Combined thoracic paravertebral block and interscalene brachial plexus block for

lNTRODUCTlON

The National Breast Cancer Foundation has confirmed that breast cancer is the second most common cancer in women,with 3.8 million women diagnosed in the United States as of January 1,2019[1].Modified radical mastectomy(MRM)is the most common surgical treatment for breast cancer[2].Modified radical mastectomy is frequently performed under general anesthesia.However,general anesthesia may pose challenges especially in elderly and frail patients with comorbidities.Furthermore,some components of general anesthesia are associated with chronic pain,vomiting and impaired respiratory function[3,4].On the other hand,regional anesthesia is commonly believed to decrease cardiovascular,respiratory and gastrointestinal adverse events in high-risk patients[5,6],and attenuate immune suppression[7].Accordingly,there is growing interest in loco-regional anesthesia as an alternative to general anesthesia for MRM.

Thoracic epidural anesthesia combined with interscalene brachial plexus block(IBPB)has been reported to be an adequate anesthesia technique for MRM[8].Thoracic paravertebral block(TPVB)is efficacious for simple mastectomy surgery[9],but the efficacy of TPVB combined with IBPB has not yet been studied for MRM.

In this case series,we describe our experience of intraoperative anesthesia and postoperative pain management in ten elderly and fragile MRM patients who underwent ultrasound-guided two-site TPVB and small-volume IBPB combined with sedation.

CASE PRESENTATlON

Chief complaints

Ten patients scheduled for elective MRM were anesthetized by the same expert in ultrasound-guided loco-regional anesthesia in our facility between January 2019 and March 2019.

History of present illness

All patients were identified as suitable candidates for loco-regional anesthesia using current anticoagulation recommendations.

51.Loan of my horse: Horses are intelligent, strong animals highly valued and sometimes worshipped in numerous cultures. The lending of a horse is a sign of trust and faith. Horses are often considered lucky in folklore.Return to place in story.

Again, I bowed in prayer. Honk10, honk, I heard. I almost jumped out of my skin. A neighbor was driving down the street. He waved at me and smiled. I waved back, happy that he cared. I quickly tried once again to settle down, repeating the familiar verse in my mind. Be still and know that I am God.

History of past illness

Postoperative pain was well controlled.Eight patients reported a maximum pain score of 2 out of 10 points and did not require additional analgesics during a 12-h-interval follow-up in the first three postoperative days.Two patients needed one dose of celecoxib 8 h after surgery.None of the patients required morphine.All patients were satisfied with their anesthesia and pain management.All patients resumed normal food intake within 4 h and were able to use the surgical-side hand within 24 h.The recovery period was uneventful,with no reports of postoperative nausea and vomiting(PONV).Timeline of all cases are shown in Table 2.

Imaging examinations

All of the ten cases were diagnosed as breast neoplasm by preoperative imaging examinations either by unltrasoud or computerized tomography,suspected to be malignant.

FlNAL DlAGNOSlS

All patients were identified as suitable candidates for loco-regional anesthesia using current anticoagulation recommendations.

TREATMENT

On arrival in the preoperative area,standard monitoring was conducted and the patients were placed in the lateral decubitus position and received intravenous sedation with midazolam.TPVB was then initiated.A 10 MHz linear array transducer was vertically placed in the sagittal,paramedian plane,approximately 2-2.5 cm lateral to the spinous process at the predetermined level,and the following structures were identified: transverse process,parietal pleura,superior costotransverse ligament and the desired paravertebral space.Following infiltration of the skin with 2% lidocaine,a 22-G × 50-mm needle was advanced using the out-of-plane technique.Eventually,a“pop”was felt as the needle tip penetrated the anterior border of the superior costotransverse ligament.Hydro dissection with normal saline was used to confirm correct placement of the needle tip by anterior displacement of the parietal pleura(Figure 1).Ten and 15 mL of 0.5% ropivacaine were injected at two thoracic(T)levels: T2-T3 and T5-T6,respectively[10,11].TPVB was supplemented with ipsilateral IBPB using the in-plane technique at C6 Level with an injection of 5 mL ropivacaine(0.5%).Sensory blockade was assessed by pin prick testing using a 22-G short bevel needle.A satisfactory anesthetic effect was defined as the absence of ipsilateral tactile sensation covering the region between the clavicle and T7 dermatome,and from the ipsilateral parasternal area to the axilla within 30 min after local anesthetic administration.The time required to perform the blocks ranged from 5 to 10 min.

