Effects of rhomboid intercostal nerve, serratus anterior plane, and paravertebral block on the quality of recovery after breast cancer surgery: A randomized controlled clinical trial

doi:10.21203/rs.3.rs-4905136/v1

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Effects of rhomboid intercostal nerve, serratus anterior plane, and paravertebral block on the quality of recovery after breast cancer surgery: A randomized controlled clinical trial

https://doi.org/10.21203/rs.3.rs-4905136/v1

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Nerve blocks are among the most important methods of postoperative analgesia in breast cancer surgery. We used a randomized controlled clinical trial to compare the effects of rhomboid intercostal nerve block (RIB), serratus anterior plane block (SAPB), and paravertebral block (PVB) on the postoperative quality of recovery and postoperative analgesia in modified radical mastectomy. A total of 132 breast cancer surgery patients were randomized 1:1:1 into three groups. 0.375% ropivacaine 20 ml for ultrasound-guided RIB (RIB group, n = 44), SAPB (SAPB group, n = 44), and PVB (PVB group, n = 44). The primary outcome was the QoR-40 score at 24 hours after surgery. The postoperative 24-hour QoR-40 scores of the RIB (median: 186; interquartile range: 177, 190.5) and PVB (median: 186.5; interquartile range: 176.25, 190.5) groups were higher than those of the SAPB group (median: 168; interquartile range: 163.25, 172) (P < 0.001). In addition, the intraoperative sufentanil consumption (P < 0.001), number of intraoperative sufentanil users (P < 0.001), and postintubation NRS scores (P = 0.01) of the RIB and PVB groups were significantly lower than those of the SAPB group, but there was no statistically significant difference between the RIB and PVB groups.

Compared with SAPB, RIB and PVB improve the quality of postoperative recovery, reduce intraoperative opioid use, and improve early postoperative analgesia. RIB may be one of the best alternatives to PVB as a facial plane block.

Health sciences/Diseases/Cancer/Breast cancer

Health sciences/Signs and symptoms/Pain

Rhomboid intercostal nerve

Serratus anterior plane block

Paravertebral block

Quality of recovery

Postoperative pain

Breast cancer surgery

Breast cancer is the most common malignant tumor in women worldwide.[1] Surgical resection remains the primary treatment modality[2]. Approximately half of all surgical patients experience moderate to severe acute pain after surgery[3].

Regional anesthetic techniques are an important part of multimodal analgesia as they have been demonstrated to reduce opioid consumption and numerical rating scale (NRS) in breast cancer surgery[4–6]. Furthermore, evidence from the 40-item Quality of Recovery Questionnaire (QoR-40), a validated patient-oriented multidimensional assessment tool, indicates that regional analgesia may promote recovery following surgery.[7, 8] Paravertebral block (PVB) is the most used regional analgesia in breast cancer surgery[9–12]. However, PVB can also cause adverse effects such as hypotension, pneumothorax, hemorrhage, and respiratory depression[13, 14]. Furthermore, PVB is demanding for the operator and difficult to master[15, 16]. With the increasing popularity and development of ultrasound, the safety and efficacy of fascial plane blocks have improved. In recent years, several planes of fascial plane blocks have been found in breast cancer surgery, including pectoral nerve block (PECS), erector spine plane block (ESPB), serratus anterior plane block (SAPB), and rhomboid intercostal nerve block (RIB) [4, 9, 17, 18]. However, it is unclear which technique can provide more effective analgesia in breast cancer surgery.

Our previous network meta-analysis revealed that RIB and SAPB may be the optimal nerve block modalities, but this conclusion was based on indirect comparisons and statistical probabilities and was not confirmed by direct clinical trials[4]. We hypothesized that RIB and SPAB would provide better analgesia than PVB in breast cancer surgery. Therefore, we conducted this prospective randomized study to assess the impact of the use of RIB, SAPB, and PVB in modified radical mastectomy on postoperative recovery and analgesic effects.

Study design and participants

The prospective single-center, parallel-group, single-blind randomized, and controlled trials were approved on 22 November 2023 by the Ethics Committee of the Chongqing University Cancer Hospital (CZLS2023325-A). The trial was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants before enrollment. The trial was registered with ClinicalTrials.gov (ChiCTR2300079196). The reporting complies with the most recent version of the Consolidated Standards of Reporting Trials (CONSORT).

