Comparison Of The Perioperative Analgesia And Security Between Ultrasound-guided Transversus Thoracic Muscle Plane-pectoral Nerves Block(TTP-PECS) And Thoracic Paravertebral Block(TPVB) In Patients Undergoing Modified Radical Mastectomy

Objective:In this study,we explored to compare the perioperative analgesia,security,and inflammatory response,as well as early postoperative recovery quality between ultrasound-guided transversus thoracic muscle plane-pectoral nerves block and thoracic paravertebral block in patients undergoing modified radical mastectomy,and provide reference for rational use of anesthesia and postoperative multimodal analgesia in these peoples.Method:Seventy eight patients of female,ASA physical status I-II,aged 28-74 yr,with body mass index of 17-29.9 kg/m²,scheduled for elective modified radical mastectomy,were randomly divided into ultrasound-guided TTP-PECS（TP）group and ultrasound-guided TPVB（T）group.The patients of Group P received a ultrasound-guided TTP-PECS with ropivacaine 0.5%30ml,whereas Group T received a ultrasound-guided TPVB using same volume of ropivacaine 0.5%before induction of anaesthesia.30 min after block,the range of sensory block was assessed.General anesthesia was induced using fentanyl 2μg/kg,propofol 3 mg/kg,and atracurium cis-benzene sulfonate 0.2 mg/kg.Sevoflurane was continuously infused to maintain anesthesia,and fentanyl and atracurium cis-benzene sulfonate was injected as a supplemental analgesia if necessary.Then patient-controlled fentanyl analgesia（PCIA）was performed for postoperative pain relief.The PCIA pump was loaded with16μg/kg of fentanyl and was set to deliver on demand bolus doses of 2 ml with a 15minutes lockout interval.Flurbiprofen was injected intravenously as a rescue analgesic when the VAS score more than 3 at quiescence or more than 5 at motion.The cumulative consumption of PCA fentanyl at 0～2 h、2～6 h、6～12 h、12～24 h postoperation were recorded.VAS scores for rest and during activity were evaluated at 2 h,6 h,12 h,and 24 h postoperation.Also,the rate of satisfaction of VAS scores for rest and during activity were compared.Analgesia duration,the effective pressing times of PCIA pump,and case as well as dose of remedial analgesia of flurbiprofen axetil were recorded.Intraoperative fentanyl consumption,PACU fentanyl consumption,and PCA fentanyl consumption 24 h postoperation were also recorded.The AUC of VAS scores for rest and during activity at 0～2 h、2～6 h、6～12 h、12～24h postoperation were recorded too.Time-consuming and area-blocking were recored.Adverse reactions of each nerve block such as pneumothorax,local anesthetic toxicity,nerve injury,hematoma and infection were compared.Meanwhile,the perioperative usage of vasoactive agents（oxyepinephrine,ephedrine,atropine）were recorded.The postoperative adverse reactions on the day after surgery（postoperative nausea and vomiting,urinary retention,pruritus,hypotension,bradycardia and respiratory depression）were also recorded.Blood samples were collected for examinations of pain related inflammatory mediators（PGE₂,NPY,andβ-endorphin）by radioimmunoassay,and proinflammatory cytokines（IL-6,MCP-1,and TNF-α）by enzyme-linked immunoabsorbent assay（ELISA）at preoperative,immediate postoperative,12 h and 24 h postoperation.The Qo R-40 was repeated on the day before surgery and on the day after surgery.The relative indexes of postoperative outcomes such as awakening time,length of stay in PACU,postoperative first feeding time,first time of exhaust time,postoperative first out-of-bed,the score of DSIS,the transfer rate of ICU,mortality and postoperative hospital stay were also compared between the two groups.Results:All the patients in group TP were tried successfully,while one patient in group T failed and excluded.The cumulative consumption of PCIA fentanyl in Group TP was significantly lower at 6～12 h and 12～24 h postoperation（P<0.01）.Not only at rest but also during activity,the patients in Group TP showed a lower pain degree at 12 h postoperation（P<0.01）.And the rate of satisfaction of VAS scores for rest and during activity were increased 12 h postoperation in Group TP（P<0.05）.Compared with group T,the duration of block analgesia was longer,the effective pressing times and the case as well as dose of postoperative remedial analgesia of flurbiprofen were reduced in Group TP（P<0.05）.The PCIA fentanyl consumption24 h postoperation were reduced significantly（P<0.01）.The AUC of VAS scores for rest and during activity were significantly lower at 6～12 h and 12～24 h postoperation（P<0.01）.Blockage-related complications were not occurred in the two groups.The blocking area was T_2⁶and axillary region in group TP and T_2⁷in group T,only 18cases reached axillary region in group T.Axillary region dermatomal spread was significantly increased but T₆and T₇dermatomal spread decreased in group TP（P<0.05）.Compared with group T,the nerve block time-consuming was shorter,the usage of vasoactive agents were reduced,and the incidence of postoperative hypotension and bradycardia were decreased in group TP（P<0.05）.The dynamic changes of serum pain related inflammatory mediators of NPY,PGE2,andβ-endorphin,as well as proinflammatory cytokines of IL-6,MCP-1and TNF-αwere changed significantly over time,increased overall in 24 h postoperation（P<0.05）.Compared with group T,the levels of PGE₂,NPY,andβ-endorphins,as well as those of IL-6,MCP-1,and TNF-a were significantly lower in Group TP at 12h postoperation（P<0.05）.There was no significant difference of the total and each scores between the two groups on the day before surgery（P>0.05）.Compared with group T,the scores of emotional state,patient support,and pain were higher in the Group TP on the day after surgery,and the total scores was also higher（P<0.05）.Scores of 12 h daily sleep interference scale and time of first ambulation were significantly reduced in the TP group（P<0.05）.Conclusion:Compared with thoracic paravertebral block,ultrasound-guided transversus thoracic muscle plane-pectoral nerves block can provide better postoperative analgesia and perioperative security,better inhibit postoperative inflammatory reaction and promote postoperative recovery in patients underdoing modified radical mastectomy.