Breast Blocks

[Noyac]

Ok regional experts. What’s your “go to” block for mastectomy one-sided and bilateral?
PECS2?
Serratus Anterior?
Erector Spinae?

I’m thinking that the ES is too much. Do you just do the T5 level? Also, not a good candidate for bilateral surgery due to sympathetic block potential.

Educate me!

Now is your chance.

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[dhb]

I've not had great succes with these blocks, maybe because i don't do them right.
I did a mastectomy the other day: gave 20mg of ketamine pre incision no narcs and no pain in pacu... just saying

 

[facted]

Erector spinae though my group does paravertebral mostly. Serratus Anterior if you're too lazy to turn the pt over. But ES is so easy and safe, I'd pick that all day.

 

[Noyac]

Erector spinae though my group does paravertebral mostly. Serratus Anterior if you're too lazy to turn the pt over. But ES is so easy and safe, I'd pick that all day.

What level or levels? T5? T8? Both?

 

[sevoflurane]

ES

I’ve started to do them on my fast track AVRs/CABGs.

 

[BLADEMDA]

I've not had great succes with these blocks, maybe because i don't do them right.
I did a mastectomy the other day: gave 20mg of ketamine pre incision no narcs and no pain in pacu... just saying

The Erector Spinae is a VOLUME block. It's a cheap version of a PVB. So, you need VOLUME like 30 mls to get adequate spread back to the Paravertebral space. Without sufficient volume the ESB isn't very good for analgesia medial to the anterior axillary line.

 

[BLADEMDA]

Ok regional experts. What’s your “go to” block for mastectomy one-sided and bilateral?
PECS2?
Serratus Anterior?
Erector Spinae?

I’m thinking that the ES is too much. Do you just do the T5 level? Also, not a good candidate for bilateral surgery due to sympathetic block potential.

Educate me!

Now is your chance.

For a mastectomy I prefer the KISS approach: Pecs2 or the Serratus Anterior. They both work fine but I tend to favor the Serratus Anterior.

Pectoralis and Serratus Fascial Plane Blocks Each Provide Early Analgesic Benefits Following Ambulatory Breast Cancer Surgery: A Retrospective Prop... - PubMed - NCBI

Impact of the Ultrasound-Guided Serratus Anterior Plane Block on Post-Mastectomy Pain: A Randomised Clinical Study

Too Deep or Not Too Deep?: A Propensity-Matched Comparison of the Analgesic Effects of a Superficial Versus Deep Serratus Fascial Plane Block for A... - PubMed - NCBI

 

[BLADEMDA]

 

[BLADEMDA]

 

[BLADEMDA]

I inject underneath the SA muscle which means just above the rib. Fast, Easy, KISS. It's a 1-2 minute block. As a bonus, if you place a catheter beneath the SA muscle the muscle itself helps keep the catheter in place.

 

[Aether2000]

Same as Blademda

 

[facted]

What level or levels? T5? T8? Both?

T5, there is pretty good level spread with this block.

 

[facted]

I inject underneath the SA muscle which means just above the rib. Fast, Easy, KISS. It's a 1-2 minute block. As a bonus, if you place a catheter beneath the SA muscle the muscle itself helps keep the catheter in place.

View attachment 259064

Out of curiosity, why do you deep serratus vs superficial? In the original Blanco study, they discussed that superficial lasted a bit longer and was just as effective, plus it's a bit safer simply by the nature of the structures around.

Also, I agree that ESP needs volume, but I'm my experience, so does Serratus... Both are plane blocks.

For Serratus, the most important thing for me is to make sure to really hydrodissect posterior as you go. (I do superficial serratus)

 

[vector2]

ES

I’ve started to do them on my fast track AVRs/CABGs.

How much local/what concentration you using on each side?

 

[BLADEMDA]

Out of curiosity, why do you deep serratus vs superficial? In the original Blanco study, they discussed that superficial lasted a bit longer and was just as effective, plus it's a bit safer simply by the nature of the structures around.

Also, I agree that ESP needs volume, but I'm my experience, so does Serratus... Both are plane blocks.

