Ultrasound-Guided Continuous Interpectoral Block for Patient Undergoing Mastectomy and Axillary Clearance

Continuous Pectoral Nerve Block Compared With Continuous Thoracic Paravertebral Block and Intravenous Opioid Analgesia for the Postoperative Analgesic Efficacy in Patients Undergoing Modified Radical Mastectomy: A Prospective Randomized Trial

OBJECTIVES

Postoperative pain following mastectomy is often severe and pain management is necessary. We evaluated the analgesic efficacy of continuous pectoral nerve block (PEC) in comparison with that of the continuous thoracic paravertebral block (TPVB) and the intravenous opioid analgesia in patients scheduled for modified radical mastectomy (MRM).

MATERIALS AND METHODS

A total of 90 female patients aged 20 to 70 years, American Society of Anesthesiologists (ASA) I to III, undergoing unilateral MRM were randomly allocated into 3 groups. All patients received postoperative morphine patient-controlled analgesia (PCA). Continuous TPVB and continuous PECs were added in group II and group III, respectively. Postoperative morphine consumption during the first 48 hours and postoperative visual analog scale were recorded.

RESULTS

The cumulative morphine consumption in the first 24 hours postoperative was higher in the PCA-M group (27.47±4.95 mg) than that of the TPVB group (8.43±2.67 mg) and PEC group (13.47±3.89 mg) (P<0.001, confidence interval: 16.6-21.5 and 11.6-16.4, respectively). It was significantly higher in the PEC group as compared with the TPVB group (P<0.001, confidence interval: 2.6-7.5). On admission to postanesthesia care unit till 2 hours postoperative, the median visual analog scale score at rest was higher in the PCA-M group than that of the TPVB group (P<0.05) and PEC group (P<0.05) without statistical difference between the TPVB group and PEC group.

DISCUSSION

Continuous PEC and continuous TPVB reduced the postoperative morphine consumptions as compared with the intravenous opioid analgesia in patients undergoing MRM with greater reduction in TPVB and without increased adverse effects.

Novel use of a continuous PECS II block for mastitis pain treatment

Nipple trauma and mastitis (an inflammatory condition of the breast) are common causes of intense pain during breast feeding. Although such pain normally results in early weaning, which has negative impacts on both maternal and child health, little is understood about the treatment of pain experienced during breast feeding. Here, we describe our experience with a woman who presented at 26 days post partum with a 15-day history of deep nipple wounds that caused bilateral mastitis and excruciating pain that radiated dorsally. Antibiotic, antifungal and non-pharmacological therapies were unsuccessful, and she wished to suspend breast feeding. We performed a bilateral pectoralis nerve block type II and inserted intrafascial catheters between the pectoralis minor and serratus muscles for continuous analgesia. Following block completion, the pain in her torso resolved immediately. The local anesthetic infusion continued for 40 hours and the patient had sustained analgesia with rapid healing of nipple lesions and her breast feeding commencing at 36 hours after block placement.

Pectoralis blocks for insertion of an implantable cardioverter defibrillator in two patients with Duchenne muscular dystrophy

Patients with Duchenne muscular dystrophy (DMD) often have systemic manifestations with comorbid involvement of the cardiac and respiratory systems that increase the risk of anesthetic and perioperative morbidity. These patients frequently develop progressive myocardial involvement with cardiomyopathy, depressed cardiac function, and arrhythmias. The latter may necessitate the placement of an automatic implantable cardioverter defibrillator (AICD) insertion. As a means of avoiding the need for general anesthesia and its inherent potential of morbidity, regional anesthesia may be used in specific cases. We present two cases of successful AICD insertion in patients with DMD using unilateral pectoralis and intercostal nerve blocks supplemented with intravenous sedation. Relevant anatomy for this regional anesthetic technique is reviewed and benefits of this anesthetic technique compared to general anesthesia are discussed.