The reliable impeccable anesthesia effect and simple and convenient operation associated with ultrasound-guided two-spot TPVB combined with small-volume IBPB has been highlighted and initially proved by the present ten cases.Regarding the thoracic dermatotome and breast MRM,ultrasoundguided TPVB provide thorough anesthetic effect similar to thoracic epidural anesthesia,with better visualization and higher successful rate.Two-sites TPVB guarantee more extensive anesthesia scope than single-site,especially for intercostobrachial nerve,avoiding neither tedious process nor puncturerelated pain required by 3-5 sites injection.Because axillary dermatotome,pectoral major and minor muscles are dominated by nerve roots of bronchial plexus,IBPB is more straightforward,impeccable and efficient than terminal branch block and superficial plane block,such as serratus anterior plane block,Pecs II nerve block,medial bronchial cutaneous nerve block,which facilitate puncture operation and local anesthetics dosing.The fearful anxiety of phrenic nerve paralysis associated with IBPB,is also evitable when using 5 mL rather than routine volume of 20 mL,with equivalent effect.With the better visualization and higher successful rate provided by ultrasound-guided intervention technique,the method might be also feasible in the morbid obesity population.

Patients were sedated with a continuous infusion of propofol 3 mg/kg/h,and oxygen supplementation

a nasal cannula during surgery.A bolus of 1 μg/kg fentanyl was available for intraoperative breakthrough pain.Conversion to general anesthesia was considered if required.The patients were offered 200 mg celecoxib orally as needed for moderate postoperative pain,and an intravenous bolus of 3 mg morphine for severe pain.

OUTCOME AND FOLLOW-UP

Li K was the patients’ anesthetist;Sun G was the patients’ surgeon;Li K reviewed the literature and contributed to study conception and design,acquisition,analysis and interpretation of data,drafting the article,revising it critically for important intellectual content;Hu ZT and Wang ST were contributed to follow-up,acquisition,revising the article critically for important intellectual content;all authors have read and approved the final manuscript,and agreed to be accountable for all aspects of the work.

Patient characteristics are shown in Table 1.

DlSCUSSlON

To the best of our knowledge,compared to single cases using TPVB for awake mastectomy[9],there are no previous reports on the combination of two-sites TPVB with IBPB as the sole anesthetic technique for MRM.In our 10 elderly patients with multiple comorbidities,this technique provided potent alternative anesthesia with extended postoperative analgesia,and avoided the use of opioids,vasopressors,neuromuscular blocking agents and mechanical ventilation.In addition,PONV,cardiovascular and pulmonary complications were not observed.A similar observation was confirmed by a single case report[12].Also,thoracic epidural anesthesia combined with IBPB[8]provided similar anesthesia and analgesia compared to ultrasound-guided TPVB;however,the latter is a safer option.Although our technique requires expertise in ultrasound-guided loco-regional blocks and might not replace general anesthesia as routine for MRM,it remains a reliable alternative when general anesthesia is deemed undesirable or poses unacceptable risks.

The poor girl bore all patiently, and dared not tell her father,9 who would have rattled5 her off; for his wife governed him entirely6. When she had done her work, she used to go into the chimney-corner, and sit down among cinders7 and ashes,10 which made her commonly be called Cinderwench;11 but the youngest, who was not so rude and uncivil as the eldest8, called her Cinderella.12 However, Cinderella, notwithstanding her mean apparel, was a hundred times handsomer than her sisters,13 though they were always dressed very richly.

Job security meant everything to my educated dad. Learning meant everything to my rich dad. Educated dad thought I went to school to learn to be a ship s officer. Rich dad knew that I went to school to study international trade. So as a student, I made cargo8 runs, navigating9 large freighters, oil tankers10 and passenger ships to the Far East and the South Pacific. While most of my classmates, including Mike, were partying at their fraternity houses, I was studying trade, people and cultures in Japan, Thailand, Singapore, Hong Kong, Vietnam, Korea and the Philippines. I also was partying, but it was not in any frat house. I grew up rapidly.

Our observation was performed in a single site and restricted to 10 Chinese patients.Both efficacy and safety outcomes were highly related with anesthetist’s manipulation capability of ultrasoundguided regional anesthesia.Further multi-center randomized control trial with enough sample size is needed to finally determine the feasibility,efficiency and safety of the novel combinations.For further improvement,subcutaneous infiltration of the supraclavicular nerve might be supplemented for the dermatomal area around the clavicle,pectoralis major,and deltoid[12].Further decrease of either concentration or volume of ropivacaine is worth of investigation with regard to the equivalent and safe alternative approach.Diaphragmatic activity monitoring by ultrasound,or pulmonary function test should be performed during perioperative period to provide authentic proof in terms of pulmonary function.

