| BackgroundData from China’s cancer registry show that breast cancer is one of the four most common cancers among women,especially among urban women.Surgical treatment plays an important role in the diagnosis,staging and treatment of breast cancer.Surgical treatment with radiotherapy,chemotherapy,endocrine therapy,molecular targeted therapy and other methods can often achieve better short-term and long-term prognosis.With the improvement of the overall diagnosis and treatment of breast cancer,in recent years,people’s attention has gradually shifted to the early rehabilitation,long-term outcome and postoperative quality of life of breast cancer patients.Breast cancer surgery often has a large wound,and the traditional breast surgery analgesic technology is relatively simple,with imposed analgesic effect and the postoperative analgesic situation of breast tumor and therefore patients are mostly suffering from moderate pain after surgery,and some patients will even develop chronic pain,developing post-mastectomy pain syndrome(PMPS),which will seriously affect their postoperative recovery and postoperative quality of life.In recent years,with the promotion and popularization of the idea of enhanced recovery after surgery(ERAS),the intraoperative and postoperative analgesia of breast tumor surgery is increasingly valued by people.The emergence of new ultrasound-guided anesthesia analgesia techniques for nerve block has provided more technical options for the analgesia of breast tumor surgery,and the ultrasound-guided regional nerve block technique has gradually occupied a dominant position in the perioperative multi-mode analgesia of breast tumor patients.The effect of traditional high spinal canal nerve block anesthesia analgesic is exact,and can completely inhibit the pain in chest surgery,but the complex operation,high failure rate,big puncture risk,the inhibition of sympathetic nerve contribute to great difficulties to deal with the occurrence of complications so that anesthesiologists are discouraged by it,and the current clinical practice is not ideal.The traditional paravertebral nerve block technique is one of the earliest traditional nerve block methods because it can fully block the intercostal nerves and has an ideal analgesic effect on the chest wall after surgery.However,the traditional thoracic paravertebral nerve block puncture is relatively complex,technically difficult,strict requirements for sterility,and the incidence of serious complications such as hemopneumothorax is relatively high.For breast surgery,the surgical wound range is large and the intercostal segment is large.If the thoracic paravertebral nerve block technique is used for analgesia,more segments are often required for puncture,which significantly increases the complexity of puncture and the incidence of complications.Therefore,the traditional thoracic paravertebral nerve block technique is not widely used in the actual clinical application of breast tumor surgery.In recent years,new type of chest wall nerve block guided by ultrasound technology emerge in endlessly,and technologies such as ultrasound-guided thoracic intermuscular nerve block technique,ultrasound-guided anterior serratus nerve block technique,ultrasound-guided erector spinal muscle block technique,ultrasound-guided posterior laminar nerve block technique,ultrasound-guided transverse thoracic muscle nerve block technique are used more in clinical anesthesia and pain management.Ultrasound-guided thoracic wall nerve block is easy to operate,with fewer complications and ideal blocking effect.It is increasingly widely used in clinical practice,especially in thoracic surgery and breast surgery,with a tendency to gradually replace the traditional high intravertebral nerve block technology and the traditional thoracic paravertebral nerve block technology.Postoperative breast pain syndrome seriously affects the early postoperative rehabilitation and long-term life quality of patients with breast cancer,causing great psychological pressure and physiological trauma to patients.The traditional analgesia is mainly carried out by intravenous or oral drugs,but its analgesic effect is not ideal,the incidence of nausea,vomiting,dizziness and other adverse reactions is high and the analgesic effect varies greatly among individuals with unpleasant comfort.Therefore,it is urgent to seek an ideal analgesic method during and after operation.The ultrasound-guided nerve block technology perfectly corresponds to the ERAS’idea of reducing the application of opioid analgesics,which can meet the actual clinical needs and the development requirements of the idea due to its simple operation,accurate effect,fewer complications and obvious reduction in the application of intraoperative and postoperative opioid analgesics.Hence,the popularization