|Year : 2021 | Volume
| Issue : 1 | Page : 123-126
Successful postoperative pain management by a surgeon-assisted interfascial plane block under vision in patients undergoing modified radical mastectomy: A case series
Richa Joshi1, Deepak Dwivedi2, Kaminder Bir Kaur3, Debashish Paul3
1 Department of Oncosurgery, Command Hospital, Pune, Maharashtra, India
2 Department of Anaesthesiology, Command Hospital, Pune, Maharashtra, India
3 Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||13-Nov-2020|
|Date of Decision||27-Jan-2021|
|Date of Acceptance||30-Jan-2021|
|Date of Web Publication||26-Jun-2021|
Dr. Debashish Paul
Department of Anaesthesiology and Critical Care, AFMC, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
As anatomical structures get exposed intraoperatively, we present a case series of 18 patients of the surgeon-assisted interfascial plane block with local anesthetic infiltration between pectoralis minor and serratus anterior (SA) and between SA and latissimus dorsi for postoperative analgesia in patients undergoing modified radical mastectomy. Surgeons infiltrated 25 ml of 0.25% bupivacaine with dexmedetomidine (0.5 μg/kg) in the above-mentioned plane after the completion of axillary dissection and the removal of axillary content en bloc with the breast. The median pain score was assessed by numeric rating scale for pain. This score was <3 with no requirement of rescue analgesia in the first 24 h postoperatively. Intraoperative hemodynamic parameters were stable, and there was no adverse event. Hence, surgeon-assisted interfascial plane block under vision can be a feasible option for providing adequate postoperative analgesia.
Keywords: Analgesia, infiltration, local anesthetics, modified radical mastectomy
|How to cite this article:|
Joshi R, Dwivedi D, Kaur KB, Paul D. Successful postoperative pain management by a surgeon-assisted interfascial plane block under vision in patients undergoing modified radical mastectomy: A case series. Arch Med Health Sci 2021;9:123-6
|How to cite this URL:|
Joshi R, Dwivedi D, Kaur KB, Paul D. Successful postoperative pain management by a surgeon-assisted interfascial plane block under vision in patients undergoing modified radical mastectomy: A case series. Arch Med Health Sci [serial online] 2021 [cited 2021 Dec 8];9:123-6. Available from: https://www.amhsjournal.org/text.asp?2021/9/1/123/319389
| Introduction|| |
The most common cancer in women, both in the developed and the developing world, is breast cancer (11.6%), with a mortality rate of 1.61% in the southeastern Asia. It is the second most common cancer in India and the leading cause of death in the age group of 40–60 years. According to the latest report of the Cancer Registry of the Indian Council of Medical Research, breast cancer has become the number one disease with an estimated 14% new cases reported in 2016.
Modified radical mastectomy (MRM) is a standard surgical procedure for operable breast cancer. The extensive tissue dissection and the resulting nociception barrage in MRM initiates a cascade of events that can alter the perception pathway and cause severe pain and discomfort to patients in the postoperative period. In developed countries, 86% of patients undergoing MRM documented experiencing postoperative pain, whereas 75% of them described it as moderate to severe during the immediate postsurgical period.
Various analgesic modalities are available to counter postmastectomy pain such as oral-systemic nonsteroidal anti-inflammatory drugs and opioids or central neuraxial blocks such as thoracic epidural or thoracic paravertebral blocks (PVBs). Ultrasound-guided (USG) interfascial plane blocks such as pectoral nerve (PECS) block types I and II and serratus plane block (SPB) are the other alternatives, with the advantages of prolonged analgesia.,,
The surgeons do expose the nerves and visualize the anatomical structures, which are to be identified in USG for a successful block. We present a case series of the surgeon-assisted local anesthetic (LA) infiltration in the interfascial plane between pectoralis minor (PM) and serratus anterior (SA) and also between SA and latissimus dorsi (LD) for postoperative analgesia in MRM surgeries.
| Case Report|| |
All female patients aged between 36 and 63 years, planned for MRM, in the American Society of Anesthesiologist (ASA) Physical Status II and III, were included. Institutional ethics committee approval was taken before enrolling the patients. Numeric rating scale (NRS) for pain was explained to the patient in the preoperative period, for the assessment of pain [Figure 1].
