|LETTER TO THE EDITOR
|Year : 2016 | Volume
| Issue : 2 | Page : 243
Role of regional catheters for postoperative analgesia following reconstructive surgeries for breast cancer
SG Bakshi, S Pokhale, S Sharma
Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
|Date of Web Publication||6-Jan-2017|
S G Bakshi
Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Parel, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bakshi S G, Pokhale S, Sharma S. Role of regional catheters for postoperative analgesia following reconstructive surgeries for breast cancer. Indian J Cancer 2016;53:243
|How to cite this URL:|
Bakshi S G, Pokhale S, Sharma S. Role of regional catheters for postoperative analgesia following reconstructive surgeries for breast cancer. Indian J Cancer [serial online] 2016 [cited 2020 Jan 28];53:243. Available from: http://www.indianjcancer.com/text.asp?2016/53/2/243/197712
Reconstructive work following breast onco surgeries is on the rise as it provides oncological safer resections with larger margins and immediate esthetic results. These surgeries include large donor areas from the abdomen. Hence, postoperative pain management is challenging. We discuss two such representative cases which were successfully managed with regional catheters.
A 30-year-old, American Society of Anesthesiologists-I (ASA-I), female diagnosed with phyllodes tumor was planned for radical mastectomy with deep inferior epigastric perforator flap reconstruction. Intraoperatively, a 16-gauge tuohy needle was placed between internal oblique and transverses abdominus muscle superolateral to the incision, on either side, using a sterile ultrasound probe-38x (13–6 MHz) linear array transducer with in plane needle technique. The transversus abdominus plane (TAP) was confirmed with hydrodissection and 16-gauge multiorifice epidural catheter was threaded around 5 cm in the plane. The patient received 15 cc of 0.25% bupivacaine on either side eight hourly basis along with round the clock acetaminophen and diclofenac. No rescue boluses of opioids were needed. Catheters were removed on day 3. Average pain score at rest 1/10 (10-worst pain), at movement - 2/10.
A 58-year-old, ASA I female underwent radical mastectomy for fungating growth in left breast extending from infraclavicular region till infra-mammary crease. The defect was closed with a right vertical rectus abdominis muscle flap. Under ultrasound guidance, a subcoastal TAP catheter was placed on the right side and rectus sheath (RS) catheter placed on the left side. At the end of surgery and every eight hourly patient received 20 cc of 0.25% bupivacaine through the RS catheter and 15 cc through the TAP catheter along with oral acetaminophen and diclofenac. The worst pain score recorded at movement was 3/10.
Pain management after reconstructive surgeries is often opioid-based. Epidural analgesia causes steal phenomenon and hypotension causing diversion of blood to normal tissues away from the denervated flap. In addition, there are concerns with the concomitant administration of antiplatelet and anticoagulant drugs. As the site of harvest for the pedicle flap depends on the extent of resection and abdominal pannus, regional catheters can be planned accordingly. With the knowledge of abdominal blocks and relevant ultrasound anatomy, the choice can range from subcostal TAP, standard TAP or a combination with RS block. With promising evidence emerging for the use of regional catheters for laparotomies, this technique should be considered a safe, feasible opioid sparing technique for pain relief following breast reconstructive surgeries with abdominal donor sites.
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Conflicts of interest
There are no conflicts of interest.
| » References|| |
Hamdi M, Sinove Y, DePypere H, Van Den Broucke R, Vakaet L, Cocquyt V, et al.
The role of oncoplastic surgery in breast cancer. Acta Chir Belg 2008;108:666-72.
Adams J, Charlton P. Anaesthesia for microvascular free tissue transfer. Br J Anaesth CEPD Rev 2003;3:33-7.
Webster K. Ultrasound Guided Rectus Sheath Block-Analgesia for Abdominal Surgery. Update in Anaesthesia 2010;26:12-7.
Bakshi S, Mapari A, Paliwal R. Ultrasound-guided rectus sheath catheters: A feasible and effective, opioid-sparing, post-operative pain management technique: A case series. Indian J Anaesth 2015;59:118-20.