For Serratus, the most important thing for me is to make sure to really hydrodissect posterior as you go. (I do superficial serratus)

• Format: Abstract

Send to




Reg Anesth Pain Med. 2018 Jul;43(5):480-487. doi: 10.1097/AAP.0000000000000768.
Too Deep or Not Too Deep?: A Propensity-Matched Comparison of the Analgesic Effects of a Superficial Versus Deep Serratus Fascial Plane Block for Ambulatory Breast Cancer Surgery.
Abdallah FW, Cil T, MacLean D, Madjdpour C1, Escallon J, Semple J, Brull R2.
Author information

Abstract
BACKGROUND AND OBJECTIVES:
Serratus fascial plane block can reduce pain following breast surgery, but the question of whether to inject the local anesthetic superficial or deep to the serratus muscle has not been answered. This cohort study compares the analgesic benefits of superficial versus deep serratus plane blocks in ambulatory breast cancer surgery patients at Women's College Hospital between February 2014 and December 2016. We tested the joint hypothesis that deep serratus block is noninferior to superficial serratus block for postoperative in-hospital (pre-discharge) opioid consumption and pain severity.
METHODS:
One hundred sixty-six patients were propensity matched among 2 groups (83/group): superficial and deep serratus blocks. The cohort was used to evaluate the effect of blocks on postoperative oral morphine equivalent consumption and area under the curve for rest pain scores. We considered deep serratus block to be noninferior to superficial serratus block if it were noninferior for both outcomes, within 15 mg morphine and 4 cm·h units margins. Other outcomes included intraoperative fentanyl requirements, time to first analgesic request, recovery room stay, and incidence of postoperative nausea and vomiting.
RESULTS:
Deep serratus block was associated with postoperative morphine consumption and pain scores area under the curve that were noninferior to those of the superficial serratus block. Intraoperative fentanyl requirements, time to first analgesic request, recovery room stay, and postoperative nausea and vomiting were not different between blocks.
CONCLUSIONS:
The postoperative in-hospital analgesia associated with deep serratus block is as effective (within an acceptable margin) as superficial serratus block following ambulatory breast cancer surgery. These new findings are important to inform both current clinical practices and future prospective studies.

 

[facted]

• Format: Abstract

Send to




Reg Anesth Pain Med. 2018 Jul;43(5):480-487. doi: 10.1097/AAP.0000000000000768.
Too Deep or Not Too Deep?: A Propensity-Matched Comparison of the Analgesic Effects of a Superficial Versus Deep Serratus Fascial Plane Block for Ambulatory Breast Cancer Surgery.
Abdallah FW, Cil T, MacLean D, Madjdpour C1, Escallon J, Semple J, Brull R2.
Author information

Abstract
BACKGROUND AND OBJECTIVES:
Serratus fascial plane block can reduce pain following breast surgery, but the question of whether to inject the local anesthetic superficial or deep to the serratus muscle has not been answered. This cohort study compares the analgesic benefits of superficial versus deep serratus plane blocks in ambulatory breast cancer surgery patients at Women's College Hospital between February 2014 and December 2016. We tested the joint hypothesis that deep serratus block is noninferior to superficial serratus block for postoperative in-hospital (pre-discharge) opioid consumption and pain severity.
METHODS:
One hundred sixty-six patients were propensity matched among 2 groups (83/group): superficial and deep serratus blocks. The cohort was used to evaluate the effect of blocks on postoperative oral morphine equivalent consumption and area under the curve for rest pain scores. We considered deep serratus block to be noninferior to superficial serratus block if it were noninferior for both outcomes, within 15 mg morphine and 4 cm·h units margins. Other outcomes included intraoperative fentanyl requirements, time to first analgesic request, recovery room stay, and incidence of postoperative nausea and vomiting.
RESULTS:
Deep serratus block was associated with postoperative morphine consumption and pain scores area under the curve that were noninferior to those of the superficial serratus block. Intraoperative fentanyl requirements, time to first analgesic request, recovery room stay, and postoperative nausea and vomiting were not different between blocks.
CONCLUSIONS:
The postoperative in-hospital analgesia associated with deep serratus block is as effective (within an acceptable margin) as superficial serratus block following ambulatory breast cancer surgery. These new findings are important to inform both current clinical practices and future prospective studies.

So it's just as effective per this article. But it's also slightly less safe as you're closer to pleura. Any particular reason to use it OVER superficial?

 

[PainDrain]

So for a mastectomy with ax dissection then I go with PECs blocks/serratus anterior. I haven’t used ES blocks for these yet but will probably start soon. I know that when a PECs/SA block works it works very well and I don’t give any narcs during a case. I typically hear from the surgeons that their patients have no post op pain complaints until the next day and even then it is mild. Like anything though it is dependent on the surgeon and patient.

 

[Lecithin5]

So it's just as effective per this article. But it's also slightly less safe as you're closer to pleura. Any particular reason to use it OVER superficial?