After obtaining the written informed consent and confirming the adequate fasting status, the patient was taken inside the operation theater. The American Society for Testing and Materials, International standards, monitors were placed, and intravenous (IV) access was established. Patients were premedicated with 1 mg midazolam, 1 μg/kg fentanyl, and 200 μg glycopyrrolate; induction was done with 1.5–2 mg/Kg propofol in titrated doses. I-Gel of appropriate size was used. Anesthesia was maintained with a mixture of air: O2 (50:50) and sevoflurane maintaining MAC at 1.0. All patients were administered injection paracetamol 1 g IV in the intraoperative period. After the axillary dissection was completed and axillary content was removed en bloc with the breast, the surgeon infiltrated the plane with 25 ml solution of 0.25% bupivacaine and dexmedetomidine (0.5 μg/kg).
The SA is bounded by deep and superficial potential spaces. At the level of the fifth rib, the superficial plane is formed from the anterior aspect of the SA and the posterior aspect of the LD muscle. The deep plane is formed from the posterior aspect of the SA and the external intercostal muscles and ribs. Either plane will achieve analgesia to the anterolateral chest wall with reportedly similar efficacy and an equivalent area of cutaneous sensory loss.,, The surgeon infiltrated the drug under vision in the planes between PM and SA, between SA and LD [Figure 2], and over the long thoracic nerve [Figure 3].
|Figure 2: Drugs infiltration in the interfascial layers between the serratus anterior plane and pectoralis minor and between serratus anterior plane and latissimus dorsi|
Click here to view
|Figure 3: Drugs infiltration over the nerve to serratus anterior muscle and the surrounding structures|
Click here to view
Toward the end of the surgery, two drains were placed, one beneath the chest flap and one in the axilla. As the drug has been placed in interfascial planes, drains were kept clamped initially for 10 min before declamping them with negative suction.
Removal of the I-Gel was done when the patient became fully awake. NRS was noted immediately after extubation and subsequently two hourly for the next 6 h and then six hourly for 24 h. The duration of analgesia was defined as the time interval from the time of extubation to the time for the first demand of analgesia. Heart rate (HR), systolic blood pressure, diastolic blood pressure, mean arterial pressure (MAP), and oxygen saturation (SpO2) were also monitored at the same time intervals. Injection tramadol as rescue analgesia was administered if the pain score was more than four in the NRS scale. Patients were monitored for 24 h postoperatively for the occurrence of any complications.
| Results|| |
Demographic data including, age, weight, and ASA class are presented in [Table 1]. The average age of the patient was 47.9 ± 8.46 (mean ± standard deviation [SD]) years, and body weight was 51.5 ± 6.80 (mean ± SD) kg. Of 18 patients, 10 were accepted in ASA III, whereas 8 patients were accepted in ASAII.
|Table 1: Demographic data analysis and hemodynamic changes in all the patients in the 24 h postoperative period|
Click here to view
Median pain score as assessed by the NRS scale is reflected in [Figure 4]. Within the first 6 h, the median pain score was 1, and at 24 h, it came within the range of mild pain score (≤3) [Figure 4].
Hemodynamic parameters such as HR and MAP were stable throughout the observed period, which was statistically significant (P ≤ 0.05). The mean ± SD values for the HR and MAP were analyzed from a hypothetical value of 100, for both the variables (one sample t-test was applied to compare the means with this hypothetical value of 100) [Table 1].
Adverse effects such as pruritus, headache, dizziness, and features of LA toxicity were absent in these patients.
| Discussion|| |
Effective postoperative pain management is an integral part of modern anesthetic practice. Local anesthetic drugs have become increasingly popular because of their analgesic properties and lack of opioid-induced adverse effects for treating postoperative surgical pain.
The techniques such as PVB, brachial plexus block by infraclavicular approach, USG-guided PECS I, and PECS II block have been tried for postoperative analgesia following mastectomy. Kumar et al. found that USG-guided PECS block provided excellent analgesia for MRM patients compared to no regional anesthesia. However, these techniques are laborious and technically challenging.
Any approach toward regional anesthesia requires an understanding of the relevant anatomy. The SPB has been described as a technique to obtain regional thoracic anesthesia through blockade of the intercostal nerves at the level of T2–T12. USG of the relevant anatomy of the thoracic wall has revealed two potential spaces for injection, superficial, and deep to SA. The lateral cutaneous branches of intercostal nerves can be targeted as they traverse these planes. During the extensive dissection in surgery, the surgeon is at an advantage of constant visualization of the intercostal nerves and the interfascial plane.,
USG-guided block has a steeper learning curve and requires a higher degree of skill to perform a successful block. Blanco et al. proposed SPB as an alternative to PVB for surgeries on the anterior and lateral thoracic wall, including breast surgeries. Patients who were administered LA anterior to SA were found to have long-lasting paresthesias and dermatomal blockade from T2 to T9 with no side effects.
