Update on regional anesthesia for breast surgery - Michael Herrick - SSAI2017
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1) Breast cancer is a common form of cancer that often requires surgery. Regional anesthesia techniques can help decrease the risk of chronic pain after breast surgery called post-mastectomy pain syndrome (PMPS). 2) The breast tissue and muscles of the chest wall are innervated by different nerves, so the optimal regional technique depends on the planned surgery and innervation of the specific tissues being operated on. 3) Dartmouth initially used local infiltration and paravertebral blocks but found the pectoral nerve blocks provided better pain coverage, side effect profile, and ease of patient positioning for breast surgeries.
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Update on regional anesthesia for breast surgery - Michael Herrick - SSAI2017
- 1. Update on Regional Anesthesia for Breast Surgery Michael Herrick 34th SSAI Congress Malmö, Sweden
- 2. COI I have no disclosures
- 3. Dartmouth-Hitchcock Medical Center • 400 bed level 1 trauma center • Geisel School of Medicine at Dartmouth • CHAD, Norris Cotton Cancer Center
- 4. Outline • Cancer statistics • Breast innervation • Chronic pain after breast surgery • Regional anesthesia options • Dartmouth Experience
- 5. Breast Cancer Rates • 2012: 14.1 million new cancer cases and 8.2 million deaths • 2012: 1.7 million new breast cancer cases and 522,000 deaths CA CANCER J CLIN 2015;65:87–108
- 7. Breast Cancer Surgeries • Breast conserving surgeries: lumpectomy, partial mastectomy • Non BCS: simple mastectomy, modified radical mastectomy, radical mastectomy • Node biopsies
- 8. Breast Cancer Surgeries Reconstructive Procedures • Implants • Tissue expanders • Flaps
- 9. Post Mastectomy Pain Syndrome (PMPS) • Can occur after mastectomy or breast conservation surgery • Defined as pain in the area of surgery or arm at least 4 days/week with severity at least 3 on a 0-10 pain scale • Occurs in 23-68% of patients
- 10. Risk factors for PMPS British Journal of Cancer (2008) 99, 604 – 610 • Prior breast surgery • Younger age • Upper lateral quadrant breast surgery
- 11. Risk factors for PMPS Chinese Medical Journal ¦ January 5, 2016 ¦ Volume 129 ¦ Issue 1 • PMPS in 84/131 patients • Tumor in upper lateral quadrant • Secondary treatment with radiotherapy
- 12. Risk factors for PMPS Anesthesia-analgesia March 2013 • Volume 116 • Number 3 • Younger age • Axillary lymph node dissection • 24-hour postoperative morphine consumption
- 13. Breast Innervation Reg Anesth Pain Med 2017;42: 609–631
- 14. Breast Innervation Reg Anesth Pain Med 2017;42: 609–631
- 15. Breast Innervation Reg Anesth Pain Med 2017;42: 609–631
- 16. Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
- 17. Regional Options • Local Infiltration • Epidural • PVB • PECs Block • Newer blocks (Serratus plane block)
- 18. Local Infiltration Annals of the Royal College of Surgeons of England (1985) vol. 67 • Wound infiltration with bupivicaine • Complete relief in 14/19
- 19. Local Infiltration Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
- 20. Epidural • Epidural injections or catheters placed at T3-T5
- 22. Epidural
- 24. History • 1979: Eason and Wyatt • Reappraisal of the TPVB and described a catheter insertion technique
- 25. Batra RK, Krishnan K, Agarwal A. Paravertebral block. J Anaesthesiol Clin Pharmacol 2011;27:5-11 ] Batra RK, Krishnan K, Agarwal A. Paravertebral block. J Anaesthesiol Clin Pharmacol 2011;27:5-11
- 26. Classic Approach
- 28. Lönnqvist, P. A., MacKenzie, J., Soni, A. K. and Conacher, I. D. (1995), Paravertebral blockade. Anaesthesia, 50: 813–815. Complications Block failure in adults 10.7% Pleural puncture 0.9% Pneumothorax 0.3% Vascular puncture 3.8% Spread to contralateral side 1.1%
- 29. Technique • 2000 Pusch: Sonographic measurements of depth to the TP and parietal pleura TP Pleura
- 30. Live Ultrasound
- 32. Complications • Failed block • Pneumothorax • Vascular puncture • Epidural/Intrathecal Spread
- 33. Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
- 34. PEC I Block Anaesthesia 2011 The Association of Anaesthetists of Great Britain and Ireland Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
- 35. Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
- 37. Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
- 38. Anaesthesia 2013, 68, 1107–1113 Serratus
- 39. Serratus
- 40. Serratus Ld S TM
- 41. Serratus Anaesthesia 2013, 68, 1107–1113
- 43. Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
- 45. TTP Blocking of Multiple Anterior Branches of Intercostal Nerves (Th2-6) Using a Transversus Thoracic Muscle Plane Block Hironobu Ueshima, MD, PhD Akira Kitamura, MD, PhD Department of Anesthesiology Saitama Medical University International Medical Center Saitama, Japan
