|Year : 2022 | Volume
| Issue : 5 | Page : 65-67
Modified radical mastectomy under paravertebral block in a patient diagnosed with active pulmonary tuberculosis with moderate restriction of pulmonary function
Mohammad Abuzahid Uns, Dyva Manogna Reddypogu, M Sneha Valli
Department of Anaesthesiology, Kurnool Medical College, Kurnool, Andhra Pradesh, India
|Date of Submission||29-Dec-2021|
|Date of Decision||23-Apr-2022|
|Date of Acceptance||05-May-2022|
|Date of Web Publication||30-Aug-2022|
Dyva Manogna Reddypogu
Assistant Professor, H. No. 87/684-A, Maruthi Nagar, Kurnool- 518 002, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Mastectomy is mostly performed as definitive management for resectable breast cancer (BC). Implementing paravertebral nerve block for patients with metastasis features of cancer to lungs and other organs, patients with co-morbidity, geriatrics and malnourished individuals will eliminate the risks and complications of general anaesthesia (GA). Although thoracic paravertebral block is an established technique as post-operative pain management for breast surgery, there is no conclusive evidence on its use as a sole anaesthetic for modified radical mastectomy (MRM). In this case report, we present a 45-year-old woman who underwent a successful MRM for Stage IIIb BC associated with pulmonary tuberculosis with moderately restricted pulmonary function test under paravertebral nerve block. We believe that paravertebral nerve block can be used as an alternative anaesthetic technique for MRM in a resource-limited setting for patients who are expected to have a high risk of perioperative complications under GA.
Keywords: Breast cancer, high-risk patients, pain relief, paravertebral block, post-operative care, post-operative nausea vomiting
|How to cite this article:|
Uns MA, Reddypogu DM, Valli M S. Modified radical mastectomy under paravertebral block in a patient diagnosed with active pulmonary tuberculosis with moderate restriction of pulmonary function. J Clin Sci Res 2022;11, Suppl S1:65-7
|How to cite this URL:|
Uns MA, Reddypogu DM, Valli M S. Modified radical mastectomy under paravertebral block in a patient diagnosed with active pulmonary tuberculosis with moderate restriction of pulmonary function. J Clin Sci Res [serial online] 2022 [cited 2022 Oct 6];11, Suppl S1:65-7. Available from: https://www.jcsr.co.in/text.asp?2022/11/5/65/355065
| Introduction|| |
General anaesthesia (GA), which is the frequently used type of anaesthesia for breast surgery, is considered as the main cause of perioperative complications, and the risk of nausea and vomiting is estimated to be 50%.,,, Thoracic paravertebral block (TPVB) is one of the options for intraoperative and post-operative pain management for patients who undergo breast surgery. Furthermore, studies also suggested that TPVB attenuates perioperative immunosuppression and decrease cancer metastasis.,,,,,
TPVBs provide extensive anaesthesia and analgesia for breast procedures with reduced post-operative nausea and vomiting, and hence an attractive alternative to GA. TPVB has been described in pain relief from rib fractures, herpes zoster and pleurisy. In experienced hands, TPVB is one among regional anaesthetic techniques for modified radical mastectomy (MRM) that is considered to be relatively safe, easy to perform with lower drug dosage and minimal haemodynamic alterations.
TPVB involves eliciting loss of resistance. At the appropriate dermatome under aseptic precautions, the nerve block needle is inserted 2.5cm–3 cm lateral to the most cephalad aspect of the spinous process and advanced perpendicular to the skin in all planes to contact the transverse process. The needle is then withdrawn to the skin and reintroduced 1 cm beyond the transverse process until a loss of resistance is felt, allowing the positioning of the needle past the transverse process. After gentle aspiration, local anaesthetic (LA) will be injected. The median skin-to-paravertebral depth has been demonstrated to be 55.0 mm, with the depth being greater at the upper (T1–T3) and lower (T9–T12) thoracic levels.
