|Year : 2020 | Volume
| Issue : 3 | Page : 140-142
Regional anesthesia options in managing mastectomy: A case series
Hinarto Hinarto, Tjokorda Gde Agung Senapathi, I Gede Budiarta, Cynthia Dewi Sinardja
Department of Anesthesiology, Pain Management, and Intensive Care, Udayana University, Sanglah General Hospital, Bali, Indonesia
|Date of Submission||04-Mar-2020|
|Date of Decision||22-Apr-2020|
|Date of Acceptance||01-May-2020|
|Date of Web Publication||18-Jul-2020|
Dr. Hinarto Hinarto
Jl. Prof. Moh Yamin No. 16, Denpasar, Bali 80239
Source of Support: None, Conflict of Interest: None
Regional anesthesia can be a choice of technique in mastectomy surgery. The paravertebral block provides a safer setting by maintaining stable hemodynamic compared to thoracic epidural block and less of opioid needed in the postoperative period. We report our observations to ten patients who underwent a modified radical mastectomy. We either manage the case by thoracic paravertebral block or thoracic epidural anesthesia, both by combination to laryngeal mask airway.
Keywords: Numerical rating score, pain, paravertebral block, thoracic epidural
|How to cite this article:|
Hinarto H, Agung Senapathi TG, Budiarta I G, Sinardja CD. Regional anesthesia options in managing mastectomy: A case series. Bali J Anaesthesiol 2020;4:140-2
|How to cite this URL:|
Hinarto H, Agung Senapathi TG, Budiarta I G, Sinardja CD. Regional anesthesia options in managing mastectomy: A case series. Bali J Anaesthesiol [serial online] 2020 [cited 2021 Jan 22];4:140-2. Available from: https://www.bjoaonline.com/text.asp?2020/4/3/140/290085
| Introduction|| |
Cancer is the second leading cause of death worldwide. The burden is still increasing too in low-income countries besides infectious diseases and maternal, infant, childhood mortality. In addition to the burden of morbidity and mortality, cancer carries an economic burden including treatment or indirect cost due to loss of income.
Regional anesthesia techniques combined with general anesthesia have become common in the management of the patient for breast cancer surgery. It provides excellent analgesia, less opioid demand, and reduces the incidence of postoperative nausea and vomiting.
The thoracic paravertebral block (TPVB) allows local anesthetic to be injected into the paravertebral space. Mastectomy and lymph node dissection will need block between level C5 and T7, while multiple injections of 3–5 mL may be needed for a more extensive spread. Patients who received injection local anesthesia in paravertebral space had less acute postoperative pain in 72 h after surgery and will be protected from developing chronic postsurgical pain after 6 months.
Thoracic epidural anesthesia (TEA) can also be used for breast surgery. It has higher technical difficulty and a high failure rate if implemented by inexperienced anesthesiologists. The majority of cases who underwent TEA and continued to epidural analgesia had potential intraoperative and postoperative hypotension.
| Case Reports|| |
We managed ten women aged 18–65 years old with the American Society of Anesthesiologists I–II physical status who underwent mastectomy surgery. We managed them with general anesthesia using laryngeal mask airway (LMA) in combination with either TPVB or TEA. We observed only small changes in hemodynamic parameters in all patients. In terms of postoperative pain, we measured the pain score using a numerical rating score (NRS) at 24 h postsurgery.
A 60-year-old female with right breast carcinoma was planned for mastectomy. We managed the case with TPVB with ultrasonogrqaphy (US) guiding. Her demand for a postoperative opioid was 5 mg, with an NRS of 2.
A 42-year-old female with left breast carcinoma was scheduled for mastectomy. We managed the case with TEA. Her demand for a postoperative opioid was 10 mg, with an NRS of 3.
A 57-year-old female with right breast carcinoma was planned for mastectomy. We managed the case with TPVB with US guiding. Her demand for a postoperative opioid was none, with an NRS of 0.
A 41-year-old female with left breast carcinoma was scheduled for mastectomy. We managed the case with TEA. Her demand for a postoperative opioid was 3 mg, with an NRS of 2.
A 47-year-old female with right breast carcinoma was planned for mastectomy. We managed the case with TPVB with USG guiding. Her demand for a postoperative opioid was 3 mg, with an NRS of 2.
A 45-year-old female with right breast carcinoma was scheduled for mastectomy. We managed the case with TEA. Her demand for a postoperative opioid was 10 mg, with an NRS of 3.
A 50-year-old female with left breast carcinoma was planned for a mastectomy procedure. We managed the case with TPVB with USG guiding. Her demand for a postoperative opioid was 1 mg, with an NRS of 1.
A 39-year-old female with right breast carcinoma was scheduled for mastectomy. We managed the case with TEA. Her demand for a postoperative opioid was 3 mg, with an NRS of 2.
A 36-year-old female with right breast carcinoma was scheduled for mastectomy. We managed the case with TPVB with USG guiding. Her demand for a postoperative opioid was 1 mg, with an NRS of 1.