of ultrasound-guided thoracic wall nerve block is of great significance.Ultrasound visualization technology makes chest wall muscles and blood vessels clearly visible.According to the shape characteristics of nerves in the musculoaponeurotic space,the operation of various chest wall nerve blocks is simple and feasible,and the appropriate chest wall nerve block mode can be selected according to the range of different mammary gland section resection and lymph node dissection.New methods of ultrasound-guided thoracic wall nerve block for breast surgery include ultrasound guided Ⅰ thoracic nerve block technique(Pecs blockⅠ),ultrasound guided Ⅱ thoracic nerve block technique(Pecs block Ⅱ),ultrasound-guided planar nerve block technique of the sersais anterior muscle,modified ultrasound-guided planar nerve block technique of anterior serration muscle,ultrasound-guided intercostal planar nerve block of the serratus anterior muscle,ultrasound-guided planar nerve block of erector spinalis muscle,ultrasound-guided planar nerve block technique of transverse thoracic machine and so on.In the face of so many methods of thoracic wall nerve block,how to choose the appropriate nerve block has become a problem.In this paper,the clinical application effect of common ultrasound-guided thoracic wall nerve block in breast surgery was compared and studied,so as to obtain exact results to guide clinical application.OBJECTIVE:Study and compare the situation of the application in Pecs block Ⅱ,ultrasound-guided planar nerve block technique of the anterior serratus muscle,improved ultrasound-guided planar nerve block technique of the anterior serratus muscle,and ultrasound-guided planar nerve block technique of the erector spine muscle etc,and choose the most ideal for breast cancer radical surgery of the nerve block method.To observe the indexes of blocking effect and adverse reaction of various kinds of blocking methods,and to provide the basis for choosing various kinds of anesthesia and nerve blocking methods for breast diseases.To compare the application of ultrasound-guided planar nerve block of anterior serration muscle with that of erector spine muscle in breast cancer surgeryTo select the best anesthesia and nerve block method for the radical operation of breast cancer according to the scope,effect and complications of various ultrasound-guided thoracic wall nerve blockMethods1.Experimental data(1)research objectsThis study has been approved by the Medical Ethics Committee of Linyi People’s Hospital,and the informed consent has been signed with patients or their families Select 120 cases of breast benign tumor resection of female patients,treated(axillary lymph node dissection),150 cases of female patients.Inclusion criteria:ASA gradeⅠ-Ⅱ,age 25-55,weight 40-75kg.Exclusion criteria:Patients with SA grade>grade II,mental retardation or inability to perform visual analogue scoring for pain,long-term use of analgesics,and patients with coagulation dysfunction,local anesthetic allergy,puncture site infection and other nerve block contraindications(2)Experiment grouping1.We have selected 120 patients undergoing elective breast benign tumor resection,surgical within a scope is mammary gland quadrant,and meet the criteria for the patients,and they were randomly divided into Pecs block Ⅱ group,under the guidance of ultrasound before saw muscle plane nerve block group,under the guidance of ultrasound-guided planar nerve block group of erector spines and the nerve block group,30 cases in each group2.We have selected 120 patients undergoing elective patients with breast cancer radical,surgery include ipsilateral axillary lymph node cleaning.The patients were randomly divided into three groups:ultrasound-guided planar nerve block group of anterior serratus muscle,improved ultrasound-guided planar nerve block group of anterior serratus muscle,ultrasound-guided planar nerve block group of erector spinalis muscle and non-nerve block group.3.We have selected thirty patients with electiveModified radical mastectomy for breast cancer.The surgical scope included ipsilateral axillary lymph node dissection and ultrasound-guided anterior sawe-brachial intercostal nerve block.Routine anesthesia induction was performed in the above groups:Sufentanil 0.3ug/kg,Propofol 1.5mg/kg,Midazolam 0.02mg/kg,Rocuonium Bromide 0.8mg/kg,mask ventilation for oxygen and nitrogen removal for 3 minutes,laryngeal mask was placed,and mechanical control ventilation was performed.Thoracic wall nerve block was conducted under ultrasound guidance,and 0.375%Ropivacaine 20ml was injected.Breast surgery was performed under total intravenous anesthesia combined with ultrasound-guided nerve block anesthesia and Sufentanil was added for a single time as required to maintain the fluctuation of the patient’s heart rate and blood pressure within 30%of the basic value.After surgery,the patient was sent to the anesthesia and resuscitation room.