The Clinical Journal of Pain Publish Ahead of Print
DOI:10.1097/AJP.0000000000001055
D
Comparing effect of adding ketamine versus Dexmedetomidine to
bupivacaine in Pecs-ⅠⅠ block on postoperative pain control in
patients undergoing breast surgery
TE
Corresponding Author
Dr.Amira Fathy Hefni
Academic Position: Assistant professor
Department: Department of Anaesthesia, Intensive care and pain management, Faculty of
Medicine, Ain Shams University.
EP
Dr. Abeer Mohamed Eldeek
Academic Position: Late Assistant professor
Department: Department of Anesthesia,ICU,and pain management , Faculty of Medicine, Ain
Shams university.
Dr.Shereen Atef Ismael
C
Academic Position: Internship at Ain Shams university Hospitals.
Department: Medical college Ain Shams university Hospitals .
Dr. Ahmed R Shaban
AC
Academic Position: Assistant professor
Department: Department of Anesthesia,ICU,and pain management , Faculty of Medicine, Ain
Shams university.
Comparing effect of adding ketamine versus Dexmedetomidine to
bupivacaine in Pecs-II block on postoperative pain control in
patients undergoing breast surgery
The authors declare no conflict of interest.
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Abstract
Background:
Pecs-II block has previously and successfully demonstrated a good quality of perioperative
analgesia for breast surgery.
Objective:
This study aimed to compare the quality of postoperative pain control when adding either
ketamine or dexmedetomidine to bupivacaine 0.25% for Pecs-II block.
Methods:
This prospective randomized double-blind study was conducted on 159 female patients with
American society of anesthesiologist (ASA) physical status class I-III scheduled to have
modified radical mastectomy. Patients were randomly assigned into three groups. Each group
included 53patients to receive ultrasound guided Pecs-II blocks with either 32 ml of 0.25%
bupivacaine added to ketamine hydrochloride 1mg/kg (BK group), 32 ml of 0.25%bupivacaine
D
added to dexmedetomidine 1ug/kg (BD group) or 32 ml of 0.25%bupivacaine only (B group).
The primary outcome of this study was the total postoperative morphine consumption for the
first 24 hours postoperatively. The time of the first request of analgesia, the pain scores at rest of
TE
ipsilateral arm, and the intra-operative fentanyl requirements, were the secondary outcome
measures. Any side effects occurred were recorded.
Results:
The total postoperative morphine consumption was significantly lower in patients received
bupivacaine with addition of either ketamine (BK group), (10.3 ±2.6 mg), or dexmedetomidine
(BD group), (3.8±0.2mg) respectively, versus patients received only bupivacaine (B group),
EP
(16.9 ±5.3mg). Both ketamine (BK group) and dexmedetomidine (BD group) added to
bupivacaine significantly prolonged the time to first analgesic request (16.7±4.5hrs),
(21.6±1.6hrs) in both groups respectively compared to patients received bupivacaine alone (B
group), (11.5±1.2hrs).
The pain score was variable between the three groups over different times during the first 24
hours postoperatively. There was no significant difference in perioperative hemodynamics, O2
C
saturation, sedation scores or side effects observed between the three groups. Patient satisfaction
was reported to be the best in patients received dexmedetomidine added to bupivacaine than the
other patients who received ketamine as an additive or those who received bupivacaine alone.
AC
Conclusion:
Adding dexmedetomidine to bupivacaine provides more effective postoperative pain control than
adding ketamine during Pecs-II blocks for breast cancer surgery.
Key Words: Pecs-II, Dexmedetomidine, Ketamine, perioperative pain, Breast Surgery
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Introduction:
Significant postoperative pain following major surgical procedures for breast cancer are common
and well-known consequence (1). Uncontrolled postoperative pain implicates negative
sequelae as patient’s discomfort, increased hospital costs with extended hospital stay, and risks
in the development of chronic post-mastectomy pain (1) Procedural interventions involving
regional blocks were found to be more effective than pharmacologic methods (2). Different
regional anesthetic techniques have been used to provide adequate analgesia and even anesthesia
for patients undergoing breast cancer surgery, including, intercostal nerve block, thoracic
epidural, paravertebral block, or the recently discovered ultrasound guided Pecs-II block which
showed superior postoperative analgesia. Pecs-II block was first described by Blanco in 2011 (8)
and it was found to be an easy and reliable superficial block and is quite safer and has less
incidence of pneumothorax than paravertebral block. Additionally, Pecs-II block has no
D
sympathetic nerve block as thoracic epidural does (14). Pecs-II block can also provide effective
postoperative analgesia for such procedures. (3) Pecs-II block is a field block that aims to deposit
the local anesthetic between the pectoralis major and pectoralis minor muscles and between
TE
pectoralis minor and serratus anterior muscles to block the different peripheral nerves supplying
the breast (the lateral and medial pectoral nerves and the intercostal branches for the axilla and
chest) providing complete analgesia for breast surgery. (3,36)
Dexmedetomidine is an alpha2 receptor agonist that has been used as an adjuvant to local
anesthetic for various regional anesthetic techniques with significant prolongation of duration of
analgesia (4).Ketamine is a N-methyl-D-aspartate receptor antagonist that has a reported local
EP
anesthetic and analgesic properties (5).Studies on caudal administration of ketamine combined
with the local anesthetic has shown that it is effective for prolonging the duration of
postoperative analgesia (6). Nevertheless, there are very few studies (with variable conclusions)
about the effect of ketamine on prolonging the duration of analgesia when combined with local
anesthetic for peripheral nerve blocks. (6,7). Our study was planned to compare the quality of
C
postoperative pain control after adding either ketamine or dexmedetomidine to bupivacaine for
ultrasound guided Pecs-II block as regards to the efficacy and duration of postoperative analgesia
in patients undergoing breast cancer surgery.
