In patients with cardiovascular disease, the perioperative period is critical in the long-term prognosis and the anesthetic technique has a direct impact on the risk of perioperative complications. Regional anesthesia has many benefits for this patient population, including provision of high-quality analgesia, reduced requirements for opioids and nonsteroidal anti-inflammatory drugs, avoidance of general anesthesia, and reduced autonomic system activation.1,2 Surgery for breast cancer is a common operative procedure that results in moderate postoperative pain. For this surgery, regional anesthesia techniques such as epidural and paravertebral blocks have been shown to provide effective analgesia and enhance postoperative recovery. Ultrasound-guided erector spinae plane (ESP) block is a recently described technique providing thoracic analgesia.3 This is the first case report that describes the use of this block to accomplish complete surgical anesthesia for modified radical mastectomy and axillary dissection in a high cardiovascular risk patient.
Written informed consent was obtained from the patient for inclusion in this report. A 75-year-old woman (73 kg, 153 cm) was scheduled for an elective radical mastectomy and axillary dissection of her invasive carcinoma in her right breast. Notable comorbidities included hypertension, type 2 diabetes mellitus, dyslipidemia, obesity, bipolar affective disorder, ischemic stroke in 2012, and coronary artery disease with acute myocardial infarction in 2013. Three months before her surgery, she underwent an angioplasty with bare-metal stent due to positive myocardial scintigraphy for ischemia. She was treated with dual antiplatelet therapy with acetylsalicylic acid and clopidogrel for 4 weeks when clopidogrel was interrupted. Her current medications were acetylsalicylic acid, carvedilol, hydrochlorothiazide, furosemide, metformin, simvastatin, risperidone, biperiden, sodium valproate, and clonazepam. A preoperative echocardiogram revealed akinesia in the inferior wall and septum of the left ventricular, pulmonary systolic pressure 36 mm Hg, and ejection fraction 0.55 (Figure).
The patient received a preoperative ESP block in the operating room under standard monitoring. With her in the left lateral decubitus position, a high-frequency (12–15 MHz) linear ultrasound transducer (GE LOGIQe; General Electric Company, Wauwatosa, WI) was placed in a longitudinal parasagittal orientation lateral to the T5 spinous process when the superior costotransverse ligament is visualized. The target is the plane deep to the erector spinae muscle (Figure). A 50-mm needle (Stimuplex A50; B. Braum, Melsungen, Germany) was inserted in-plane in a cranial-to-caudal direction to target the area between the erector muscle of the spine and the transverse process of T5. On visualizing the fluid spread lifting erector spinae muscle off the bony shadow of the transverse process, a total of 20 mL of 0.5% ropivacaine with epinephrine 1:200,000 and dexamethasone 8 mg was administered. The sensory assessment performed 20 minutes after the ESP block confirmed the anesthesia in dermatome from T2 to T9. During the surgery, sedation was achieved with fentanyl 100 µg and intravenous propofol infusion. The initial target setting for blood concentration of propofol was 1.7 µg/mL, and the values of the lower and upper limits during the surgery were 1.2 and 1.9 µg/mL, respectively. Target-controlled infusion system was titrated to a bispectral index level of 65–75 (bispectral index; Aspect Medical Systems, Norwood, MA). We monitored the patient by using noninvasive cardiac output measurements based on bioreactance (CHEETAH NICOM; Cheetah Medical, Inc, Newton Center, MA).
The surgery lasted 2½ hours and was uneventful. At the end of the surgery, the patient received standard medications as per our protocol of multimodal pain management: 2 mg morphine and 2 g dipyrone intravenously. Metamizole (dipyrone) is an analgesic and nonopioid drug. It is widely used to treat pain.
In the recovery area, the patient reported no pain and remained hemodynamically stable for 2 hours and was subsequently transferred to the semi-intensive unit. She was followed up by the pain service at the hospital and did not complain of any pain for 24 hours, after which she received only intravenous dipyrone 2 g every 6 hours.
Because of the high cardiovascular risk, we chose the regional anesthesia technique as the main anesthesia for this surgery. In addition, regional anesthesia provides better pain control, which might potentially lead to a reduction in the stress response, with a subsequent reduction in cardiac work and cardiac oxygen demand. Effective analgesia can improve respiratory dynamics that can be beneficial to this patient who had pulmonary systolic pressure of 36 mm Hg.
