Combined thoracic paravertebral and pectoral nerve blocks for breast surgery under sedation: a prospective observational case series

Abstract

Avoidance of general anaesthesia for breast surgery may be because of clinical reasons or patient choice. There is emerging evidence that the use of regional anaesthesia and the avoidance of volatile anaesthetics and opioid analgesia may have beneficial effects on oncological outcomes. We conducted a prospective observational case series of 16 breast cancer surgeries performed under thoracic paravertebral plus pectoral nerve block with propofol sedation to demonstrate feasibility of technique, patient acceptability and surgeon satisfaction. Fifteen out of 16 cases were successfully completed under sedation and regional anaesthesia, with one conversion to general anaesthesia. Eleven out of 16 cases required low-dose intra-operative opioid analgesia. Out of the 15 surgical procedures completed under regional anaesthesia with sedation, all patients experienced either no or minimal intra-operative pain, and all would choose this anaesthetic technique again. Surgeon-reported operating conditions were 'indistinguishable from general anaesthesia' in most cases, and surgeons were 'extremely satisfied' or 'satisfied' with the technique after every procedure. Combined thoracic paravertebral plus pectoral nerve block with intra-operative sedation is a feasible technique for breast surgery.

PROSPECT guideline for oncological breast surgery: a systematic review and procedure‐specific postoperative pain management recommendations

“…It should also be noted that for anatomical reasons neither the PECS nor paravertebral blocks can reliably provide sufficient analgesia to the axilla (i.e. T1 nerve distribution) . Thus, supplemental local anaesthetic wound infiltration may be beneficial for these cases.…”

A randomised controlled trial of the pectoral nerves‐2 (PECS‐2) block for radical mastectomy

“…There are alternative blocks that might be employed for breast surgery , as well as wound infiltration . Regional and local analgesia might be relatively more important in the context of opioid‐sparing methods or in the absence of general anaesthesia .…”

“…Regional and local analgesia might be relatively more important in the context of opioid-sparing methods or in the absence of general anaesthesia [27].…”

Reports in anaesthesia come of age!

“…One of the great advantages of regional anaesthesia techniques is the potential to undertake awake surgery. Although epidurals, and more recently paravertebral blocks , have been successfully used for surgery involving the thoracic dermatomes, ‘paravertebral by proxy’ techniques such as the erector spinae plane (ESP) and midpoint transverse process (MTP) blocks have typically been used for analgesia. The ESP block has been reported as effective for awake breast surgery , and now, Costache is the first to describe the MTP block for the same purpose .…”