AC
Methods:
This prospective randomized double blind clinical trial was conducted in Ain Shams university
hospitals. Following the department of anesthesiology Ain Shams University ethical committee
approval (FMASU R 24/2019), the study was registered with the Clinical Trials.gov PRS
(NCT04380168).
159 female patients ASA physical status Ⅰ-Ⅲ, aged between 18 and 60 years scheduled for
modified radical mastectomy were included in this study which extended over one year. An
informed written consent for the study protocol including details of the anesthetic technique that
was fully explained at the preoperative visit, was obtained from each patient before inclusion in
the study. Exclusion criteria included patients with history of advanced cardiac disease, sepsis,
patients with prior surgery in areas above or below the clavicle or in the axillary region, those
with opioid dependence or alcohol or drug abuse, those with coagulopathy, and those with
psychiatric illness that prevent them from proper perception and assessment of pain.
In the pre-induction room, the patients were taught how to assess their own pain score using the
numerical rating scale (NRS) (0–10; 0 = no pain, 10 = worst imaginable pain) and how to use the
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
device for a patient-controlled analgesia (PCA). Patients in all groups received 5mg oral
midazolam 20 minutes prior to surgery. For every patient a 20gauge IV cannula was inserted in
the upper limb contralateral to the side of surgery upon reaching the operating room. Before
induction of anesthesia electrocardiography (ECG), non-invasive blood pressure (NIBP), arterial
oxygen saturation (SaO2), and end-tidal carbon dioxide (Et CO2) were connected to the patient.
In all groups general anesthesia was started using 2 μg/kg fentanyl, 2.5 mg/kg propofol and 1
mg/kg lidocaine. Endotracheal intubation was facilitated by 0.5 mg/kg atracurium and was
maintained by 1 MAC sevoflurane in 50% Oxygen /air mixture, and ventilator parameters were
adjusted to maintain normocapnia.
Patients were randomized using computer generated number and concealed using sequentially
numbered, sealed opaque envelope technique. For each group, the 32ml solution constituents
were different, for B group (the control group) the 30ml solution contained only 0.25%
bupivacaine and 2ml of normal saline, while for group BK it contained1mg/kg ketamine in 2ml
D
volume in addition to 30 ml bupivacaine0.25%, while for group BD it contained 1ug/kg
Dexmedetomidine in 2ml volume in addition to 30 ml bupivacaine0.25%.In every patient 12 ml
volume was injected between the pectoral major and minor muscles and 20 ml volume was
injected between the pectoralis minor and serratus anterior muscles.
TE
Pecs-II block technique:
After anesthesia induction and while the patient under GA, Pecs-II block was done using in plane
approach, with a 100 mm needle (PajunkR SonoPlex Stim cannula U.S.A) and a linear array
ultrasound probe of high frequency 12Hz (SonositeR, Inc. U.S.A) of SonoSite M-Turbo®
ultrasound (US) system (FUJIFILM SonoSite, Bothell, WA, USA) by regional anesthesiologist
EP
staff who was blinded to the randomized intervention. The technique used was in accordance
with the description by Blanco and Barrington. Patient was in the supine position, with the arm
abducted 90 degrees. The probe was placed below the clavicle, then the coracoid process located
on US in the paramedian sagittal plane. At this point the scan demonstrated the clavicle and
pectoralis major superficially and then the pectoralis minor whilst inferiorly the axillary artery
and vein were demonstrated with the 2nd rib and pleura adjacent to them.
C
From this initial scan position the probe was slid down through chest in a caudal direction until
the 3rd rib was identified where the probe was rotated 90 degrees so that the view scanned
pectoralis major superficially whilst the pectoralis minor was viewed inferiorly with the 3rd rib.
