|LETTERS TO EDITOR
|Year : 2019 | Volume
| Issue : 3 | Page : 420-421
Continuous erector spinae plane block as an anesthetic technique for breast cancer surgery
Raghu S Thota, Dipannita Mukherjee
Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, (Homi Bhabha National Institute), E Borges Road, Parel, Mumbai, Maharashtra, India
|Date of Web Publication||3-Sep-2019|
Dr. Raghu S Thota
Department of Anaesthesia, Critical Care and Pain, Tata Memorial Centre, (Homi Bhabha National Institute), E Borges Road, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Thota RS, Mukherjee D. Continuous erector spinae plane block as an anesthetic technique for breast cancer surgery. J Anaesthesiol Clin Pharmacol 2019;35:420-1
|How to cite this URL:|
Thota RS, Mukherjee D. Continuous erector spinae plane block as an anesthetic technique for breast cancer surgery. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2019 Sep 20];35:420-1. Available from: http://www.joacp.org/text.asp?2019/35/3/420/265904
We report a case of successful erector spinae plane (ESP) block using a continuous catheter anesthetic technique for a modified radical mastectomy (MRM).
A 49-year-old woman, New York Heart Association II, with history of ostium secundum atrial septal defect with pulmonary hypertension, diagnosed incidentally 7 years back, was scheduled for right sided MRM. Her two-dimensional echocardiogram reported left to right shunt with significant right atrium, ventricle volume overload, and severe functional tricuspid regurgitation with right ventricular systolic pressure of 45 mm Hg. The cardiologist stratified the risk to be very high under general anesthesia. Thus, a continuous ESP block under USG guidance was planned for this patient.
The patient was explained about procedure, and consent was taken. A wide bore intravenous (IV) cannula (18-Guage) was taken in induction room, and standard monitoring was attached. Under all aseptic precautions, in sitting position, ultrasound (M-Turbo®, FUJIFILM SonoSite, Inc.) guided right sided ESP was carried out using a linear (L38xi, 10–5 MHz) probe and in plane needling technique by 18-gauge Tuohy needle at the level of T6 vertebra, in parasagital plane approximately 2.5 cm from the midline [Figure 1]. Twenty ml of 0.5% bupivacaine was injected and an 18-gauge epidural catheter inserted. Midazolam 1.5 mg and fentanyl 100 μg were given IV and oxygen at 2 L/min using nasal prongs. After around 30 min, 10 ml of 2% lignocaine was given through ESP catheter. After 15 min, the surgical incision site (with dermatomes from T3-T8) was checked for any painful response. The patient had a mild painful sensation at the inferior flap of surgical incision at T6 level. We gave 20 mg of ketamine IV, on a precautionary note, and rest of the surgery went on without any hindrance. Because we had used a very low sub anesthetic dose of ketamine, this dose does not have any effects on systemic vascular resistance, which is a real concern in a patient with ASD. The surgery lasted for 1 h 30 min. At time of closure, there was mild pain, thus 15 mg of ketamine was given IV. The procedure was uneventful, and vitals were stable during and at the end of the surgery. On arrival to recovery room, her pain scores according to numerical rating scale (NRS) were 2/10 at rest and 3/10 on movement. She was given injection paracetamol 1gm IV stat, and tablet tapentadol 50 mg was advised SOS. Thereafter, 10 cc of 0.5% bupivacaine (because we were giving bolus doses, we wanted to achieve a dense block with 0.5% concentration) was given every 8 h for 24 h through the ESP catheter. The patient did not require any rescue analgesic for 24 h.
|Figure 1: USG image showing the erector spinae plane for local anesthetic deposition|
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Her pain scores on NRS were 0 and 1 out of 10 at rest and movement, respectively on postoperative day 1, and catheter was removed. She was discharged from hospital with tablet paracetamol 1mg every 8 h.
Although paravertebral blocks are commonly employed for anesthetic management of breast cancer surgeries, this novel technique was described by Forero Met al. for management of thoracic neuropathic pain; we have used this technique as a sole anesthetic for management of breast cancer surgery. This was clearly demonstrated in our patient, where we employed a continuous catheter technique inserted in the ESP to achieve anesthesia for the T3 to T8 dermatomes.
In recent years, there has been a lot of literature supporting the use of fascial plane blocks, which target the dorsal, lateral, and anterior cutaneous nerves of the thorax and abdomen, which include the transversus abdominis plane block2, rectus sheath block, quadratus lumborum block, PECS block, serratus plane block, retrolaminar block, and now the newer ESP block.
The effect of analgesic and anesthetic is due to the diffusion of LA into the paravertebral space, in addition to its effect at the rami communicantes that supply the sympathetic chain. As per the study done by Adhikary DSet al., there was a spread of the dye to neural foramina and epidural space. In a pooled review of 242, ESP block appeared to be a safe and effective option for multiple types thoracic, abdominal, and extremity surgeries.
This novel technique has the potential to benefit patients who are at risk with general anesthesia. This can also reduce postoperative opioid consumption for analgesia. Unlike PECS block, there was no hindrance to use of electrocautery intraoperatively, and in addition, the risk of pneumothorax is almost nil compared to paravertebral blocks as the local anesthetic is deposited posterior to the transverse process. There may be limitations for using this technique, as it may not be able to block the anterior branches of intercostal nerve and have some medial as well as mild axillary sparring anesthesia. Thus, these blocks need to be supplemented with additional IV analgesics or an additional block in the form of PECS.
Thus, we conclude ESP block is a good alternative to other regional block techniques for providing anesthesia as well as analgesia with minimal skills and complications. In addition, ESP requires an additional evaluation as a randomized study to evaluate its true potential with respect to benefits and complications.
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.
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Tsui BCH, Fonseca A, Munshey F, McFadyen G, Caruso TJ. The erector spinaeplane (ESP) block: A pooled review of 242 cases. J ClinAnesth 2019;53:29-34.
Ueshima H, Otake H. Limitations of the erector spinaeplane (ESP) block for radical mastectomy. J ClinAnesth 2018;51:97-8.[Figure 1]: USG image showing the erector spinae plane for local anesthetic deposition