| Background:Autologous costal cartilage is often used in plastic surgeries,such as ear reconstruction,rhinoplasty or nasal reconstruction.However,costal cartilage harvest leads to severe chest pain,which seriously affects postoperative recovery.Currently,patient-controlled intravenous analgesia(PCIA),the main ingredients of which are opioids,is commonly used to relieve such pain.This analgesic option is associated with increased incidences of postoperative nausea and vomiting(PONV)and other opioid-related complications.Intercostal nerve block has been reported to effectively reduce this pain.Clinically,surgeons inject local anesthetics into muscles after costal cartilage harvest,at which time the anatomical structure of intercostal nerves has already been destroyed by costal cartilage harvest,therefore,intercostal nerve block is not so precise.This practice is called incision infiltration(Ⅱ).The paravertebral block(PVB)and the thoracic epidural block can block the intercostal nerves and are effective for relieving this pain.However,PVB and thoracic epidural blocks are respectively limited by a high incidence of pneumothorax and spinal cord injury risks.Both approaches require the patient to be in a lateral position while the technician should have a high technical know-how.Ultrasound-guided interfascial plane block is a new nerve block approach for delivering local anesthetics to target nerves.This procedure simultaneously blocks multiple nerves without multiple injections,and exerts satisfactory analgesic outcomes with high security.Serratus Anterior Plane Block(SAPB),a fascia plane block approach,was first introduced in 2013 by Blanco et al.This approach has few complications,is simple to perform,does not require the injection of local anesthetics near intercostal nerves and only requires the injection of local anesthetics into the fascia plane where the intercostal nerves cross.The diffusion of local anesthetics in the fascia plane leads to blockage of intercostal nerves.Given that the injection site is far from the surgical field,the impact of anatomical changes can also be overcome.In addition,S APB simultaneously blocks multiple intercostal nerves without multiple injections.Local anesthetics can also be stored in the fascial plane for continuous action,thus,the analgesic duration is significantly longer than that of Ⅱ.Currently,SAPB is widely used for analgesia in patients who undergo thoracic surgery,breast surgery,and rib fracture surgery or other similar procedures.The suitability of SAPB for relieving pain after autologous costal cartilage harvest has not been reported.In this study,we aimed at investigating the significance of SAPB for chest analgesia after autologous costal cartilage harvest in patients undergoing plastic surgeries.Our findings will form a basis for development of better analgesic methods for these patients,and provide a reference for future clinical studies.Objectives:1.To determine the analgesic efficacy and safety of ultrasound-guided SAPB in children undergoing ear reconstruction.2.To investigate the effects of dexmedetomidine(Dex)as an adjuvant combined with ropivacaine for SAPB on quality of recovery and analgesia in children undergoing ear reconstruction.3.To compare the analgesic effects of SAPB combined with improved Parasternal Block(PSB)and SAPB alone in patients undergoing rhinoplasty with autologous costal cartilage.Methods and Results:Part 1:Comparisons of Analgesic Effects between Serratus Anterior Plane Block and Local Anesthetic Infiltration in Children Undergoing Ear ReconstructionMethods:This study was approved by the Institutional Ethical Review Board(ethics number ZX202244),and was registered in the Chinese Clinical Trial Registry website(ChiCTR2200057616).Based on pre-experimental results,PASS 15.0 was used to calculate the minimum sample size,which was 40.A total of 63 children who underwent external ear reconstruction were enrolled in this study.Among them,3 children were excluded because they did not meet the inclusion criteria.The remaining sixty children were randomized into two groups:the SAPB group(SAPB with 3 mg/kg 0.25%ropivacaine)or the Ⅱ group(Ⅱ with 3 mg/kg 0.75%ropivacaine).Twenty nine children from each group completed the study.All children received patient-controlled intravenous analgesia(PCIA).The primary outcomes were numerical rating scale(NRS)scores of chest pain while rest and coughing at 1,6,12,24,and 48 h after surgery.The secondary outcomes were sufentanil use within 24 h,analgesia duration,oral rescue analgesic usage,first time out of bed,and incidences of treatment-related adverse effects.The independent sample t-test or repeated measures analysis of variance(ANOVA)or Mann-Whiney U test were used to compare continuous variables while categorical variables were compared using the chi-square or Fisher’s exact tests.Results:At 6 h and 12 h after surgery,the SAPB group had significantly low rest and coughing NRS scores(all P<0.001),but the scores were similar at other time points(all P>0.05).The SAPB group used significantly less sufentanil within 24 h,but had a significantly longer analgesia duration(both P<0.001).The Ⅱ group used more oral rescue analgesics within 48 h,had a longer time until first time out of bed,and had more opioid-related