Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 6  |  Page : 605-607  

Thoracic epidural anesthesia and interscalene block for a pneumonectomized patient posted for modified radical mastectomy


Department of Anesthesiology, Dr DY Patil Medical College, Hospital and Research Center, Dr DY Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission03-Jan-2017
Date of Acceptance10-May-2017
Date of Web Publication17-Jan-2018

Correspondence Address:
Dr. Mridul Dua
Flat No. 202, Keshava Chhotani Mansion, Road No. 10, Kalyani Nagar, Pune - 411 006, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_2_17

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  Abstract 


Thoracic epidural anesthesia with ipsilateral brachial plexus block is emerging as an alternative to general anesthesia for oncologic breast surgery.1. A 31 year old, pneumonectomised female with a past history of MDR TB was diagnosed with infiltrating ductal carcinoma in left breast 2 months ago and was posted for MRM. She also had moderate Pulmonary Arterial Hypertension. Thoracic epidural anesthesia was induced with 12 ml of 0.5% Ropivacaine at T6-T7 level. Interscalene block was given with 10 ml 0.5% Ropivacaine using peripheral nerve locator. Patient was comfortable throughout the procedure and remained vitally stable. Post-operative analgesia was given with 10 ml of 0.2% ropivacaine and patient was discharged the following week. Thoracic epidural anesthesia provides the advantage of superior intra and post-operative analgesia without the adverse effects of general anesthesia like postoperative nausea, vomiting, respiratory depression and sedation.2 Coupled with interscalene block for axillary lymph node dissection, it can be successfully used as an alternative to GA for MRM.

Keywords: Modified radical mastectomy, pneumonectomy, thoracic epidural anesthesia


How to cite this article:
Dua M, Raval B, Nasreen SF, R. Chari V R. Thoracic epidural anesthesia and interscalene block for a pneumonectomized patient posted for modified radical mastectomy. Med J DY Patil Univ 2017;10:605-7

How to cite this URL:
Dua M, Raval B, Nasreen SF, R. Chari V R. Thoracic epidural anesthesia and interscalene block for a pneumonectomized patient posted for modified radical mastectomy. Med J DY Patil Univ [serial online] 2017 [cited 2018 Nov 20];10:605-7. Available from: http://www.mjdrdypu.org/text.asp?2017/10/6/605/223360




  Introduction Top


Pneumonectomized patients and patients with chronic obstructive pulmonary disease are at an increased risk of perioperative complications.[1] Thoracic epidural anesthesia with interscalene block is emerging as an alternative to general anesthesia for oncologic breast surgery.[2] It provides superior postoperative analgesia without respiratory depression and sedation. In our patient, we therefore chose regional over general anesthesia.[3]


  Case Report Top


A 31-year-old female was diagnosed with Stage III infiltrating intraductal carcinoma of the left breast and was posted for a modified radical mastectomy (MRM). She was on neoadjuvant chemotherapy since 1 month.

She had a history of multidrug-resistant tuberculosis (MDR-TB) 2 years ago, refractory to conservative management, and had undergone left-sided pneumonectomy 6 months ago. In addition, the patient complained of dyspnea, Grade 2 on Modified Medical Research Council Scale. She had no other comorbidities and no relevant family history. On examination, the patient was well preserved and slightly pale. Vital parameters were normal, and on auscultation, breath sounds were absent on the left side.

Patient's hemoglobin was 9 gm%. All other blood and urine investigations were normal. Her chest X-ray showed the absence of left lung [Figure 1]. High-resolution computed tomography thorax showed left side pneumonectomy, mediastinal shift to left, and fibrotic areas in the right lung. Two-dimensional echocardiography showed moderate pulmonary artery hypertension (40 mmHg).
Figure 1: Chest X-ray showing left pneumonectomy

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Intraoperative management

Thoracic epidural was planned as anesthesia of choice, with all preparations for general anesthesia in case of failure. The procedure and anesthetic risks were explained to the patient and relatives, and written consent was obtained.

