RevBrasAnestesiol.2019;69(3):307---310
REVISTA
BRASILEIRA DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologia www.sba.com.brCLINICAL INFORMATION
Ultrasound guided erector spinae plane block for postoperative analgesia after augmentation
mammoplasty: case series
Bas ¸ak Altıparmak
a,∗, Melike Korkmaz Toker
b, Ali ˙Ihsan Uysal
b, Semra Gümüs ¸ Demirbilek
aaMu˘glaSıtkıKoc¸manUniversity,DepartmentofAnesthesiologyandReanimation,Mu˘gla,Turkey
bMu˘glaSıtkıKoc¸manUniversity,TrainingandResearchHospital,DepartmentofAnesthesiologyandReanimation,Mu˘gla,Turkey
Received2July2018;accepted16November2018 Availableonline3January2019
KEYWORDS Analgesia;
Augmentation mammoplasty;
Erectorspinaeplane block;
Postoperativepain;
Peripheralblock
Abstract
Augmentationmammoplastyisthethirdmostfrequentlyperformedestheticsurgicalprocedure worldwide.Breastaugmentationwithprostheticimplantsrequirestheinsertionofanimplant underbreasttissue,whichcausesseverepainduetotissueextensionandsurgicaltraumato separatedtissues.Inthiscaseseries,wepresentthesuccessfulpainmanagementofsixpatients withultrasound-guidedErectorSpinae Planeblock afteraugmentation mammoplasty.Inthe operating room,all patientsreceived standardmonitoring. Whilethe patientswere sitting, theanesthesiologistperformedbilateralultrasound-guidederectorspinaeplaneblockatthe levelofT5.Bupivacaine(0.25%,20mL)wasinjecteddeeptotheerectorspinaemuscle.Then, inductionofanesthesiawasperformedwithpropofol,fentanyl,androcuroniumbromide.All patients receivedintravenousdexketoprofentrometamolfor analgesia.Themean operation timewas72.5◦±6minandnoneofthepatientsreceivedadditionalfentanyl.Themeanpain scores ofthe patients were 1, 2, 2, and2 atthe postoperative 5th, 30th,60th and120th minutes,respectively.Atthepostoperative24thhour,themeanNumericalRatingScalescore was1.Themeanintravenoustramadolconsumptionwas70.8±15.3mginthefirst24h.None ofthepatientshadanycomplicationsrelatedtoerectorspinaeplaneblock.
©2018SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by- nc-nd/4.0/).
PALAVRAS-CHAVE Analgesia;
Mamoplastiade aumento;
Bloqueiodoplano eretordaespinha;
Bloqueiodoplanoeretordaespinhaguiadoporultrassomparaanalgesia pós-operatóriaemmamoplastiadeaumento:sériedecasos
Resumo
A mamoplastiadeaumento éoterceiro procedimentocirúrgico estéticomaisrealizado em todo o mundo.A cirurgia comimplantes protéticos requera inserc¸ão de um implantesob otecidomamário, oquecausador intensadevidoàextensãodotecidoetrauma cirúrgico
∗Correspondingauthor.
E-mail:basakugurlu@yahoo.com(B.Altıparmak).
https://doi.org/10.1016/j.bjane.2018.12.008
0104-0014/©2018SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
308 B.Altıparmaketal.
Dorpós-operatória;
Bloqueioperiférico
aostecidosseparados.Nestasériedecasos,apresentamosomanejobem-sucedidodadorem seispacientescombloqueio doplanoeretordaespinhaguiado porultrassom(US-ESP)após mamoplastiadeaumento.Nasaladecirurgia,todasospacientesreceberammonitoramento padrão. Enquanto aspacientesestavam sentadas, o anestesiologistafez obloqueio US-ESP bilateralnoníveldeT5.Bupivacaína(0,25%,20mL)foiinjetadaentreosmúsculosromboide maioreeretordaespinha.Emseguida,ainduc¸ãoanestésicafoifeitacompropofol,fentanil erocurônio.Todasaspacientesreceberamdexcetoprofenotrometamolporviavenosapara analgesia.Otempomédiodeoperac¸ãofoide72,5±6minutosenenhumadaspacientesrecebeu fentaniladicional.Osescoresmédiosdedordaspacientesforam1,2,2e2no5◦,30◦,60◦e120◦ minutosdepós-operatório,respectivamente.No24◦diadepós-operatório,oescoremédioda EscaladeAvaliac¸ãoNumérica(NRS)foi1.Oconsumomédiodetramadolfoide40±33,4mgnas primeiras24horas.Nenhumadaspacientesapresentoucomplicac¸õesrelacionadasaobloqueio US-ESP.