The needle was inserted at medial edge of the probe and directed laterally to inject 12ml of
AC
already prepared solution in the fascial plane between the pectoral major and pectoralis minor
muscles. Then the probe was moved to the lateral aspect of the chest so that the 3rd and 4th ribs
came in view with pectoral major and pectoralis minor above them. The needle was then
advanced laterally again to the fascial plane between pectoralis minor and serratus anterior
muscles to inject 20ml of the prepared solution. (8)
Surgical sterilization and draping started immediately after the block but surgical incision started
30 minutes after the block has been given. Fentanyl 0.50 ug was given as a bolus if HR or SBP
rose <20% above the baseline values. Bradycardia (HR<50/minute) was treated with atropine
0.5mg bolus, and hypotension (decrease in SBP <20% below the baseline values) was treated
with 10 mg boluses of IV ephedrine. Patients were extubated after adequate neuromuscular
reversal using atropine 0.02mg/kg and 0.05mg/kg neostigmine. Duration of anesthesia and
surgery were recorded. Anesthesia time was calculated from induction of anesthesia till
discontinuation of anesthetics, while Surgical time was calculated from sterilization of skin and
draping till skin closure.
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
After that the patients were transferred to post-anesthesia care unit where they were followed up
and assessed for the following parameters: Oxygen saturation( SpO2)respiratory rate(RR), non-
invasive blood pressure(NIBP),heart rate(HR), and sedation agitation scores using Richmond
Agitation Sedation Scale(RASS)( +4=combative +3=very agitated +2=agitated +1=restless
0=alert and calm,-1=drowsy,-2=light sedation,-3=moderate sedation ,-4=deep sedation,-
5=unarousable sedation) (10).These were measured 5, 10, 20, 30, 45, and 60 min
postoperatively. Episodes of postoperative nausea and vomiting, sedation scale < -2, any
psychological complications (as hallucinations, dreams), were recorded and treated. Nausea and
vomiting were treated by IV ondansetron. If sedation scale scores was < -2 patient received
flumazenil 0.15mg IV over 15 seconds, and if patient manifested hallucination or RASS >+1,
1mg Midazolam IV was given.
Pain score (NRS) at rest of the ipsilateral arm was recorded every 2 hours for 24hour
Postoperatively. Total intraoperative fentanyl consumption and total postoperative morphine
D
consumption for the first 24 hours postoperatively were calculated and the time of the first
request of analgesia was recorded. When analgesia is requested postoperatively (once the pain
is expressed by the patient or the NRS at rest was >3), an initial morphine PCA bolus of
0.05mg/kg was administrated followed by 1mg bolus with a lock-out periods of 15minutes with
TE
no background infusion allowed. At the end of the 24 h, the patient’s satisfaction about the post-
operative analgesia was rated on a three-point scale, i.e., good = most satisfied, average =
somewhat satisfied, poor= dissatisfied. This was assessed by asking patients about the quality of
overall perioperative analgesia. The total postoperative morphine consumption over the first 24
hours postoperatively was the primary outcome The time of the first request of analgesia, the
EP
pain scores at rest of ipsilateral arm, and the intra-operative fentanyl requirements were the
secondary outcome measures. Side effects including bradycardia, hypotension, sedation scores,
nausea/vomiting, hallucination, nystagmus, or dissociative effects and patient satisfaction were
recorded.
Statistical Methods
Data were analyzed using IBM© SPSS© Statistics version 26 (IBM© Corp., Armonk, NY).
C
Numerical data are presented as mean and standard deviation (SD) or standard error (SE) and
between-group differences are compared using one-way analysis of variance (ANOVA) with
application of the Tukey test for post hoc comparison when needed.
We used a general linear model to analyze repeated measures and corrected P-values for all
AC
pairwise comparisons using the Bonferroni method. Time to event analysis was done using the
Kaplan-Meier (KM) method and the log-rank test was used to compare different KM curves.
Two-sided P-values <0.05 are considered statistically significant. Categorical data were
presented as numbers and percentage and analyzed using Chi square test or Fisher exact test as
appropriate.
Sample Size calculation:
The required sample size has been calculated using the G*Power Software (Heinrich-Heine
Universität, Düsseldorf, Germany) version 3.1.9.2. No previous study compared the three
interventions; so, we calculated that a sample size of 53 patients in each study group achieves a
power of 80% to detect a statistically significant difference among the three groups regarding the
primary outcome measure (morphine consumption) and 2ndry outcome measures (pain scores,
and time to first analgesic requirements) corresponding to a medium effect size of a Cohen’s f of
0.25 (η2 = 0.0588) using a two-sided F-test with a type I error of 0.05.
Results:
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
165 female patients were enrolled in our study, only 160 patients were randomized for it, as the
surgery was cancelled for three patients and the other two declined the procedure at the day of
surgery. One patient from those who were randomized declined the block inside the operating
room. So only 159 patients were included in the study.