A 50-year-old female with right breast carcinoma was scheduled for mastectomy. We managed the case with TEA. Her demand for a postoperative opioid was 5 mg, with an NRS of 2.
| Discussion|| |
Breast cancer is still one of the most frequently diagnosed cancers in women. Mastectomy is the primary technique removing the solid lesion. Sellheim found a method to block the nerves lateral to the spinal column as an alternative to central neuraxial blocks in 1905. This paravertebral block was found to be safer than neuraxial anesthesia in the context of hemodynamic.
TPVB is indicated as a primary anesthetic technique for simple chest wall surgeries, rib resection, and for breast surgery. It is a safe and effective technique and should be considered as an ideal alternative to general anesthesia. Any other conditions such as postherpetic neuralgia, relief of pleuritic chest pain, and multiple fractured ribs.
Before implementing the TPVB, make sure there is no contraindication including infection at the site of injection, allergy to a local anesthetic drug, empyema, and a neoplastic mass occupying the paravertebral space. For a special condition, spine anomaly or kyphoscoliosis may predispose to inadvertent thecal or pleural puncture.
Kulkarni et al. published a case report where they performed TPVB in a 92-year-old patient with cardiopulmonary dysfunction, and during the procedure, they provide adequate anesthesia and cardiopulmonary stability. TPVB has more advantages in providing more stable hemodynamic unless the patient is hypovolemic, and thus, shorter recovery time is possible. The benefit of more stable hemodynamic in TPVB is supported by several studies.
Complications and side effects reported with TPVB are very low and can be minimized with ultrasound guidance. Visualizing the catheter and the drug spread allowing us to perform safer anesthesia. The paravertebral space spans the vertebral column and is continuous with the epidural space medially and the intercostal space laterally. The spread depends on the level of injection, anatomic variance amongst patients, and the volume of injected local anesthetic.
The use of regional anesthesia, reducing opioid consumption, seems to attenuate perioperative immunosuppression and lower incidence of metastases. Lower morphine or opioid demand in 24 h postsurgery can contribute to decreasing episodes of nausea vomiting and rapid recovery. From an economic perspective, TPVB uses fewer types of equipment and fewer drugs, provides a stable hemodynamically, and reduces complication rates, early mobilization, and shorter length of stay.
One of the most important findings in this study is that TPVB might have the potential to reduce the incidence of chronic postsurgical pain. Better control of acute pain may reduce the development of persistent pain and improve quality of life. However, Biswas et al. reported that epidural analgesia provided better pain relief compared to continuous paravertebral analgesia. Further studies must be conducted to better compare the two techniques.
| Conclusion|| |
In this case series, TPVB provides a good option in managing mastectomy cases under regional anesthesia in combination with LMA.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Cancer Society. Global Burden of Cancer in Women. Vol. 1. Darmstadt, Germany: World Cancer Congress; 2016.
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.
Sherwin A, Buggy DJ. Anaesthesia for breast surgery. BJA Educ 2018;18:342-8.
Bojaxhi E, Kalava A, Greengrass R. Utilization of paravertebral nerve blocks as part of a multimodal analgesic regimen in a patient with Bernard-Soulier syndrome undergoing a Nuss procedure. Rom J Anaesth Intensive Care. 2016;23:67-71. doi:10.21454/rjaic.7518.231.nss.
Kulkarni KR. Single needle thoracic paravertebral block with ropivacaine and dexmeditomidine for radical mastectomy: Experience in 25 cases. Int J Anesthesiol Pain Med 2016;2:2-17.
Hadzic A. Hadzic's Text Book of Regional Anesthesia and Acute Pain Management. 2nd
ed. Darmstadt, Germany: McGraw-Hill Education; New York 2017.
Kulkarni K, Dubey P, Ray MS. Management of radical mastectomy under sole thoracic paravertebral block in a 92 years old patient with cardiopulmonary dysfunction. ARC J Anesthesiol 2017;2:1-3.
D'Ercole F, Arora H, Kumar PA. Paravertebral block for thoracic surgery. J Cardiothorac Vasc Anesth 2018;32:915-27.
Terkawi AS, Tsang S, Sessler DI, Terkawi RS, Nunemaker MS, Durieux ME, et al
. Improving analgesic efficacy and safety of thoracic paravertebral block for breast surgery: A mixed-effects meta-analysis. Pain Physician 2015;18:E757-80.
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;21:1341-5.
Patel L, Patel B, Prajapati G, Sanghvi P, Agarwal M. Thoracic paravertebral block for analgesia after modified radical mastectomy. Indian J Pain 2014;28:160. [Full text]
Beyaz S. Thoracal paravertebral block for breast surgery. Dicle Medical Journal 2012;39:594-603.
IliC´ MK, Adam VN, MatoliC´ M, Kogler J, Butkovic D. Paravertebral block: Review of the literature. Period Biol 2015;117:315-7.
Biswas S, Verma R, Bhatia VK, Chaudhary AK, Chandra G, Prakash R. Comparison between thoracic epidural block and thoracic paravertebral block for post thoracotomy pain relief. J Clin Diagn Res 2016;10:UC8-12.