©2018SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by- nc-nd/4.0/).
Introduction
Augmentation mammoplasty withbreast prosthesis is the thirdmostfrequentlyperformedestheticsurgicalprocedure worldwide.Animplantisinsertedunderbreasttissueinthis procedure. There are three implant insertion approaches according to the level of pectoralis major muscle; subg- landular insertion, subpectoral insertion, and dual plane.
Subpectoralinsertioncausesextensionofbreasttissueand the pectoralis major muscle and leads to damage of the separatedtissue.Consequently,severe painisseen inthe postoperativeperiod.1
Todate,differentpostoperativepainmanagementtech- niques,includingmodified pectoralblocks,2 paravertebral block3orintercostalblocks1havebeenreportedafterbreast surgery.However,thereisstillnoconsensusontheoptimum approach.
In this case series, we present the successful pain managementofsixpatientswithUltrasound-guidedErector SpinaePlane (US-ESP) block after augmentation mammo- plastywiththesubpectoralinsertionapproach.
Case reports
We selected six patients who were American Society of Anesthesiologists Grade 1 or 2, aged between 29 and 41 years, and scheduled for an augmentation mammoplasty with prosthetic implants. Written informed consent was obtainedfrom allparticipants to reportthe cases.In the operatingroom,all patientsreceivedstandard monitoring includingelectrocardiography,non-invasivebloodpressure, peripheral oxygensaturation, and bi-spectralindex moni- toring.Aftertheplacementofa22gaugeintravenousline, allpatientsreceived0.05mg.kg−1midazolamforsedation.
Whilethepatientsweresitting,theanesthesiologistplaced ahigh-frequencyultrasoundprobeinlongitudinal orienta- tionat the level of T5 spinous processand 3cm laterally fromthemidlinetothesideinvolvedinthesurgery(Fig.1).
Trapezius M Rhomboid major M Erector spinae M
Figure1 High-frequencyultrasoundprobeinlongitudinalori- entation.
Underasepticconditions,an80mm21gaugeblockneedle wasinsertedin-planeinthecranial-to-caudaldirectionuntil thetipcontactedtheT5transverseprocess(Fig.2).After thehydrodissectionwith2---3mLofisotonicsalinesolution, 25mLof0.25%bupivacainewasinjecteddeeptotheerec- torspinaemuscle(Fig.3).Thesameprocedurewasrepeated with25mlof0.25%bupivacaineatthecontralateralside.
The patients werethen placed in thesupine positionand the anesthesiologistperformed induction of general anes- thesia with2---3mg.kg−1propofol,1mcg.kg−1 fentanyland 0.6mg.kg−1rocuroniumbromide.AftertheBISscoreofeach patient was between 40 and 60, the patients were intu- bated.Weused4%---6%desfluraneina40%oxygen60%N2O
Erectorspinaeplaneblockforanalgesiaofaugmentationmammoplasty 309
Lokal anesthetic
Figure2 Lokalanesthetic.
Longitudinal lokal anesthetic spreading
Figure3 Bupivacainewasinjecteddeeptotheerectorspinae muscle.
mixture.Allpatientsreceivedintravenous4mgondansetron forpostoperativenauseaandintravenous75mgdexketopro- fentrometamolforanalgesia.Attheendoftheoperation, patientsweresenttotherecoveryroomwheretheywere assessed for postoperative pain using a Numeric Rating Scale(NRS).Intherecoveryroom,thepatientsreceiveda Patient-ControlledAnalgesia(PCA)deviceforpostoperative analgesia(10mgbolusdosewitha20minlock-timeandno basalinfusion).After30min,theyweresenttothesurgical ward.Thepainassessment ofthepatients wasperformed duringmovementatthepostoperative1sthour,2ndhour,6th hour, 12th hour, and 24th hour using theNRS in the surgi- calward.WhentheNRSscoreduringcoughingwas≥4,the patientswereplannedtoreceiveintravenousmorphine4mg asrescueanalgesic.
Themeanoperation timewas72.5±6min andnoneof thepatientsreceivedadditionalfentanylduring theoper- ation. The mean pain scores of the patients were 1.2 (min. 0, max. 2), 1.6±1 (min. 0, max. 3), 2±0.9 (min.1,max.3)and2.3±0.5(min.2,max.3)atthepost- operative 5th, 30th, 60th, and 120th minutes, respectively.