All patients in the three groups showed no significant differences in age, weight, BMI, baseline
heart rate and systolic blood pressure, percentage of controlled hypertensives and the duration of
surgery or anesthesia. Table 1,2
The total morphine consumption over the first 24 hours was significantly less in those who
received bupivacaine- ketamine (Group BK) (10.3±2.6 mg) than in patients who received only
Bupivacaine (Group B),( 16.9±5.3 mg) and even more significantly less in those who received
Bupivacaine – Dexmedetomidine (Group BD) ( 3.8±0.2 mg) .Table 3
In regards to the analgesic potency, the intraoperative fentanyl increments showed no significant
difference between the patients who received bupivacaine only Group B (58±6 ug) or the
D
patients who received Bupivacaine and ketamine Group BK (56±7) or those who received
Bupivacaine and Dexmedetomidine Group BD (57±7). Table 3
The time for the first request of rescue analgesia was prolonged significantly in patients who
received bupivacaine- ketamine Group BK (16.7±4.5hrs) than in those who received
TE
Bupivacaine only Group B (11.5±1.2hrs), and even much more prolonged in patients who
received bupivacaine and dexmedetomidine (Group BD) (21.6±1.6hrs). Table3.
Until 6 hours postoperatively, no statistically significant difference in the NRS was present
between patients received bupivacaine alone or combined with either ketamine or
dexmedetomidine during the Pecs-II block. At 8,10 and 12 hours postoperatively, there was an
EP
increase in NRS in those who received bupivacaine alone compared to those who received either
dexmedetomidine or ketamine in addition to bupivacaine and this increase was statistically and
clinically significant, while no difference was detected between both groups who received either
ketamine or dexmedetomidine as an additive.
At 14,16, and 18 hours postoperatively the NRS was significantly higher in those with added
ketamine during the block than both who received bupivacaine alone or combined with
C
dexmedetomidine with statistical and clinical difference. Although the NRS was statistically
higher significantly in those received bupivacaine alone than those receive block combined with
dexmedetomidine, this difference was not clinically significant. At 20,24 hours postoperatively
AC
there were significant statistical differences between the three groups but these differences were
not clinically significant as the NRS was < 3 in all groups while at 22 hours postoperatively there
were no significant statistical differences between the three groups.
The patients who received Dexmedetomidine in addition to bupivacaine had the lowest pain
scores at rest from the 2nd hour till 22 hours postoperatively when compared to those who
received the block with either bupivacaine or bupivacaine combined with dexmedetomidine and
only asked for analgesia at about 21 hours postoperatively, only 3 patients asked for analgesia at
this particular time. While patients who received bupivacaine- ketamine (Group BK) started to
have pain at rest that required treatment at about 16 hours postoperatively, this was still later than
those who received bupivacaine only (Group B-the control group) who started to have pain at
rest at about 12 hours post-operatively. Fig 1.
Only 3 patients developed intraoperative hypotension in Bupivacaine- Dexmedetomidine group
(Group BD), compared to 1 patient in bupivacaine- ketamine group and 2 patients in those who
received bupivacaine only. The required ephedrine dose 10 mg IV bolus did not differ between
the three groups. Only one and two patients in group (B)and (BD) respectively developed
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
intraoperative bradycardia and received atropine at dose 0.5 mg IV bolus which was equal in all
patients. Post-operatively, there were no significant differences in HR or SBP at various time
points in all patients in the three groups. Fig2,3.
Sedation scores were comparable in all patients in the three groups. Fig 4.
None of the patients in any group developed hallucination, nystagmus, or dissociative effects.
While 8 patients in group (B) and 4 patients in group (BK) developed nausea and one patient
vomited, all of which received treatment with ondansetron 8mg IVI over 2 minutes. None of the
patients developed nausea or vomiting in group BD Table 5
Addition of dexmedetomidine to bupivacaine during the Pecs-II block (group BD) resulted in a
better patient satisfaction than either those who received ketamine as an additive (group BK) or
those who received bupivacaine only (group B). About 96% of the patients who received
dexmedetomidine as additive rated their satisfaction score as most satisfied or somewhat
satisfied and only about 3% of patients were unsatisfied. About 75% of patients received
D
ketamine as an additive rated their satisfaction score as most satisfied or somewhat satisfied and
25% of patients were unsatisfied, while only half of patients who received bupivacaine alone
during the block were satisfied while nearly other half of patients were unsatisfied. Table 4.
TE
Discussion:
In this prospective, randomized double blind study, we aimed to compare the effect of adding
either 1ug/kg dexmedetomidine or 1mg/kg ketamine to the bupivacaine 0.25% in Pecs-II block
for patients undergoing major breast cancer surgery. We found that adding dexmedetomidine
induced longer block duration without more side effects compared to ketamine. Both drugs
delayed the first morphine rescue dose and decreased the total morphine consumption compared
EP
to the Bupivacaine alone.