Mayes et al., in their cadaveric study, concluded that anesthesia of the superficial structures of the lateral thorax and axilla can provide excellent analgesia for axillary dissection.
Infiltration of LA along the suture line has shown to provide analgesia for marginal lesions. This method may not be recommended because of the fear of needle track seedlings and the cutaneous spread of malignancy. USG-guided interfascial blocks such as PECS or SPB may pose a risk of blindly seeding the malignant cells with the needle into the tissues. Surgeon giving the block in the interfascial plane between SA and LD after the removal of tumor under vision will eliminate the risk of tumor seeding into the tissues.
In this case series, we did not require to administer rescue analgesia in the postoperative period, and we can comment that the average time for pain relief by this technique is more than 24 h as reflected in the data.
None of our patients required rescue analgesia, and there was no incidence of any form of complications. The average time of pain relief in all the cases was more than 24 h as we observed for that period only. This suggests that interfascial plane block has the potential to be an excellent analgesic technique without the assistance of an USG and the skill for regional anesthesia.
Surgeon-assisted interfascial plane block has provided adequate analgesia in our subsets of patients undergoing MRM, but a randomized controlled trial with a larger sample size preferably a comparative study with other standard techniques with an observation period till the requirement of the first dose of rescue analgesia is recommended to substantiate the findings of this study and to establish it as an alternative option to the other techniques for providing long-lasting postoperative analgesia.
| Conclusion|| |
This technique of regional block is an effective modality in achieving prolonged analgesic duration with its inherent opioid-sparing effect. Surgeon-assisted interfascial plane block offers significant additional advantage in terms of prolonged postoperative pain relief and obviating the complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ferlay J, Colombet M, Soerjomataram I, Mathers C, Parkin DM, Pineros M, et al
. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer 2019;144:1941-53.
Gupta S. Breast cancer: Indian experience, data, and evidence. South Asian J Cancer 2016;5:85-6.
] [Full text]
Sharma DC. Cancer data in India show new patterns. Lancet Oncol 2016;17:e272.
Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: Results from a US national survey. Curr Med Res Opin 2014;30:149-60.
Chakraborty A, Khemka R, Datta T. Ultrasound-guided truncal blocks: A new frontier in regional anaesthesia. Indian J Anaesth 2016;60:703-11.
] [Full text]
Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: A novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013;68:1107-13.
Tighe SQ, Karmakar MK. Serratus plane block: Do we need to learn another technique for thoracic wall blockade? Anaesthesia 2013;68:1103-6.
Biswas A, Castanov V, Li Z, Perlas A, Kruisselbrink R, Agur A, et al
. Serratus plane block: A cadaveric study to evaluate optimal injectate spread. Reg Anesth Pain Med 2018;43:854-8.
Southgate SJ, Herbst MK. Ultrasound guided serratus anterior blocks. In: Stat Pearls. Treasure Island, FL: Stat Pearls Publishing; 2020.
Kumar S, Goel D, Sharma SK, Ahmad S, Dwivedi P, Deo N, et al
. A randomised controlled study of the post-operative analgesic efficacy of ultrasound-guided pectoral nerve block in the first 24 h after modified radical mastectomy. Indian J Anaesth 2018;62:436-42.
] [Full text]
Farias-Eisner G, Kao K, Pan J, Festekjian J, Gassman A. Intraoperative techniques for the plastic surgeon to improve pain control in breast surgery. Plast Reconstr Surg Glob Open 2017;5:e1522.
Andersen KG, Kehlet H. Persistent pain after breast cancer treatment: A critical review of risk factors and strategies for prevention. J Pain 2011;12:725-46.
Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. Efficacy and safety of paravertebral blocks in breast surgery: A meta-analysis of randomized controlled trials.Br J Anaesth 2010;105:842-52.
Mayes J, Davison E, Panahi P, Pattten D, Eljelani F, Womack J, et al
. An Anatomical evaluation of the serratus anterior plane block. Anaesthesia 2016;71:1064-9.
Uematsu T, Kasami M. Risk of needle tract seeding of breast cancer: Cytological results derived from core wash material. Breast Cancer Res Treat 2008;110:51-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]