Ultrasound Guided Regional Anaesthesia for Breast Surgery in High Risk Patients- A Retrospective Observational Study

Abstract

Introduction: Modified radical mastectomy (MRM) or breast conservative surgery (BCS) done under general anaesthesia (GA) in high-risk patients may be associated with significant morbidity, Intensive Care Unit stay and increased hospital stay leading to cost issues. In this case-series, we describe our experience with regional anesthesia for MRM or BCS and sentinel / complete axillary clearance in 61 patients with breast carcinoma who were high risk for perioperative complications in view of their co-morbidities. None required ICU or increased hospital stay postoperatively. Material & Methods: Sixty-one ASA III/IV patients operated under regional anaesthesia for carcinoma of the breast were included. Multiple level USG guided thoracic paravertebral block (PVB), PECS block (1/2), Pecto-intercostal fascial block (PIFB), Serratus-anterior plane block (SAPB), brachial plexus block, Superficial cervical plexus blocks (SCPB), Erector spinae block (ESB) were given in different combinations. Result: There were 60 female patients (Age: 30-97 years) and 1 male patient (59 years) (Left side -27 patients, right side- 34 patients). Of the total 61 patients, 23 patients underwent BCS with axillary dissection, 36 patients underwent MRM with axillary dissection, 2 patients had MRM with Pectoralis Major muscle resection. Patients received different combinations of blocks PVB or ESB, PECS1/2 and SAPB. 43 patients received the PVB, 61 got the PECS1/2, 12 patients received ESP, 32 patients required SCPB, 1 infra-clavicular block and 35 patients got PIFB. All procedures were completed under regional anaesthesia with 51 patients getting intravenous midazolam (0.01-0.02mg/kg), 59 patients were given IV fentanyl (1-3ug/kg , 43 patients were given IV propofol (1-2mg/kg), These were given in small aliquots during the duration of the procedure. 2 patients had IV ketamine (0.5mg/kg) and 1 patient had IV dexmeditomidine (0.2-0.3ug/kg/hr). IV paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDS) ie. Inj Diclofenac Sodium IV in the dose of 1mg/kg (max 75mg) were given when not contraindicated. There was single case of axillary hematoma with no other complications. No patient required ICU care postoperatively and were discharged as routine. Conclusion: A combination of blocks may be an option for surgical anaesthesia for breast surgeries in high risk patients. Careful planning, patient counseling and attention to toxic dose of local anaesthetics must always be considered. Keywords: Paravertebral block, Thoracic wall blocks, PECS block, Serratus Anterior plane block, Pecto-intercorstal fascial block, Superficial cervical plexus, Modified radical mastectomy, Breast conservative surgery.