regards sedation, the difference between Group C and Groups B and M on arrival to PACU, 1 h, and 2 h postoperatively was considerable with no difference at 3, 6, 12, 24 h postoperatively, while there was no significant difference between Group B and Group M at the all measurement times [Table 5] and [Table 6].
Table 1: Comparison between the three studied groups regarding demographic data

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Table 2: Comparison between the three studied groups regarding fentanyl and pethidine consumption

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Figure 1: Mean arterial blood pressure (mmHg) in the three studied groups at different periods of follow-up

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Figure 2: Mean heart rate (beat/minute) in the three studied groups at different periods of follow-up

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Table 3: Postoperative pain scores in within 24 h as regards visual analog score

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Table 4: Comparison between the three studied groups regarding the first time of analgesia and number of patients require analgesia in 1st 6 h (min)

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Table 5: Comparison between the three studied groups regarding Ramsay sedation score

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Table 6: Comparison between different studied groups regarding side effect

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   Discussion Top


Effective control of the postoperative pain can prevent the negative physiological and psychological consequences that can occur if it is badly managed. Furthermore, this control can protect immunity by suppressing the stress response to surgery and reducing the need for opioid and general anesthetics. Chronic postmastectomy pain can be developed from poorly managed acute postomastectomy pain. The severity of acute pain can be modified by the use of regional anesthesia techniques, and this leads to less chronic pain.

There was a considerable difference between Group C and Group B and Group M as regards the HR and BLPduring the operation, on arrival to PACU and at 1, 2, 3, and 6 h postoperatively. In agreement with our study, Fujiwara et al. found that PECS produces hemodynamic stability in his research on the effect of intercostal nerve block and PECS block for cardiac resynchronization therapy device. This can be explained by the fact that PECS is a nerve block without sympathetic affection and hemodynamic changes.[11]

In agreement with our results, Sopena-Zubiria et al. in their study on the reconstructive breast surgery found that the PECS has a good hemodynamic stability when added to the paravertebral block compared to the TPVB alone. Moreover, they considered it as a good, simple, and safe anesthetic and analgesic technique block; further, they consider it better than PVB and the thoracic spinal anesthesia where it provided satisfactory surgical anesthesia with prolonged duration of postoperative analgesia.[12]

AS regards the VAS in the three groups, the study showed highly significant changes in the VAS on arrival to PACU, and at 1, 2, 3, and 6 h, with a considerable difference at 12 and 24 h postoperatively. In addition, there was a significant difference between Groups B and M at 12 and at 24 h postoperatively. In agreement with our study, Hala in their study on the anesthesia for conservative breast surgery in breast found that in PECS groups, VAS throughout surgery and during the first 24 h postoperative was better than that in the thoracic spinal anesthesia.[13]

In agreement with our results, Lee showed that, on adding magnesium sulfate to a bupivacaine–epinephrine mixture for interscalene nerve block, there were prolonged duration of analgesia and reduction of postoperative pain.[14]

Furthermore, Elshamaa et al. in their study on the femoral nerve block showed that by adding magnesium sulfate to local anesthetic bupivacaine, this mixture provides a great prolongation of both sensory and motor block durations, with a considerable diminish in postoperative pain scores and total dose of the needed analgesia, with a longer tolerable pain duration in the first 24 h.[15]

Furthermore, Amr and Ahmed showed that the addition of magnesium sulfate to lidocaine in an interscalene plexus block for shoulder arthroscopic acromioplasty significantly prolongs the pain-free time and reduces the Numerical Rating Scale (NRS) pain score and postoperative opioid necessities without side effects.[16]

In agreement with our results, Abd-Elsalam et al. in their study on 60 women undergoing total abdominal hysterectomy showed that the addition of 200 mg of magnesium sulfate to bupivacaine in an ultrasound-guided transversus abdominis plane block significantly reduced postoperative opioid requirements, prolonged the duration of the analgesia, and reduced the VAS score without significant side effects.[17]

As regards the total intraoperative fentanyl, there was an evident variation between the Group C and the other two groups. Further, as regards the total amount of pethidine in the postoperative period, there was an evident variation between Group C and the other two groups and also a major variation between Group B and the Group M. In agreement with our results, Bashandy et al. during their study on the effect of PECS on breast cancer excision found that the total morphine consumption dose during the first 24 h postoperatively was considerably lower in the PECS group than that in the PVB group.[18]

Kulhari et al., during their study on the effect of PECS block versus TPVB using ropivacaine 0.5% for postoperative analgesia after radical mastectomy, found that the 24 h morphine consumption was also less in the PECS-II block group (mean [SD], 3.90 [0.79] vs. 5.30 [0.98] mg in PECS-II and TPVB group, respectively; P < 0.0001) and found that the duration of analgesia was significantly longer in patients who received the PECS versus those who received TPVB (mean [SD], 197.5 (31.35) vs. 294.5 (52.76) min in the TPVB group and the PECS-II, respectively; P < 0.0001).[19]

These results are in agreement with Wahba and Kamal, who classified 60 patients undergoing elective MRM into two groups: 30 patients who received PECS block with total 30 ml of levobupivacaine 0.25% and 30 patients who received PVB with 15–20 ml of levobupivacaine 0.25% at the level of fourth thoracic vertebra. They found that morphine consumption was reduced in PECS block in the first 24 h and reduced pain scores in the first 12 postoperative h in comparison with PVB after mastectomy. Furthermore, they showed that it took a significantly longer time for the first request for morphine in the PECS group (175 [155–220] min) than in the PVB group (137.5 [115–165] min, P < 0.001).[20]