I think the potential advantage of doing it below is when you have fatter patients where it is hard to differentiate between various muscle layers (ie the fascial layer above the serratus in this case). It is almost universally easy to find rib, even in fatties, and you literally contact rib, and blast away, watching the serratus peel away from the rib. Not much risk of violating pleura as long as you see rib and you contact it.

 

[facted]

I think the potential advantage of doing it below is when you have fatter patients where it is hard to differentiate between various muscle layers (ie the fascial layer above the serratus in this case). It is almost universally easy to find rib, even in fatties, and you literally contact rib, and blast away, watching the serratus peel away from the rib. Not much risk of violating pleura as long as you see rib and you contact it.

True, though if I was teaching residents, I'd beg to differ

Honestly though, i rarely have any issues with the muscle layers. I make sure to start really anterior where I see the alligator sign and the lat starting off and I go from there. Can usually find the small artery in the layer as well and just hydrodissect posterior. Lots of ways to skin the cat..

 

[dhb]

The Erector Spinae is a VOLUME block.

Funny that it works fine for me with 20cc...

 

[sevoflurane]

How much local/what concentration you using on each side?

30 ccs per side of .25% bupi 1:200k fresh epi.

 

[Hork Bajir]

@sevoflurane curious to hear more about your experience with this- are you doing it pre- or post-op? How much opioid are you giving during the case, and are you needing to use more downers to treat hypertension with less opioid on board? What has been your success rate for covering a median sternotomy? Any major complications or considerations you find specific to cardiac workflow? I'm trying to convince one of my department to start doing these for certain cardiac cases, but there's resistance to change...

 

[sevoflurane]

@sevoflurane curious to hear more about your experience with this- are you doing it pre- or post-op? How much opioid are you giving during the case, and are you needing to use more downers to treat hypertension with less opioid on board? What has been your success rate for covering a median sternotomy? Any major complications or considerations you find specific to cardiac workflow? I'm trying to convince one of my department to start doing these for certain cardiac cases, but there's resistance to change...

We are doing them on our “healthy” hearts. We’ve been dinged a few times for prolonged intubation times on STS database metrics (mainly ICU docs letting some of our straight forward cases “rest” on the vent inappropriately). So we have spear headed an enhanced recovery after cardiac surgery pathway (ERACS). We are using multimodals, methadone, IV tylenol after clamp is off, mag, about 500 mcgs of fentanyl and very little midaz for the case. Liberal use of volatile anesthetics along with the other stuff we typically do.

ESP block goes before sternotomy always—> awake. Either in pre-op holding or in the room.

So far we are doing good with proper patient selection. Extubated within 3 hours.

We have a fantastic relationship with our surgeons. They typically don’t bother cardiology if they need a stat echo on a pre or post op heart if they know we are around.

Did one yesterday between cases to decide if we were going to do a double valve or a TAVR on a patient who came in with severe AS, afib with RVR, pulmonary edema, systolic failure and poor TTE eval of mitral valve. Went up between cases, looked at the appendage with TEE, cardioverted the patient, assessed heart function after converting to sinus and then interrogated the mitral valve. Severe MAC with no significant gradient or regurgitation. Improved systolic function post cardioversion. Scheduled for TAVR.

Definitely a team approach. We are interviewing a transplant surgeon for our team next week and our CTS team always invite us to interview dinners and we later discuss candidates.

So… when we want to bring something new to our flow, there is little resistance if it’s all reasonable.

I am a strong believer in ESP blocks. Doesn't hurt to give it a try and see what you think.

 

[BLADEMDA]

Single-Shot ESP Versus Continuous Catheter Block. We initially began with single-shot ESP blocks for rib fractures. However, we found that although this improved the pain and effectiveness of breathing significantly, the pain often recurred within 2 to 3 hours of the block, despite the use of long-acting local anesthetics. We postulated that systemic absorption of local anesthetic may be a contributing factor to the shorter-than-expected duration. This led to our current practice of inserting a catheter in all our patients, which has allowed us to provide prolonged analgesia.

Continuous Catheter Infusion Regimens. We initially used a continuous infusion regimen of ropivacaine 0.2% at 8–10 ml/h with patient-controlled regional analgesia (PCRA) boluses of 8 ml every 60 minutes. However, we observed that patients reported significantly lower pain scores at rest and improved respiration after the bolus doses. We have therefore moved to a programmed intermittent bolus regimen of 15 ml of 0.2% ropivacaine every 3 hours with additional patient-controlled boluses of 5 ml every 60 minutes, resulting in superior analgesia and patient satisfaction.

