Axillary local anesthetic spread after the thoracic interfacial ultrasound block – a cadaveric and radiological evaluation (original) (raw)
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Local and Regional Anesthesia
Few studies have described segmental thoracic spinal anesthesia (STSA) as primary anesthesiologic method in breast and axillary surgery, documenting the association of intrathecal local anesthetics and opioids. This case series reports an opioid-free scheme of STSA in four elderly patients undergoing major breast and axillary oncological surgery. Patients and Methods: STSA was performed in three female patients undergoing unilateral mastectomy ± axillary lymph node dissection (ALND) or sentinel lymph node biopsy for invasive ductal carcinoma and in one male patient undergoing ALND for melanoma metastases. The level of needle insertion was included between T6-8, via a median or paramedian approach. Midazolam (2 mg) and ketamine (20 mg) were used as adjuvants for intrathecal sedation, followed by the administration of hypobaric ropivacaine 0.25% at a dose of 8 mg. The level of sensory blockade achieved was comprised between C2-3 and T11-12. Postoperative analgesia was maintained through continuous intravenous administration of Ketorolac by an elastomeric pump (90 mg over 24 hrs.). Results: Spinal anesthesia was completed without complications in all patients. Conversion to general anesthesia (GA) and perioperative intravenous sedation were not required. No major postoperative complications and no episodes of postoperative nausea and vomiting (PONV) were reported. No rescue analgesic was administered. All patients were discharged in postoperative day 2 and are alive at 30, 29, 27 and 13 months after surgery, respectively. High grade of satisfaction on the anesthesiologic method was expressed by all cases. Conclusion: STSA with local anesthetic plus midazolam and ketamine might be considered a safe and effective alternative to GA, even in surgeries involving the breast and axillary region, particularly in elderly and frail patients. Larger prospective studies are required to validate these findings.
Journal of Pain Research
Purpose: Thoracic paravertebral block (TPVB), in conjunction with intravenous sedation, is reported to provide surgical anesthesia for primary breast cancer surgery (PBCS). Although ultrasound-guided (USG) TPVB has been described, there are no reports of USG multilevel TPVB for surgical anesthesia during PBCS. The aim of this prospective observational study was to determine the feasibility of performing USG multilevel TPVB, at the T1-T6 vertebral levels (6m-TPVB), and to evaluate its efficacy in providing surgical anesthesia for PBCS. Patients and Methods: Twenty-five female patients undergoing PBCS received an USG 6m-TPVB for surgical anesthesia. Four milliliters of ropivacaine 0.5% (with epinephrine 1:200,000) was injected at each vertebral level. Dexmedetomidine infusion (0.1-0.5 µg.kg −1 .h −1) was used for conscious sedation. Success of the block, for surgical anesthesia, was defined as being able to complete the PBCS without having to resort to rescue analgesia or convert to GA. Results: The USG 6m-TPVB was successfully performed on all 25 patients but it was effective as the sole anesthetic in only 20% (5/25) of patients. The remaining 80% (20/25) reported pain during separation of the breast from the pectoralis major muscle and its fascia. Surgery was successfully completed using small doses of intravenous ketamine (mean total dose, 38.0±20.5 mg) as supplementary analgesia. Conclusion: USG 6m-TPVB is technically feasible but does not consistently provide complete surgical anesthesia for PBCS that involves surgical dissection on the pectoralis major muscle and its fascia. Our data suggest that the pectoral nerves, which are not affected by a 6m-TPVB, are involved with afferent nociception.
Open Journal of Anesthesiology, 2019
Background and Aims: Erector spinae plane block, Paravertebral block and serratus anterior block are three formats for analgesia post-operatively following radical mastectomy. This study compares the analgesic efficacy of these modalities for analgesia post-operatively by articaine 2% with adrenaline. Methods: Seventy-five patients with ASA physical status I or II subjected to modified radical mastectomy with axillary clearance were enrolled for the study. After induction of general anaesthesia all patients received 20 mL 2% articaine with adrenaline in each technique of the study. Patients in Group 1 (Erector spinae block [ESB], n = 25), Group 2 paravertebral block [PVB] n = 25), Group 3 (serratus anterior plane block [SAPB] n = 25) were ultrasound-guided on ipsilateral side. Patients were estimated for pain scores at 0, 2, 4, 6, 12 and 24 h, and duration of analgesia post-operatively and relieve analgesic doses required of morphine up to 24 h. Results: Visual analogue scale scores post-operatively were lower in ESB and PVB group compared with SAPB at 4, 6, 12 and 24 h (P < 0.05). The first analgesic dose requirement was significantly longer in ESB (416 ± 68 min) than PVB group (371 ± 67 min) in compared with SAPB (343.5 ± 54.7 min). Mean duration of analgesia was significantly longer in ESB and PVB group (P < 0.001) in compared with SAPB. Total morphine dose of relieving analgesic was significantly lesser in ESB (4 ± 2 mg) than PVB group (6 ± 2 mg) compared with SAPB
Background: The ultrasound-guided proximal intercostal block (PICB) is performed at the proximal intercostal space (ICS) between the internal intercostal membrane (IIM) and the endothoracic fascia/parietal pleura (EFPP) complex. Injectate spread may follow several routes and allow for multilevel trunk analgesia. The goal of this study was to examine the anatomical spread of large-volume PICB injections and its relevance to breast surgery analgesia. Methods: Fifteen two-level PICBs were performed in ten soft-embalmed cadavers. Radiographic contrast mixed with methylene blue was injected at the 2nd(15ml) and 4th(25ml) ICS, respectively. Fluoroscopy and dissection were performed to examine the injectate spread. Additionally, the medical records of 12 patients who had PICB for breast surgery were reviewed for documented dermatomal levels of clinical hypoesthesia. The records of twelve matched patients who had the same operations without PICB were reviewed to compare analgesia and opioid...