Following the acquisition of written informed consent from the patients, the women with physical statuses Ⅰ to Ⅲ as determined by the American Society of Anesthesiologists (ASA), aged 18 years or older, and scheduled for elective modified radical mastectomy were included in the study. The surgical procedures performed included radical mastectomy with sentinel lymph node biopsy, radical mastectomy, and modified radical mastectomy with axillary lymph node dissection. The following criteria were used to exclude patients from the study: unsuitability for regional anesthesia when the anesthetist assessed the patient in the pre-anesthetic; coagulation disorders, infections, or a history of allergy to local anesthetic medications; speech disorders; a body mass index greater than 35 kg m^− 2; and an age of less than 18 years or more than 85 years. Subjects who met the eligibility criteria were randomly assigned to receive RIB, SAPB, or PVB at a ratio of 1:1:1 on the day of surgery. Randomization was performed via SPSS-generated random numbers. Concealment was achieved using sealed opaque envelopes. All patients, surgeons, and outcome assessors were unaware of the group assignment, whereas the anesthetist performing the nerve block was aware of the group assignment.

Intervention

RIB group: The patient was positioned in the lateral position, with the surgical side facing upward and the upper limb of the surgical side extending downward naturally. The high-frequency line array probe (8–14 MHz) is located on the lower edge of the scapula on the operative side of the medial T5–6 level. The probe marking point indicates the cephalic side. The ultrasound image revealed, in turn, the trapezius, rhomboid, intercostal muscles, ribs, pleura, and other structures. The puncture needle is inserted from the caudal end to the cephalic end. The cephalic end of the piercing is visible through the trapezius, rhomboid, and rhomboid muscles and the intercostal muscles between the gaps. After the injection of 20 ml of 0.375% ropivacaine, the local anesthetic diffused in a shuttle-shaped manner into the gap. Following the completion of the block, the skin was observed for twenty minutes to determine whether there was any loss of sensation. Ultrasound images of the RIB are shown in the Appendix.

In the SAPB group, the patient was placed in the supine position. A high-frequency line array probe (8–14 MHz) was placed in the sagittal direction at the level of the midclavicular line on the operative side. The 2nd rib at the axillary artery and vein was identified, and the probe was moved downward and outward to count the ribs until they reached the level of the 5th rib in the midaxillary line. The superficial posterior latissimus dorsi muscle and the caudal deep side of the anterior serratus should be identified ultrasonographically, after which the nerve block needle should be advanced from the anterosuperior to posterior-inferior direction until it is between the latissimus dorsi muscle and the anterior serratus muscle. Following the withdrawal of no blood or gas, 20 ml of 0.375% ropivacaine was injected between the latissimus dorsi and the serratus anterior muscle. The local anesthetic was observed to diffuse in the interstices in the shape of a shuttle. Following the completion of the block, the skin was observed for twenty minutes to determine whether there was any loss of sensation.

In the PVB group: All patients were positioned in the lateral decubitus position with the operative side up and the upper extremity of the operative side naturally extending downward. The seventh rib is located at the angle of the scapula, and a high-frequency line array probe (8–14 MHz) is selected to locate and mark the third rib and T3 spinous process at the level of the seventh rib. The probe was placed on the marked spinous processes with the long axis of the probe parallel to the spine, and the probe was moved along the alignment of the ribs to the affected side to view the image of the stacked transverse processes. The nerve block needle was inserted in the lateral to the medial intermediate plane, advancing the needle medially to the transverse processes. After the bloodless and airless injection of 20 ml of 0.375% ropivacaine is withdrawn, the puncture needle should be placed deep in the transverse process of the highly echogenic bulge, and the local anesthetic should diffuse into the interstitial space in the form of a shuttle. Following the completion of the block, the skin was observed for 20 minutes to ascertain whether any loss of sensation had occurred. Ultrasound images of the PVB are shown in the Appendix. The procedure involved the administration of nerve blocks by two anesthetists with extensive experience in this field (Jiali Yu and Yi Qi).

