The Use of Pectoralis Blocks in Breast Surgery: A Practice Advisory and Narrative Review from the Society for Ambulatory Anesthesia (SAMBA).

Although pectoralis (PECS) blocks are commonly used for breast surgery, recommendations regarding the efficacy of these blocks have thus far not been developed by any professional anesthesia society. Given the potential impact of PECS blocks on analgesia after outpatient breast surgery, The Society for Ambulatory Anesthesia (SAMBA) convened a task force to develop a practice advisory on the use of this analgesic technique. In this practice advisory, we compare the efficacy of PECS blocks with systemic analgesia, local infiltration anesthesia, and paravertebral blockade. Our objectives were to advise on two clinical questions. (1) Does PECS-1 and/or -2 blockade provide more effective analgesia for breast-conserving surgery than either systemic analgesics or surgeon-provided local infiltration anesthesia? (2) Does PECS-1 and/or -2 blockade provide equivalent analgesia for mastectomy compared with a paravertebral block (PVB)? Among patients undergoing breast-conserving surgery, PECS blocks moderately reduce postoperative opioid use, prolong time to analgesic rescue, and decrease postoperative pain scores when compared with systemic analgesics. SAMBA recommends the use of a PECS-1 or -2 blockade in the absence of systemic analgesia (Strength of Recommendation A). No evidence currently exists that strongly favors the use of PECS blocks over surgeon-performed local infiltration in this surgical population. SAMBA cannot recommend PECS blocks over surgical infiltration (Strength of Recommendation C). For patients undergoing a mastectomy, a PECS block may provide an opioid-sparing effect similar to that achieved with PVB; SAMBA recommends the use of a PECS block if a patient is unable to receive a PVB (Strength of Recommendation A).

Paravertebral block: anatomy and relevant safety issues.

Paravertebral block, especially thoracic paravertebral block, is an effective regional anesthetic technique that can provide significant analgesia for numerous surgical procedures, including breast surgery, pulmonary surgery, and herniorrhaphy. The technique, although straightforward, is not devoid of potential adverse effects. Proper anatomic knowledge and adequate technique may help decrease the risk of these effects. In this brief discourse, we discuss the anatomy and technical aspects of paravertebral blocks and emphasize the importance of appropriate needle manipulation in order to minimize the risk of complications. We propose that, when using a landmark-based approach, limiting medial and lateral needle orientation and implementing caudal (rather than cephalad) needle redirection may provide an extra margin of safety when performing this technique. Likewise, recognizing a target that is not in close proximity to the neurovascular bundle when using ultrasound guidance may be beneficial.

Regional anesthesia for a total knee arthroplasty on an adult patient with spastic diplegia and an intrathecal baclofen pump.

We describe the clinical presentation of a patient with spastic diplegia, and its unique perioperative challenges. Opioids and antispasmodic medications are the primary therapy for managing pain and spasticity in the perioperative setting. However, such combination results in several side-effects and their sedative properties are synergistic. A 64-year-old woman with a history of spastic diplegia and an intrathecal baclofen pump for the treatment of her lower extremity spasticity was scheduled for a third elective left knee arthroplasty. She requested a regional anesthetic for the anticipated surgery and an opioid sparing postoperative analgesic regiment. We describe the successful use of a lumbar plexus and a sciatic nerve block as the primary anesthetic for the surgery and the use of a continuous lumbar plexus catheter for the postoperative course. Based on our patient's past anesthetic history, a regional anesthetic/analgesic technique is the ideal strategy in controlling perioperative pain and spasticity.

Opioid consumption in total knee arthroplasty patients: a retrospective comparison of adductor canal and femoral nerve continuous infusions in the presence of a sciatic nerve catheter.