It is crucial to understand the innervation of the chest wall in choosing the regional anesthesia technique for breast surgery. The majority of the cutaneous sensation to the breast is derived from the intercostal nerves. On exiting the intervertebral foramina, the thoracic spinal nerves divide into dorsal and ventral rami. The ventral rami continue laterally as the intercostal nerve, give rise to the lateral cutaneous branch at the angle of the rib, and terminate in an anterior cutaneous branch. Medially, the anterior cutaneous branches innervate the medial breast. The lateral cutaneous branches of the intercostal nerves provide innervation to the lateral breast and lateral chest wall. Based on the anatomy, there are some important considerations regarding the anesthetic effect. The surgery involved removal of the entire breast tissue and all the overlying skin. The underlying fascia of the pectoralis major muscle was not disrupted (modified radical mastectomy), and the pectoralis muscles are preserved. This is important because pectoralis muscles are innervated by nerves from brachial plexus (medial and lateral pectoral nerves), and ESP block at level T5 will not cover the manipulation of the pectoralis muscles during the surgery. Special consideration should be given to the course of the lateral cutaneous branch arising from the T2 intercostal nerve, termed the “intercostobrachial nerve.” As with the other lateral cutaneous branches, this nerve branches off the intercostal nerve around the angle of the rib. After piercing the intercostal and serratus muscles, the T2 lateral cutaneous branch travels laterally along the floor of the axilla to reach the medial aspect of the upper arm. The intercostobrachial nerve provides cutaneous innervation to the axillary tail of the breast, the axilla, and the medial aspect of the upper arm.4 Other nerves in the region of axilla and lateral chest wall are the long thoracic nerve and thoracodorsal nerves, and both originate from the brachial plexus. Local anesthetic spreading up to the brachial plexus with an ESP at T5 is unlikely. For this patient, the contribution of these nerves in the axillary region is probably less important because we obtained satisfactory anesthetic effect.
The successful use of epidural and paravertebral blocks has been reported for this type of surgery, but we decided against performing these more invasive blocks given the medical status of the patient and the potential for serious complications. We opted to perform an ESP block because of the simplicity, safety, and the cardiovascular stability. The sonoanatomy to perform an ESP block is easily recognizable, and vital structures such as the pleura and spinal nerves are further away from the needle target compared with paravertebral and interpleural blocks. The mechanism of action is believed to be related to the spread of local anesthetic to the costotransverse foramen, where it can reach the paravertebral space and the ventral and dorsal rami of the thoracic spinal nerves, as well as the rami communicants that contain sympathetic nerve fibers.3,5,6 Deep to the erector spinae muscle, it is postulated that both cephalad and caudad local anesthetic spread are facilitated by the thoracolumbar fascia. Previous cadaver studies showed that a single injection at the level of the T5 transverse process produced craniocaudal spread between C7 and T8, accounting for the extensive sensory block observed.3,7 The extensive dermatomes covered by ESP block is important for pain control of the axillary tail and axilla in this patient, especially for intercostobrachial nerve.
In conclusion, ESP block was successfully described as part of multimodal analgesia for breast surgery by other authors,8–10 but we presented the first case report that described the use of ESP block as a complete anesthesia technique for a patient undergoing modified radical mastectomy and axillary dissection. As with all plane blocks, there is likely an interindividual variability in the physical spread of local anesthetic and the consequent intensity and extent of analgesia. Further investigation is required to determine if there is a proportional relationship between the volume injected and the extent of analgesia.
Name: Pedro Paulo Kimachi, MD.
Contribution: This author helped care for the patient, collect the data, and prepare and analyze the manuscript.
Name: Elaine Gomes Martins, MD, CIPS.
Contribution: This author helped design the report, collect the data, and prepare and write the manuscript.
Name: Philip Peng, MBBS, FRCPC.
Contribution: This author helped analyze and prepare the manuscript.
Name: Mauricio Forero, MD, FIPP.
Contribution: This author helped analyze and prepare the manuscript.
This manuscript was handled by: Mark C. Phillips, MD.
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