2024 FSA Podium and Poster Abstracts
P078: OPTIMIZING ANALGESIA AND PATIENT EXPERIENCE IN MAJOR BREAST SURGERY
Jitzely Rodriguez, DO1; Behnaz Hatami, MD2; Daniel Castillo, MD1; Zachary Deutch, MD1; 1University of Florida College of Medicine Anesthesiology; 2University of Florida Jacksonville Shands
Introduction: Regional anesthesia is an essential part of perioperative pain management. Pectoralis blocks (PECS I/II) the medial and lateral pectoral nerves, intercostal nerves 3 to 6, intercostobrachial nerves, and the long thoracic nerve, making them useful adjuncts in anterolateral thoracic wall surgeries, notably breast procedures. Local anesthetic is injected in the fascial plane between the pectoralis major and minor muscles to perform PECS I, while PECS II is a deeper injection, between pectoralis minor and serratus anterior [1-3].
Administration of intrathecal opioids has been also recognized for its role in optimizing pain management. In a meta-analysis of 27 trials and 645 adult patients given intrathecal morphine and undergoing major surgeries, the medication was shown to decrease pain intensity at rest and pain intensity on movement, from post-operative hours 4 to 24. The analgesic effect of spinal morphine is reported as equivalent to continuous epidural techniques and superior to intravenous ketamine [5].
Methods: We describe the care of a 55-year-old otherwise healthy woman with left breast ductal carcinoma in situ who underwent a bilateral mastectomy and reconstruction. The patient received single-shot spinal opioid anesthesia followed by PECS I and PECS II blocks. Spinal puncture was performed at L4-5, via midline approach, with a 25g 3.5-inch Pencan needle. 20 mcg of fentanyl and 200 mcg of morphine were injected intrathecally without problem. After induction of general anesthesia, bilateral single-shot PECS I and PECS Il blocks were performed using a 4-inch 20g Stimuplex Ultra needle under ultrasound guidance. 30 mL of 0.5% ropivacaine (7.5 mL per block) was injected and adequate spread of the local anesthetic was observed under direct vision. Intraoperative anesthetic technique consisted of a supraglottic airway and total intravenous anesthesia with propofol.
Results: In the post-anesthesia care unit, 0.5 mg of intravenous hydromorphone and 10 mg oral oxycodone was administered. Although the patient denied significant pain, she was tearful and emotional due to the nature of the procedure and her diagnosis, which the PACU nurse interpreted as inadequate analgesia and therefore administered opioid. PACU discharge was delayed due to low respiratory rate. Upon admission to the surgical floor and throughout her stay, no narcotics were administered. The patient reported being comfortable overnight. When visited by the attending anesthesiologist the following day (15 hours post-op), she requested no additional opioids. Her pain was controlled with the regional techniques, and oral acetaminophen, gabapentin, and methocarbamol. The patient reported no nausea or vomiting, and no pruritus, and gave her pain score as 0/10 at discharge (24 hrs after surgery).
Discussion/Conclusion: In this case, intrathecal opioids combined with a PECS I/IIblocks for major breast surgery optimized intraop and post-op analgesia, as well as patient experience. Important considerations for this approach are patient selection – our patient lacked significant comorbidities and was not elderly, and therefore was at low risk for intrathecal morphine-related complications such as respiratory depression. Clear communication with the surgical and nursing teams is also crucial as additional opioids must be given with caution to patients who have received spinal morphine. We believe this technique should be protocolized and could prove highly beneficial in the proper patient population.