改良根治性乳腺癌手术中胸肌间沟筋膜平面阻滞联合肋间臂神经阻滞的镇痛效果：一项前瞻性随机试验。

The Analgesic Efficacy of Pecto-Intercostal Fascial Block Combined with Pectoral Nerve Block in Modified Radical Mastectomy: A Prospective Randomized Trial.

机构信息

Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt.

出版信息

Pain Physician. 2020 Sep;23(5):485-493.

Abstract

BACKGROUND

Pectoral nerve (Pecs) block is one of the most promising regional analgesic techniques for breast surgery. However, Pecs II block may not provide analgesia of the medial aspect of the breast or the entire nipple-areolar complex.

OBJECTIVES

The aim of the present study was to investigate the efficacy of combining the pecto-intercostal fascial block (PIFB) and Pecs II block for perioperative analgesia following modified radical mastectomy (MRM).

STUDY DESIGN

A prospective randomized study.

SETTING

An academic medical center.

METHODS

Sixty women undergoing unilateral MRM were randomly divided into 2 groups. The Pecs II group received Pecs II block using 20 mL bupivacaine 0.25% between the serratus anterior and the external intercostal muscles, and 10 mL bupivacaine 0.25% between the pectoralis major and minor muscles, together with sham PIFB using 15 mL normal saline solution in the interfascial plane between the pectoralis major muscle and the external intercostal muscle. PIFB-Pecs II group received the same Pecs II block combined with PIFB using 15 mL bupivacaine 0.25%.

RESULTS

The median (interquartile range [IQR]) time to the first morphine dose was significantly longer in the PIFB-Pecs II group (327.5 [266.3-360.0] minutes) than the Pecs II group (196 [163.8-248.8] minutes) (P < 0.001, 95% confidence interval [CI] 79.98, 150.00).The median (IQR) cumulative morphine consumption was higher in the Pecs II group (14.0 [11.0-18.0] mg) than the PIFB-Pecs II group (8.0 [7.0-9.0] mg) (P < 0.001; CI, 4.0-8.0). Intraoperative consumption of fentanyl was significantly lower in PIFB-Pecs II group with a median (IQR) of 0 (0-15 mu g) than the Pecs II group median 57.5 (0-75 mu g) (P = 0.022, CI; 0-60). The Visual Analog Scale scores for the first 12 postoperative hours were lower in the PIFB-Pecs II group than the Pecs II group at rest and on moving the ipsilateral arm (P < 0.001). The dermatomal block on the lateral chest wall was comparable between the 2 studied groups. PIFB-Pecs II provided extensive sensory block on the anterior chest wall, whereas Pecs II block failed to achieve any sensory block.

LIMITATIONS

This study was limited by its small sample size.

CONCLUSIONS

The combination of Pecs II and PIFB provide better perioperative analgesia for MRM than Pecs II alone.

摘要

背景

胸神经（Pecs）阻滞是一种很有前途的乳房手术区域镇痛技术。然而，Pecs II 阻滞可能无法提供乳房内侧或整个乳晕复合体的镇痛。

目的

本研究旨在探讨胸肌间沟筋膜阻滞（PIFB）联合 Pecs II 阻滞在改良根治性乳房切除术（MRM）围术期镇痛中的效果。

研究设计

前瞻性随机研究。

地点

学术医疗中心。

方法

60 例行单侧 MRM 的女性患者被随机分为 2 组。Pecs II 组采用 20 mL 0.25%布比卡因阻滞胸大肌和胸小肌之间的胸神经，同时采用 10 mL 0.25%布比卡因阻滞胸肌和胸小肌之间的胸神经，并在胸大肌和肋间肌之间的筋膜平面内注射 15 mL 生理盐水进行假 PIFB。PIFB-Pecs II 组采用同样的 Pecs II 阻滞联合 15 mL 0.25%布比卡因的 PIFB。

结果

PIFB-Pecs II 组首次吗啡剂量的中位数（四分位距 [IQR]）时间明显长于 Pecs II 组（327.5 [266.3-360.0] 分钟比 196 [163.8-248.8] 分钟）（P < 0.001，95%置信区间 [CI] 79.98，150.00）。PIFB-Pecs II 组的累积吗啡消耗量中位数（IQR）为 8.0 [7.0-9.0] mg，高于 Pecs II 组的 14.0 [11.0-18.0] mg（P < 0.001；CI，4.0-8.0）。PIFB-Pecs II 组术中芬太尼用量中位数（IQR）为 0（0-15 µg），明显低于 Pecs II 组的 57.5（0-75 µg）（P = 0.022，CI；0-60）。PIFB-Pecs II 组在术后 12 小时内的视觉模拟评分在静息和同侧手臂运动时均低于 Pecs II 组（P < 0.001）。2 组研究对象的外侧胸壁皮节阻滞相似。PIFB-Pecs II 提供了前胸部广泛的感觉阻滞，而 Pecs II 阻滞未能达到任何感觉阻滞。