OBJECTIVE: To compare opioid consumption among patients who receive a continuous adductor canal block (ACB) versus continuous femoral nerve block (FB) for total knee arthroplasty analgesia in the presence of an intermittent sciatic nerve catheter (iSB). DESIGN: Matched cohort retrospective study. SETTING: Mayo Clinic, Jacksonville, FL. PATIENTS: Ninety patient charts were included in this study: 45 patients with continuous ACB/iSB and 45 with continuous FB/iSB. Patients were matched according to mean preoperative opioid consumption and pain scores, BMI, age, and gender. MEASUREMENTS: The primary outcome of the study was postoperative on-demand opioid consumption on postoperative days 0 (POD 0), 1 (POD 1), and 2 (POD 2). Secondary outcomes included postoperative Visual Analog Scale (VAS) scores for anterior and posterior knee pain, incidence of nausea and pruritus, need for intravenous rescue opioid, and need for catheter bolus by a physician. MAIN RESULTS: On POD 0, mean opioid consumption in milligrams of oral morphine equivalent [mean±SD (95% CI)] was 43.98mg±33.36 (33.96, 54) in the ACB/iSB group vs 38.45mg±30.99 (29.14, 47.76) in the FB/iSB group, respectively (P=.42); on POD 1, 74.96mg±37.23 (63.78, 86.14) vs 72.40mg±62.34 (53.67, 91.13) (P=.81); on POD 2, 28.19mg±17.69 (22.87, 33.51) vs 31.84mg±23.09 (24.90, 38.78) (P=.40). On POD 1, median anterior knee VAS scores at rest were equivalent in both the ACB/iSB and FB/iSB groups (1 vs 1, respectively, P=.46); however, patients in the ACB/iSB group were more likely to have higher anterior knee pain scores with movement (4 vs 1, P=.002). CONCLUSION: In the first 2 days after a total knee arthroplasty, opioid consumption in patients with continuous ACB/iSB was not significantly different from patients receiving continuous FB/iSB. Continuous adductor canal block appears to provide adequate analgesia when compared to continuous femoral blockade.

Intermediate-term follow-up of chronically ill patients with digital ischemia treated with peripheral digital sympathectomy.

Digital ischemia is commonly found in patients with scleroderma and has been shown to respond to peripheral digital sympathectomy. While favorable long- and intermediate-term results have been documented in the literature, minimal objective data are available and the mechanism of surgical sympathectomy has not been entirely elucidated. Patients with digital ischemia secondary to Raynaud's phenomenon that had undergone peripheral sympathectomy surgery between 2001 and 2009 were identified and contacted for participation. Radial artery Doppler ultrasound studies were performed and compared to those done at the time of their sympathectomy. Of 11 patients treated over a 9-year period, only two patients were available for detailed follow-up analysis. Four patients were deceased, and two were lost to follow-up. Four of the five remaining patients reported excellent use of the hand and no significant episodes of digital ischemia. Of the two patients studied, functional results were favorable and pain was markedly improved despite worsening of the digital flow resistance over time. We conclude that peripheral digital sympathectomy may provide favorable long-term results in patients with digital ischemia from autoimmune causes, although this intervention should be considered in the early stages once ischemic symptoms manifest. Interestingly, Doppler data did not appear to correlate with functional status and symptom severity in these two patients. Further research, particularly prospective studies, is warranted to guide clinical decisions in this patient population.

Bilateral thoracic paravertebral nerve blocks for placement of percutaneous radiologic gastrostomy in patients with amyotrophic lateral sclerosis: a case series.

BACKGROUND AND AIMS: To assess the efficacy of bilateral thoracic paravertebral nerve blocks (PVB) in providing procedural anesthesia and post-procedural analgesia for placement of percutaneous radiologic gastrostomy tubes (PRG) in patients with amyotrophic lateral sclerosis (ALS). METHODS: We prospectively observed 10 patients with ALS scheduled for PRG placement that had bilateral thoracic PVBs at thoracic 7, 8, and 9 levels with administration of a mixture of 3 mL of 1% ropivacaine, 0.5 mg/mL dexamethasone, and 5 µg/mL epinephrine at each level. The success of the block was assessed after 10 minutes. PRG placement was done in the interventional radiology suite without sedation. All patients were followed up via phone 24 hours after the procedure. RESULTS: All 10 patients had successful placement of PRG with PVBs as the primary anesthetic. Segmental anesthesia over the surgical site in all cases was successful with first attempt of the blocks. Three patients had significant hypotension after the block, requiring boluses of vasopressors and intravenous fluids. All patients reported high levels of satisfaction and sleep quality on the night of the procedure. CONCLUSIONS: Bilateral thoracic PVBs provided satisfactory procedural anesthesia and post-procedural analgesia, and thus, seem promising as a safe alternative to sedation in ALS patients having PRG placement.

