Journal of Clinical Anesthesia 45 (2018) 12–17

Contents lists available at ScienceDirect

Journal of Clinical Anesthesia

Original Contribution

Pectoral nerve blocks to improve analgesia after breast cancer surgery: A

prospective, randomized and controlled trial
Neethu M a, Ravinder Kumar Pandey a,⁎, Ankur Sharma b,1, Vanlalnghaka Darlong a, Jyotsna Punj a, Renu Sinha a,
Preet Mohinder Singh a, Nandini Hamshi a, Rakesh Garg a, Chandralekha Chandralekha a, Anurag Srivastava c,2
a
Dept. of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India
b
Dept. of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
c
Department of Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India

a r t i c l e i n f o a b s t r a c t

Article history: Study objective: To evaluate the analgesic efficacy of ultrasound guided combined pectoral nerve blocks I and II in
Received 28 August 2017 patients scheduled for surgery for breast cancer.
Received in revised form 14 November 2017 Design: Prospective, randomized, control trial.
Accepted 20 November 2017 Setting: Operating rooms in a tertiary care hospital of Northern India.
Available online xxxx
Patients: Sixty American Society of Anesthesiologists status I to II adult women, aged 18–70 years were enrolled
in this study.
Keywords:
Pectoral nerve blocks
Interventions: Patients were randomized into two groups (30 patients in each group), PECS (P) group and control
Analgesia (C) group. In group P, patients received both general anesthesia and ultrasound guided combined pectoral nerve
Ultrasound blocks (PECS I and II). In group C, patients received only general anesthesia.
Breast surgery Measurements: We noted pain intensity at rest and during abduction of the ipsilateral upper limb, incidence of
postoperative nausea and vomiting; patient's satisfaction with postoperative analgesia and maximal painless ab-
duction at different time intervals in both groups.
Main results: There was significant decrease in the total amount of fentanyl requirement in the in P group
{(140.66 ± 31.80 μg) and (438 ± 71.74 μg)} in comparison to C group {(218.33 ± 23.93 μg) and (609 ± 53.00
μg)} during intraoperative and post-operative period upto 24 h respectively. The time to first analgesic require-
ment was also more in P group (44.33 ± 17.65 min) in comparison to C group (10.36 ± 4.97 min) during post-
operative period. There was less limitation of shoulder movement (pain free mobilization) on the operative site
at 4 h and 5 h after surgery in P group in comparison to C group. However there was no difference in the incidence
of post-operative nausea and vomiting (22 out of 30 patients in group P and 20 out of 30 patients in group C) but
patients in group P had a better satisfaction score with postoperative analgesia than C group having a p value of
b 0.001(Score 1; 5 VS 20; Score 2; 12 VS 9; Score 3; 13 VS 1).
Conclusions: Ultrasound guided combined pectoral nerve blocks are an effective modality of analgesia for patients
undergoing breast surgeries during perioperative period.
Clinical trial registration: CTRI/2015/12/006457
© 2017 Elsevier Inc. All rights reserved.

1. Introduction to actively participate in postoperative rehabilitation, which may im-

Patients undergoing breast surgeries experience high grade post-
operative pain, thus increasing patient morbidity [1–3]. Patients in
whom pain is controlled in the early postoperative period may be able
⁎ Corresponding author at: Department of Anaesthesiology, Pain Medicine and Critical
Care, Room no. 5013, 5th floor Teaching Block, All India Institute of Medical Sciences,
Ansari Nagar, NewDelhi 110029, India.
E-mail address: ravindrapandey1972@gmail.com (R.K. Pandey).
1
Department of Anaesthesiology, All India Institute of Medical Sciences, Jodhpur, India
2
Department of Surgery, All India Institute of Medical Sciences, New Delhi, India
prove short- and long-term recovery after surgery [4]. Thus, control of
post-operative pain is an essential requirement in these surgeries [5].
First characterized in 2011 and 2012 respectively, the pectoral nerve
block I (PECS I) and pectoral nerve block II (PECS II) provide analgesia
for breast surgeries with very little adverse effects. PECS I blocks the me-
dial and lateral pectoral nerves which derive from the brachial plexus
and the PECS II block anesthetizes the lateral branch of intercostal
nerve [6]. It is important to emphasize the advantages of pectoral
nerve block as there is no sympathetic block, and it is a simple and
fast-acting block. Other advantages include superficial block, performed
with supine patient, covers the majority of the breast/chest wall [6–8].

https://doi.org/10.1016/j.jclinane.2017.11.027
0952-8180/© 2017 Elsevier Inc. All rights reserved.
 N. M et al. / Journal of Clinical Anesthesia 45 (2018) 12–17 13

Fig. 1. Consort diagram.

