Int J Clin Exp Med 2020;13(6):3781-3789 www.ijcem.com /ISSN:1940-5901/IJCEM0109905 Review Article Analysis of thoracic nerve block combined with transversus thoracic muscle plane block in breast cancer Shengbao Yang1, Baoqi Lv2, Hui Xu3, Zujiang Zhang4 1Department of Anesthesiology, Jiaozhou People’s Hospital, No. 88 Guangzhou North Road, Jiaozhou 266300, Shandong, China; 2Department of Orthopedics, Fifth People’s Hospital, Qingdao, No. 3 Jiaxiang Road, South District, Qingdao 266002, China; 3Department of General Surgery, Qingdao Fifth People’s Hospital, No. 3 Jiaxiang Road, South District, Qingdao 266002, China; 4Department of Second Anesthesiology, Jiaozhou People’s Hospi- tal, No. 88 Guangzhou North Road, Jiaozhou 266300, Shandong, China Received February 26, 2020; Accepted April 23, 2020; Epub June 15, 2020; Published June 30, 2020 Abstract: This paper aimed to explore the effects of thoracic nerve block (TNB) combined with transversus thoracic muscle plane block (TTMPB) for analgesic effect, inflammatory responses, and stress responses in patients with breast cancer after operation. Patients in the research and control groups were assessed and compared in their postoperative pain score. They were observed for their preoperative and postoperative hemodynamics, changes in respiratory function indices before and after operation, adverse reactions, and postoperative inflammatory and stress responses. Visual Analogue Scale (VAS) scores at resting state and after shoulder abduction in the research group were lower than those in the control group at 8, 12, and 24 hours after operation (P<0.05). The heart rate (HR), mean arterial pressure (MAP), and central venous pressure (CVP) were lower in the research group at 1 hour after operation (P<0.05). Patients in the research group had remarkably higher postoperative minute ventilation (MV) (P<0.05), remarkably lower incidence of adverse reactions (P<0.05), lower levels of IL-6, TNF-α, and CRP (P<0.05), remarkably higher superoxide dismutase (SOD) (P<0.05), and remarkably lower malondialdehyde (MDA) (P<0.05). In conclusion, TNB combined with TTMPB has better analgesic effects on patients with breast cancer after operation. The combination reduces inflammatory responses and avoids stress responses, so it is worthy of clinical application and promotion. Keywords: TNB, TTMPB, combination, breast cancer Introduction ously affecting surgical efficacy and aggravat- ing patients’ psychological burden [5]. After Breast cancer is an extremely common malig- radical mastectomy, intravenous opioids com- nant tumor found in clinical practice, and the bined with non-steroidal anti-inflammatory total number of affected patients accounts for drugs are mostly used for pain relief [6], but approximately 9%-12% of all malignant tumors this method has a poor analgesic effect with a [1]. It is estimated that the incidence of the dis- high incidence of adverse reactions [7]. There- ease has been on the rise in recent years and fore, the search for a good analgesic method is will surpass that of lung cancer; so this disease still a clinical research hotspot, and significant may become the malignant tumor with the high- to postoperative efficacy of patients with breast est worldwide incidence after gastric cancer in cancer and to their recovery. the next 50 years [2]. Its pathogenesis remains unclear, and the early stages usually have no First proposed by Blanco in 2011, thoracic clear symptoms, so most patients will have nerve block (TNB) is a method that injects reached the middle and advanced stages when anesthetics between the pectoralis minor mus- they are diagnosed; which therefore increases cle and pectoralis major muscle; so as to block the treatment difficulty [3, 4]. Currently, breast the lateral pectoral nerve, anterior external cancer is mainly treated by surgical resection, chest wall, medial pectoral nerve, axilla, and which often causes severe trauma, intense medial upper arm sensation [8]. It has been pain, and other adverse reactions; thereby seri- clinically confirmed that this method has a good Effects of TNB combined with TTMPB in patients with breast cancer after operation analgesic effect on thoracic closed drainage, ics or opioids; those allergic to general anes- cardiac pacemakers, breast surgery, and axil- thetic drugs; those with analgesic and sedative lary lymph node dissection [9]. Transversus drug therapy for a long period; those with a his- thoracic muscle plane block (TTMPB) is a meth- tory of drug abuse; those with coagulation dys- od that injects local anesthetics into the gap function or puncture site infection; those com- between the internal intercostal muscle (be- plicated with multiple tumors; those who could tween the fourth and fifth ribs) and musculus