- 46. Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
- 47. Dartmouth Experience • Prior to 2011 surgeon local infiltration • 2011-2014 paravertebral blocks
- 48. PVB at Dartmouth
- 49. Dartmouth Experience • Prior to 2011 surgeon local infiltration • 2011-2014 paravertebral blocks • 2014-2015 PEC blocks in block area
- 50. PEC Block
- 51. PEC: Dartmouth • Still had consent and timing issues • Improved side effect profile • Patient positioning was easier • Good pain coverage • Still had to use a lot of sedation
- 53. Dartmouth Experience • Prior to 2011 surgeon local infiltration • 2011-2014 paravertebral blocks • 2014-2015 PEC blocks in block area • 2015-Today PEC blocks asleep in OR
- 57. PM Pm S P
- 62. Table 1 TABLE 1 Patients' and Pec Block Characteristics Copyright © 2017 American Society of Regional Anesthesia and Pain Medicine 62 Nerve Blocks Under General Anesthesia: Time to Liberalize Indications? Masaracchia, Melissa M.; Herrick, Michael D.; Seiffert, Ellen A.; Sites, Brian D. Regional Anesthesia and Pain Medicine. 42(3):299-301, May/June 2017. doi: 10.1097/AAP.0000000000000579
- 65. Summary • Breast cancer is common • Rate of PMPS is high • Hopefully with regional techniques we can start to decrease the rate of PMPS
- 66. Summary • Breast tissue is mostly innervated by branches of the intercostal nerve • The underlying muscles are innervated by the pectoral nerves from the brachial plexus • Axilla is innervated by the intercostobrachial nerve
- 67. Summary Important to understand the surgical plan when deciding on a regional technique Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
- 68. Summary Need to match the block with the surgery and also consider risk profile of the block Regional Anesthesia and Pain Medicine • Volume 42, Number 5, September-October 2017
- 69. Summary Lumpectomy Simple Mastectomy Axillary Node Mod Rad Mast Tissue Expanders Implants Plastic Flap (LD) Axillary node Innervation Intercostal nerves (Ant and Lat) Intercosto- brachial (T2) Pectoral nerves Thoracodorsal (C6-8) Long thoracic (C5-7) Nerve block Local Epidural Paravertebral PECs II +/- Ant cut Serratus Local Epidural Paravertebral Infraclavicular PECs II Serratus Interscalene? Infraclavicular PECs I PECs II Local Interscalene? Infraclavicular? PECs II Serratus
Editor's Notes
- Train 400 residents and fellows per year My interest include regional anesthesiology, how we trade residents in procedural tecnhiques Large outcome studies related to blocks
- Breast cancer accounts for 25% of all cancer cases in females and 15% of all deaths making it the most frequently diagnosed ca and leading cause of female cancer death worldwide High rates are seen in North America, Australia/New Zealand, and Northern and Western Europe 1 in 8 women in US will develop breast cancer in their lifetime
- Early stage breast ca 58% breast conservation surgery, 36% mastectomy, only 5% no surgery Advanced the BCS goes down and mastectomy rate up but still 72% are having surgery
- Lumpectomy: removal wedge of subcutaneous breast tissue Partial Mastecomy: A larger portion of subq breast tissue is removed (segmental or quadrantectomy), this is done when tumors are too large for a lumpectomy, patients who cannot tolerate radiation or if more than 1 distinct area of the breast is involved Simple mastectomy: removal entire subq breast tissue with varying amounts of overlying skin, underlying fascia of PM not disrupted Modified radical: breast fascia superficial to PM and axillary nodes Radical mastecomy: removal entire breast, nipple, axillary lymph nodes and pectoralis muscles
- Tissue expander usually placed below the PM and anterior to pec minor Laterally the serratus anterior muscle may be elevated to cover the inferolateral pole of the implant Inflatable bladder is expanded over days to weeks to stretch PM muscles fascia and skin Transversus rectus abdominis flap reconstruction DIEP: Deep inferior epigastric perforator as a free flap Latissimus dorsi flap (Innervated by the thoracodorsal nerve) Donor site can be more painful than mastectomy site
- Definition varies
- 2008 study from denmark look at patients that has surgery for breast cancer from 2003-2004 258 patients in treatment arm and 774 reference patient Prevalance 24% Odds Ration of developing was 2.88
- Cross sectional study from Turkey that had 131 patients that had surgery under GA from 2012-2014, PMPS rate 64%, an additional 23.6% had PMPS-like symptoms on DN-4 Survey prevalance becomes 87.6%
- Retrosepctive study in anesthesia and analgesia of 175 women from a Korean hospital Overall incidence of 56%