At the postoperative 12th hour, the mean NRS score was 3.1±0.7 (min. 2, max. 4) and at the 24th hour 0.8±0.7 (min. 0, max. 2). The mean intravenous tramadol con- sumptionwas70.8±15.3mgin thefirst24h.None ofthe patientsrequired rescueanalgesiain thefirst24hand no complicationsrelatedtoUS-ESPblockwereseen.
Discussion
US-ESP block is a myofascial plane block that provides analgesia of the thoracic or abdominal segmental inner- vations depending on the level of injection site.4 US-ESP block hasbeen reportedto successfully reduce postoper- ative pain after modified radical mastectomy.5 However, therearenodatainthecurrentliteratureaboutitseffec- tivenessafteraugmentationmammoplasty.Afterinjection fromthe level of T5 transverse process, local anesthetic spreads in a craniocaudal pattern over several levels.
Local anesthetic is also known to penetrate anteriorly throughthe costotransverse foramina and enter the tho- racic paravertebral space where it can block the ventral and dorsal rami of spinal nerves and also the rami com- municantes.Therefore,itcan bedescribed asan indirect paravertebralblockwiththeadvantageof simpleidentifi- cationoftheultrasoundlandmarks,andpotentiallyasafer procedure.6
Inour patients,preoperative US-ESP blockmanaged to attenuatepostoperativepain.Themeantramadolconsump- tioninthepostoperativefirst24hwasonly40mg.However, thepainscores of some patients was3 inthe early post- operativeperiod.Innervation of thebreastis providedby branchesofthethoracic,humeral,andintercostalnerves.
Intercostal nerves from the second to the sixth supply branchestothebreast.Thenervesupplytothenippleand areolais a deep branch fromthe anterior divisionof the fourthlateralcutaneous nerve.Itpasses throughthesub- dermal tissue of the areola toform a plexus underneath it.Theskininnervationofbreastisprovidedbyperipheral nervoussystem originatingfromdorsal root ganglia.7 In a recentcadaveric study,Ivanusic etal.8 performed US-ESP blockwith20mLof0.25%methylenebluedyeandassessed thespreadofdye.Theauthorsreportedthatthedyespread laterallydeeptotheiliocostalismusclein75%---80%ofcases.
However,thedye spread didnot involvetheventral rami ortheparavertebral space.Similarly, Ueshimaetal.9doc- umented two cases of inadequate analgesia after breast cancersurgery.Theyreportedthattheblockdidnotreach theanteriorbranchesofT2---T6.Thelackoflocalanesthetic spreadingtotheventralbranchesislikelytobethereasonof postoperativepaininourpatients.Besideitsanalgesiceffi- cacy,US-ESPis alsobelievedtohaveless potentialriskof complicationsduetotheinjectionsite.However,Ueshima etal.alsoreportedapatientwithpneumothoraxafteruni- lateralUS-ESP.10Althoughnoneofourpatientsexperienced
310 B.Altıparmaketal.
anycomplicationsaftertheintervention,patientsshouldbe closelyfollowedupaftersurgery.
ModifiedPectoralNerveBlock(PECS)isanotherpopular analgesicapproachforanalgesiaafteraugmentationmam- moplasty.Karacaetal.assessedtheefficacyofUltrasound guided-PECSIandIIblocksforanalgesiaafteraugmentation mammoplastyand reported that PECS block wassuperior than no-intervention group.11 Besides, Ultrasound-guided PECS block has the advantage of being performed after the induction of anesthesia. However, US-ESP is mostly performed in the sitting position before the induction of anesthesia, which may cause a stress effecton patients.
Recently, we compared the effectiveness of PECS block and US-ESP block for postoperative analgesia of radical mastectomy surgery in a randomized-controlled study.12 We found that PECS block reduced postoperative pain scores and tramadolconsumption more significantly then US-ESP block. On the other hand, anesthesiologists tend toinjecta largervolumeoflocal anestheticagentduring Ultrasound-guidedPECSblock.Atotalof60mL(30mLlocal anesthetic agent+30mL saline mixture) is applied during PECSblock,and40mL(20mLlocalanestheticagent+20mL saline solution) is applied during US-ESP block. Besides, US-ESP block is performed away from the surgical site.
The technique is easy and safe. However,larger sizes of breastsmaycausedifficultyinultrasoundimagingandblock techniqueduring PECS block. In the end, both peripheral blocksappeartobe effective inproviding analgesiaafter augmentationmammoplasty.
Funding
The researchers did not receive any funds during the study.
Conflicts of interest
Theauthorsdeclarenoconflictsofinterest.
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