| Case Report|| |
A 45-year-old female patient presented with a left side breast lump of 1-month duration associated with intermittent pain. Stage IIIB breast cancer (BC) was diagnosed and confirmed with fine-needle aspiration cytology. She was also diagnosed with de novo type 2 diabetes mellitus (T2DM) and active pulmonary tuberculosis (TB) with pulmonary function testing (PFT) showing moderate restriction. She was scheduled for MRM. On presentation, her vital signs were blood pressure (BP), 110/70 mmHg; pulse rate (PR), 84 beat/min; respirations, 18 breaths/min and oxygen saturation measured with pulse oximeter (SPO2), 100%. Chest examination revealed a decreased air entry in the lower 1/3 of both lung fields. Otherwise, there were no pertinent finding on cardiovascular and other systemic examinations. A thorough pre-operative airway assessment was done and she was found to have Mallampati class II, with adequate mouth opening.
Summary of pre-operative laboratory findings was normal. Chest X-ray showed bilateral hilar lymphadenopathy. High-resolution computed tomography of the chest showed mosaic attenuation in the left lung and atelectatic bands in the right middle lobe and left lower lobe. Sputum Xpert MBT/RIF® testing detected Mycobacterium tuberculosis. Electrocardiography (ECG) was normal. Two-dimensional echocardiography was normal with a left ventricular ejection fraction of 55%.
Preoperatively, a risk–benefit analysis of doing and deferring the surgery was discussed in detail between the general surgeon and the consultant anesthetist in charge. Then, written informed consent was obtained for both surgery and anaesthesia as per the hospital's protocol. The patient was premedicated with midazolam (1 mg) and glycopyrrolate (0.2 mg). The available standard monitors (non-invasive blood pressure, pulse oximetry and electrocardiogram) were attached and the values for baseline vital signs were within the normal range (blood pressure 118/88 mmHg, pulse 98 beats/min, respirations 13 breaths/min and SPO2 100%).
In the sitting position, the needle insertion sites were marked 2.5 cm lateral to the spinous processes of T3, T5 and T7 for the right side anatomic landmark technique TPVB. The site was cleaned using iodine and alcohol. Local infiltration of the site of needle insertion by 2% plain lidocaine, a 21 gauge ×50 mm nerve block needle was introduced perpendicularly at each marked site. When the tip of the needle encountered the transverse process, it was redirected cephalad, and immediately after appreciating the loss of resistance, the LA agent was injected. The block was done using 5 mL of 0.5% isobaric bupivacaine at each level (a total of 15 mL). Twenty minutes after the block, the extent of the sensory loss was assessed by pinprick testing, and it was successful that the surgical procedure started. Oxygen, was delivered via nasal prongs at 3 L/min throughout the procedure. There was no significant derangement in vital signs during incision and intraoperative time.
MRM was done successfully without any apparent anaesthesia or surgery-related complication. The total duration of surgery and anaesthesia were 90 and >120 min, respectively. The total surgical blood loss was about 600 mL and the patient was transfused 1 unit of cross-matched whole blood. During the intraoperative time, 1000 mL of normal saline was infused and her total urine output was 350 mL. Postoperatively, she was followed at the post-anaesthesia care unit (PACU) for the first 2 h, and then at the surgical ward until she was discharged home. The whole post-operative period was uneventful, and she is on continuous follow-up for chemotherapy.
| Discussion|| |
TPVB is the technique of injecting LA alongside the thoracic vertebra close to where the spinal nerves emerge from the intervertebral foramen. This produces unilateral, segmental, somatic and sympathetic nerve blockade, which is effective for anaesthesia and in treating acute and chronic pain of unilateral origin from the chest and abdomen.