THE USE OF PARAVERTEBRAL BLOCKADE FOR ANALGESIA AFTER ANTERIOR-APPROACH TOTAL HIP ARTHROPLASTY.

BACKGROUND: Anterior approaches for total hip arthroplasty (ATHA) are becoming increasingly popular. We postulated that the use of PVB of the T12, L1, and L2 roots would provide adequate analgesia for ATHA while allowing motor sparing. METHODS: The medical records of 20 patients undergoing primary ATHA were reviewed. T12, L1 and L2 paravertebral blockade was accomplished with 3-4 ml of 1% ropivacaine with epinephrine 1:200,000 and 0.5 mg/ml of preservative-free dexamethasone per level. Primary outcomes were mean opioid consumption in intravenous morphine equivalents and worst recorded visual analog scale (VAS) pain scores during postoperative days 0 to 2 (POD 0 to 2). RESULTS: Mean opioid consumption was 8.4 mg on POD0, 16.6 mg on POD1, and 9.8 mg on POD2. Median worst VAS scores were 2 for all time intervals except POD 0, which had a median value of 0. All patients had full hip motor strength the evening of POD0.19 patients were able to ambulate the afternoon of POD1. CONCLUSION: T12-L2 PVB, when utilized as part of a multimodal analgesic regimen, results in moderate opioid consumption, low VAS scores, preservation of hip motor function, and may be an effective regional anesthesia technique for ATHA.

Lumbar plexus block surface landmarks as assessed by computed axial tomography in adult patients with scoliosis: a case series.

BACKGROUND AND OBJECTIVES: Lumbar plexus (LP) block is a common and useful regional anesthesia technique. Surface landmarks used to identify the LP in patients with healthy spines have been previously described, with the distance from the spinous process (SP) to the skin overlying the LP being approximately two-thirds the distance from the SP to the posterior superior iliac spine (PSIS) (SP-LP:SP-PSIS ratio). In scoliotic patients, rotation of the central neuraxis may make these surface landmarks unreliable, possibly leading to an increased block failure rate and an increased incidence of complications. The objective of the present study was to describe these surface landmarks of the LP in patients with scoliosis. METHODS: We selected 47 patients with known thoracolumbar scoliotic disease from our institution's radiology archives. We measured bony landmark geometry, Cobb angle, and the LP location and depth. Additionally, we calculated the SP-LP:SP-PSIS ratio for both the concave and convex sides. RESULTS: In scoliotic patients (31 females and 16 males), the median (range) Cobb angle was 23 (8-54) degrees. The LP depth was 7.5 (5.7-10.7) cm on the concave side of the scoliotic spine and 7.6 (5.4-10.8) cm on the convex side, while the distance from the SP-LP was 3.4 (1.9-4.7) cm on the concave side and 3.7 (2.4-5.1) cm on the convex side. The SP-LP:SP-PSIS ratio was 0.61 (0.20-0.97) and 0.65 (0.45-0.98) on the concave and convex sides, respectively. None of these distances were significantly different between sides. CONCLUSIONS: In patients with scoliotic disease of the spine, there is wide variability in the bony surface landmarks. The location of the LP is generally more medial than expected when compared with both modified and traditional landmarks. A review of the imaging studies and the pre-procedural ultrasound assessment of the anatomy should be considered prior to needle puncture.

Real-time two-dimensional and three-dimensional echocardiographic imaging of the thoracic spinal cord: a possible new window into the central neuraxis.