ASRA News - How I Do It: Erector Spinae Block for Rib Fractures: The Penn State Health Experience - American Society of Regional Anesthesia and Pain Medicine

 

[dhb]

We are using multimodals, methadone, IV tylenol after clamp is off, mag, about 500 mcgs of fentanyl and very little midaz for the case.

Why not cut down on the fentanyl? Without ESP or methadone i was using between 20 and 25 mcg of sufentanil for a normal case...

 

[sevoflurane]

Why not cut down on the fentanyl? Without ESP or methadone i was using between 20 and 25 mcg of sufentanil for a normal case...

That’s a small dose for a pump run. That’s like 125-250 of fentanyl equivalent.
Small dose, especially if given pre-bypass.
How comfortable are your patients before extubation?

Methadone has a good track record for hearts and is long lasting.

Max fentanyl is 500 mcgs WITH addition of methadone and Tylenol and ESP. Very comfortable and good hemodynamics b4 extubation.

Some get extubated upon arrival to ICU with a thumbs up upon drop off.

 

[sethco]

ES

I’ve started to do them on my fast track AVRs/CABGs.

We have started doing Parasternal Subpectoral Plane Blocks for our Sternotomy patients. CT surgeons and ICU nurses seen pretty happy with them and can tell who has had the block and who hasn't. As an added benefit, it definitely helps extubating my Off Pump CABGs in the OR while minimizing the Fentanyl dose

 

[ethilo]

30 ccs per side of .25% bupi 1:200k fresh epi.

I'm guessing you don't leave catheters in? Any thought about doing that? What pros/cons do you think?

I'm a big regional person and I might be joining the cardiac team soon, I'm considering introducing some of this fast track stuff to the mix.

 

[deleted162650]

Question for those that like PECS 2/Serratus blocks: Do these blocks knock out the Long Thoracic Nerve? This is a concern of one of our dedicated breast surgeons who is adamant that the Long Thoracic Nerve needs to be in tact when she's doing SNB's and node dissections. My search didn't turn up anything definitive, but anatomically, it seems like knocking out the LTN is a real possibility. My group has been leaning towards ESP as a result.

 

[Noyac]

Question for those that like PECS 2/Serratus blocks: Do these blocks knock out the Long Thoracic Nerve? This is a concern of one of our dedicated breast surgeons who is adamant that the Long Thoracic Nerve needs to be in tact when she's doing SNB's and node dissections. My search didn't turn up anything definitive, but anatomically, it seems like knocking out the LTN is a real possibility. My group has been leaning towards ESP as a result.

yes.

 

[Airlife91]

We are doing them on our “healthy” hearts. We’ve been dinged a few times for prolonged intubation times on STS database metrics (mainly ICU docs letting some of our straight forward cases “rest” on the vent inappropriately). So we have spear headed an enhanced recovery after cardiac surgery pathway (ERACS). We are using multimodals, methadone, IV tylenol after clamp is off, mag, about 500 mcgs of fentanyl and very little midaz for the case. Liberal use of volatile anesthetics along with the other stuff we typically do.

Interesting. We definitely take the multimodal approach as well. Preop tylenol and gabapentin. Fent (usually 250-400), Ketamine when appropriate, mag, lido, methadone on chronic pain patient, IV tylenol 6hrs after initial dose. Looking into blocks. Do you find the ES blocks get coverage over sternotomy site? We are also thinking serratus and/or PECs blocks for the minimally invasive mitral thoracotomy approaches. We also have a pretty good working relationship with our surgeons, and they've really pushed for us to reduce narcs as much as possible (for fast track AND they want reduction of post-op ileus).

 

[sevoflurane]

Looks like we have a similar cocktail. I underdose the methadone @ around 10-15 mg. Some of my partners go higher than this. We use it on all fast trackers (not just CP patients).

I think rib pain from retraction>>>>sternotomy pain.
ESP is fantastic for rib pain... probably covers sternotomy as well.

Nice work dude.

 

[ghastly75]

I inject underneath the SA muscle which means just above the rib. Fast, Easy, KISS. It's a 1-2 minute block. As a bonus, if you place a catheter beneath the SA muscle the muscle itself helps keep the catheter in place.

