Neoplasms

Skin and Connective Tissue Diseases

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Symptoms and General Pathology

Skin Neoplasms

Neoplasm Metastasis

Skin Diseases

Central Nervous System Depressants

All Drugs and Chemicals

Anesthetics

Anesthetics, Local

Hypnotics and Sedatives

Serratus plane block plus intravenous sedation as anesthetic technique during axillary dissection procedure.

Ultrasound guided injection of local anesthetic between latissimus dorsi and serratus muscles at mid axillary line.

Serratus plane block

Axillary dissection is a surgical procedure that incises the axilla to identify, examine, or remove lymph nodes.

Axillary dissection

Administration of sedatives thru an intravenous access to achieve relaxion and improve operative conditions.

Intravenous sedation

Daniele Theobald, MD

INTRODUCTION: The axillary lymphadenectomy procedure is known to be associated with late postoperative complications, such as chronic pain and changes in shoulder mobility. Recently, several thoracic ultrasound guided interfascial blocks have been described, including serratus plane block. These blocks were associated with reduced postoperative pain scores in breast surgeries but were never evaluated in axillary dissection. The safety and feasibility of performing axillary dissection under local anesthesia and tumescent anesthesia associated with sedation has been demonstrated in case series, although it is not already the standard technique.

DISCUSSION: This project aims to investigate the feasibility of the serratus plane block associated with intra-venous sedation in a prospective case series including 15 patients submitted to axillary dissection, by scoring patient and surgeon satisfaction with the technique, pain, quality of life with EORTC QLQ-C30 questionnaire, and quality of recovery with QoR-40 questionnaire in the first 30 postoperative days.

This study is a prospective case series. All patients should go through a preoperative evaluation with an anesthesiologist. At that time the eligibility for the study will be evaluated and if the patient consent to participate in the study.

The following parameters shall be evaluated in the ambulatory evaluation:

* Age
* Anthropometric data (weight and height);
* Presence of comorbidities;
* Revised cardiac index (LEE);
* Estimation of functional capacity in metabolic equivalents (METs) by history;
* Performance Status by the scale of Eastern Cooperative Oncology Group (ECOG);
* Determination of the physical status by the American Society of Anesthesiologists (ASA) classification;
* QoR-40 recovery quality scale, validated for Brazilian Portuguese;
* Quality of life EORTC QLQ-C30 questionnaire, validated for Brazilian Portuguese.

During the anesthetic procedure, the following standard technique should be applied: peripheral venous access, dipyrone 30 mg/kg, antibiotic according to the institutional protocol, moderate sedation with intravenous propofol in continuous infusion in the absence of any contraindication. Midazolam will be used in case of contraindication to propofol or during the execution of the block according to preference of the researcher who will perform the block. Associated with propofol infusion, the alpha agonist dexmedetomidine may be used in continuous infusion associated with fentanyl, tramadol, dextroketamine, magnesium sulfate, dipyrone and tenoxicam, whose uses will be evaluated on a case-by-case basis and will be recorded in the database.

In case of conversion to general anesthesia, the airway control should be carried out preferably with laryngeal mask, with the orotracheal intubation as an alternative option. The maintenance of anesthesia will be in this case using propofol continuous infusion in the absence of contraindications, otherwise sevoflurane will be used. Postoperative nausea and vomiting prophylaxis will be done with four milligrams of dexamethasone and ondansetron.

Patients will be submitted serratus plane block according to the technique described in Blanco. The patients will be positioned in a supine position. The transducer of the ultrasound device is protected with sterile cover. The ultrasound probe is positioned in the mid clavicular region of the thoracic wall in a sagittal plane. Using a nether-lateral path with the probe, will be counted the ribs, until the fifth rib is identified in the mid axillary line. In this position, over the fifth rib, the latissimus dorsi muscle superficially and the serratus muscle deeper and lower can be easily observed. The identification of the thoracodorsal artery with use of doppler imaging assists in identifying the superficial plane to the serratus muscle. Once identified the structures, the needle is introduced in the plane of the transducer positioning its tip on the surface of the serratus muscle. Then 40 ml of solution with 1% lidocaine, adrenaline 1:200,000 and ropivacaine 0.5% are injected in patients above 50kg and 32ml of the same solution in patients with body weight between 40 and 50kg aiming to respect the maximum dose of local anesthetic recommended.

At the end of the surgical procedure the patient will be referred to the anesthetic recovery unit. The extension of the blockade will be then evaluated. They will be discharged to ward as soon as they get the discharge criteria.