There is limited literature of combined pectoral nerve blocks on patients We hypothesize that pectoral nerve blocks with general anesthesia
undergoing breast cancer surgeries, therefore we need more confirma- provide superior analgesia with less opioid consumption during intra-
tory studies [9]. operative and post-operative period compared to opioid mediated

Fig. 2. (a) Anatomical basis of pectoral nerves block (b) ultra sound probe position (c) ultra sonographic anatomy and identification of 2ndRib (AV-Axillary Vein, AA-Axillary Artery)
(d) Pectoral nerve block I and II (PMM – Pectoral Major Muscle, Pmm – Pectoral minor muscle, LA - Local anesthetic).
14 N. M et al. / Journal of Clinical Anesthesia 45 (2018) 12–17

Table 1 surgery. Assuming a mean difference of analgesic requirement between

Comparison of demographic parameters. the 2 groups as 1.4 (95% CI: 1.31–1.49), we estimated the sample size as
Parameters Group P (n = 30) Group C (n = 30) p value 23 in each group at 99% confidence interval and 90% power [10]. Assum-
Age (years) 50.530 ± 10.44 45.66 ± 10.99 0.0841
ing a 20% attrition rate, the final sample size was taken as 30 in each
ASA ASAI 19 (63.33%) 25 (83.33%) 0.080 group.
ASA II 11 (36.67%) 5 (16.67%) Patients were randomly allocated into two groups (30 patients in
Education bMatric pass 3 (10%) 9 (30%) 0.111 each group), PECS (P) group and control (C) group on the basis of com-
Matric pass 23 (76.67%) 19 (63.33%)
puter generated random number table. In group P, patients received
Graduate 4 (13.33%) 2 (6.67%)
Professional 0 0 both general anesthesia and pectoral nerve blocks (PECS Blocks). In
Body Mass Index Under weight 0 0 0.260 group C, patients received only general anesthesia. All the three surgical
Normal 13 (43.33%) 15 (46.67%) procedures (MRM, MRM with SLNB and MRM with ALND) were evenly
weight distributed between both the groups. Sealed opaque envelopes were
Overweight 14 (46.67%) 9 (30%)
Obesity 3 (10%) 7 (23.33%)
opened by an independent observer in the operation theater and inter-
vention was decided according to the particular randomized group. All
p b 0.05 is considered significant, BMI-Body Mass Index, n = number of patients.
the 60 patients received the allocated intervention according to their
groups allotted.
All the patients received anti-aspiration prophylaxis (ranitidine
patient controlled analgesia with general anesthesia technique in pa- 150 mg per oral) on the night prior to surgery and on the day of surgery.
tients scheduled for surgery for breast cancer. During preoperative visit, visual analog scale (VAS) and patient con-
trolled analgesia (PCA) device were explained to patients.
2. Methods After transporting patients to the operating room, electrocardio-
gram, noninvasive blood pressure (NIBP) and pulse oximeter were at-
After Institutional Ethics Committee approval, the present study was tached and baseline parameters were recorded. An intravenous
registered with the Clinical Trials Registry of India (CTRI number: CTRI/ cannula (16G or 18G) was secured in hand opposite to the operative
2015/12/006457). Sixty American Society of Anesthesiologists (ASA) site. Then all patients were sedated with intravenous (IV) midazolam.
status I to II adult women, aged 18–70 years undergoing different breast General anesthesia was induced with IV fentanyl (1 μg/kg), propofol
surgeries {modified radical mastectomy (MRM), modified radical mas- and vecuronium and airway was secured using ProSeal LMA (PLMA; La-
tectomy with sentinel lymph node biopsy (MRM with SLNB), modified ryngeal Mask Company, Henley-on-Thames, UK)of appropriate size.
radical mastectomy with axillary lymph node dissection (MRM with In Group P, patient was positioned supine with the upper arm ipsi-
ALND)} were enrolled in this comparative prospective randomized con- lateral to the site of surgery kept abducted, externally rotated and
trol trial at a tertiary care hospital in northern India (Fig. 1). bend right angled at elbow joint. Then the PECS (I and II) blocks were
An informed written consent was obtained from all the patients performed by investigator using a 90–100 mm block needle
prior to the initiation of the study. Patients with these conditions were (UniPlexNanoLine, Sprotte,10 cm) and a high frequency linear ultra
excluded from the study 1. patient refusal 2. hypersensitivity to study sound probe (6–13 MHz) (Sonosite M Turbo). One investigator per-
drugs 3.hemodynamically unstable patients 4. chest wall deformity 5. formed all the blocks for patients in the P group. Anesthesia manage-
coagulopathy 6. infections at the site of block 7.uncontrolled hyperten- ment and data collection were done by personnel blinded to the
sion and diabetes 8. pregnancy 9. cardiac disease 10. previous breast allocated patient group.