Transesophageal echocardiography of the spine has been difficult to perform, and high-quality images have been difficult to obtain with earlier available technology. New capabilities in hardware and software reconstruction may allow more reliable clinical data to be obtained. We describe an initial successful attempt to image the adult spinal canal, its contents, and in situ instrumentation. This report is a retrospective review of two patients in whom transesophageal echocardiography (TEE) was used to image the thoracic spine. The thoracic spine was identified and imaged with real-time 2-D and 3-D technology with location of the thoracic aorta and slight insertion and withdrawal of the TEE probe until the intervertebral discs alignment was optimized. Images of the spinal cord anatomy and its vascular supply, as well as indwelling epidural catheters were easily identified. 2-D and 3-D imaging was performed and images were recorded in digital imaging and communications in medicine format. 3-D reconstruction of images was possible with instantaneous 3-D imaging from multiple 2-D electrocardiogram-gated image acquisitions using the Phillips TEE IE-33 imaging platform. The central neuraxial cavity, including the spinal cord and the spinal nerve roots, was easily visualized, and motion of the cord was seen in a phasic pattern (with respiratory variation); cerebrospinal fluid surrounding the spinal cord was documented. The epidural space and local anesthetic drug administration through the epidural catheter were visualized, with the epidural catheter seen lying adjacent to the epidural tissue as a bright hyperechoic line. Pulsed-wave Doppler determined a biphasic pattern of blood flow in the anterior spinal artery through pulse mapping of the anatomic area. New, advanced imaging hardware and software generate clinically useful imaging of the thoracic spine in 2-D and 3-D using TEE. We believe this technology holds promise for future diagnostic and therapeutic interventions in the operating room that were previously unavailable.

Paravertebral blocks.

PVB remains an underused block. It is easy to perform reliable and effective blocks for a wide variety of applications both for acute or chronic pain. As evidence continues to be published showing the advantages of PVB versus traditional methods of pain control, it is hoped that PVB will become part of the standard repertoire of blocks used in teaching hospitals and in private practice.

Complications of peripheral nerve catheter removal at home: case series of five ambulatory interscalene blocks.

PURPOSE: The placement of continuous peripheral nerve catheters on an ambulatory basis is increasing and is routine at our institution. There are few reports of complications associated with peripheral nerve catheter removal in the literature. Described herein is a case series of five patients where complications related to catheter withdrawal were observed. CLINICAL FEATURES: A stimulating catheter with a stainless steel coil surrounded by polyurethane (19-G, 60-cm) exhibited shearing when removal proved difficult in five patients. In four cases, catheter removal by the patients was not possible, requiring them to return to hospital for management. No long-term sequelae were observed in any patient. CONCLUSIONS: There can be various causes for difficulty with catheter removal, such as a technical aspect of catheter placement, catheter design, tissue reaction at the catheter site, or a combination thereof. The majority of complications related to outpatient perineural catheters can be handled over the telephone, but our case series may highlight a potential management dilemma in placing continuous stimulating perineural catheters on an ambulatory basis.

Real-time 3-dimensional ultrasound-assisted infraclavicular brachial plexus catheter placement: implications of a new technology.

Background. There are a variety of techniques for targeting placement of an infraclavicular blockade; these include eliciting paresthesias, nerve stimulation, and 2-dimensional (2D) ultrasound (US) guidance. Current 2D US allows direct visualization of a "flat" image of the advancing needle and neurovascular structures but without the ability to extensively analyze multidimensional data and allow for real-time manipulation. Three-dimensional (3D) ultrasonography has gained popularity and usefulness in many clinical specialties such as obstetrics and cardiology. We describe some of the potential clinical applications of 3D US in regional anesthesia. Methods. This case represents an infraclavicular catheter placement facilitated by 3D US, which demonstrates 360-degree spatial relationships of the entire anatomic region. Results. The block needle, peripheral nerve catheter, and local anesthetic diffusion were observed in multiple planes of view without manipulation of the US probe. Conclusion. Advantages of 3D US may include the ability to confirm correct needle and catheter placement prior to the injection of local anesthetic. The spread of local anesthetic along the length of the nerve can be easily observed while manipulating the 3D images in real-time by simply rotating the trackball on the US machine to provide additional information that cannot be identified with 2D US alone.