anbuitachi

10+ Year Member
Oct 26, 2008
4,637
1,627
Utah
Status
Attending Physician
What blocks do you guys/girls normally do at your practice for total mastectomy w axillary node dissections? Or breast reconstructions?

I'm looking at pecs 1 , 2, SA, or paravertebral. Anyone have experience or data comparing these alone or in combo?

And does anyone do them before putting patient to sleep? Any benefits?
 
Last edited:

facted

ASA Member
10+ Year Member
Dec 15, 2008
998
519
NYC
Status
Attending Physician
PVB is gold standard, but I do some serratus too and it works well. SA can be done asleep, but I would prefer to do PVB with light sedation.
 
OP
A

anbuitachi

10+ Year Member
Oct 26, 2008
4,637
1,627
Utah
Status
Attending Physician
PVB is gold standard, but I do some serratus too and it works well. SA can be done asleep, but I would prefer to do PVB with light sedation.
Serratus alone for mastectomies if not PVB? Why is PEc 1 block so popular for mastectomy. Simple/total mastectomies dont touch the muscle
 
About the Ads

BLADEMDA

ASA Member
10+ Year Member
Apr 22, 2007
17,701
3,939
Southeast
Status
Attending Physician
What blocks do you guys/girls normally do at your practice for total mastectomy w axillary node dissections? Or breast reconstructions?

I'm looking at pecs 1 , 2, SA, or paravertebral. Anyone have experience or data comparing these alone or in combo?

And does anyone do them before putting patient to sleep? Any benefits?

Breast Surgery and Serratus Anterior Blocks
 

ethilo

7+ Year Member
Jul 2, 2012
162
100
Status
Attending Physician
asdf.png

Here's a figure from a very new review paper on breast analgesia published in RAPM. I kept it in my personal notes as an easy reference for decision making about coverage of various blocks.

Here's the paper:
Woodworth G, Ivie R, Nelson S, Walker C, Maniker R. Perioperative Breast Analgesia: A qualitative Review of Anatomy and Regional Techniques. Reg Anesth Pain Med 2017;42: 609–631
 

AppTrail

10+ Year Member
May 26, 2007
115
0
Status
Attending Physician
I usually perform pecs1/2/SA right after induction
 

Foodie

ASA Member
10+ Year Member
Aug 22, 2005
117
15
Status
Attending Physician
Preop PVB for mastectomies with or without axillary lymph node dissections. When I discussed offering PEC blocks with surgeons, they said that they were happy with PVB and that they have experienced PEC block local anesthetics leaking into their surgical field. Oh well.
 

BLADEMDA

ASA Member
10+ Year Member
Apr 22, 2007
17,701
3,939
Southeast
Status
Attending Physician
Preop PVB for mastectomies with or without axillary lymph node dissections. When I discussed offering PEC blocks with surgeons, they said that they were happy with PVB and that they have experienced PEC block local anesthetics leaking into their surgical field. Oh well.
Serratus Plane Block? Have you tried that plus local injection into the field by the surgeon? The evidence seems to suggest this is worth trying in your situation.

"We have shown that injection of local anaesthetic superficial or deep underneath serratus anterior provides predictable and relatively long-lasting regional anaesthesia, which would be suitable for surgical procedures performed on the chest wall. We propose this as an alternative to other regional anaesthetic techniques"

https://ccme.osu.edu/RSSeriesBrochure/33319-Ultrasound Guided Thoracic Wall Nerve Block.pdf

(See Page 5 for a nice picture)
 

BLADEMDA

ASA Member
10+ Year Member
Apr 22, 2007
17,701
3,939
Southeast
Status
Attending Physician
The serratus plane block is a progression from our work with the Pecs I and II blocks. We have strived to make the technique easier in its application and to lower the potential side-effect profile associated with injection in close proximity of vascular structures [18]. This technique has removed the requirement of possible multiple needle insertion points and changes in needle orientation. This is coupled with the fact that deposition of the local anaesthetic solution at the effective site should correlate with superior analgesic pro- files as the local anaesthetic solution does not need to track back to the effector site


https://ccme.osu.edu/RSSeriesBrochure/33319-Ultrasound Guided Thoracic Wall Nerve Block.pdf
 

BLADEMDA

ASA Member
10+ Year Member
Apr 22, 2007
17,701
3,939
Southeast
Status
Attending Physician
 

BLADEMDA

ASA Member
10+ Year Member
Apr 22, 2007
17,701
3,939
Southeast
Status
Attending Physician
 

BLADEMDA

ASA Member
10+ Year Member
Apr 22, 2007
17,701
3,939
Southeast
Status
Attending Physician

Hoya11

Senior Member
15+ Year Member
Sep 4, 2004
908
448
Status
Why dont the surgeons just infiltrate local in the appropriate tissue planes during the operation? Why come percutaneously with an US guided needle, vs just doing it under a live dissection?
 

dhb

Member
Lifetime Donor
10+ Year Member
Jul 12, 2006
3,984
1,211
Status
Attending Physician
Why dont the surgeons just infiltrate local in the appropriate tissue planes during the operation? Why come percutaneously with an US guided needle, vs just doing it under a live dissection?
Because most of them are not good at it (and i would never call a gynecologist's work dissection) and a block lasts longer than plain local.
 
  • Like
Reactions: BLADEMDA

Hoya11

Senior Member
15+ Year Member
Sep 4, 2004
908
448
Status
Because most of them are not good at it (and i would never call a gynecologist's work dissection) and a block lasts longer than plain local.
? Arent you doing the block with the same local? Whats the difference if you give it or if they give it? The surgeon is staring at the tissue plane.. and the patient is asleep...vs with US and an awake patient.

Our surgeons give the local as they go, no need for blocks, these cases are minimally painful and IMO do not require an invasive block by me
 
  • Like
Reactions: imrep1972

Foodie

ASA Member
10+ Year Member
Aug 22, 2005
117
15
Status
Attending Physician
Serratus Plane Block? Have you tried that plus local injection into the field by the surgeon? The evidence seems to suggest this is worth trying in your situation.

"We have shown that injection of local anaesthetic superficial or deep underneath serratus anterior provides predictable and relatively long-lasting regional anaesthesia, which would be suitable for surgical procedures performed on the chest wall. We propose this as an alternative to other regional anaesthetic techniques"

https://ccme.osu.edu/RSSeriesBrochure/33319-Ultrasound Guided Thoracic Wall Nerve Block.pdf

(See Page 5 for a nice picture)
Thank you for the link, I'll bring this up for the breast next case.
 
About the Ads