There is an increased interest nowadays in the advanced recovery program for cancer surgery
and its impact on patient’s satisfaction and on the hospital stay cost. Effective post-operative
pain relief is found to be a paramount component for advanced recovery.
Opioids are still the mainstay of postoperative pain therapy despite their significant side effects
such as respiratory depression, nausea, vomiting, pruritic reaction, constipation, and the
C
plausibility of dependence and addiction with long-term use (23). Therefore, it is common now
to use preemptive regional anesthesia combined with general anesthesia for breast cancer
surgeries which allows early recovery, low incidence of nausea, vomiting and chronic
AC
postsurgical pain (CPSP). Furthermore, some anesthetists consider regional anesthesia
techniques a way of reducing metastatic disease progression after radical mastectomies (24).
Our study clarified the effectiveness of adding Ketamine to local anesthetics during peripheral
nerve block although it is found to be less effective than adding dexmedetomidine. The previous
studies done using perineural ketamine added to the local anesthetic, either bupivacaine or
ropivacaine showed nearly the same analgesic efficacy and duration as our study (1,32). Ahmed.
H et al found that adding ketamine 1 mg/kg to 0.25% of bupivacaine in modified PECs block
prolonged the mean time of first request of analgesia (18.25±1.98hrs) compared to (16.7 ±
8.4hrs) in our study and total dose of morphine consumed postoperatively was (12.50 ±4.63mg)
compared to (10.3 ±4.6 mg) in our study (1).
Addition of ketamine 2mg/kg to bupivacaine 2mg/kg of 0.5% bupivacaine in ultrasound guided
ilioinguinal and ilio-hypogastric nerve block produced more effective postoperative analgesia
compared to bupivacaine alone (32).
On the other hand, in a study done by Senel AC et al adding 50 mg tramadol was more effective
than adding 50 mg ketamine to extend the duration of the block and improved the quality of
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
postoperative analgesia when either of them added to 0.375% ropivacaine for axillary brachial
plexus block for forearm surgery, and the incidence of nausea was more common in patient's
group with added ketamine (7).
The variable effects of ketamine presumably arise from the different ketamine concentrations
used in different studies. In the studies showing ketamine effectiveness, ketamine was used as 1
or2 mg/kg while studies deny effectiveness ketamine was used as fixed dose 50 mg (7,1,32).
Moreover, it has been noticed that the effect of ketamine might vary when injected at the level of
inflamed tissue compared with the normal tissue site (7).
In our study, we confirmed the beneficial effects of adding dexmedetomidine to bupivacaine in
Pecs-II block which leads to more prolonged analgesic effect, less morphine consumption and
better patient sedation. Moreover, the lack of significant side effects and the hemodynamic
stability make dexmedetomidine an appealing choice as an adjuvant for Pecs-II block.
The efficacy of peripheral perineural dexmedetomidine added to bupivacaine or ropivacaine to
D
enhance the onset of sensory and motor blockade along with increased duration of analgesia for
sciatic nerve blocks in rats has been established by Brummett et al., 2011 (29).More recently,
some clinical trials were conducted in humans and confirmed its analgesic effect which may be
attributed to its peripheral α2 agonist action which produces analgesia by reducing the release of
TE
norepinephrine, or α2 receptor-independent inhibitory effects on nerve fiber action potentials by
blocking the hyperpolarization-activated cation current (4,18,29).
Our findings coincide with other clinical trials in which dexmedetomidine was added to local
anesthetics during regional anesthesia and some peripheral nerve blockade .(4,16,17,18,20).In
these researches, dexmedetomidine was added in different doses to various concentrations of
EP
ropivacaine (0.75%,0.5%, 0.375%,0.197%) for various nerve blocks such as axillary, femoral
,ulnar, and saphenous nerve blocks done for orthopedic surgeries or Ilioinguinal and illio-
hypogastric nerve blocks for hernia repair in children. Rashmi Hd et al (16) also concluded that
adding 50 ug dexmedetomidine to 0.75% ropivacaine in interscalene brachial plexus block
significantly shortened the time of onset of the block and prolonged the duration of sensory and
motor block.
C
On the other hand, only one study done by Andersen JH et al concluded that dexmedetomidine
prolongs the duration of saphenous nerve block by peripheral mechanism that was not
necessary clinically relevant (19).
It was also found that the addition of dexmedetomidine 0.5 mcg/kg as an adjuvant to
AC
levobupivacaine of 0.25% in ultrasound-guided serratus plain block during modified radical
mastectomy surgery can give extended analgesic effect and lower postoperative opioid
consumption. (30) Also adding dexmedetomidine 0.5 µg/kg to bupivacaine 28 ml 0.25% in US-
guided erector spinae plane block provided more effective and safe analgesia in thoracotomy.