- Published description of breast innervation vary widely due to anatomic variation and variable research techniques Majority of cutaneous sensation to breast is from the intercostal nerves The thoracic spinal nerves exit the intervertebral foramina and divide into the dorsal and ventral rami Dorsal rami innervate the skin and muscles over the medial back Ventral rami pass through the PVB space and become the intercostal nerves (travel in the intercostal space below the rib along with the intercostal vein and artery) Similar to abdominal musculature the innercostal region has 3 muscle layers (external intercostal, internal intercostal and the innermost intercostal) the nerves travel between the internal and innermost intercostal muscles and terminate as anterior cutaneous branches providing innervation to the medial chest and sternum At about the midaxillary line a lateral cutaneous branch arises that travels through the internal icm, external icm and the serratus anterior muscle
- Summary Medial breast innervated by Anterior cutaneous branches of T2-T5 with variable input from T1-T6 Lateral breast lateral cutaneous braches T2-T5 with variable involvement of T1, T6 and T7 Nipple Areola Complex is innervated by both anterior and lateral braches of intercostal nerve T3-T4 with variable coverage from T2 and T5 T2 intercostal nerve is what is know as the intercostal brachial nerve after branching off travels along the floor of the base of the axilla to reach the upper medial arm providing innervation to the axillary tail of the breast, axilla and the medial part of the arm (intercostal brachial often implicated in post-mastectomy pain) A small portion of the superior breast skin may be innervated by suprclavicular nerves that originate from the superficial cervical plexus
- We have discussed how the intercostal nerves innervate the breast; However the muscles deep to the breast (except the intercostalmuscles) are innervated by the brachial plexus Majority of breast tissue is immediately anterior to the pectoralis muscles with pec major the most superfical and pec minor deep to it and the serratus anterior muscle deep to that Lateral Pectoral Nerve: Supplies upper portion of PM and arises from either the anterior division of the upper trunk or the lateral cord (C5-C7) Medial Pectoral Nerve Supplies pec minor and lower portion of PM and arrises from C7-T1 and comes off the medial cord Long thoracic Nerve: Arrises from the C5-C7 nerve roots and runs superficial to SAM which it innervates Thoracodorsal nerve: C6-C8 nerve roots posterior cord of the brachial plexus and supplies the latissimus dorsi muscle All of the these nerves have been implicated in postmastectomy pain
- Great summary slide in a review by Glenn Woodworth from OHSU just came out in the most recent RAPM Now that we know what the nerves are lets figure out where to deposit the local and block the pain pathway
- Lot of literature for local infiltration for a variety of research appeared in the early 1980s This study 10mls of 0.5% bupivicaine or 10mls of saline, complete relief of pain in 14/19
- Local works well for lumpectomies but for bigger surgeries harder to cover and you need more and more volume (start to worry about local toxicity) and post-op pain as block wears off
- Epidurals without cervical spread would not cover the braches of the brachial plexus that contribute to muscle innervation (pectoral nerves) 5 studies included in woodworth review all demonstrated improvement in analgesia with epidural, shorter hospital stays, faster PACU discharges and improved patient satisfaction
- 1999 study 32% failure rate primary failure rate of 22-23% but no individual docs rate is > 5% Of course we are better but in recent studies confirming 23-24% failure rate Daring Discourse in RAPM 2016 Primary failure: incorrect placement of the epidural catheter Secondary failure: catheter migration, suboptimal dosing of local anesthetic agents
- A quick aside, we place all our non obstetric epidurals with fluro guidance and shoot an epidural gram, picture on the left is an AP and picture on the right is a lateral allows us to confirm placement and prevent type 1 errors. Also often can enter the space lower and thread the catheter up
- Start to move away from the axis with the PVB
- 1970s eason and wyatt presented a reappraisal on Throacic Paravertebral block Used at first as an alternative to a spinal to spare the cardiovascular and respiratory effects of central neural blockade
- Batra RK, Krishnan K, Agarwal A. Paravertebral block. J Anaesthesiol Clin Pharmacol 2011;27:5-11 Injection results in onesided somatic and sympathetic blockade in multiple continuous thoracic dermatomes Medial border is the vertebral body and vertebral foramen, the posterior boder is the superior costotransverse ligament
- The classic technique of a PVB uses a blind approach in which the needle is inserted 2.5 to 4 cm lateral to the posterior spinous process in search of the transverse process
- Lönnqvist, P. A., MacKenzie, J., Soni, A. K. and Conacher, I. D. (1995), Paravertebral blockade. Anaesthesia, 50: 813–815.