After confirming overnight fasting, the patient was made to lie supine on the operating table, and standard monitors were attached. Pulse rate was 95 beats/min, oxygen saturation was 98% on room air, electrocardiogram was normal, and baseline blood pressure was 124/80 mmHg.

Patient was premedicated with injection ondansetron 4 mg intravenous (IV) and given sitting position. Under all aseptic precautions, thoracic epidural anesthesia was induced with 18-gauge Tuohy's needle at T6–T7 level using loss of resistance technique [Figure 2]. Catheter was fixed at 8 cm mark, with 4 cm of catheter in epidural space. After giving a test dose with 3 ml 2% injection lignocaine + adrenaline, 12 ml 0.5% injection ropivacaine was injected after negative aspiration. Dense sensory block from level T2 to T8 was achieved within 20 min.
Figure 2: Thoracic epidural anesthesia being induced

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Interscalene block was given on left side, using peripheral nerve locator, with 10 ml 0.5% injection ropivacaine to cover any axillary sparing [Figure 3].
Figure 3: Interscalene block using peripheral nerve locator

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One milligram injection midazolam IV was given after induction and surgery was commenced.

Throughout the surgery, patient's respiratory rate was 14–18 breaths/min, end-tidal carbon dioxide was between 34 and 38, and there was no evidence of diaphragmatic paralysis.

Intraoperatively, 1 L of crystalloids and 1 unit of packed red blood cells were transfused. Three hundred milliliters was total blood loss, and urine output was adequate. The surgery was completed in 2 h.

Patient was comfortable throughout the surgery and vitals remained stable. There was no additional requirement for sedative or analgesic agents.

Postoperative management

After monitoring the patient for 1 h in the recovery room, patient was shifted to the ward in a stable condition. Postoperative analgesia was given through epidural catheter, with 10 ml 0.2% ropivacaine 8 h after surgery and 12 hourly thereafter for 36 h, following which, the epidural catheter was removed. The patient was discharged the following week.


  Discussion Top


With the advent of improvement in surgical technique, after year 2014, more and more MDR-TB patients were treated with combined medical and surgical therapy to achieve better morbidity and mortality profile.[4]

Pneumonectomized patients posted for surgery pose a wide range of perioperative complications. Excessive mediastinal shift away from the pneumonectomy space into the contralateral hemithorax can result in decreased lung volume, retained secretions, and respiratory compromise.[5]

General anesthesia and invasive mechanical ventilation can cause barotrauma and precipitate pulmonary edema and acute respiratory distress syndrome in patients with pulmonary arterial hypertension.[6]

Breast cancer is the most common female cancer worldwide representing nearly a quarter (23%) of all cancers in women.[7] For infiltrating ductal carcinoma stage IIb or more, MRM with neoadjuvant chemotherapy continues to be the mainstay of treatment. In most centers in India, oncologic breast surgeries are performed under general anesthesia. However, we are slowly observing a shift toward regional and locoregional anesthesia for these surgeries.

Sundarathiti et al. conducted a clinical trial in 2005 on fifty females with breast cancer posted for MRM. Half the patients were operated under general anesthesia and half under thoracic epidural and interscalene block with 0.2% injection ropivacaine. They concluded that thoracic epidural anesthesia is one of the regional anesthetic techniques that can be performed using a low dose of local anesthetic in combination with ipsilateral brachial plexus block for axillary node dissection. Thoracic epidural can provide better pain relief without potential paralysis of respiratory muscle and sedation that are associated with general anesthesia.[2]

Doss et al.,[3] in their study, continuous thoracic epidural anesthesia with 0.2% ropivacaine versus general anesthesia for perioperative management of MRM concluded that thoracic epidural with ropivacaine provides better postoperative pain relief and less nausea and vomiting, facilitates postanesthesia recovery, and gives greater patient satisfaction than general anesthesia.