The surgical time, time for execution of the blockage (counted from the placement of the sterile field until the removal of the needle), the surgical room time, estimated bleeding, presence of surgical complications or anesthetic and number of lymph nodes extracted will be registered. At the end of the surgery the surgeon will be asked to fill out a range of Likert 5 points on his opinion on the quality of anesthesia (extremely satisfied, satisfied, not satisfied or dissatisfied, dissatisfied, extremely dissatisfied) and to compare the quality of anesthesia with general anesthesia on a 3-point scale (indistinguishable from general anesthesia, sufficient to perform the procedure, extremely challenging/inadequate).

On the first day of postoperative the standard analgesia will be carried out with dipyrone 30 mg/kg IV every 4 hours, associated with tenoxicam 20mg every 12 hours. In case of contraindication to dipyrone, will be administered paracetamol 500 mg VO every 6 hours. As a rescue therapy the default option is tramadol 50mg IV up to every 4 hours (daily maximum dose of 300mg/day and morphine 4 mg each hour (in case of allergy or intolerance to tramadol and rescue the tramadol). If necessary more than 24 hours of hospitalization, postoperative analgesia will be performed as option of the assistant team. The use of postoperative painkillers will be recorded in the database.

All patients should be evaluated on the first postoperative day with record of the verbal numerical scale for the evaluation of pain at rest, cough and abduction of 90 Degrees of the member and the presence of adverse effects. They be asked to fill the scale of Likert of 5 points with his opinion on the quality of anesthesia (extremely satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, extremely dissatisfied) and the scale of recovery quality QoR-40. Between the twenty-eighth and the thirtieth-fifth postoperative day All patients will be reassessed, occasion where the scale of recovery quality QoR-40 and the scale of quality of life EORTC QLQ-C30, presence of surgical wound infection will be applied, cutaneous necrosis, seroma, lymphedema, lymphatic fistula and date of drain removal.

Feasibility of Serratus Plane Block Associated With Sedation in Axillary Dissection

Assessment of the Feasibility of Ultrasound Guided Serratus Plane Block Associated With Sedation as Anesthetic Technique in Axillary Dissection

Percentage of patients who needed conversion to general anesthesia. A percentage from 0 to 100%, where 0% means that no patient needs technique conversion to general anesthesia and 100% means that all patients need it.

The QLQ-C30 is composed of multi-item scales and single-item measures. These include:

* A global health status / QoL scale
* Five functional scales (Physical functioning, Role functioning, Emotional functioning, Cognitive functioning, Social functioning)
* Three symptom scales (Fatigue, Nausea and vomiting, Pain)
* Six single items (Dyspnoea, Insomnia, Appetite loss, Constipation, Diarrhoea, Financial difficulties) Each of the multi-item scales includes a different set of items. All of the scales and single-item measures range in score from 0 to 100. A high scale score represents a higher response level. Thus a high score for a functional scale represents a high / healthy level of functioning, a high score for the global health status / QoL represents a high QoL, but a high score for a symptom scale / item represents a high level of symptomatology / problems . The scales are scored as described as described in EORTC QLQ-C30 Scoring Manual. 2001 EORTC, Brussels.

Quality of Recovery - 40 Item questionnaire

QoR-40 score is a score developed to estimate the quality of recovery after anesthesia. It consists of a 40-item questionnaire with items on a five- point Likert scale (for positive items, 1 'none of the time' to 5 'all of the time'; for negative items the scoring was reversed). It is scored as follows:

QoR-40 dimensions

* Emotional state (9-45)
* Physical comfort (12-60)
* Psychological support (7-35)
* Physical independence (5-25)
* Pain (7-35) Global QoR-40 (40-200)

A five points Likert scale will be applied to the main surgeon responsible for the operation.

The surgeon will be asked to fill out a Likert 5 points scale to access his opinion about the quality of anesthesia (extremely satisfied, satisfied, not satisfied or dissatisfied, dissatisfied, extremely dissatisfied).

A five points Likert scale will be applied to the patient in the first postoperative day visit to access his opinion about the quality of the anesthesia (extremely satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, extremely dissatisfied).

Eleven point numeric pain rating scale (0 means no pain and 10 means worst possible pain).

All the anesthetics and analgesics used in intraoperative and postoperative period will be recorded. Doses will be recorded in database.

Number of lymph nodes extracted according to anatomopathological report.