- After the depth was obtained a landmark based technique was used with the benefit of having a known depth to encounter the TP and how far would be too far with resultant pleural puncture
- Here you can see an example of a transverse in plane technique benefit is you can see the needle the entire way. This is the preferred technique for catheter placement for many. The down side is that you are pointing the needle to the neuraxis. You can come from the top of the probe here with the benefit of not pointing to the neuraxis but you loose the ability to see the needle the entire way If you are not doing blocks already you should not start with the PVB
- Once the costotransverse ligament is pierced, local anesthetic is injected 31 studies in Woodworth review, studies varied in amount of injections and single shot vs catheter Favorable outcomes when compared to GA alone, IV opioid and local anesthesia
- Safety profile became more of a concern with out patient surgeries and he fact that these are now being done at stand alone surgery centers.
- Point our epidural and paravertebral and transition to PEC
- Blanco case series of 50 patients, infraclav view injected between pec major and pec minor, noted especially useful breast expanders and subpectoral prostheses, makes sense from what we know about anatomic innervation No RCTs in woodworth review
- PEC 2 between minor and serratus now getting the lateral cutaneous branches of innercostal nerves including intercostal brachial and resultant Axillary spread of coverage 4 studies in review 1 study compared PEC II to no block for modified radical mastectomy with reduction of pain scores in the block group as well as fewer opioid consumption, less PONV, shorter PACU and hospitlal stays Wahba and Kamal compared PEC II to single injected T4 PVB for mod rad mastectomy, PEC group had reduced pain scores in the first 12 hours, longer time to first analgesic request reduced analgesic consumption at 24 hours but pain scores were higher at 16 and 24 hours showing a likely shorter duration of action of PC compared to PVB despite an early analgesic benefit Study was 60 patients mod rad mast 15-20 ml levobupivicaine PVB T4 or 20ml levo between Pen minor and serratus
- Block between latissimus dorsi and serratus
- Now come out mid axillary line
- Block thoracic intercostal nerves
- Block above and below Top image injective above, bottom image injecting below, skin coverage appears good in both but better dye studies when injecting above See that it covers a lot of the medial portion of the breast
- Pec 1 Pec 2 and serratus
- Serratus alone wouldn’t be good for breast surgery involving the Pec muscles What you do not get here are the anterior cutaneous braches of the nerves with any of these techniques
- Figure 1 This 38-year-old woman received a pecto-intercostal fascial block (PIFB) ultrasound-guided block prior to undergoing mastectomy. (A) Ultrasound probe positioning and needle insertion. (B) Ultrasound image of the anterior thoracic wall showing local anesthetic infiltration (yellow asterisks) of the ribs (r) and pectoralis major muscle (PMM). ICM, intercostal muscle.
- Letter to the editor RAPM 2015 FIGURE 1. Ultrasound appearance of 20 mL of local anesthetic (LA) solution filling the transversus thoracic muscle plane. IIM indicates internal intercostal muscle; NT, needle tip; TTM, transversus thoracic muscle.
- Patient timing issue, needed to go to radiology, surgical consent from 2 teams
- Left is PEC 1 showing lateal and medial pectoral nerves PEC II showing lateral branches of the intercostal nerves
- PVB technically challenging trainees (1 month)
- 1 needle pass 2 injection, first go deep and block between Pm and serratus ant put with 15-20 mls and withdraw and inject between the 2 pec muscles 10-15 ml’s
- Wide range of nerves PMPS Intercostobrachial Intercostals, Pectoral nerves, Thoracodorsal, long thoracic