Does Type of Anesthesia Influence Inflammation Change After Breast Surgery?

Centro di Riferimento Oncologico - Aviano68 enrolled

Overview

The Neutrophil to Lymphocyte Ratio (NLR) is a frequently used biomarker of the systemic inflammatory response and is considered one of the most sensitive markers of inflammation. Many studies have documented the association between the use of opioid drugs in the acute phase -as it can be considered the use during general anesthesia- and the increase of the NLR value. Such increase could determine a temporary phase of immunodepression in the immediate post operative period with consequent increase of the inflammatory state. This study intends to assess whether different anesthetic techniques can be associated with different variations of the intra-patient NLR value between pre- and post-surgery. Patient will be randomized to receive either local regional anesthesia protocols with thoracic wall blocks (PEC I and serratus plane block) associated with opioid-free general anesthesia (PECS + Opioid-free GA) or general anesthesia.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

BASIC_SCIENCE

Masking

NONE

Enrollment

Conditions

Breast Cancer Female

Interventions

PECSPROCEDURE

Loco-regional anesthesia: PEC I and serratus plane block with an echoguided technique. For the PEC I: infiltration of 10 ml of local anesthetic (Levobupivacaine 0.25% or Ropivacaine 0.5%) between the bands of the pectoralis major muscle and the small pectoralis muscle at the height of the third rib on the anterior axillary line. For the serratus plane block: identification of the fifth rib on the average axillary line and infusion of about 20 ml of local anesthetic (Levobupivacaine 0.25% or Ropivacaine 0.5%) between the bands of large dorsal muscle and of the anterior serratus muscle.

Opioid-free general anesthesiaPROCEDURE

Induction with Propofol 1.5-2 mg/kg; laryngeal mask for airway management after eventual administration of Rocuronium 0.6 mg/kg. Anesthesia will be maintained with Propofol in Target-Controlled Infusion (TCI) of 6 mcg/ml, subsequently modified to maintain a Bispectral Index (BIS) value between 40 and 60. Fentanyl 50ug in bolus IV, in case of mean arterial pressure or heart rate increase \>20%. In case of hypotension: 5mg ephedrine and infusion of 250 ml Lactated Ringer.

General anesthesiaPROCEDURE

Induction with Propofol 1.5-2 mg/kg; Fentanyl 1μg/kg; laryngeal mask for airway management after eventual administration of Rocuronium 0.6 mg/kg. Anesthesia will be maintained with Propofol in TCI of 6 mcg/ml, subsequently modified to maintain a BIS value between 40 and 60. Fentanyl 50ug in bolus IV, in case of mean arterial pressure or heart rate increase \>20%. In case of hypotension: 5mg ephedrine and infusion of 250 ml Lactated Ringer.

Eligibility

Sex: FEMALEMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: * First diagnosis of histologically confirmed breast cancer * Candidate to external quadrantectomy and axillary surgery (biopsy of the sentinel lymph node and possible axillary lymphadenectomy) * Able to provide adequate informed consent * With intact cognitive abilities Exclusion Criteria: * Ongoing pregnancy * In therapy or in follow-up for other cancers at the time of the study * Concurrent therapy with opioids or other drugs, for chronic pain conditions related to cancer or other diseases * History of documented allergy or previous adverse reaction to local anesthetics * Documented history of anesthesiology related problems during previous surgical interventions or history of problems in airway management * Unable to comply to study protocol schedule for logistic or other reasons * Refusal to participate to the study (absence of signed informed consent)

Outcomes

Primary Outcomes

24h NLR variation

Intra-patient variation of the NLR value between the pre-operative and the first post-operative day

Time frame: Pre-operative and at 24 hours after the end of surgery

Secondary Outcomes

1h NLR variation

Intra-patient variation of the NLR value between pre-operative and 1 hour after the end of surgery, and between 1 hour after the end of surgery and 24 hours after the end of surgery

Time frame: Pre-operative, 1 hour and 24 hours after the end of surgery

Opioid consumption

Consumption of intra-operative Fentanyl and post-operative Morphine hydrochloride during the first 24 hours after surgery

Time frame: 24 hours

Complication

Complications related to the loco-regional anesthesia technique or to the administration of the local anesthetic. For pain evaluation, the validated Numeric Rating Scale (NRS) will be used, the score ranges from 0 to 10 with higher values corresponding to worse pain.

Time frame: until hospital discharge, an average of 48 hours

Chronic pain

Chronic pain after surgery will be assessed with Brief Pain Inventory questionnaire (composed by pain severity and pain interference scores). "Douleur Neuropathique 4" (DN4) questionnaire will be used for the identification of neuropathic pain. All the scores range from 0 to 10, with 10 indicating the worst results.

Time frame: 3, 6 and 12 months after surgery

Change in the levels of circulating cytokines in the post-operative period (one hour and 24 hours after surgery), compared to the baseline pre-operative values, in the two arms

differences in fold change of selected cytokines between the two arms