View attachment 259064

i had a healthy teen for bilateral breast reduction today. Did Bilateral PECs1/2, Ropivacaine .25% , 50 ml divided PeC1 10ml/each and PEC2 15 ml each side, added dexamethasone 10 PF to total 50 ml. Great visuals , for PECs 2 , injected just over 4th rib and thus under SA.
Woke patient up at end and overall she was good but definitely had incision pain at inferior aspect bilateral. Nothing at nipples or vertical incision.
Also gave dexmedetomidine and ketamine intraop.
Overall pleased but wondering how the inferior aspect of incision was missed, looked like T5 or T6 dermatome. perhaps more volume but she was only 60kg. could have stuck to .2% Ropi and used a bit more volume.

 

[BLADEMDA]

i had a healthy teen for bilateral breast reduction today. Did Bilateral PECs1/2, Ropivacaine .25% , 50 ml divided PeC1 10ml/each and PEC2 15 ml each side, added dexamethasone 10 PF to total 50 ml. Great visuals , for PECs 2 , injected just over 4th rib and thus under SA.
Woke patient up at end and overall she was good but definitely had incision pain at inferior aspect bilateral. Nothing at nipples or vertical incision.
Also gave dexmedetomidine and ketamine intraop.
Overall pleased but wondering how the inferior aspect of incision was missed, looked like T5 or T6 dermatome. perhaps more volume but she was only 60kg. could have stuck to .2% Ropi and used a bit more volume.

I would have used 30 ml 0.25% Rop with decadron per side. I think the extra volume helps the spread especially for Pecs2. A 60kg female can easily tolerate 150 mg of Ropivacaine IMHO. If you wish to be more conservative add some Epi to the Rop to decrease peak blood level concentration.


Systematic review of the systemic concentrations of local anaesthetic after transversus abdominis plane block and rectus sheath block

 

[ghastly75]

sure- I did 25ml per side. Next time will do. Thanks

 

[BLADEMDA]

Fascial plane blocks
Fascial plane blocks have become increasingly popular in recent years as a method of providing regional anesthesia of the torso. Most studies pertain to the transversus abdominis plane (TAP) block, but they all share the common characteristic of large-volume (>20 mL) LA injection into a fascial intermuscular plane. As muscles generally have a rich vascular supply, there is a significant risk of LAST from systemic absorption of LA. The time to peak plasma concentration following a TAP block is 30 minutes on average, but can be as long as 90 minutes in some individuals.40–43 This may also vary with the type and site of block; for example, the rectus sheath block has been shown to have a consistently longer time to peak concentration (60 minutes) compared to the TAP block.41,42 Although most studies report that the average maximum LA plasma concentration following TAP block with commonly used dosing regimens falls below the generally accepted toxic threshold, there are consistently individuals in whom this is approached or exceeded.40,43–45

Epinephrine reduces the systemic absorption and the maximum LA plasma concentrations – even for ropivacaine – and thus should always be added to the LA solution where possible.43,45 Lower concentrations and doses of LA should also be used, particularly if epinephrine is omitted.46 The American Society of Regional Anesthesia and Pain Medicine guidelines further recommend that dosing should be based on lean body weight.47

Local anesthetic systemic toxicity: current perspectives

 

[BLADEMDA]

sure- I did 25ml per side. Next time will do. Thanks

With these fascial plane blocks there is NEVER a guarantee of 100% analgesia postop. My post was not meant to be critical. Keep up the good work.

 

[ghastly75]

With these fascial plane blocks there is NEVER a guarantee of 100% analgesia postop. My post was not meant to be critical. Keep up the good work.

Didn’t take that way. I haven’t done enough of these with peds . Do a lot of pecs 1 for ports but those aren’t really painful anyway, so this was a bigger case. Good to know that coverage can be spotty.

 

[JWebar]

An US guided paravertebral block is like a one sided epidural (5–6 dermatomes with 1 single shot 25 mL dose). If its a BIG breast case, thats my first go to. ESP for me is the plan B. If I dont get good sonoanatomy or needling, I'll switch to it right away. Same spot so I dont have to prep again. Not as good analgesia, but comparable. For smaller cases, if Im doing any blocks at all, I'll do Serratus (20 mL). Just cause its really easy and fast (awake patient on the side before starting induction). You get good sensory block of the mamary gland. If muscle is being involved (subpectoral) I'll do PEC2 (which are 2 injections, PEC 1 = 10 mL + PEC 2 = 20 mL). Thats my algorithm

Two articles I highly recommend are:
Perioperative breast analgesia – A qualitative review of anatomy and regional techniques (Woodworth, 2017)
Different approaches to US guided thoracic paravertebral block (Krediet, 2015)

Good luck!