side effects(all P<0.01).There were no SAPB-related complications.Part 2:Comparisons of Quality of Recovery between Dexmedetomidine Combined with Ropivacaine and Ropivacaine Alone for Serratus Anterior Plane Block in Children Undergoing Ear ReconstructionMethods:This study was approved by the Institutional Ethical Review Board(ethics number ZX2022129),and was registered in the Chinese Clinical Trial Registry website(ChiCTR2200060089).Based on pre-experimental results,PASS 15.0 was used to calculate the minimum sample size,which was 72.A total of 87 children who underwent external ear reconstruction were enrolled in this study.Among them,3 children were excluded because they did not meet the inclusion criteria.The remaining 84 patients were randomized into the R(Ropivacaine alone for SAPB)or DR(Dex combined with ropivacaine for SAPB)groups,with 42 cases in each group.The primary outcomes were Quality of Recovery Scores(QoR-15)of the day before surgery,24 h and 48 h after surgery while the secondary outcomes were rest and coughing NRS scores of chest pain at postoperative 2 h,4 h,8 h,12 h,24 h,36 h and 48 h,analgesia duration,intraoperative anesthetic consumption,PCIA pump consumption within the first 24 h,oral rescue analgesic usage,first time out of bed,opioid-and SAPB-related side effects.The independent sample t-test or Mann-Whiney U test were used to compare continuous variables while categorical variables were compared using the chi-square or correction chi-square or Fisher’s exact tests.Results:Two cases in both groups were lost to follow-up,with 40 cases in each group completing the study.The QoR-15 scores of the day before surgery between the groups were comparable(134.63±7.45 vs 135.60±8.09,P>0.05).The QoR-15 scores at 24 and 48 h after surgery in the DR group were significantly higher than those in the R group(126.35±9.81 vs 115.53±8.58 and 131.78±8.67 vs 122.80±8.59,all P<0.001).The NRS scores of the chest while at rest and coughing in the DR Group at postoperative 2 h,4 h,8 h,12 h and 24 h were all significantly lower than those in the R group(all P<0.05).but were comparable at 36 h and 48 h after surgery(all P>0.05).The analgesia duration in the DR group was significantly longer,but the first time out of bed was significantly shorter than that in the R group(all P<0.001).Intraoperative anesthetic consumption,PCIA pump consumption within the first 24 h and oral rescue analgesic usage in the DR group were all significantly lower than those in the R group(all P<0.05).The incidence of opioid-related side effects in the DR Group was significantly lower than that in the R group(P<0.05).No SAPB-related complications occurred in the two groups.Part 3:Comparisons of Analgesic Effects between Serratus Anterior Plane Block Combined with Improved Parasternal Block and Serratus Anterior Plane Block Alone in Patients Undergoing Rhinoplasty with Autogenous Costal CartilageMethods:This study was approved by the Institutional Ethical Review Board(ethics number ZX202210),and was registered in the Chinese Clinical Trial Registry website(ChiCTR2200058211).Based on pre-experimental results,PASS 15.0 was used to calculate the minimum sample size,which was 56.Sixty eight patients,aged 18 to 60,who received rhinoplasty with autogenous costal cartilage were enrolled in this study.Six patients were excluded because they did not meet the inclusion criteria.The remaining 62 patients were randomized into the SAPB+PSB or SAPB groups,with 31 cases in each group.After anesthesia tracheal intubation,patients in the SAPB+PSB group were treated with SAPB combined with improved PSB(0.375%ropivacaine,25mL+15mL),patients in the SAPB group were treated with SAPB(0.375%ropivacaine,25mL).The analyzed parameters for both groups included the rest and coughing NRS pain scores of the chest and NRS pain scores of the nose at postoperative 2,4,8,12,24,and 48 h,the consumptions of propofol and remifentanil,PCIA pump consumption within the first 24 h,oral rescue analgesic usage,side effect incidence and patient satisfaction among others.Results:One case from both groups was lost to follow-up,therefore,thirty patients in each group completed the study.The rest and coughing NRS scores of the chest and NRS scores of the nose at postoperative 2,4,8,12 h were lower in the SAPB+PSB group,compared to the SAPB group(all P<0.05).These scores were comparable between the two groups at postoperative 24 and 48 h(all P>0.05).Relative to the SAPB group,consumptions of propofol and remifentanil as well as PCIA pump consumption within the first 24 h were all reduced(all P<0.001),the oral rescue analgesic usage was significantly lower(P<0.05),the PONV incidence was lower(P<0.05),while patient satisfaction was markedly higher(P<0.001)in the SAPB+PSB group.Conclusions:1.Ultrasound-guided SAPB can provide safe and effective chest pain relief for children undergoing ear reconstruction after costal cartilage harvest.2.As an adjuvant,Dex,combined with ropivacaine in SAPB improved the quality of recovery in children undergoing ear reconstruction.It is a safe and effective intervention.3.Ultrasound-guided SAPB,combined with improved PSB,is superior to SAPB alone in relieving pain after costal cartilage harvest in rhinoplasty. |
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