All patients received a dose of midazolam (2 mg) and sufentanil (5 µg) via standard monitoring and oxygenation via a facemask before the nerve block. Standard monitoring methods include electrocardiography, peripheral pulse oximetry, noninvasive blood pressure (BP) measurement, temperature measurement, and the bispectral index (BIS). Anesthesia was induced following successful nerve block puncture. Following the successful administration of a nerve block, all patients were preoxygenated with 100% oxygen for three minutes before induction. General anesthesia was induced using 2 mg kg^− 1 propofol and 0.5 µkg^− 1 sufentanil, with 0.6 mg kg^− 1 rocuronium administered to promote muscle relaxation. The anesthesia was maintained with an oxygen/air mixture (FiO2 = 0.5, fresh gas flow rate 3/L min^− 1) and sevoflurane [1.0 to 1.5 minimum alveolar concentration (MAC)] to a BIS of 40 to 60. An endotracheal tube with a 7.0-mm internal diameter and a cuffed endotracheal tube were used for tracheal intubation. The initial respiratory rate was 12 breaths per minute, the positive end-expiratory pressure was 5 cmH₂O, and the tidal volume was 6 ml per ideal body weight. The respiratory rate was adjusted to maintain end-tracheal carbon dioxide (ETCO2) levels between 35 and 45 mmHg. Vasoactive drugs were administered intraoperatively based on alterations in blood pressure and heart rate. All patients received a preoperative dose of dexamethasone (4 mg) and ondansetron (0.1 mg/kg) to prevent postoperative nausea and vomiting (PONV). When the patient's depth of anesthesia was adequate and the heart rate and blood pressure were 20% above normal, 5 µg of sufentanil was given. Tramadol 50 mg or 100 mg was given to the patient after extubation when the postoperative NRS score was greater than 4. If tramadol was not controlled, morphine (0.1mg kg^− 1) was given.

Outcomes

The primary outcomes included postoperative 24-hour NRS scores (resting and movement), postoperative 24 morphine consumption, and postoperative quality of recovery. The primary outcome measure was the quality of recovery, which was evaluated at 24 hours postoperatively via the Chinese version of the QoR-40. The QoR-40 is composed of two parts: the QoR-40A and the QoR-40B. The questionnaire comprises 40 items that assess five dimensions of recovery: emotional state (9 items), physical comfort (12 items), psychological support (7 items), physical independence (5 items), and pain (7 items).

The secondary outcomes included post-extubation, postoperative 2-hour, and postoperative 48-hour NRS scores (resting and movement) and intraoperative sufentanil consumption (excluding sufentanil given before intubation), number of intraoperative users of sufentanil and postoperative 24-hour tramadol, incidence of intraoperative adverse events such as hypotension, arrhythmia, and pneumothorax, PONV, and average length of stay.

Statistical analysis

Our sample size was calculated for two-tailed testing. A pre-experimental analysis revealed that the postoperative 24-hour QoR-40 scores for RIB, PVB, and SAPB were 178.9 ± 5.01, 175.11 ± 4.17, and 174.8 ± 6.61, respectively. One-way analysis of variance allowing unequal variances (a = 0.05 and β = 0.1) in the PASS (21.03, USA) was used for the analysis. A sample size of 37 participants per group was deemed necessary. In consideration of a 20% dropout rate, 44 participants were required per group[19].

Statistical analyses were conducted via SPSS 25.0 software (SPSS, Chicago, IL, USA). The distribution of continuous data was initially evaluated via the Shapiro‒Wilk test and Q‒Q plots. Data with a normal distribution were analyzed via one-way ANOVA or repeated-measures ANOVA, and the results are expressed as the means ± standard deviations (SDs). Data with a nonnormal distribution were analyzed via the Kruskal‒Wallis test, and the results are expressed as medians and interquartile ranges(IQR). Comparisons between groups were made via Kruskal‒Wallis one-way ANOVA. Categorical variables were analyzed via the χ² test or Fisher's exact test, with the results described as numbers (%). Post hoc analyses were performed via the Bonferroni correction. The P value for significant differences was adjusted to 0.05.

