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Anestesia
1 dicembre numero
2016
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Periodico Trimestrale Gratuito di divulgazione Medico Scientifica DICEMBRE 2016 ANNO 1 N. 1 Editore Improve Communications Sede Legale: Via Viticella, 48 - 80010 Quarto (NA) Sede Operativa : Via Giustiniano, 1119 - 80126 Napoli Direttore Responsabile Gianluca Passaretti Direzione e redazione Via Giustiniano, 119 - 80126 Napoli tel: 081 0362332 e-mail: info@improvecommunications.it web: www.improvecommunications.it Diffusione : Periodico Telematico Service Provider ARUBA S.P.A. Loc. Palazzetto, 4 - 52011 Bibbiena (AR) Hanno collaborato a questo numero: D.ssa Flavia Cianciulli Anaesthesia, ICU center and pain medicine A.O.U. Federico II – Naples Dr. Giuseppe De Simone Anaeshesia, ICU, liver transplant center and UTIF A.O.R.N. A. Cardarelli - Naples Prof. Giuseppe Servillo Director of anesthesia, ICU and pain medicine graduate school A.O.U. Federico II - Naples La testata MTD - More Than Drug è registrata presso il Tribunale di Napoli - reg. n° 49 del 17 ottobre 2016
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ROLE OF PECS BLOCK TYPE II IN THE MANAGEMENT OF BREAST CANCER SURGERY AND PAIN CONTROL: OUR EXPERIENCE. De Simone G.***, Cianciulli F**, Servillo G.* *** Anaeshesia, ICU, liver transplant center and UTIF – A.O. R. N. A. Cardarelli – Naples ** Anaesthesia, ICU center and pain medicine – A.O.U. Federico II – Naples * Director of anesthesia, ICU and pain medicine graduate school - Federico II - Naples
ABSTRACT Breast cancer is reported as the most diagnosed malignancy in women and it affects all age groups in various degrees. Therapeutic management often includes surgery which can be both quadrantectomy or mastectomy. Nowday in all these cases, usually, the most widely type of anesthesia adopted remains the general anesthesia. This kind of anesthesia is known to be burdened by post-anesthesiologic complications reducing the degree of satisfaction of patients already annoyed by neoplastic disease. We selected 10 patients with different comorbidities, undergoing breast surgery. Four of them undergoing mastectomy and six of them undergoing quadrantectomy. For all of them PECs block type II was performed in assosiacion with analgo-sedation. Our experience showed how this practice decreases complications and improves quality of pain management and patients degree of satisfaction.
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INTRODUCTION Breast cancer is reported as the most diagnosed malignancy in women and it affects all age groups in various degrees. There are various therapeutic interventions depending on feasibility, aggressiveness and invasiveness of the course of the disease and it often includes surgery which can be both quadrantectomy or mastectomy according by the part of the mammary gland affected, its extension and the assessmentof the axillary lymphnodes Nowday in all these cases, usually, the most widely type of anesthesia adopted remains the general anesthesia. This kind of anesthesia is known to be burdened by post-anesthesiologic complications of which we remember, among the most impactful PONV, postoperative pain requiring additive drug treatment and prolonged hospitalization periods, all those reduces the degree of satisfaction of patients already annoyed by neoplastic disease. The study began on grounds of necessity: use analgo-use sedation to allow the execution of interventions in patients who are not candidates for general anesthesia because of the presence of an high anesthetic risk. As the practice of anesthesia, the reduction of complications and the increase of the degree of satisfaction of patients, we wondered why not extend this technique also to routine clinical breast surgery, and therefore also to younger patients, generally without major comorbidities and low anesthetic risk. That's the reason why we chose PECs BLOCK type II to treat these few patient enrolled. Indeed this practice consists of a peripheral nerve block, useful to perform regional anesthesia and, above all, post-operative analgesia. the PECs BLOCK Type II (PECs BLOCK type I modified) consists of a peripheral nerve block, useful to perform regional anesthesia and post-operative analgesia in breast surgery, by injection of local anesthetic between the muscles of the chest wall. The muscle groups of the anterior chest wall affected by nerve block include the pectoralis minor muscle, the pectoralis major muscle, the serratus anterior muscle and the intercostal muscles. The innervation of the anterior chest wall and breast is served by lateral and middle pectoral nerves, by spinal nerves T2 – T6, the thoracodorsal nerve and the long thoracic. The PECs BLOCK Type II involves injection of local anesthetic between the large and small pectoral muscles at the level of the third rib, to block the lateral and medial pectoral nerves (PECs BLOCK type I) with an addictional injection of local anesthetic between the pectoralis minor muscle, by a side, and serratus anterior, also at the level of the third rib. Thus the lateral branches of the spinal nerves T2-T4, and also the front branches are blocked if sufficient anesthetic spreads in external intercostal muscles. Finally proceeding with infiltration of local anesthetic in the middle portion of the axilla can be blocked even the long thoracic nerve to obtain a synergistic effect and an optimal intra- and post-operative analgesia.