Table 2
Comparison of VAS (post-operative period) at rest and at movement between the groups.

Time interval VAS (post-operative period) at rest VAS (post-operative period) at movement

Group P Group C Z value (Wilcoxon p value Group P Group C Z value (Wilcoxon p value
(n = 30) (n = 30) Signed Rank Test) (n = 30) (n = 30) Signed Rank Test)

Immediate postoperatively
Mean ± SD 1.73 ± 0.78 3.2 ± 1.51 −3.982b b0.001# 3.36 ± 1.60 5.5 ± 1.43 −4.080b b0.001#
Median (range) 2 (0, 3) 3 (2, 8) 3 (0, 7) 5 (3, 9)
At 0.5 h
Mean ± SD 1.8 ± 0.95 3.13 ± 1.43 −3.762b 0.001# 3.66 ± 1.6 5.4 ± 1.47 −4.044b b0.001#
Median (range) 2 (0, 3) 3 (1, 8) 3.5 (0, 7) 5 (2, 9)
At 1 h
Mean ± SD 1.8 ± 0.81 2.9 ± 1.29 −3.586b b0.001# 3.36 ± 1.51 5.03 ± 1.47 −3.935b b0.001#
Median (range) 2 (0, 3) 3 (1, 8) 3 (0, 7) 5 (3, 8)
At 2 h
Mean ± SD 1.8 ± 0.98 2.8 ± 1.29 −3.323b b0.001# 2.93 ± 1.48 4.93 ± 1.46 −4.270b b0.001#
Median (range) 2 (0, 3) 2 (1, 7) 3 (0, 6) 5 (3, 8)
At 4 h
Mean ± SD 0.4 ± 0.96 2.26 ± 1.46 −4.303b b0.001# 0.53 ± 1.38 3.76 ± 1.88 −4.496b b0.001#
Median (range) 0 (0, 4) 2 (0, 7) 0 (0, 5) 4 (0, 8)
At 6 h
Mean ± SD 0.43 ± 1.1 0.76 ± 1.62 −1.469b 0.142 0.6 ± 1.47 1.16 ± 2.06 −1.463b 0.143
Median (range) 0 (0, 5) 0 (0, 7) 0 (0, 6) 0 (0, 8)
At 12 h
Mean ± SD 1.20 ± 0.93 1.4 ± 0.89 −0.939b 0.348 0.6 ± 1.42 1.53 ± 1.88 −2.504b 0.012
Median (range) 1 (0, 5) 1 (0, 5) 0 (0, 6) 0.5 (0, 6)
At 24 h
Mean ± SD 0.5 ± 0.97 0.53 ± 0.81 −0.284b 0.776 0.6 ± 1.42 1.53 ± 1.88 −1.156b 0.248
Median (range) 0 (0, 4) 0 (0, 5) 0 (0, 6) 0.5 (0, 6)
b
Based on negative rank.
#
Statistically significant.
 N. M et al. / Journal of Clinical Anesthesia 45 (2018) 12–17 15