(31)
The effect of systemic absorption of perineurally administrated ketamine and dexmedetomidine
was not assessed (the serum levels of both drugs were not measured) which considered one of
our study's limitation .Although it is uncertain whether the placement of drugs in a perineural
and hence more targeted manner improves their efficacy or safety as adjuncts compared with
systemic administration, (33) still many studies concluded the more effectiveness of perineurally
administrated dexmedetomidine or ketamine than its intravenous administration. (34,35).
Another limitations to our study that, we did not investigate the incidence of postoperative
chronic pain, this could be remedied by arranging a follow up appointment for the patients at the
pain clinic. Another limitation was that we did not assess the quality of the block before starting
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
the surgery and postoperative pain was measured only at rest while for more precise comparison
it would be better if postoperative pain was also measured on movement.
Conclusion:
1 ug/kg dexmedetomidine added to 0.25% bupivacaine for ultrasound guided Pecs-II blocks
provided more effective postoperative pain control with effective analgesia, less morphine
consumption and less side effects than adding 1mg/kg ketamine in patients undergoing modified
radical mastectomy for breast cancer.
D
TE
EP
C
AC
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
References:
1-Ahmed H Othman, Ahmed Abd El-Rahman, and Fatma Adel E Sherif: Efficacy and safety of
ketamine added to local anesthetic in modified pectoral block for management of postoperative
pain in patients undergoing modified radical mastectomy. Pain Physician:2016; (19):485-494.
2-Cheng Gs, Ilfeld BMA review of postoperative analgesia for breast cancer surgery. Pain
management: Nov;2016 :6(6):603-618.
3-Chakraborty A, KhemkaR, DattaT, Mitra S. COMBIPECS, the single-injection technique of
pectoral nerve blocks 1and 2 : a case series. J clin Anesth: Dec 2016; 35:365-368.
4-Marhofer D,Kettner SC, Marhofer P, PilsS,Weber M, Zeitlinger M. Dexmetomedine as an
adjuvant to ropivacaine prolongs peripheral nerve blocks a volunteer study. Br J Anesth Mar
2013;110(3):438-42.
5-Haas DA and Harper DG. Ketamine: A review of its pharmacologic properties and use in
ambulatory anesthesia. AnesthProg 1992; 39:61-68.
D
6-Schnabel A,PoeppingDM,KrankeP,ZahanPK,Pogatzki-Zahn EM. Efficacy and adverse effects
of ketamine as an additive for pediatric caudal anesthesia: a quantitative systematic review of
randomized controlled trails. Br J Anesth ; Oct 2011:107(4):601-11.
7-Ahmet Can Senel,OzlemUkinc,andAplerTimurkaynak. Does the addition of Tramadol and
TE
ketamine to ropivacaine prolong the axillary Brachial plexus block?.BioMed Research
International;May 2014: Article ID 686287.
8-Blanco R, Barrington MJ. Pectoralis and serratus plane blocks In: Hadzic A, editor. Hadzic’s
Textbook of Regional Anesthesia and Acute Pain Management. 2nd ed. New York: McGraw-
Hill Education; 2017:650–660.
EP
9-Arunangshu Charkraborty, Rakhi Khemka, Taniya Datta. Ultrasound guided truncal blocks: A
new frontier in regional anesthesia. Indian Journal of Anesthesia. 2016;(60):10;703-711.
10- Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV,Keane KA. The Richmond
Agitation–Sedation Scale: validity and reliability in adult intensive care unit patients. Am J
Respir Crit Care Med. 2002;166: 1338–44.
11-Huang T, Parks DH, Lewis SR. Outpatient breast surgery under intercostal block anaesthesia
C
Plast Reconstr Surg 1979; 63:299-303.
12- Lynch EP, Welch KJ, Carabuena JM, EberleinTJ. Thoracic epidural anesthesia
improves outcome after breast surgery.Ann Surg 1995; 222: 663-669.
AC
13-Wahba SS, Kamal SM. Thoracic paravertebral block versus pectoral nerve block for
analgesia after breast surgery. Egyptian Journal of Anaesthesia 2014;30: 129-135.
14-Bashandy GM, Abbas DN. Pectoral nerves I and II blocks in multimodal analgesia for breast
cancer surgery. Reg Anesth Pain Med 2015; 40:68-74.
15-Kulhari S,Bharti N,Bala I,Arora S,Singh. Efficacy of pectoral nerve block versus thoracic
paravertebral block for postoperative analgesia after radical mastectomy: a randomized
controlled trail. Br J Anaesth.2016.Sep;117(3):382-6.
16-Rashmi Hd,Komala HK. Effect of dexmetomedine as adjuvant to 0.75% ropivacaine in
interscalene brachial plexus block using nerve stimulator: A prospective, randomized, double
blind study.Anesth Essays Res Jan-Mar 2017:11(1):134-139.
