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4970
Regional Anesthesia as Primary Anesthetic for Mastectomy: A Case Report of an Alternative Approach
Session: MP-09b
Sat, April 21, 8-9:30 am
Uris (Shubert Complex), 6th floor

Please note, medically challenging cases are removed three months after the meeting and scientific abstracts after three years.

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Regional Anesthesia as Primary Anesthetic for Mastectomy: A Case Report of an Alternative Approach

Adrian Jonan, MD,  Alvaro Macias, MD, and Kamen Vlassakov, MD

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School

Introduction

•Growing concern for perioperative cognitive complications in elderly patients
•Regional anesthesia may be associated with lower risk of postoperative cognitive dysfunction
•Alternative approach to traditional paravertebral block described

Materials and Methods

•Informed consent obtained after risk/benefit discussion
•Two level proximal intercostal block single shot, PECS I, superficial cervical plexus single shots performed as primary anesthetic using 0.5% ropivacaine with dexamethasone

Case Report

•95-year-old female with history of HTN, HLD, CAD, DM2 presents for right simple mastectomy
•Patient and supporting family concern for POCD, request primary regional anesthesia with minimal sedation
•Right-sided T2-3 and T4-5 proximal intercostal block, PECS I block, and superficial cervical plexus using 30 mL 0.5% ropivacaine with 4 mg dexamethasone
•Intraoperatively, propofol gtt at 40 mcg/kg/min, awake and alert throughout procedure
•Supplementation in surgical field with 5 mL 0.5% bupivacaine-1:200,000 epinephrine at lower segment
•Tolerated procedure well, no pain in postoperative phase, dicharged on postoperative day 2

Discussion

•Traditional PVB for mastectomy can be technically challenging and is not without risk or anticoagulation restrictions
•Proximal intercostal blocks potentially safer due to optimal pleural visualization
•Supplementation of proximal intercostal block with superficial cervical plexus and PECS I aids in anesthetizing upper portion of breast
•Care must be taken for bilateral mastectomies due to local anesthetic dose limitations

Conclusion

•Utilization of proximal intercostal blocks, superficial cervical plexus block, and PECS I block is an alternative approach to primary anesthetic for mastectomy
•May be beneficial when paravertebral blocks are deemed high risk or technically challenging
•Potentially helpful for reducing risk of POCD in high risk population

References

Mason SE, Noel-Storr A, Ritchie CW. J Alzheimers Dis. 2010. 22: 67-79

Rasmussen LJ et al.  Acta Anaesthesiol Scand. 2003. 47(3):260-266

Kairaluoma PM, Bachmann MS, Rosenberg PH, Pere PJ.  Anesth Analg. 2006. 103(3):703-708

Chowdhury A et al. ASRA 2017 Poster Presentation

Knight JB, Schott NJ, Kentor ML, Billiams BS.  Curr Opin Anaesthesiol. 2015. 28(5):598-604

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