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MATERIALS AND METHODS This study was conducted from April to June 2014 at the General Surgery Department of 'A.O.U. "Federico II" of Naples. The study enrolled 10 patients, aged 18-88 years, of which 3 with ASA I, 5 with ASA II and 2 ASA III, who were about to be submitted to breast surgery. SIx of them were about to be submitted to quadrantectomy and four of them to mastectomy. Breast surgery was always performed by the same surgical team to allow a proper comparison of the interventions on the durations. PECs BLOCK type II was performed for all of the patients in addition to endovenous analgo-sedation. Rates of recovery of the patients at the end of every surgery, through integrity assessment of the sensorium (eye opening to voice command, verbal response, execution of simple commands), duration of surgery (recorded as the time between the first administration of anesthetics / sedatives and the complete recovery of the patient) ,magnitude of post-operative pain reported by the patient in the immediate post-operative (time 0) and at 6h, through the numeric rating scale (NRS scales) were noted.
RESULTS Patients underwent mastectomy in analgo-sedation method associated with ultrasound guided PECs block type II were 4, aged between 49 and 81 years, weighing between 55 and 80 kg , with BMI between 23.4 and 29.4. 4 patients were classified as ASA class II, one patient as ASA class III. The duration of the operative time was between 50 and 168 minutes (average 82.1 minutes, ± 37.2). The time required to complete recovery of the patients was between 0.5 and 18 minutes (average 2.5 minutes, ± 5.1). None of the patients had complications during and / or after surgery. The extent of the pain reported by the patients in the immediate postoperative (time: 0h) ranged from level 0 to level 4 of the NRS scale (mean 1.4 ± 1.2). At 6 h it was in average 0.1 (± 0.4) For 2 of the 4 patients required post-operative analgesia: one patient was given 1000mg paracetamol, the other patient was associated with an elastomeric pump infusion duration of 24h. Patients subjected to the quadrantectomy interventions, conducted in analgo-sedation associated with ultrasound guided Block PECs were 6, aged between 22 and 84 years (mean 60.7 years ± 14.5), body weight between 50 and 100 kg (average 68.4Kg, ± 12.5), with BMI between 18.4 and 40.5 (mean 26.5, ± 5.3). 3 patients were classified as ASA class I, one patient as ASA class II, one patient as ASA class III. The duration of the operative time was between 28 and 177 minutes (mean 73.3 minutes ± 31.3). The time required to complete recovery of patients was between 0.5 and 2 minutes (average 1 minut, ± 0.4). Complications were recorded in 2 patients: one patient experienced tachycardia upon waking with a 145 heart rate; one patient experienced bronchospasm on waking. The extent of the pain reported by the patients in the immediate postoperative (time: 0h) ranged from 0 level to level 3 (average 0.5 ± 0.8). For 1 of the 6 patients required post-operative analgesia with Paracetamol 1000mg.