17-Li J,Wang H,Dong B,Ma J,Wu X.Adding dexmetomedine or femoral nerve block inhibit
local inflammatory response. Minerva Anestesiol; Jan 2017;20(17)11430-6.
18-Bangera A,Manasa M,Krishna P.Comparison of effects of ropivacaine with and without
dexmetomedine in axillary brachial plexus block: A prospective randomized double –blinded
clinical trial. Saudi J Anaesth 2016.Jan-Mar;10(1):38-44.
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
19-Andersen JH,Grevstad U,Siegel H,Dahl JB,Mathiesen O,Jaeger P.Does dexmetomedine have
a perineural mechanism of action when used as an adjuvant to ropivacaine? : A paired
,blinded,randomized trial in healthy volunteers.Anesthesiology;Jan2017:126(1):66-73.
20-Lundblad M,Marhofer D,Eksborg S,Lonnqvist PA. Dexmetomedine as adjunct to
illioinguinal/ illiohypogastric nerve blocks for pediatric inguinal hernia repair:an exploratory
randomized controlled trail.Pediatr anesth;Sep 2015;25(9):897-905.
21-Medha Mohta,Bhumika Kalra,Ashok Sethi,Navneet Kaur.Efficacy of dexmetomidine as an
adjuvant in paravertebral block in breast cancer surgery. J Anesth(2016):30:252-260.
22- Chad M. Brummett, and Brian A. Williams. Additives to Local Anesthetics for Peripheral
Nerve Blockade. Int Anesthesiol Clin; 2011:49(14):104-116.
23- Vadivelu N, Mitra S, Schermer E, Kodumudi V, Kaye AD, Urman RD. Preventive analgesia
for postoperative pain control: a broader concept. Local Reg Anesth.2014;7:17-22.
24- Garimella V, Cellini C. Postoperative pain control. Clin Colon Rectal Surg. 2013 Sep; 26(3)
D
: 191-6.
25- Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain.
Curr Opin Anaesthesiol.2009;22:588–593.
26- Bugedo GJ, Carcamo CR, Mertens RA, Dagnino JA, Munoz HR. Preoperative percutaneous
TE
ilioinguinal and iliohypogastric nerve block with 0.5% bupivacaine for post-herniorrhaphy
pain management in adults. Reg Anesth.1990; 15:130–133.
27- Nowakowski P1, Bieryło A, Duniec L, Kosson D, Łazowski T. The substantial impact of
ultrasound-guided regional anaesthesia on the clinical practice of peripheral nerve blocks.
Anaesthesiol Intensive Ther. 2013 Oct-Dec;45(4):223-9
EP
28-N.S. SarhadI, J. Shaw-Dunn,and D.S. Soutar .Clinical Anatomy; 1997:10:283–288.
29- Chad M Brummett 1, Elizabeth K Hong, Allison M Janda, Francesco S Amodeo, Ralph
Lydic. Perineural dexmedetomidine added to ropivacaine for sciatic nerve block in rats
prolongs the duration of analgesia by blocking the hyperpolarization-activated cation current
Anesthesiology. 2011 Oct;115(4):836-43.
30-Mona Gad, Mohamed Elmetwally. Efficacy of adding dexmedetomidine as adjuvant with
C
levobupivacaine in ultrasound-guided serratus plane block for modified radical mastectomy
surgery. Research and opinion in anesthesia and intensive care,2019, Volume: 6, Issue:
2, Page: 234-242.
31-Mamdouh Mahmoud, Reham Mohamed Gamal,Aya Mohamed Ahmed ,Nevine Mahmoud
AC
Gouda &Mohamed Mohammed Abdelhaq..Efficacy of adding dexmedetomidine as adjuvant
with bupivacaine in ultrasound-guided erector spinae plane block for post thoracotomy pain:
Randomized controlled study. Egyptian Journal of Anaesthesia, 2021, Volume 37, - Issue 1.
32-Noha O. AL-Mobayad, .;Hala M. EL-Gendy,. Hoda A. Ezz, . and Mohammed G. Ayad. The
Effect of Adding Ketamine to Bupivacaine in Ultrasound Guided Ilioinguinal and
Iliohypogastric Nerve Block for Inguinal Hernia Operations. Med. J. Cairo Univ. 2018, Vol
. 86, No. 3, June: 1847-1853,
33- N. Desai, E. Albrecht and K. El-Boghdadly. Perineural adjuncts for peripheral nerve block.
BJA Education, 2019: 19(9): 276e282.
34- Nasir Hussain,Chad M Brummett , Richard Brull , Yousef Alghothani , Kenneth
Moran,Tamara Sawyer , Faraj W Abdallah . Efficacy of perineural versus intravenous
dexmedetomidine as a peripheral nerve block adjunct: a systematic review. Reg Anesth Pain
Med. 2021 Aug;46(8):704-712.