Fig. 3. a: Visual analog scale (VAS) at rest at different time intervals in both groups. b:
Visual analog scale (VAS) on movement at different time intervals in both groups.
After full aseptic preparation of skin (supra clavicular, infraclavicular
and axillary region), the ultrasound probe was placed first at mid infra
clavicular region and then angled inferolaterally (Fig. 2a & b). Once
the axillary artery and axillary vein were located on the screen, the
probe was moved laterally until the pectoral major, pectoral minor
and serratus anterior muscles were located on the screen (Fig. 2c). Si-
multaneously the 2nd rib was also located, which was found
immediately adjacent and under the axillary artery. After locating 2nd
rib, the 3rd and 4th ribs were also localized by counting and moving
the ultrasound probe downward and laterally on the patient's chest
wall.
With the image centered at the level of the 3rd rib, the block needle
(10 cm Stumiplex needle) was inserted by in plane technique from me-
dial to lateral in an oblique manner by an investigator until the needle
tip positioned between pectoral major and minor (PECS I) (Fig. 2d).
Then the same investigator injected 10 ml of ropivacaine 0.25% in the in-
terfacial plane between pectoral major and minor. Now after adminis-
tration of PECS I block, the same investigator further advanced the
block needle in the same plane from medial to lateral (i.e., in plain tech-
nique) and placed the block needle tip between pectoral minor and
serratus anterior muscle (PECS II) (Fig. 2d). After this PECS II block
was administered by same investigator by injecting 20 ml of ropivacaine
0.25% in increments of 5 ml after aspiration.
In Group C, patients received standard general anesthesia only as de-
scribed above and PECS block was not administered to these patients.
Anesthesia was maintained with isoflurane 1–2% in Oxygen/air mixture
(50:50), keeping the total minimum alveolar concentration (MAC) be-
tween 1 and 1.2. After ruling out causes altering hemodynamics other
than pain, IV fentanyl 0.5 μg/kg bolus was given, if the mean arterial
pressure (MAP) or heart rate (HR) exceeded 20% of the preoperative
value. Hypotension was defined as a decrease of MBP N 20% of the
base line and it was treated with increments of 6 mg boluses of IV
ephedrine and 250 ml of crystalloids. Any intraoperative bradycardia
(HR b 50 beats/min) was treated with IV Atropine (0.3–0.6 mg). At
the end of surgery, neuromuscular blockade was reversed with injection
neostigmine and glycopyrrolate.
After recovery from anesthesia, patients were shifted to post-
anesthetic care unit (PACU) for the first 6 h. In the PACU, an indepen-
dent observer, who was not aware about the group allocation, assessed
all the patients. Once the patient is fully awake and able to comprehend,
patient controlled analgesia (PCA) pump was programmed to deliver 20
μg bolus of IV fentanyl per demand with a lockout interval of 15 min.
Fentanyl consumption in the first 24 h was noted. If patient further com-
plains of any pain (VAS N 3), then IV paracetamol 1 g was administered
(not to be repeated within a gap of minimum 6 h). Pain intensity was
measured using VAS scale at rest and during abduction of the ipsilateral
upper limb at 30 min, 1 h, 2 h, 3 h, 4 h, 5 h, 6 h. and at 24 h after surgery.
Nausea lasting for N 10 min or vomiting was treated with IV
ondansetron. Patient's satisfaction with postoperative analgesia was
noted according to a satisfaction score. The patient satisfaction scores
were described as score 1 as not satisfied, score 2 as good or satisfied

Table 3
Comparison of limitation of shoulder movement on operated side between the groups.