Ain-Shams Journal of Anesthesiology
Background: Thoracic paravertebral block may be used for analgesia after breast surgery. Ultrasound can be used during the whole technique of paravertebral block to increase success rate and decrease its complications. As well, pectoral nerve block is now used for pain relief after modified radical mastectomy with or without axillary clearance. Objective: To compare thoracic paravertebral block and pectoral nerve block for postoperative analgesia after modified radical mastectomy Methods: The study was performed over 30 female patients that were randomly divided into 2 groups with 15 patients in group A for thoracic paravertebral block (TPVB) and 15 in group B for pectoral nerve block (PECS) with injection of total 20 ml bupivacaine 0.25% in each block. Outcome measures of the study are postoperative analgesia duration (time to first rescue analgesia (0.5 mg/kg pethidine) after administration of block) and total analgesic dose in 24 h after surgery and postoperative pain which will be assessed using a visual analog scale (VAS, 0-10 as 0 = no pain and 10 = worst imaginable pain). The vital signs and pain score will be recorded at 0, 1, 2, 4, 6, 8, 12, 18, and 24 h after surgery. Results: Our study showed decrease in systolic blood in PVB group immediately postoperative and in the first 6 h postoperative with p value < 0.05. Less time to perform the block in PECS group with p value < 0.001. Less VAS score in PECS group with statistically significant difference between groups at 1 h, 2 h, and 4 h. More time is needed for the 1st requested rescue analgesia in PECS group with p value < 0.05. Patients in the PECS group received less total dose of pethidine with a p value < 0.05 Conclusion: The PECS can be effectively and safely used, provides better relief of pain and less hemodynamic changes compared with the TPVB, and reduces postoperative analgesic consumption. Therefore, the PECS can be used safely for postoperative analgesia in patients undergoing breast surgeries with axillary dissection.
A&A practice, 2018
We described the first ultrasound-guided erector spinae plane block that provided complete surgical anesthesia for a right-sided mastectomy and axillary dissection in a patient with high cardiovascular risk. The block targeted at T5, and 20 mL of 0.5% ropivacaine with epinephrine 1:200,000 and dexamethasone 8 mg was administered. Complete anesthesia was accomplished in 20 minutes, and the patient received propofol infusion for sedation. The patient reported no pain and remained hemodynamically stable throughout the 2.5-hour procedure. At the end of the surgery, patient received morphine 2 mg and dipyrone 2 g intravenously, and demanded no analgesic until 24 hours after the procedure.
Anesthesia: Essays and Researches, 2020
Background and Aims:Despite the latest advances in breast surgery, the procedure is frequently associated with postoperative pain, nausea, and vomiting, which leads not only to increased patient's suffering but also to a prolongation of hospital stays and related costs. Thoracic paravertebral block (TPVB) has been successfully used to provide analgesia for multiple thoracic and abdominal procedures in both children and adults.Methods:Forty patients were allocated for this observational, comparative study and divided into two groups of 20 each, namely thoracic paravertebral group (Group P) study group and general anesthesia (GA) group (Group G), control group, and observations made for duration of procedure, visual analog score, rescue analgesia, surgeon and patient's satisfaction, postoperative complications, and duration of postanesthesia care unit (PACU) stay in both the groups.Results:We found that there was a statistically significant difference in duration of procedure, more time was taken in performing TPVB. Pain was better controlled in Group P and requirement of rescue analgesia was higher in Group G patients, postoperative complications such as shivering, nausea, vomiting, and duration of PACU stay were more in patients receiving GA.Conclusion:Hence, we conclude that ultrasound-guided TPVB appears to be safe, reliable, and effective technique for breast surgeries with several advantages over GA in terms of long-lasting pain relief, fewer complications, and shorter hospital stay.
Journal of Evolution of medical and Dental Sciences, 2013
BACKGROUND: this randomised control trial is to evaluate unilateral para- vertebral block in elective breast surgery in comparison with general anaesthesia METHODS: 106 patients of breast surgery were randomised in 2 groups- group-P and group-G. group-P patients received unilateral multiple level paravertebral block with 0.25% levo-bupivacaine at T2 to T5 level and group-G patients received general anaesthesia. Pulse, BP were recorded in the perioperative period and rescue analgesic requirement time and VAS scores were recorded in PACU. Recorded data were evaluated after that. RESULTS: In PACU rescue analgesia needed in group-P in 69.22 minutes and in group-G in 41.27 minutes. Post-operative VAS scores were lower in group-P patients at 30 minutes, 1 hr. and 2 hr. There was no incidence of hypotension or hypertension or bradycardia or tachycardia in any group. Patients overall satisfaction score in group-P was 4 vs 3.6 in group-G (p value <0.05) CONCLUSION: Thoracic para-vertebral...
2019
OBJECTIVES Due to the complex breast innervation, postoperative analgesia after breast surgery is a challenge for the anesthesiologists. The erector spinae plane block (ESPB) is a newly defined promising technique for this purpose. The main purpose of this study was to evaluate the analgesic efficacy of the ultrasound-guided ESPB in breast surgery, monitoring its effect on the postoperative opioid consumption. METHODS Fifty female patients, who were scheduled to undergo elective breast surgery, with the American Society of Anesthesiology physical score I-II, and aged between 25 and 70 years, were included into the study. Patients were randomized into two groups, as the ESPB and the control group. All patients in the ESPB group received a bi-level (T2-T4) ultrasound-guided ESPB with 20 ml 0.25 % bupivacaine (10 ml for each level) preoperatively. An intravenous patient-controlled analgesia device for the postoperative analgesia was given to all patients. The numeric rating scale (NRS)...