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
35-TianqiZhu, YuanGa, XimouXu, ShuyingFu, WendongLin, JiehaoSun. Effect of Ketamine
Added to Ropivacaine in Nerve Block for Postoperative Pain Management in Patients
Undergoing Anterior Cruciate Ligament Reconstruction: A Randomized Trial. Clinical
Therapeutics.2020, May,Volume 42, Issue 5, Pages 882-891.
36- Tjokorda Gde Agung Senapathi, I Made Gede Widnyana, I Gusti Ngurah Mahaalit, Aribawa
A A Gde Putra Semara Jaya I Made Darma Junaedi. Combined ultrasound-guided Pecs II
block and,general anesthesia are effective for reducing pain from modified radical
mastectomy. Journal of Pain Research 2019:12 1353–1358
D
TE
EP
C
AC
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Table 1. Baseline characteristics of patients in the three study groups
Group B Group BK Group BD
Variable P-value
(n=53) (n=53) (n=53)
Age (years) 46.1 ± 4.2 47.8 ± 5.9 47.2 ± 5.2 0.229
Weight (kg) 86.3 ± 6.1 85.2 ± 2.6 85 ± 5.3 0.342
BMI (33.5 ± 3.3) 33.35 ± 3.2 33.61 ± 2.8 33.45 ± 3.9 0.921
HTN 13 (24.53%) 14 (26.42%) 12 (22.64%) 0.903
Baseline heart rate (bpm) 84 ± 14 85 ± 6 84 ± 12 0.869
D
Baseline SBP rate (mmHg) 130 ± 6 132 ± 7 129 ± 7 0.066
Data are mean ± SD.HTN data as counting and percentage
TE
EP
C
AC
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Table 2. Duration of anesthesia and surgery in the three study groups
Variable Group B (n=53) Group BK (n=53) Group BD (n=53) P-
value*
Duration of anesthesia (min) 164.6 ± 9.4 161.9 ± 14 160.8 ± 14.6 0.292
Duration of surgery (min) 141.7 ± 13.6 144 ±14.9 145 ± 19 0.516
Data are mean ± SD.
*. One-way analysis of variance (ANOVA).
D
TE
EP
C
AC
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Table 3. Analgesic consumption in the three study groups
Variable Group B Group BK Group BD P-
(n=53) (n=53) (n=53) value*
Intraoperative fentanyl supplementation 58 ± 6 56 ± 7 57 ± 7 0.328
(µg)
Time to first rescue analgesic request 11.5± 1.2 16.7 ± 4.5† 21.6 ± 1.6 †‡ <0.001
(min)
Total 24-h morphine consumption (mg) 16.9 ± 5.3 10.3 ± 2.6† 3.8 ± 0.2 †‡ <0.001
Data are mean ± SD.
*. One-way analysis of variance (ANOVA).
†. P <0.001 vs Group B (Tukey post hoc test).
D
‡. P <0.001 vs. Group BK (Tukey post hoc test).
TE
EP
C
AC
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Table4.Patient satisfaction
B group BK group BD group
Patients satisfaction Test value P-value Sig.
No. = 53 No. = 53 No. = 53
Most satisfied 15 (28.3%) 25 (47.2%) 48 (90.6%)
Somewhat satisfied 13 (24.5%) 15 (28.3%) 3 (5.7%) 47.373* 0.000 HS
Unsatisfied 25 (47.2%) 13 (24.5%) 2 (3.8%)
Multi-comparisons between groups
D
B group Vs BK group B group Vs BD group BK group Vs BD group
0.040 0.000 0.000
TE
P-value > 0.05: Non significant; P-value < 0.05: Significant; P-value < 0.01: Highly significant*: Chi-square test
Data are presented as counts and percentage of total number.
EP
C
AC
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Table 5.Side effects
B group BK group BD group
Side effects Test value P-value Sig
No. = 53 No. = 53 No. = 53
Intraoperative hypotension 2 (3.77%) 1 (1.89%) 3 (5.66%) 1.039 0.594 NS.
Intraoperative bradycardia 1 (1.89%) 0 (0.0%) 2 (3.77%) 2.038 0.361 NS
Hallucination, nystagmus, or dissociative effects 0 (0.0%) 0 0 (0.0%) 0 0 (0.0%) 0.000 1.000 NS
Nausea and/or vomiting 8 (15.1%) 5 (9.43%) 0 (0.0%) 8.210 0.016 S
P-value > 0.05: Non significant; P-value < 0.05: Significant;
Data are presented as counts and percentage of total number
D
TE
EP
C
AC
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
D
TE
EP
C
AC
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
D
TE
EP
C
AC
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
D
TE
EP
C
AC
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
D
TE
EP
C
AC
Copyright © 2022 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