Vigilance and continuous monitoring are mandatory,regarding potential complications such as inadvertent vascular puncture,epidural or intrathecal spread,pneumothorax,serious bradycardia,contralateral Harlequin syndrome and Horner’s syndrome[16].Even though there is less possibility of spreading to the intervertebral foramen and phrenic nerve and extensive intramuscular deposition with 5 mL IBPB than with 20 mL[17],it is also much better to administer nasal oxygen for 12 h.Despite the aforementioned potential complications,regional anesthesia and analgesia enhance postoperative oral intake,ambulation and rehabilitation[5],and potentially increase patient tolerance to early chemotherapy as compared with general anesthesia.

Other superficial facial blocks have been reported in case reports of MRM despite the uncertainty of local anesthetic diffusion and patchy coverage.In order to ensure the anesthesia effect,serratus anterior plane block was often combined with remifentanil infusion and 3 supplementary subcutaneous infiltrations of the intercostobrachial nerve,medial branches of the intercostal nerve and superficial cervical plexus[18],or 30 mg ketamine[19].It was confirmed that the erector spinae plane at T4 was feasible for MRM,however fentanyl supplementation was required in all cases[20].The Pecs II nerve block with high volume and perfect diffusion may be an alternative to the combination of two-site TPVB and smallvolume IBPB for further avoidance of respiratory depression[21].Pecs II nerve block is aimed to block at least the pectoral nerves,the intercostobrachial,intercostals III-IV-V-VI and the long thoracic nerve.These nerves need to be blocked to provide complete analgesia during breast surgery,and it is an alternative or a rescue block if paravertebral blocks and thoracic epidurals failed,with the indications such as tumorectomies,extensive excisions,and axillary clearances.

The sparrow hopped6 about as usual, twittering happily, and thinking no evil, and all the while the woman s brow became blacker and blacker, and at length her fury broke out

When the Prince saw how different the wolf looked when he had finished his meal, he said to him, Now, my friend, since you have eaten up my horse, and I have such a long way to go, that, with the best will in the world, I couldn t manage it on foot, the least you can do for me is to act as my horse and to take me on your back

With the assistance of real-time ultrasound,many high-risk regional blocks,such as TPVB,have become more popular and are safer.TPVB involves the injection of local anesthetics in the vicinity of spinal nerves emerging from the intervertebral foramina resulting in ipsilateral somatic and sympathetic nerve blockade in multiple contiguous dermatomes above and below the site of injection[13].Although four or five site blocks provide reliable analgesia[14],this is not practical for MRM.One study showed that contrast dye spread to 4.5 dermatome segments vertically after a single paravertebral injection compared to 6 segments after double-level injections[13].An improved analgesic effect was demonstrated with double-level TPVB compared to single-level[11].Based on these previous reports,we decided to use two-level TPVB.Effective anesthesia of the axilla and pectoral major muscle are essential for MRM,and is not achieved by TPVB alone.This area is innervated by the lateral and medial pectoral nerves,long thoracic nerve and thoracodorsal nerve,all originating from the brachial plexus[15].Accordingly,IBPB is an essential complement for TPVB in MRM.

The authors declare that they have no conflict of interest.

CONCLUSlON

Two-spot TPVB combined with small-volume IBPB is considered a reliable and safe alternative anesthetic technique for MRM,which avoids the potential risks of general anesthesia especially in frail patients with multiple comorbidities,and provides extended postoperative analgesia.

FOOTNOTES

The average duration of surgery was 115(± 21.7)min.None of the patients required intraoperative narcotics,or conversion to general anesthesia.The patients were hemodynamically stable and did not require vasopressors.No complications due to local anesthesia,such as allergic reaction,paresthesia,vascular injury and toxicity were observed.All patients were transferred to a regular nursing ward shortly after surgery.

Informed written consent was obtained from the patient for publication of this report and any accompanying images.

In spite of all, however, Tsarevitch Ivan would not leave off his beseeching21 till at length his father consented, and he took Tsar Vyslav s blessing, chose a swift horse for his use and rode away he knew not whither.

The authors have read the CARE Checklist(2016),and the manuscript was prepared and revised according to the CARE Checklist(2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial(CC BYNC 4.0)license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Zhou-Ting Hu 0000-0002-3440-7621;Guang Sun 0000-0001-5174-9829;Shen-Tong Wang 0000-0003-0296-2636;Kai Li 0000-0002-9342-8836.

Liu JH

A

Several months later, the director of the orphanage was on furlough in the United States. He wanted to visit all the churches that supported him in China, so he came to speak on Sunday night at my grandfather’s small church in Chicago. Grandpa and his family sat in their customary seats among the sparse5 congregation.

Liu JH

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