Instituto Nacional de Cancer, Brazil

Pain, Postoperative

Postoperative Complications

Pain

Subcostal transversus abdominis plane block(STAPB)

To prevent postoperative pain, the researchers applied a subcostal transversus abdominis plane block in addition to the posterior transversus abdominis plane block to a group of patients who underwent surgery with a midline incision due to major gynecological cancer.

Patients undergoing subcostal transversus abdominis plane block and posterior transversus abdominis plane block

To prevent postoperative pain, the researchers applied a rectus sheath block in addition to the posterior transversus abdominis plane block to a group of patients who were operated on through a midline incision due to major gynecological cancer.

Patients undergoing rectus sheat block and posterior transversus abdominis plane block

The aim of this prospective randomized study was to compare the effectiveness of subcostal transversus abdominis plane block or rectus sheath block applied in addition to posterior transversus abdominis plane block for postoperative analgesia in major gynecological cancer surgeries.

The main question(s) it aims to answer are:

\[Is subcostal transversus abdominis plane block more effective in postoperative analgesia? \] \[Is there a difference in pain scores at 24 hours after surgery? \] Since pain scores within the first 24 hours after surgery will be evaluated, participants will be asked to give a value between 0 and 10 at certain time periods.

This prospective, randomized study was conducted at Başakşehir Çam and Sakura City Hospital in accordance with the Declaration of Helsinki. After ethics committee approval (decision no: 2023-596, date: 22.11.2023) and written consent from all patients, the study was conducted according to Consolidated Standards of Reporting Trials (CONSORT) guidelines. In the study, which included a total of 50 patients, the patients were divided into two groups: subcostal transversus abdominis plane block (STAPB) or rectus sheath block (RSB). Postoperative 24-hour VAS values, opioid demand and administration amounts in intravenous patient-controlled analgesia, presence of nausea and vomiting, surgical complications and length of hospital stay were evaluated (6th hour, 12th hour, 24th hour).

Comparison of the Efficacy of Peripheral Nerve Blocks in Major Open Gynaecological Cancer Surgery

Comparison of the Efficacy of Subcostal Transversus Abdominis Plane Block and Rectus Sheath Block for Postoperative Analgesia in Major Open Gynaecological Cancer Surgery: a Prospective Randomised Study

Our primer aim was to compare postoperative pain scores. The first 24 hours postoperatively were evaluated.Visual analog scale(VAS) was used to assess postoperative pain.6th, 12th, 24th hour VAS values were recorded For example, 0-10 where 0 is no pain and 10 is the worst pain imaginable.

Our secondary aim was to evaluate the opioid amount (mg) in the first 24 hours of intravenously administered opioids with patient-controlled analgesia.

Bakirkoy Dr. Sadi Konuk Research and Training Hospital

Principal Investigator

Analgesics

Morphine

Analgesics, Opioid

Narcotics

Group 1: Intrathecal morphine administered group

Group 2: Four quadrant transversus abdominis plane block applied group

Intrathecal morphine administered group and Four quadrant transversus abdominis plane block applied group

Intrathecal morphine administered group, Four quadrant transversus abdominis plane block applied group

Duygu Akyol

The aim of this study is to compare the effectiveness of intrathecal morphine and four-quadrant transversus abdominis plane block applied for postoperative analgesia in gynecological cancer surgeries.

The key question(s) it aims to answer are:

\[Is intrathecal morphine more effective in postoperative analgesia?\] Patients who underwent gynecological cancer surgery were examined retrospectively. The investigators evaluated the effect of intrathecal morphine and four-quadrant transversus abdominis plane block applied for postoperative analgesia on pain scores and postoperative opioid use.

Our study was designed retrospectively. The investigators evaluated analgesia methods in patients who underwent laparoscopic or open surgery due to gynecological cancer between June 2023 and December 2023. The investigators evaluated the effect of intrathecal morphine and four-quadrant transversus abdominis plane block on postoperative analgesia and opioid use.

Group 1: Intrathecal morphine administered group Group 2: Four quadrant transversus abdominis plane block applied group

The Effect of Analgesia Methods Applied in Gynecological Cancer Surgeries on Postoperative Analgesia

Four-quadrant Transversus Abdominis Plane Block Versus Intrathecal Morphine in Gynecological Cancer Surgeries: a Single-center Retrospective Study.

Our primary aim was to evaluate numerical rating scale at 24 hours postoperatively. numerical rating scale(NRS) was used to assess postoperative pain. NRS values were recorded For example, 0-10 where 0 is no pain and 10 is the worst pain imaginable.

