Ultrasound guided single injection costotransverse block in a breast conserving surgery patient; the first clinical report for novel interfascial block
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KünyeAygün, H., Thomas, D., T., Nart, A. (2020). Ultrasound guided single injection costotransverse block in a breast conserving surgery patient; The first clinical report for novel interfascial block. Journal of Clinical Anesthesia. 61, s. 1-2.
Dear editor, Thoracic paravertebral blocks (TPB) may be used for postoperative analgesia and sometimes as part of the anesthetic method in breast surgeries . However, in order to avoid complications such as pneumothorax and vascular-nerve damage in TPV applications, a large number of ultrasound-guided interfacial blocks have been described in the last decade and have been reported to provide successful perioperative and postoperative analgesia in patients undergoing breast surgery . Pectoral nerves blocks (I-II), serratus anterior block, erector spinae plane block (ESPB) and rhomboid intercostal block are the current interfacial blocks applied for breast surgeries. These blocks can also be used to compliment TPV or as the main anesthesia method in breast surgery . In a recently published cadaveric study, multiple injection costotransverse block (CTB) has been described and the authors reported consistent spread of dye into the thoracic paravertebral space that coloured the ventral rami, the communicating rami, and the sympathetic trunk . In this new block that uses an in-plane cranial-to-caudal needle trajectory, the needle tip is advanced into the thoracic intertransverse tissue complex parallel to the Superior CostoTransverse Ligament (SCTL) and stopped just prior to contact with the cranial part of the neck of the underlying rib. The authors used 4 mL of dye for each injection. ESPB has been used successfully for postoperative analgesia in breast surgery, however, controversy exists as there can be patchy/insufficient or no sensory blockade in the parasternal region [5,6]. We hypothesized that with CTB, in which higher rates of dye transfer to the paravertebral spaces were reported in the cadaver study, it was possible to avoid worries about PVB and to increase the chances of success compared to ESPB. Herein, we present our ultrasound guided single injection CTB application in a patient undergoing breast surgery. A 42 year old ASA II female patient with no systemic disease was scheduled to undergo right breast conserving surgery and sentinel node biopsy. Following routine general anesthesia induction and intubation the patient was positioned so the right arm was lying superiorly. A high frequency linear ultrasound transducer was placed 2–3 cm lateral of 4th thoracic vertebra spinous process. Cutaneous and subcutaneous layers, trapezius and erector spinae muscles, third and fourth transverse processes, intertransverse ligament, SCTL and pleura were visualized. As aforementioned, the needle is advanced parallel to the SCTL and stopped just prior to contact with the cranial part of the neck of the fourth rib and 25 mL of local anesthetic (LA) was administered (15 ml bupivacaine %0.5 and 10 ml lidocaine %2). The patient was then placed in the supine position and the surgical procedure was completed uneventfully in approximately 75 min under general anesthesia. Paracetamol 1 g IV and tenoxicam 20 mg IV was administered peri-operatively for analgesia. Following extubation the patient was transferred to the recovery room and NRS was observed as 0/10. There was sensory block of the thoracic area from Th1 to Th6. However pinprick test revealed mild to moderate parasternal pain. The patient's NRS was <2/10 until the postoperative 24th hour and no additional analgesia was required to except for scheduled paracetamol. This case has demonstrated that like PVB and other interfascial plane blocks, single injection CTB is an effective and long lasting regional anesthesia technique in the thoracic region. This report is the first clinical report of CTB. It is noteworthy that contrary to our hypothesis and prediction by the cadaver study, there was no sensory blockade in the parasternal area. Clinical trials are required to confirm our results.
KaynakJournal of Clinical Anesthesia
- Makale Koleksiyonu