Furthermore, Chakraborty et al. in their study on a single injection of PECS block showed that the pain-free duration extended to 24 h after PECS injection.[21]

Pedrosa in his study showed that the PECS block is an effective analgesic technique for breast reconstructive surgery and allows reduction of opioid (tramadol) consumption and its undesirable effects and he mentioned that it should be considered as an alternative to conventional analgesia.[22] While Morioka et al. during their study on the Pectoral nerve block combined with general anesthesia for breast cancer showed that no change in the intraoperative fentanyl consumption or the postoperative opioid supplement.[23] This can be explained by that they compared the total i.v. anesthesia (TIVA) versus TIVA + PECS, as the use of remifentanil during operation showed no difference in fentanyl dose intraoperatively. Furthermore, the escape of the anterior divisions of the intercostal nerves from the block in PECS made the pain to be the same over the sternum in all groups with the same opioid requirement and differed personally from one to one.


   Conclusion Top


We conclude that PECS block reduce the intra and post operative dose of narcotics with postoperative pain free, while magnesium sulfate extends the pain free duration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
DeSantis C, Ma J, Bryan L, Jemal A. Breast cancer statistics, 2013. CA Cancer J Clin 2014;64:52-62.  Back to cited text no. 1
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Kelly AH, Amr SS, Ahmed H, Ibrahim AS, Mohamed R, Mousumi B, et al. Trends in breast cancer incidence rates by age and sage at diagnosis in Gharbiah, Egypt, over 10 years (1999-2008). J Cancer Epidemiol 2013;2013:916394.  Back to cited text no. 2
    
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Mohamed SA, Abdel-Ghaffar HS, Kamal SM, Fares KM, Hamza HM. Effect of topical morphine on acute and chronic postmastectomy pain: What is the optimum dose? Reg Anesth Pain Med 2016;41:704-10.  Back to cited text no. 3
    
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Fahy AS, Jakub JW, Dy BM, Eldin NS, Harmsen S, Sviggum H, et al. Paravertebral blocks in patients undergoing mastectomy with or without immediate reconstruction provides improved pain control and decreased postoperative nausea and vomiting. Ann Surg Oncol 2014;21:3284-9.  Back to cited text no. 4
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11.
Fujiwara A, Komasawa N, Minami T. Pectoral nerves (PECS) and intercostal nerve block for cardiac resynchronization therapy device implantation. Springerplus 2014;3:409.  Back to cited text no. 11
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12.
Sopena-Zubiria LA, Fernández-Meré LA, Valdés Arias C, Muñoz González F, Sánchez Asheras J, Ibáñez Ernández C, et al. Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery. Rev Esp Anestesiol Reanim 2012;59:12-7.  Back to cited text no. 12
    
13.
Hala MS. Ultrasound guided pectoral nerve blockade versus thoracic spinal blockade for conservative breast surgery in cancer breast: A randomized controlled trial. Egypt J Anaesth 2016;32:29-35.  Back to cited text no. 13
    
14.
Lee AR, Yi HW, Chung IS, Ko JS, Ahn HJ, Gwak MS, et al. Magnesium added to bupivacaine prolongs the duration of analgesia after interscalene nerve block. Can J Anaesth 2012;59:21-7.  Back to cited text no. 14
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Elshamaa HA, Mohamed I, Hossam E. Magnesium sulfate in femoral nerve block, does postoperative analgesia differ? A comparative study. Egypt J Anaesth 2014;30:169-73.  Back to cited text no. 15
    
16.
Amr MA, Ahmed NE. The effect of adding magnesium sulfate to lidocaine in an interscalene plexus block for shoulder arthroscopic acromioplasty ain-shams. J Anesth 2014;7:59-64.  Back to cited text no. 16
    
17.
Abd-Elsalam KA, Fares KM, Mohamed MA, Mohamed MF, El-Rahman AM, Tohamy MM, et al. Efficacy of magnesium sulfate added to local anesthetic in a transversus abdominis plane block for analgesia following total abdominal hysterectomy: A Randomized trial. Pain Physician 2017;20:641-7.  Back to cited text no. 17
    
18.
Bashandy GM, Abbas DN. Pectoral nerves I and II blocks in multimodal analgesia for breast cancer surgery: A randomized clinical trial. Reg Anesth Pain Med 2015;40:68-74.  Back to cited text no. 18
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Kulhari S, Bharti N, Bala I, Arora S, Singh G. Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: A randomized controlled trial. Br J Anaesth 2016;117:382-6.  Back to cited text no. 19
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20.
Wahba SS, Kamal SM. Thoracic paravertebral block versus pectoral nerve block for analgesia after breast surgery. Egypt J Anaesth 2014;30:129-35.  Back to cited text no. 20
    
21.
Chakraborty A, Khemka R, Datta T, Mitra S. COMBIPECS, the single-injection technique of pectoral nerve blocks 1 and 2: A case series. J Clin Anesth 2016;35:365-8.  Back to cited text no. 21
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22.
Pedrosa F. PECS block as a post-operative analgesic strategy for reconstructive breast surgery: Preliminary results. ESRA Acad 2016;138532.  Back to cited text no. 22
    
23.
Morioka H, Kamiya Y, Yoshida T, Baba H. Pectoral nerve block combined with general anesthesia for breast cancer surgery: A retrospective comparison. JA Clin Rep 2015;1:15.  Back to cited text no. 23
    


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