(3)The observation indexesRecord the patient intraoperative use of Opioids ShuFen patients,the total amount and finish decannulation time T1,awakening time T2(steward score>6 separated from the end of the surgery to patients recovery room time),VAS score(VAS score V1,the recovery room patients after 4 h VAS score V2,V3 surgery until tomorrow 12 h VAS score,finish operation 24 h VAS score V4),PONV score(0=no nausea/vomiting,1=nausea,2=vomiting)and finish 24 h patient anesthesia satisfaction scores.Results1.For patients with breast benign tumor excision,compare with Pecs block Ⅱgroup,ultrasound-guided planar nerve block of anterior serratus muscle,modified ultrasound-guided planar nerve block of anterior serratus muscle,and ultrasound-guided planar nerve block of erector spinalis muscle,significantly reduced the amount of intraoperative Sufentanil,and can reduce the T1,T2,V1-V4 significantly lower scores,reduced PONY score,finish 24 h operation anesthesia satisfaction improved obviously;2.For patients with breast cancer radical,compared with a nerve block group,ultrasound-guided planar nerve block of anterior serratus muscle,modified ultrasound-guided planar nerve block of anterior serratus muscle,and ultrasound-guided planar nerve block of erector spinalis muscle can significantly reduce the amount of intraoperative Sufentanil,reduce V1-V4 score,reduce PONV score,finish 24 h operation anesthesia satisfaction has improved significantly.Ultrasound-guided planar nerve block of the erector spine can provide pain block in the lateral chest wall,but it is not effective in the axillary region.In the ultrasound-guided group and the modified ultrasound-guided group,the pain block of the axillary and lateral chest wall was better,but the pain block of the axillary lateral wall and the medial region of the upper arm was not good.The comparison between the ultrasound-guided group and the modified ultrasound-guided group showed that the vl-v4 score of the erector spinalis plane block group was significantly higher than that of the erector spinalis plane block group,and the modified erector spinalis plane block group had the lowest v2-v4 score.3.In another group of experiments of radical treatment of breast cancer,in view of the deficiency of ultrasound-guided planar nerve block of the anterior serrate muscle for the lateral wall of the axilla and the medial region of the upper arm,we improved the method of ultrasound-guided planar nerve block of the anterior serration muscle,Under the guidance of ultrasound,the insertion point of plane nerve block of the anterior serratus muscle was moved up to the level of the surface of the anterior serratus muscle and the deep surface of the pectoralis minor muscle in order to better block the intercostal brachial nerve.Here we call it anterior serratus-intercostal brachial nerve block under ultrasound guidance.The results showed that the v2-v4 score in the ultrasound-guided group of anterior sawing muscle-intercobar brachial nerve block was significantly lower than that in the ultrasound-guided group of anterior sawing muscle-intercobar brachial nerve block and the improved ultrasound-guided group of anterior sawing muscle-plane nerve block,without increasing the incidence of T1,T2 and PONY.Conclusion1.Under the chest wall nerve block guided by ultrasound can provide patients with breast benign tumor resection with good intraoperative analgesia effect,reduce the dosage of intraoperative opioid anesthesia drugs,shorten the awaken time and extubation time of patients,and can provide good postoperative analgesia effect,effectively reduce the incidence of postoperative adverse reactions such as nausea and vomiting,improve patient satisfaction with anesthesia.2.Ultrasound-guided planar nerve block of the anterior sawing muscle,modified ultrasound-guided planar nerve block of the anterior sawing muscle,and ultrasound-guided planar nerve block of the erector spinal muscle can all provide good intraoperative and postoperative analgesia for patients undergoingModified radical mastectomy,reduce the amount of intraoperative opioid anesthetic drugs,shorten the anesthesia extubation time and anesthesia waking time,reduce postoperative complications such as nausea and vomiting,and improve the anesthesia satisfaction of patients.However,these methods are not perfect for the pain block in the axillary lymph node dissection area.3.Our improved ultrasound-guided planar intercostal brachial nerve block of the anterior saws can provide a relatively more complete analgesic effect for patients undergoingModified radical mastectomy,and the anesthesia satisfaction score is higher. |
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