Patient characteristics

The clinical trial was conducted between March 2016 and June 2017 at Chongqing University Cancer Hospital. Figure 1 presents a summary of the study flow according to the Consolidated Standards of Reporting Trials (CONSORT) statement. A total of 143 participants were first evaluated for eligibility to participate in the study. Seven did not meet the inclusion criteria, and three declined to participate, leaving 132 individuals available for enrollment (Fig. 1). Baseline personal and clinical characteristics and perioperative global QoR-40 scores were comparable between the groups (Table 1).

Table 1

Characteristics of the patients at baseline
Characteristic	RIB group	SPAB group	PVB group	F/χ2values	P values
Age, yr	55.61 ± 7.22	55.62 ± 8.85	55.63 ± 7.16	0.87	0.42
Weight, kg	60.44 ± 7.61	57.99 + 9.67	59.26 ± 6.91	1.44	0.24
Height, cm	154.59 ± 5.05	154.60 ± 6.3	154.61 ± 5.69	0.995	0.37
BMI, Kg/m2	25.27 + 3.06	24.77 + 3.06	24.86 + 2.82	0.35	0.7
ASA physical status				1.53	0.57
Ⅱ	34(77.3%)	29(65.9%)	30(68.2%)	N	N
Ⅲ	10(22.7%)	15(34.1%)	14(31.8)	N	N
Chemotherapy	14(31.8%)	17(38.6%)	11(25%)	1.89	0.41
Type of surgery				1.35	0.87
Mastectomy	7(38.9%)	5(27.8%)	6(33.3%)	N	N
Mastectomy with sentinel lymph node biopsy	13(27.7%)	18(38.3%)	16(34%)	N	N
Mastectomy with axillary lymph node dissection	24(35.8%)	21(31.3%)	22(32.8%)	N	N
Operation time, min	129.1 ± 23.7	134.8 ± 31.1	135.8 ± 28.8	0.73	0.49
Intraoperative intravenous fluid, ml	1300(1200,1700)	1300(1200,1600)	1300(1200,1600)	0.87	0.65
Intraoperative urine Output, ml	200(150,250)	200(150,300)	300(200,337.5)	7.36	0.03
Intraoperative blood loss, ml	80(50,80)	80(80,80)	80(80,80)	2.53	0.28
Intraoperative sevoflurane, ml	29.68 ± 7	28.40 ± 8.34	28.32 ± 5.39	0.52	0.59
Intraoperative propofol, mg	44.68 ± 8.71	45.86 ± 11.39	43.14 ± 12.63	0.677	0.51
Note: Data are presented as mean ± SD, median (interquartile range), or number (percentage); N: none

QoR-40 scores

The RIB, SAPB and RIB groups had statistically significant global QoR-40 scores at 24 hours postoperatively. A comparison of each group revealed that the global QoR-40 scores for the RIB group (median: 186; IQR: 177, 190.5) and the PVB group (median: 186.5; IQR: 176.25, 190.5) were significantly higher than those for the SAPB group (median: 168; IQR: 163.25, 172) (P < 0.001). There was no statistically significant difference in global QoR-40 scores between the RIB and SAPB groups (P = 0.54). Among the QoR-40 scores, the comfort and pain scores were significantly different across the groups. A comparison of the comfort and pain scores within each group revealed that the RIB and PVB groups had significantly higher comfort scores than did the SAPB group (P < 0.001). There was no statistically significant difference in the comfort or pain scores between the RIB and SAPB groups. There were no statistically significant differences in the other scores between the groups in terms of the postoperative 24-hour QoR-40 scores. Figure 2 shows the global QoR-40 scores at 24 hours postoperatively. The detailed scores of the QoR-40 are shown in Table 2.

