Indian Journal of Pain

CASE REPORT
Year
: 2019  |  Volume : 33  |  Issue : 2  |  Page : 106--108

Continuous erector spinae plane block in a patient with multiple comorbidities undergoing modified radical mastectomy


Rakesh Kumar, Rashmi Syal, Manoj Kamal, Ravi Shankar Sharma 
 Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Correspondence Address:
Dr. Rashmi Syal
Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
India

Abstract

Anesthesia in patients with multiple comorbidities is always challenging for anesthesiologists. Moderate-to-severe pain is common after modified radical mastectomy. Good perioperative analgesia in such surgeries enhances recovery, leads to early ambulation, prevents any cardiac event, and decreases chances of chronic pain.



How to cite this article:
Kumar R, Syal R, Kamal M, Sharma RS. Continuous erector spinae plane block in a patient with multiple comorbidities undergoing modified radical mastectomy.Indian J Pain 2019;33:106-108


How to cite this URL:
Kumar R, Syal R, Kamal M, Sharma RS. Continuous erector spinae plane block in a patient with multiple comorbidities undergoing modified radical mastectomy. Indian J Pain [serial online] 2019 [cited 2020 Jan 25 ];33:106-108
Available from: http://www.indianjpain.org/text.asp?2019/33/2/106/264076


Full Text

 Introduction



Perioperative anesthetic management of patients with multiple comorbidities, especially coronary artery disease (CAD), is challenging for anesthesiologists. Balanced anesthesia with adequate analgesia is of prime importance while managing such patients to prevent surgical stress response and balance between cardiac oxygen demand and supply. Modified radical mastectomy (MRM) is a usually performed procedure for carcinoma breast and is associated with moderate-to-severe postoperative pain. Poor perioperative pain management can lead to increased chances of recurrence of malignancy and development of chronic pain.[1],[2] Regional block for pain management has many advantages in such patients including provision of adequate analgesia, reduced need for opioids, decreased postoperative nausea and vomiting, postoperative pulmonary complications, enhanced recovery, and early ambulation. Ultrasound-guided erector spinae plane (ESP) block is a newer myofascial plane block in which drug is deposited deep to erector spinae muscle that anesthetizes the dorsal and ventral rami and rami communicants of the spinal nerves.

We report the use of ultrasound-guided ESP block as a perioperative analgesic modality in a patient with multiple comorbidities, posted for MRM. Informed consent from the patient was obtained for block and for possible publication.

 Case Report



A 64-year-old, 96-kg morbidly obese female was scheduled for MRM for infiltrating ductal carcinoma of the right breast. She was a known case of CAD, hypertension (HTN), type II diabetes mellitus (DM), and obstructive sleep apnea (OSA). She had a history of shortness of breath in her daily routine activity (NYHA Class III). Preoperative two-dimensional echocardiography showed moderate left ventricular (LV) hypertrophy, reduced LV ejection fraction (20%–25%), and regional wall motion abnormality in the apical and lateral walls. Her preoperative ECG showed Q-wave and ST-segment depression in the left chest leads.

In the operative room, routine American Society of Anesthesiologist (ASA) monitoring was applied. Under all aseptic precautions, an ultrasoundguided inplane continuous ESP block was performed in sitting position with the help of highfrequency (8–15 MHz) linear ultrasound transducer (LOGIQe, GE Healthcare, China) at T4 level [Figure 1]. A 50-mm long, short-bevel block needle (Contiplex, B BRAUN) was inserted in plane with direction from cranial to caudal until the tip of the needle hit transverse process of T4 vertebra; location of the needle tip was confirmed by visible lifting of erector spinae muscle after injection of normal saline. A total 20 ml of 0.5% ropivacaine in 3-ml aliquots was injected deep to erector muscle and superficial to transverse process, followed by insertion of indwelling catheter through the needle. Sensory effect was confirmed with spirit swab after 20 min after injection of local anesthetic (LA) agent injection from dermatomal level from T2 to T6.{Figure 1}

After confirmation of effect of block, anesthesia was induced with injection fentanyl 90μg and injection etomidate 12 mg. Airway was secured with supraglottic airway, i-gel number 5. Maintenance of anesthesia was achieved with isoflurane and air and oxygen mixture (50:50) with the aim of maintaining MAC 0.8–0.9 without the use of muscle relaxant throughout the surgery. The total surgical duration was 168 min. Intraoperative analgesia was achieved with infusion of 0.2% of ropivacaine at the rate of 5 ml/h through the catheter without any additional requirement of opioids. There were no significant changes in vital parameters on surgical skin incision and whole intraoperative period. Infusion of ropivacaine 0.2% of 5 ml/h was continued till 48 h postoperatively for analgesia. The ESP catheter was removed after 48 h of surgery. The visual analog score (VAS) score at rest was 1/10 and on movement was 2/10, and the patient was able to ambulate in the ward.

 Discussion



Systemic administration of opioids and nonsteroidal anti-inflammatory drugs combined with thoracic epidural (TE) or thoracic paravertebral is usual practice for postoperative pain management for MRM surgery. Although TE is considered as the gold standard for breast surgery, it is challenging to perform in upper thoracic region. It also has chances of dural puncture, hemodynamic instability, epidural hematoma and spinal cord injury. Since our patient was morbidly obese and landmarks were not easily palpable, we decided to manage intraoperative as well as postoperative analgesia by ESP block.

The ESP block was first described by Forero. It can be used for acute postoperative pain to chronic neuropathic pain.[3] The transverse processes of the thoracic vertebrae are the main target structures while performing block, which are easily identified with high-frequency linear or a low-frequency curved array transducer depending on weight and body habitus of the patient. LA drug is injected deep to erector spinae muscle which is a group of three muscles including iliocostalis, longissimus, and spinalis. It extends from sacrum and lumbar spinous processes up to C2 cervical vertebrae, encased in aponeurosis called as thoracolumbar fascia.[4] The columnar arrangement of erector muscle leads to extensive craniocaudal spread of drug.

Diffusion of LA into the paravertebral space is the main postulated mechanism of analgesic action of ESP Block. It acts at both the ventral and dorsal rami of the thoracic spinal nerves, as well as at the rami communicants that contain sympathetic nerve fibers and thus provide analgesia along the posterior, lateral, and anterior thoracic walls.

Since our patient was morbidly obese with multiple comorbidities (ischemic heart disease, OSA, HTN, and DM with low ejection fraction), paramount importance was given to provide excellent analgesia in perioperative period to prevent surgical stress response, avoid opioids as postoperative analgesia as they produce respiratory depression, and hamper early recovery and ambulation. We choose ESP block in this patient because landmarks were difficult to identify for epidural catheter placement. It is simpler to perform, provide equivalent analgesic efficacy with no additional side effects and better safety profile. The chances of pleural puncture are very less in ESP block in comparison to paravertebral block because drug injection site was at the level of transverse process of corresponding vertebra. The rest of the complications mentioned in literature were similar to other continuous blocks such as catheter migration, accidental breakage or removal of catheter, and LA toxicity on prolonged infusion.

 Conclusion



The ESP block was used as an alternative to TE and paravertebral blocks for MRM with similar efficacy and with lesser incidence of 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

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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3Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A Novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.
4Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R. The thoracolumbar fascia: Anatomy, function and clinical considerations. J Anat 2012;221:507-36.