Time period Grading of limitation of shoulder joint movement Group P (n = 30) Group C (n = 30) Z value (Wilcoxon Signed Rank Test) p value
b
4 h post op None 1 (3.33%) 0 −4.845 b0.001#
Mild 23 (76.67%) 0
Moderate 4 (13.33%) 4 (13.33%)
Severe 2 (7.14%) 26 (86.67%)
5 h post op None 1 (3.33%) 0 −4.674b b0.001#
Mild 22 (73.33%) 0
Moderate 7 (23.33%) 14 (46.67%)
Severe 0 16 (54.33%)
6 h post op None 1 (3.33%) 0 −1.995b 0.066
Mild 7 (23.33%) 2 (6.67%)
Moderate 19 (63.33%) 22 (73.33%)
Severe 3 (10%) 6 (20%)
24 h post op None 11 (36.67%) 11 (36.67%) −0.093c 0.926
Mild 13 (43.33%) 13 (43.33%)
Moderate 5 (16.67%) 5 (16.67%)
Severe 1 (3.33%) 1 (3.33%)
b
Based on negative rank.
c
Based on positive rank.
#
Statistically significant.
16 N. M et al. / Journal of Clinical Anesthesia 45 (2018) 12–17
Fig. 4. Limitation of shoulder movement in group P and group C.
and score 3 as excellent or very satisfied. Complications related to local
anesthetic drug and PECS blocks were also recorded. The maximal pain-
less abduction at 4, 5, 6 and 24-h after surgery was noted to assess any
restriction of shoulder movement on the operative side. Limitation of
shoulder movement on the operative site were classified into none
(full range of movement), mild (slightly limited and able to abduct
N90 degrees), moderate (unable to abduct N 90 degrees) and severe
(unable to move).
The primary outcome of this study was to evaluate the analgesic ef-
ficacy {amount of fentanyl requirement in the intraoperative and post-
operative period (24 h)}of combined PECS I and PECS II block with GA
in these patients as compared to conventional group (only GA). The sec-
ondary outcomes were to find out time to first analgesic request (VAS
N3) in post-operative period, limitation of shoulder movement on the
operative site at 4 h, 5 h,6 h and 24 h after surgery, incidence of post-
operative nausea and vomiting (PONV) and patient's satisfaction with
postoperative analgesia.
2.1. Statistical analysis
Data for continuous variables were presented as the mean ± stan-
dard deviation (SD) and analyzed by Student's t-test. Data for categori-
cal variables were presented as the counts (n). It was found that
dependent variables at rest and movement at different time period
were not following normal distribution; therefore, non-parametric
test had applied. The VAS score of P and C group were compared for
the same subjects at different time periods by using Wilcoxon Signed
Rank Test. All statistical analyses were performed using IBM SPSS 20.0
software (IBM, Armonk, NY, USA).All p values were two-sided. A p
value of b 0.001 was considered significant.
3. Results
As our institute is a tertiary care center, no participant refused to
take part in this intervention. Thus, a total of sixty patients participated
in this clinical trial. There was no significant intergroup difference in de-
mographic parameters {age, Body Mass Index (BMI)}, ASA grades and
educational status (to become familiar with VAS scale and functioning
of PCA pump) of the patients (Table 1).
The mean total fentanyl consumption in the intraoperative period in
group P was 140.66 ± 31.80 μg and in group C was 218.33 ± 23.93 μg.
This value was highly statistically significant (p b 0.001).The difference
of this value between the groups was 77.67 μg with a CI of 63.12–92.21.
The perioperative period (first 6 h after performing block) fentanyl re-
quirement was significantly high in group C as compared to group P
with a difference between the values of 127.16 μg with 95% CI between
103.84 and 150.48.The difference between the groups were statistically
significant (p value b 0.001). The total fentanyl requirement in 24 h
post-operatively was 438 ± 71.74 μg in group P and the same in
group C was 609 ± 53.00 μg. The difference between these two groups
were 171 with 95% CI of 138.40–203.59 and it was statistically signifi-
cant (p value b 0.001).
The VAS scores at rest and movement were significantly less in
group P at immediate post-operative period, 30 min, 1 h, 2 h and 4 h
in the post-operative period. VAS scores at rest and movement were
not statistically significant in all other study periods between the groups
(Table 2 and Fig. 3a, b).
The mean time required for first analgesia was 44.33 ± 17.65 min in