Table 2

The QoR-40 and dimensions scores at postoperative 24 hours
Variables	RIB(n = 44)	SPAB (n = 44)	PVB(n = 44)	F values	P values
Part A
Comfort	17(16,18) ^a	16(15.16) ^b	17(15.25,18) ^a	13.735	0.001
Emotions	14(13,15)	13(12,14)	14(13,15)	5.836	0.054
Physical independence	24(23,24)	24(23,24)	24(23,24)	5.136	0.076
Patient support	30(28,30)	28(27.25,30)	30(28,30)	4.911	0.086
Part A total score	85(81,87)	81(79.25,83)	84.5(81.25,86)	16.349	< 0.001
Part B
Comfort	39(38,39) a	27(26,25) b	39(38,39) ^a	86.621	< 0.001
Emotions	26(25,28)	26(25,28)	26(25,28)	0.141	0.932
Patient Support	5(4,5)	5(4,5)	5(4,5)	0.186	0.911
Pain	33(29.5,34.75) ^a	28(25,32) b	32.5(28,34) ^a	16.422	< 0.001
Part B total score	102(95.5,104) ^a	86.5(83,89.75) ^b	100(94.5,105.75) ^a	69.464	< 0.001
Global total scores	186(177,190.5) ^a	168(163.25,172) ^b	186.5(176.25,190.5) ^a	60.989	< 0.001
Note: Data are presented median (interquartile range); For within-group comparisons, comparison between a and a: no statistical significance between the two groups(P < 0.05); comparison between a and b: statistical significance between the two groups(P < 0.05);

Postoperative NRS score

The RIB, SAPB, and RIB groups had statistically significant NRS scores after extubation (resting: P = 0.01; movement: P < 0.01). A comparison of each group revealed that the RIB [median: 0; IQR: 0, 0 (resting), median: 0; IQR: 0, 1 (movement)] and PVB groups [median: 0; IQR: 0, 0 (resting), median: 0; IQR: 0, 0.75 (movement)] had significantly lower post-extubation NRS scores than did the SAPB group [median: 1; IQR: 0, 1 (resting), median: 1; IQR: 1, 2 (movement)] (P < 0.01). There was no statistically significant difference in NRS scores after extubation between the RIB and SAPB groups. There was no statistically significant difference in NRS scores between the RIB, SAPB, and PVB groups at 2, 24, and 48 hours postoperatively, respectively. Figure 3 shows the postoperative NRS scores.

Intraoperative sufentanil consumption

There was a statistically significant difference in intraoperative sufentanil consumption among the RIB, SAPB, and PVB groups. A comparison of each group revealed that the intraoperative consumption of sufentanil was significantly lower in the RIB (median: 0; IQR: 0, 0) and PVB groups (median: 0; IQR: 0, 5) than in the SAPB group (median: 0; IQR: 0, 5) (P < 0.01), and there was no statistically significant difference in intraoperative sufentanil consumption between the RIB and PVB groups. Furthermore, the number of patients requiring sufentanil intraoperatively was significantly greater in the SAPB group (40.9%) than in the RIB (11.4%) and PVB groups (13.6%) (P < 0.001). There was no statistically significant difference in the number of patients requiring sufentanil intraoperatively between the RIB and PVB groups. Table 3 shows the intraoperative sufentanil consumption.

Table 3

Secondary outcomes during the study period
Outcomes	RIB group	SPAB group	PVB group	F/χ2values	P values
Intraoperative sufentanil consumption, µg	0(0,0) ^a	0(0,5) ^b	0(0,0) ^a	15.1	< 0.001
Number of intraoperative sufentanil users	5(11.4%) ^a	18(40.9%) ^b	6(13.6%) ^a	13.88	< 0.001
PACU tramadol, mg	0(0,0)	0(0,0)	0(0,0)	0.512	0.77
Postoperative 24-hour tramadol, mg	0(0,100) ¹	0(0,100) ²	0(0,0) ³	6.25	0.046
Intraoperative hypotension	20(40.6%)	21(48.8%)	24(54.5%)	0.79	0.67
Intraoperative bradycardia	14(33.3)	13(31%)	15(35.7%)	0.21	0.972
Intraoperative arrhythmia	0	1(2.3%)	2(4.5%)	2	0.368
terms of the time to extubation	5(3,5)	5(3,6)	3(2,5.75)	1.49	0.661
PONV	5(11.3%)	12(27.3%)	6(13.6%)	4.53	0.126
Hospital length of stay	14.3 ± 4.3	12.75 ± 4.97	13.14 ± 3.68	1.49	0.23
Notes: Data are presented as mean ± SD, median (interquartile range), or number (percentage). For within-group comparisons, comparison between a and a, 1 and 2 or 1 and 3: no statistical significance between the two groups(P < 0.05); comparison between a and b or 2 and 3: statistical significance between the two groups(P < 0.05); comparison between a and c: statistical significance between the two groups(P < 0.05). Multiple comparisons within groups have been adjusted for significance values by Bonferroni correction for multiple tests; PONV: postoperative nausea and vomiting.

