Ambulatory Breast Surgery.pdf
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Regional Anesthesia In breast surgery Javier Webar | McGill University
Reg Anesth Pain Med 2017;42: 609–631
Erector Spinae Block
Reg Anesth Pain Med 2017;42: 609–631
Anesthesiology 2015; 123:459-74
•
•
Alternative to thoracic epidural analgesia with equivalent analgesia. -
Can be placed in awake, sedated or GA patient.
-
Advantages = Unilateral block, less hypotension, pruritus and urinary retention.
Risk of pneumothorax (~ 0.5%) and bleeding complications. -
•
Must follow similar guidelines regarding anticoagulation therapy/prophylaxis.
Ultrasound vs Landmarks Technique (Patnaik et al. RAPM, 2018) -
Increase success with US (94 vs 72%).
-
More dermatomes blocked with US after single–shot.
Anesthesiology 2015; 123:459-74
PARASAGITAL VIEW
2–5 MHz
20–25 mL of LA (single shot)
Anterior displacement of the pleura
TRANSVERSE VIEW
2–5 MHz
ed (ne
le)
Visualize TIP to avoid epidural spread!
20–25 mL of LA (single shot)
Anterior displacement of the pleura
Reg Anesth Pain Med 2017;42: 575–581
•
Single–level injections at T2–T4.
•
40–80% reduced opioid consumption during the first 24 hrs.
•
Lower pain scores during the first 12 hrs.
•
Lower incidence of PONV (RR 0.27).
•
Significantly shorter hospital stay, with 28% of same day discharge (versus 11% with GA).
•
Complication rate < 2.6%, most commonly hypotension secondary to epidural spread.
Reg Anesth Pain Med 2017;42: 609–631
•
Found 6 complications in 856 patients (0.70%).
•
No pneumothorax.
•
Four cases of hypotension & bradycardia.
•
Two suspected LAST.
•
One cardiac arrest with successful resuscitation.
•
All surgeries proceeded as planned.
Anesth Analg 2016;122:1186–91
CAN’T SEE THE SCTL? …you are not alone.
“Paravertebral by Proxy”
Anaesthesia 2018, 73, 1185–1188
“Consistently achieved spread of dye at least to the paravertebral space at the level of injection, and frequently to adjacent levels”.
•
Injection in the musculofascial plane deep to the erector spinae muscles and superficial to the transverse process.
•
Blockade of the ipsilateral thoraco–lumbar spinal nerves.
•
May work by LA spread to the paravertebral space through the ligamentous complex.
•
Single injection at T5 can produce extensive analgesia of the ipsilateral thoracic wall.
•
Alternative to TEA/TPVB when refused/unsafe/not–feasable, such as the anticoagulated pt.
•
No efficacy/dose finding RCT available.
LATERAL
MEDIAL
Rib
Transverse Process
Anechoic “band” between ESM and TV (ESP)
Reg Anesth Pain Med 2018;43: 567–571
TP T4 20 mL of Levobupivacaine 0.25%
Journal of Clinical Anesthesia 50 (2018) 65–68
THANK YOU QUESTIONS?
Reg Anesth Pain Med 2017;42: 609–631
Erector Spinae Block
Reg Anesth Pain Med 2017;42: 609–631
Anesthesiology 2015; 123:459-74
•
•
Alternative to thoracic epidural analgesia with equivalent analgesia. -
Can be placed in awake, sedated or GA patient.
-
Advantages = Unilateral block, less hypotension, pruritus and urinary retention.
Risk of pneumothorax (~ 0.5%) and bleeding complications. -
•
Must follow similar guidelines regarding anticoagulation therapy/prophylaxis.
Ultrasound vs Landmarks Technique (Patnaik et al. RAPM, 2018) -
Increase success with US (94 vs 72%).
-
More dermatomes blocked with US after single–shot.
Anesthesiology 2015; 123:459-74
PARASAGITAL VIEW
2–5 MHz
20–25 mL of LA (single shot)
Anterior displacement of the pleura
TRANSVERSE VIEW
2–5 MHz
ed (ne
le)
Visualize TIP to avoid epidural spread!
20–25 mL of LA (single shot)
Anterior displacement of the pleura
Reg Anesth Pain Med 2017;42: 575–581
•
Single–level injections at T2–T4.
•
40–80% reduced opioid consumption during the first 24 hrs.
•
Lower pain scores during the first 12 hrs.
•
Lower incidence of PONV (RR 0.27).
•
Significantly shorter hospital stay, with 28% of same day discharge (versus 11% with GA).
•
Complication rate < 2.6%, most commonly hypotension secondary to epidural spread.
Reg Anesth Pain Med 2017;42: 609–631
•
Found 6 complications in 856 patients (0.70%).
•
No pneumothorax.
•
Four cases of hypotension & bradycardia.
•
Two suspected LAST.
•
One cardiac arrest with successful resuscitation.
•
All surgeries proceeded as planned.
Anesth Analg 2016;122:1186–91
CAN’T SEE THE SCTL? …you are not alone.
“Paravertebral by Proxy”
Anaesthesia 2018, 73, 1185–1188
“Consistently achieved spread of dye at least to the paravertebral space at the level of injection, and frequently to adjacent levels”.
•
Injection in the musculofascial plane deep to the erector spinae muscles and superficial to the transverse process.
•
Blockade of the ipsilateral thoraco–lumbar spinal nerves.
•
May work by LA spread to the paravertebral space through the ligamentous complex.
•
Single injection at T5 can produce extensive analgesia of the ipsilateral thoracic wall.
•
Alternative to TEA/TPVB when refused/unsafe/not–feasable, such as the anticoagulated pt.
•
No efficacy/dose finding RCT available.
LATERAL
MEDIAL
Rib
Transverse Process
Anechoic “band” between ESM and TV (ESP)
Reg Anesth Pain Med 2018;43: 567–571
TP T4 20 mL of Levobupivacaine 0.25%
Journal of Clinical Anesthesia 50 (2018) 65–68
THANK YOU QUESTIONS?
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