Alternative techniques for MRM are as follows. High thoracic epidural anaesthesia has been the alternative to GA for surgery of the thorax, chest wall and axilla. However, despite providing good operative conditions, thoracic epidural blockade can be associated with hypotension, bradycardia and cardiac arrest from bilateral sympathetic, blockade and other physiologic reflexes. In addition, post-operative analgesia via a thoracic epidural continuous infusion requires increased monitoring in the post-operative period. Analgesia from an epidural technique is also limited when the infusion is discontinued, which is not the case for PVB. PVB requires no continuous infusion to maintain post-operative analgesia for a mean of 18 h when bupivacaine 0.5% with epinephrine was the LA of choice.
In a study on continuous thoracic epidural anaesthesia with 0.2% ropivacaine versus GA for perioperative management of MRM it was reported that GA for MRM led to nausea and vomiting, pain, cardiovascular instability and delayed home discharge of study participants. They concluded that TEA with ropivacaine provides better post-operative pain relief and less nausea and vomiting, facilitates post-anaesthesia recovery and gives greater patient satisfaction than GA.
Although TPVB and GA are often combined for MRM, for some patients, GA is either contraindicated or undesirable due to factors including frailty, co-morbidities, anxiety and patient choice. In our case, since the BC was associated with active pulmonary TB and T2DM, it was better to avoid GA; a decision was made to perform the surgery using multiple injection TPVB as it decreases the possible intraoperative and post-operative complications associated with GA.
Epidural and TPVB blocks are commonly performed as intraoperative anaesthesia or analgesia and post-mastectomy pain control. For breast surgery, a paravertebral block is usually performed between thoracic spinal nerves two (T2) and six (T6) with either single or multiple injection techniques. It can be performed in lateral, sitting or prone position using the anatomic landmark technique or ultrasound guidance.
TPVB for mastectomies has shown that it is a promising option in providing a comfortable surgical field in addition to reducing the complications and risks of GA. Furthermore, it is associated with minimal hemodynamic instability and early discharge from hospital with reduced cost of the treatment. TPVB can be used as an alternative anaesthesia technique for MRM for patients who have a high risk of perioperative complication under GA.
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|| |
Quinn AC, Brown JH, Wallace PG, Asbury AJ. Studies in postoperative sequelae. Nausea and vomiting – Still a problem. Anaesthesia 1994;49:62-5.
Richardson J, Sabanathan S. Thoracic paravertebral analgesia. Acta Anaesthesiol Scanda 1995;39:1005-15.
Mandl F. Paravertebral block. New York: Grune and Stratton; 1947.
Weltz CR, Greengrass RA, Lyerly HK. Ambulatory surgical management of breast carcinoma using paravertebral block. Ann Surg 1995;222:19-26.
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.
Warltier DC. Thoracic paravertebral block. Anesthesiology 2001;95:771-80.
Edge J, Buccimazza I, Cubasch H, Panieri E. The challenges of managing breast cancer in the developing world – A perspective from sub-Saharan Africa. S Afr Med J 2014;104:377-9.
Abebe E, Demilie K, Lemmu B, Abebe K. Female breast cancer patients, mastectomy-related quality of life: Experience from Ethiopia. Int J Breast Cancer 2020;2020:8460374.
Kulkarni KR. Single needle thoracic paravertebral block with ropivacaine and dexmeditomidine for radical mastectomy: Experience in 25 cases. Int J Anesthesiol Pain Med 2016;2:1-6.
Gudaitytė J, Dvylys D, Šimeliūnaitė I. Anaesthetic challenges in cancer patients: Current therapies and pain management. Acta Med Litu 2017;24:121-7.
Coveney E, Weltz CR, Greengrass R, Iglehart JD, Leight GS, Steele SM, et al
. Use of paravertebral block anesthesia in the surgical management of breast cancer: experience in 156 cases. Ann Surg 1998;227:496-501.
Doss NW, Ipe J, Crimi T, Rajpal S, Cohen S, Fogler RJ, et al
. Continuous Thoracic Epidural Anesthesia with 0.2% Ropivacaine Versus General Anesthesia for Perioperative Management of Modified Radical Mastectomy. Anesthesia & Analgesia: 2001;92:1552-7.