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CONCLUSIONS Breast cancer sees still involved a large portion of the female population associating often, in addition to emotional distress, even the stress of surgery and discomfort related to the hospital permanence, as well as post-operative pain. For these reasons and for its great impact on society, it requires an interdisciplinary treatment approach evolving, aimed at improving the treatment and the hospital management of patients treated, not only to provide more comfort, from the psychological point of view, a healing path that involves women of every age group, but also to improve hospital management by reducing the time of the hospitalization, the use of drugs, especially intravenously, and optimizing healthcare costs. While surgical techniques become less invasive time after time with shorter and shorter operating times, on the other side, a correct intraoperative anesthetic management and optimal management of post-operative analgesia are indispensable elements for the therapeutic procedure. With our work we wanted to extend the use of a technique, the PECs BLOCK Type II, previously almost exclusively used for the treatment of ineligible patients to undergo general anesthesia, even the interventions without predicted anesthesia risks. In doing so, the PECs BLOCK associated with analgo-sedation has clearly shown the following benefits 1) Reduction in the operating time (intented bewteen the beginning of the procedure until discharge from the operation theatre) which results in a lower exposure of patients to the administration of anesthetic / sedative drugs reducing the side effects. 2) Reduction in the recovery time, increasing the comfort of the patients with a more prompt recovery of cognitive functions after the initial moment of the post-awakening 3) Better management of intraoperative pain thanks to antalgic coverage provided by the administration of local anesthetic, which translates into a lower algic perception in the immediate postoperative time 4) Decreased need for rescue analgesia with IV paracetamol and noneed to apply an elastomeric h24 pump We can conclude that the least exposure to the anesthetics agents, the best management of pain due to infiltration of local anesthetic and therefore also here the reduction of the administration of post-operative analgesic therapy and rescue therapy reduce complications, increase the comfort of the pacients , the mobilization and consequently the faster resumption of normal activities making patients more compliant and reducing the potential length of stay related to the difficulty of management, especially of the pain one. Finally the perfect compatibility with the surgical act and the full satisfaction by the operating part of the team, as the infiltration of anesthetic does not affect the surgical field or
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intraoperative localization of the tumor nor affect the presentation of surgical complications such as hematoma or seroma, lead us, in our experience, to consider, in the future, this as a technique of choice in the increasingly common practice.
REFERENCES
1) Postgrad Med J. 1996 Feb;72(844):105-8. Local anaesthesia for major general surgical procedures. A review of 116 cases over 12 years. Dennison A1, Oakley N, Appleton D, Paraskevopoulos J, Kerrigan D, Cole J, Thomas WE. 2) Ann R Coll Surg Engl. 1985 Jul;67(4):243-4. Simple mastectomy under local anaesthesia. Dennison AR, Watkins RM, Ward ME, Lee EC. 3) Eur J Surg Oncol. 1996 Apr;22(2):134-6. A prospective audit of simple mastectomy under local anaesthesia. Oakley N1, Dennison AR, Shorthouse AJ. 4) Int J Surg. 2008;6 Suppl 1:S116-8. doi: 10.1016/j.ijsu.2008.12.006. Epub 2008 Dec 13. Breast cancer surgery in an ambulatory setting. Rovera F1, Ferrari A, Marelli M, Bellani M, Limonta G, Corben AD, Dionigi G, Boni L, Uccella L, Dionigi R, Carcano G.
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6) Chir Ital. 2004 May-Jun;56(3):415-8. One-day surgery in a series of 150 breast cancer patients: efficacy and cost-benefit analysis. Ranieri E, Caprio G, Fobert MT, Civitelli L, Ceccarelli F, Barberi S, Virno F
7) Clin J Oncol Nurs. 1999 Jul;3(3):99-106. A critical pathway for patients undergoing one-day breast cancer surgery. Sladek ML, Swenson KK, Ritz LJ, Schroeder LM 8) Am Surg. 1996 Feb;62(2):123-7. Physical, psychological, and economic advantages of accelerated discharge after surgical treatment for breast cancer. Kambouris A
9) Am Surg. 1992 Apr;58(4):239-42. One-day hospitalization following modified radical mastectomy. Clark JA, Kent RB 3rd
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