Local anesthetic infiltration has also been used along with thoracic epidural anesthesia for MRM for axillary lymph node dissection. Wound infiltration of local anesthetic agents may be used for postoperative analgesia.[8]

Kaya et al., in their study on postoperative analgesia after MRM, demonstrated that the use of interscalene block in patients undergoing MRM improved pain scores and reduced morphine consumption during the first 24 h postoperatively.[9]

Paravertebral block is another method that can be employed as an alternative to general anesthesia for mastectomies. Surgical anesthesia by thoracic paravertebral block alone, however, causes considerable patient's discomfort during neural block and surgery. Ono et al. concluded that the combined use of paravertebral block and general anesthesia can be a preferable choice of anesthesia for patients undergoing major breast cancer surgery.[10]


  Conclusion Top


Successful intra and postoperative anesthetic management of pneumonectomized patient for MRM was achieved using thoracic epidural anesthesia with interscalene block.

Patient satisfaction was good and postoperative period was without adverse effects of general anesthesia such as respiratory depression and pulmonary edema, which may be deleterious in such patients.

Thoracic epidural anesthesia can serve as an alternative to general anesthesia for MRM and other breast surgeries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hausman MS Jr., Jewell ES, Engoren M. Regional versus general anesthesia in surgical patients with chronic obstructive pulmonary disease: Does avoiding general anesthesia reduce the risk of postoperative complications? Anesth Analg 2015;120:1405-12.  Back to cited text no. 1
    
2.
Sundarathiti P, Pasutharnchat K, Kongdan Y, Suranutkarin PE. Thoracic epidural anesthesia (TEA) with 0.2% ropivacaine in combination with ipsilateral brachial plexus block (BPB) for modified radical mastectomy (MRM). J Med Assoc Thai 2005;88:513-20.  Back to cited text no. 2
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3.
Doss NW, Ipe J, Crimi T, Rajpal S, Cohen S, Fogler RJ, et al. Continuous thoracic epidural anesthesia with 0.2% ropivacaine versus general anesthesia for perioperative management of modified radical mastectomy. Anesth Analg 2001;92:1552-7.  Back to cited text no. 3
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4.
Harris RC, Khan MS, Fielding K, Martin LJ, Allen V, Moore DA, et al. The effect of surgery on the outcome of treatment for multidrug-resistant tuberculosis: A systematic review and meta-analysis. BMC Infect Dis 2016;16:262.  Back to cited text no. 4
    
5.
Zellos L, Jaklitsch MT, Al-Mourgi MA, Sugarbaker DJ. Complications of extrapleural pneumonectomy. Semin Thorac Cardiovasc Surg 2007;19:355-9.  Back to cited text no. 5
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6.
Rush B, Biagioni BJ, Berger L, McDermid R. Mechanical ventilation outcomes in patients with pulmonary hypertension in the United States: A national retrospective cohort analysis. J Intensive Care Med 2016. pii: 0885066616653926.  Back to cited text no. 6
    
7.
Global Burden of Disease Cancer Collaboration, Fitzmaurice C, Dicker D, Pain A, Hamavid H, Moradi-Lakeh M, et al. The global burden of cancer 2013. JAMA Oncol 2015;1:505-27.  Back to cited text no. 7
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8.
Bansal P, Saxena KN, Taneja B, Sareen B. A comparative randomized study of paravertebral block versus wound infiltration of bupivacaine in modified radical mastectomy. J Anaesthesiol Clin Pharmacol 2012;28:76-80.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Kaya M, Oguz G, Senel G, Kadiogullari N. Postoperative analgesia after modified radical mastectomy: The efficacy of interscalene brachial plexus block. J Anesth 2013;27:862-7.  Back to cited text no. 9
    
10.
Ono K, Danura T, Koyama Y, Hidaka H. Combined use of paravertebral block and general anesthesia for breast cancer surgery. Masui 2005;54:1273-6.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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