group P and was 10.36 ± 4.97 min in group C. The difference between
the groups was 33.96 with 95% CI of 27.26–40.66, having a p value of
b0.001 showing high statistical significance.
Limitation of shoulder movement was significantly less in group P as
compared to group C at 4th hour and 5th hour post operatively having p
value of b0.001 for both time periods. But it was comparable at 6th
hourly post operatively and after 24 h post-surgery (Table 3 and
Fig. 4).The incidence of PONV was not statistically significant between
the two groups (p = 0.573). The patient satisfaction score (PSS) was
Table 4
Incidence of postoperative nausea and vomiting (PONV) and patient satisfaction score.
Parameters Group P (n = 30) Group C (n = 30) p value
PONV Yes 22 (73.33%) 20 (66.67%) 0.573
No 8 (27.67%) 10 (33.33%)
Patient satisfaction score 1 5 (16.67%) 20 (66.67%) b0.001#
2 12 (40%) 9 (30%)
3 13 (43.33%) 1 (3.33%)
#
Statistically significant.
 N. M et al. / Journal of Clinical Anesthesia 45 (2018) 12–17
better in the P group in comparison to C group (p b 0.001) (Table 4).
There was no incidence of adverse events in any of the patients.
4. Discussion
In the present study, less fentanyl requirement was observed in the
in P group during intraoperative and post-operative period upto 24 h.
The time to first analgesic requirement was also more in P group in
comparison to C group during post-operative period. Our study also re-
vealed less limitation of shoulder movement on the operative site at 4 h
and 5 h after surgery in P group in comparison to C group. Patients in
group P had a better satisfaction with postoperative analgesia than C
group. No other previous study of PECS blocks mentioned about limita-
tion of shoulder movement on the operative site and patient
satisfaction.
As patients in P group received both GA and PECS blocks in compar-
ison to C group (only GA); mean total fentanyl consumption during in-
traoperative period in Group P was significantly lower compared to
group C. This result is consistent with a previous retrospective study
on pectoral nerve block [6]. In the aforementioned study, the authors
reviewed charts and medical records of 146 patients who underwent
BCS (breast conservation surgery), 36 patients were included in the
TIVA group, and 35 patients were included in the TIVA + PECS Block
group. They found that intraoperative remifentanil requirements were
significantly lower in the TIVA + PECS block group than in the TIVA
group, and the cumulative distribution of remifentanil was reduced in
patients who received PECS block (TIVA: 10.9 ± 2.9 μg/kg/h; TIVA
+ PECS Block: 7.3 ± 3.3 μg/kg/h; p b 0.001).
The mean total fentanyl requirement in 24 h post-operatively was
also significantly lower in group P than group C. These results are similar
to the reports from a recent study in which one hundred twenty adult
female patients scheduled for elective unilateral modified radical mas-
tectomy [9]. They found that the intraoperative fentanyl requirements
were found to be lower in the PECS group than in the control group.
In addition, the total amount of postoperative morphine needed to
keep VAS pain scores b 3 was also significantly less in the PECS group.
They also discovered the patients in the PECS group used less morphine
in the first 12 h postoperatively than did the control group patients, but
the morphine needs of the 2 groups were comparable in the succeeding
12 h.
In this study, we performed a combined PECS I and PECS II block.
PECS I could block lateral and medial pectoral nerve. Though pectoral
nerves are described in most textbooks as purely motor nerves, it was
suggested that they also transport proprioceptive and nociceptive fibers
as shown in other motor nerves. It was suggested that blocking the pe-
ripheral nerves to reduce chronic postoperative pain or muscle spasm
after mastectomy [11]. But in case of modified radical mastectomy, we
need to block additionally the intercostal nerves from T2 to T6 and the
long thoracic nerves which are blocked by PECS II block. Hence the com-
bined use of this will results in an excellent analgesia, that is the reason
we got significantly less pain scores at rest(PECS I) as well as at move-