Our secondary aim was to evaluate opioid demand and consumption amounts in the postoperative 24 hours.

Dilatation, Pathologic

Pathological Conditions, Anatomical

Anti-Arrhythmia Agents

Channel Blockers

Adjuvants, Anesthesia

Psychotropic Drugs

Lidocaine

Fentanyl

Midazolam

Levobupivacaine

Anti-Anxiety Agents

Anesthetics, Intravenous

Anesthetics, General

GABA Modulators

Neurotransmitter Agents

Sodium Channel Blockers

Diuretics, Potassium Sparing

* Local Anesthetic infiltration with 1% lignocaine
* MAC with IV Midazolam Img\\ml and Fentanyl 10 mic\\ml

* QL block with 0.25% levobupivacaine (Chirocaine, Abbott, Ireland) and 1% lignocaine
* MAC with IV Midazolam Img\\ml and Fentanyl 10 mic\\ml

Lignocaine infiltration through the nephrostomy track

Local Anesthetic infiltration

A linear 12-MHz ultrasound probe will be placed in the anterior axillary line to visualize the typical triple abdominal layers. Then, the probe will be placed in the midaxillary line and at this point the layers of abdominal layers starte to taper. The probe will be placed in the posterior axillary line, sonoanatomy will show first the transversus abdominis disappearing then the internal oblique and external oblique forming aponeurosis and appearance of QL will be noticed. At the posterior border of the quadratus lumborum muscle and outside the fascia, Touhe needle will be inserted in plane and confirmed its position by injecting saline. Under ultrasound (US) guidance, local anesthetic mixure will be deposited separating the fascia

Quadratus Lumborum block

Incremental doses are given to the targed sedation and analgesia

Dina N Abbas, M D

Ghada M Bashandy, MD

Wael Darwish, M D

Percutaneous nephrostomy (PCN) is one of the interventions in the radiology department in which pain control is necessary. Quadratus Lumborum (QL) block will be tried to limit the use of systemic analgesics and its accompanying untoward effects in those frail patients requiring PCN that is performed in the prone position.

Quadratus Lumborum block is a novel technique in which extension into the thoracic paravertebral space may occur. QL block would seem to be able to alleviate both somatic and visceral pain so it's expected to decrease the need for systemic sedation\\analgesia to a minimum.

Quadratus Lumborum Block for Percutaneous Nephrostomy

Quadratus Lumborum Block Versus Local Anesthetic Infiltration Combined With Monitored Anesthesia Care for Percutaneous Nephrostomy

Verbal Rating Scale is assessed for degree of pain during the procedure and after till discharge from the radiology department.

Respiratory rate and airway patency is monitored with an anesthesiologist.

Ramsay Seadation Score is assessed during and after procedure till discharge

Blood pressure and Heart rate is assessed during and after procedure till discharge

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Feasibility of Serratus Plane Block Associated With Sedation in Axillary Dissection	NCT03740815	Anesthesia Regional Anesth... Axillary Metast... Nerve Block Analgesia Skin Cancer	Serratus plane ... Axillary dissec... Intravenous sed...	18 Years -	Instituto Nacional de Cancer, Brazil
Comparison of the Efficacy of Peripheral Nerve Blocks in Major Open Gynaecological Cancer Surgery	NCT06342076	Postoperative P... Postoperative C... Analgesia Regional Anesth...	Patients underg... Patients underg...	18 Years -	Bakirkoy Dr. Sadi Konuk Research and Training Hospital
The Effect of Analgesia Methods Applied in Gynecological Cancer Surgeries on Postoperative Analgesia	NCT06382376	Gynecological C... Regional Anesth...	Intrathecal mor...	18 Years - 80 Years	Bakirkoy Dr. Sadi Konuk Research and Training Hospital
Quadratus Lumborum Block for Percutaneous Nephrostomy	NCT02121951	Nephrostomy; Co... Upper Urinary T... Regional Anesth... Adverse Anesthe...	Local Anestheti... Quadratus Lumbo... MAC	18 Years - 80 Years	National Cancer Institute, Egypt
Feasibility of Serratus Plane Block Associated With Sedation in Axillary Dissection	NCT03740815	Anesthesia Regional Anesth... Axillary Metast... Nerve Block Analgesia Skin Cancer	Serratus plane ... Axillary dissec... Intravenous sed...	18 Years -	Instituto Nacional de Cancer, Brazil

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