Postoperative tramadol and morphine consumption

There was no statistically significant difference in PACU tramadol consumption among the RIB (median: 0; IQR: 0, 0), SAPB (median: 0; IQR: 0, 0), and PVB (median: 0; IQR: 0, 0) groups (P = 0.77). There was a statistically significant difference in tramadol consumption among the RIB (median: 0; IQR: 0, 100), SAPB (median: 0; IQR: 0, 100), and PVB (median: 0; IQR: 0,0) groups at 24 hours postsurgery(P = 0.046). A comparison of each group revealed that the postoperative 24 hours consumption of tramadol was significantly lower in the PVB group than in the SAPB group (P < 0.041), and there was no statistically significant difference in postoperative 24 hours tramadol consumption between the SPAB and PVB groups than in the RIB group (P = 0.334 and 1). The only one patient used morphine(5mg) at postoperative 24 hours, we did not perform statistical analyses. Table 3 shows the tramadol consumption.

Adverse events

There were no significant differences between RIB, SAPB, or PVB in the incidence of intraoperative hypotension, arrhythmia, or bradycardia. There were no significant differences among the three groups in terms of the time to extubation, PONV, or average length of stay. Table 3 shows the incidence of adverse events.

In our study, we found that postoperative 24-hour QoR-40 scores were significantly higher in the RIB and PVB groups than in the SAPB group. In addition, post-extubation NRS scores for the number of patients requiring sufentanil intraoperatively and, intraoperative sufentanil consumption were significantly lower in the RIB and PVB groups than in the SAPB group. Furthermore, there were no significant differences in the QoR-40 scores, analgesic medication consumption, or postoperative NRS scores between the RIB and PVB groups. There was no significant difference in the NRS score among the three groups at 2 h, 24 h, or 48 h after surgery. We did not find any adverse events associated with RIB, PVB, or SAPB.

The breast is innervated by the lateral and anterior cutaneous branches of the second to sixth thoracic intercostal nerve branches and several branches of the supraclavicular nerve[20, 21]. The SAPB is one of the most common interfacial blocks and is superficial and easy to perform. SAPB relieves postoperative pain and benefits patient recovery after breast surgery[7, 22, 23]. A meta-analysis by Chong et al. revealed that SAPB provides significant analgesia and reduces opioid consumption in patients undergoing breast cancer surgery. Nevertheless, the analgesic effect of SAPB is inferior to that of PVB[24]. Our study reached similar conclusions. Compared with PVB, SAPB was associated with significantly lower QoR-40 scores at 24 hours postoperatively, higher NRS scores, and increased intraoperative sufentanil consumption. SAPB is performed by blocking the lateral cutaneous branches of the intercostal nerve, which provides analgesia to the anteromedial and partial posterior thoracic wall (T2-T9) [25]. However, the anterior branch of the intercostal nerve provides innervation to the anteromedial chest wall, and it is unlikely that the SAPB adequately covers this area[26, 27]. This may result in incomplete relief of pain from the medial breast wound and cause significant pain and discomfort.

The RIB, as first described by Elsharkawy et al. in 2016[28], has been demonstrated to facilitate the spread of dye from caudad to cephalad, encompassing the T2 to T8 tissue plane and extending to the lateral branches of the intercostal nerves T3 to T8, the posterior primary rami close to the midline, and the clavipectoral fascia within the axilla[29]. Therefore, RIB can provide superior analgesia for axillary surgery. Some studies have shown that RIB improves the QoR-40 score and reduces the postoperative pain score and the consumption of opioids[30–32]. Our study revealed that RIB produced similar QoR-40 scores, postoperative pain scores, and analgesic consumption as PVB did. Jiang et al. compared the effects of RIB, SAPB, and ESPB on analgesia in breast cancer surgery and reported that the analgesic effects of RIB and ESPB were superior to those of SAPB[33]. Our study revealed that the analgesic effect of RIB was superior to that of SAPB. The RIB is in the posterior chest wall and is superficial, easily localized via ultrasound, and distant from the surgical site. Therefore, it may be an optimal alternative to PVB for an interfacial block.