ment (PECS I and PECS II).
There was no difference in the incidence of post-operative nausea
and vomiting in both the groups (p = 0.573). Various studies showed
reduction in PONV with regional techniques [10,12–13]. This may
be most probably due to decrease in opioid requirement with regional
techniques. But similar to our results, another study showed compara-
ble incidence on PONV in control and Pectoral nerve block [6]. There
was no inter-group difference in the incidence of PONV in this study,
even though the dose of intraoperative fentanyl was significantly
lower in PECS group. This could be because the etiology of PONV is
17
multifactorial, and there are several risk factors other than perioperative
opioid use, homogenous gender group, shorter duration of anesthesia,
and avoidance of volatile anesthetics.
Our study should only be considered according to its limitations.
First our sample size was small. Second, we only study patients at one
site and this may limit the generalizability of our results. In addition,
we did not check success of block, as we performed PECS blocks after in-
duction of anesthesia. Lastly, Long term outcomes like role in chronic
pain, role on immunological factors and cancer recurrence were also
not studied.
5. Conclusions
Combined PECS I and PECS II block in adult women undergoing mod-
ified radical mastectomy as compared to conventional group decreases
total amount of fentanyl requirement in the intraoperative/post-
operative period (24 h), increase duration for time to first analgesic re-
quirement (VAS N 3) in post-operative period with less limitation of
shoulder movement (pain free mobilization) on the operative site at
4 h and 5 h after surgery.
Source(s) of support/funnding
NIL.
Acknowledgement
NIL.
The authors declare no conflicts of interest.
References
[1] Ording AG, Cronin-Fenton DP, Jacobsen JB, Nørgaard M, Thomsen RW, Christiansen
P, et al. Comorbidity and survival of Danish breast cancer patients from 2000–2011:
a population-based cohort study. Clin Epidemiol 2013;5(Suppl. 1):39–46.
[2] Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from
a national survey suggest postoperative pain continues to be undermanaged. Anesth
Analg 2003 Aug;97(2):534–40.
[3] Ilfeld BM, Madison SJ, Suresh PJ, Sandhu NS, Kormylo NJ, Malhotra N, et al. Treat-
ment of postmastectomy pain with ambulatory continuous paravertebral nerve
blocks: a randomized, triple-masked, placebo-controlled study. RegAnesth Pain
Med 2014;39(2):89–96.
[4] Testa A, Iannace C, Di Libero L. Strengths of early physical rehabilitation programs in
surgical breast cancer patients: results of a randomized controlled study. Eur J Phys
Rehabil Med 2014 Jun;50(3):275–84.
[5] Calì Cassi L, Biffoli F, Francesconi D, Petrella G, Buonomo O. Anesthesia and analgesia
in breast surgery: the benefits of peripheral nerve block. Eur Rev Med Pharmacol Sci
2017;21(6):1341–5.
[6] Morioka H, Kamiya Y, Yoshida T, Baba H. Pectoral nerve block combined with gener-
al anesthesia for breast cancer surgery: a retrospective comparison. JA Clin Reports
2015:1–5.
[7] Wahba SS, Kamal SM. Thoracic paravertebral block versus pectoral nerve block for
analgesia after breast surgery. Egypt J Anaesth 2014;30:129–35.
[8] Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified
Pecs I): a novel approach to breast surgery. Rev Esp Anestesiol Reanim 2012;59:
470–5.
[9] Bashandy GMN, Abbas DN. Pectoral nerves I and II blocks in multimodal analgesia
for breast cancer surgery. Reg Anesth Pain Med 2015;40:68–74.
[10] Kulhari S, Bharti N, Bala I, Arora S, Singh G. Efficacy of pectoral nerve block versus
thoracic paravertebral block for postoperative analgesia after radical mastectomy:
a randomized controlled trial. Br J Anaesth 2016;117:382–6.
[11] Macrae WA. Chronic pain after surgery. Br J Anaesth 2001;87:88–98.
[12] Guzzetti L, Danelli G, Ricci B, Torrano V, Russo G, Fusco P, et al. An observational
analysis about novel chest wall blocks (PECS and SERRATUS) during breast surgery.
Austin J Surg 2016;3:1–5.
[13] Eldeen HMS. Ultrasound guided pectoral nerve blockade versus thoracic spinal
blockade for conservative breast surgery in cancer breast: a randomized controlled
trial. Egypt J Anaesth 2016;32:29–35.