not take care of themselves because of physi- transversus thoracis [10]. It can block sensa- cal disabilities and who stayed in bed for a long tion of the anterior branches of T2-T6 intercos- time; and those who were transferred to other tal nerves, laying a good analgesic foundation hospitals. for the anterior medial region of breast [11]. According to previous studies, TNB combined Methods with TTMPB has a good analgesic effect on patients with breast cancer after operation Anesthesia methods: Patients in the two groups [12]. For further determining the application were conventionally monitored after operation. value of this combination, its effects on the General anesthesia induction was performed analgesic effect, inflammatory responses, and with fentanyl (1 μg/kg), propofol (2 mg/kg), and stress responses in patients with breast cancer rocuronium (0.6 mg/kg). Mechanical ventila- after operation were explored in this research, tion was conducted after tracheal intubation. to provide a reliable theoretical basis for the Patients in the research group received ultra- clinical application of this method. sound-guided TNB combined with TTMPB after anesthesia induction, and 0.375% ropiva- Materials and methods caine (number of imported drug registration: H20140763; AstraZeneca) was used for ultra- General information sound-guided peripheral nerve block. Patients in the control group received only TNB. All oper- One hundred and twenty-eight patients under- ations were performed by senior anesthesiolo- going radical mastectomy, admitted to our hos- gists. TNB: Mindray ultrasound (UMT-400, pital from June 2016 to June 2018 were Shenzhen Mindray Biomedical Electronics Co., enrolled as research subjects, in which 60 Ltd.) high-frequency linear array probe was patients received TNB (control group), while 68 positioned at the level of the third and fourth patients received TNB combined with TTMPB ribs. Ultrasound images showed the pectoralis (research group). This research has been app- major muscle, pectoralis minor muscle, and roved by the Ethics Committee of our hospital. serratus anterior tissues, as well as pleura. All research subjects or their immediate fami- In-plane needle insertion was adopted to avoid lies have signed an informed consent form. the thoracic wall branch of thoracoacromial artery. After a local anesthetic (10 mL) was Inclusion and exclusion criteria injected between pectoralis major muscle and Inclusion criteria: Those included were in accor- pectoralis minor muscle, needle insertion was dance with the clinical manifestations of breast continued to penetrate the pectoralis minor cancer [13], and were confirmed by biopsy in muscle, and then the local anesthetic (15 mL) the pathology department of our hospital, and was injected between pectoralis minor muscle underwent breast cancer resection in our hos- and serratus anterior. The anesthesiologist was pital after confirmation and participated in fol- careful not to insert the needle too deeply, to low-up treatment; those who were in line with avoid breaking the pleura. TTMPB: The ultra- indications for breast cancer resection were sonic probe was placed between the fourth and included [14]; those with complete patient data the fifth ribs, parallel to the sternum. Next, the were included; those willing to cooperate with local anesthetic (15 mL) was injected between and assist the medical staff in our hospital the internal intercostal muscle and the muscu- were included. lus transversus thoracis for TTMPB. After the operation, the patients’ blood pressure, heart Exclusion criteria: Those with central or periph- rate (HR), and oxygen saturation were moni- eral nervous system diseases, hepatic and tored. Parecoxib sodium (40 mg) was injected renal dysfunction, or allergy to local anesthet- once every 8 hours as an additional remedy for 3782 Int J Clin Exp Med 2020;13(6):3781-3789 Effects of TNB combined with TTMPB in patients with breast cancer after operation analgesia when the patients suffered from Measurement data were expressed by (mean ± pain, and tropisetron (5 mg) was intravenously standard deviation), and t test was used for injected for treating nausea and vomiting. After their comparison between groups, one-way the patients were fully awake, acupuncture test analysis of variance and LSD post hoc test was was conducted in the medial and lateral skin used for comparisons between multiple groups. areas of the chest at T2-6 level, to evaluate the When P<0.05, the difference was statistically level of anesthesia. significant. Detection methods: The HR, mean arterial Results pressure (MAP), and central venous pressure (CVP) were measured before and at 1 hour after Comparison of general information operation. SpO2 and minute ventilation (MV) were