Our study is the first to perform ultrasound-guided nerve blocks for preoperative comparison of the efficacy of RIB, PVB, and SAPB in providing intraoperative analgesia. A single nerve block was performed, with additional sufentanil administered based on the patient's requirements. Approximately 13% of patients who underwent RIB and PVB required additional intraoperative sufentanil, whereas 40.9% of those who underwent SAPB required additional sufentanil. Therefore, RIB and PVB have the potential to reduce the total amount of intraoperative opioids required and provide an effective analgesic strategy for opioid-free anesthesia. We found fewer patients with postoperative pain greater than 4 in all three groups, indicating that nerve blocks are effective in reducing postoperative pain. Only 1 patient required morphine 24 hours postoperatively. Therefore, PVB was associated with significantly lower tramadol consumption than SAPB was, but RIB was not significantly different from PVB or SAPB at 24 hours postoperatively. We did not use PCA for postoperative analgesia, and postoperative tramadol consumption may be subject to patient and doctor intervention. A single nerve block does not provide continuous analgesia and may result in a burst of pain. Consequently, there was no significant difference in pain scores among the three groups after 2 hours. There were differences in the QoR-40 scores among the three groups, which were due mainly to differences in patient comfort and pain scores 24 hours after surgery. We did not find any nerve block-related complications, indicating that ultrasound-mediated RIB, SAPB, and PVB are safe and effective nerve blocks.

Our study had several limitations: First, our study revealed statistically significant differences in only the QoR-40 scores and analgesic effects among the three groups but did not reveal clinical differences. Second, our study used nerve blocks selected based on a previous network analysis and did not compare the analgesic effects of the other nerve blocks with those of the RIB. Third, postoperative tramadol consumption may be subject to human error. Fourth, we observed only QoR-40 scores at 24 hours postoperatively and did not observe long-term QoR-40 scores or the incidence of chronic pain. Fifth, we used the Chinese version of the QoR-40, which may have impacted the results.

In the current study, RIB and PVB were superior to SAPB in terms of the quality of recovery and perioperative analgesia in patients undergoing breast surgery. In addition, RIB and PVB significantly reduced NRS scores after extubation. There was no significant difference between RIB and PVB in terms of the quality of recovery and analgesia indicating that RIB may be an optimal alternative nerve block to PVB.

Disclosure

No potential conflict of interest relevant to this article was reported.

Funding

This work was supported by Technology innovation and application development project in Chongqing Shapingba District (No. 2023114), the Key R & D project of Chongqing Science and Technology Bureau (No. cstc2020jscx‑dxwtBX0010) and the Key R & D project of the Ministry of Science and Technology of China (No: 2018YFC0116704).

Author Contribution

JL Yu: Data curation, Visualization, Investigation, Writing – original draft. Y Qi: Data curation, Methodology, Formal analysis, Software, Writing – original draft. D Wang: Validation, Methodology, Formal analysis. Q Chen: Software, Validation, writing-original draft. R An: Conceptualization, Funding acquisition, Methodology, Writing-review& editing. HL Liu: Conceptualization, Methodology, Supervision, Writing-review& editing. All authors reviewed the manuscript.

Data Availability

To original contributions presented in the study are included in the article. Further inquiries can be directed to the corresponding author.

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No competing interests reported.

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Effects of rhomboid intercostal nerve, serratus anterior plane, and paravertebral block on the quality of recovery after breast cancer surgery: A randomized controlled clinical trial

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Abstract

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Introduction

Methods

Study design and participants

Intervention

Outcomes

Statistical analysis

Results

Patient characteristics

QoR-40 scores

Postoperative NRS score

Intraoperative sufentanil consumption

Postoperative tramadol and morphine consumption

Adverse events

Discussion

Conclusion

Declarations

Disclosure

Funding

Author Contribution

Data Availability

References

Additional Declarations

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