Bilateral Mastectomy: dispute of PCA Morphine vs Bilateral erector spinae plane catheters-exploring best analgesic management for breast cancer surgery

Naidu, Durgalakshmi and Wong, Shee Ven and Mohamed Zaini, Mohamed Asri and Imam Supaat, Nuraiman and Abd Rashid, Nawal Wafa and Mohd Nasaruddin, Nur Asifa and Osman, Ariff and Abd Ghani, Muhamad Rasydan (2021) Bilateral Mastectomy: dispute of PCA Morphine vs Bilateral erector spinae plane catheters-exploring best analgesic management for breast cancer surgery. Medicine and Health, 16 (Supplemetary 3). pp. 26-27. E-ISSN 2289-5728

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Abstract

Objectives: Surgical resection of the primary tumour with axillary dissection is a mainstream of breast cancer treatment. Many patients report moderate-to severe pain post-operatively. Acute post-surgical pain can cause chronic pain, and persistent use and over-prescription of opioids. The erector spinae plane block (ESPB) sufficiently blocks unilateral multi-dermatomal sensation from T1 to L3 and is a novel regional anaesthetic technique for effective analgesia after mastectomy, minimising opioid use. Methods: We study the analgesic efficacy of bilateral ESPB with continuous infusions with a bilateral rectus sheath block (RSB) in a patient undergoing bilateral mastectomy and left axillary clearance for left invasive breast carcinoma and right breast ductal carcinoma-in-situ, and incisional hernia repair. We discuss recommendations and best analgesic management after mastectomy. Results: The patient underwent ESPB using 20 ml of 0.2% Ropivacaine with catheter insertion bilaterally, and bilateral RSB with 20 ml of 0.2% Ropivacaine after the induction of general anaesthesia. Post-operatively, she was extubated, did not require intensive care, required no rescue opioids, had good pain control, and successful early mobilisation. Post-operative PCA Morphine usage was only for 24 hours. Conclusions: Regional anaesthesia for breast surgery reduces postoperative pain and opioid requirements, and, may be continued postoperatively using catheter techniques. The best analgesic technique for this patient could be PCA morphine alone, however, the combination of ESPB with continuous infusions, RSB and PCA morphine, provided excellent analgesia and allowed our patient to be discharged to the ward despite prolonged surgical hours. Patient experienced analgesic satisfaction, better night sleep, early ambulation, and recovery. Although the gold standard of analgesic techniques for bilateral mastectomy is bilateral Paravertebral Block, bilateral ESPB was performed as it is common in our centre. Despite the paucity of evidence, in the best hands, bilateral ESPB provided superior analgesia, as depicted in this case.

Item Type:	Article (Case Report)
Uncontrolled Keywords:	Erector Spinae Plane Block, Catheter technique, Mastectomy
Subjects:	R Medicine > RD Surgery > RD81 Anesthesiology
Kulliyyahs/Centres/Divisions/Institutes (Can select more than one option. Press CONTROL button):	Kulliyyah of Medicine > Department of Anaesthesiology & Intensive Care
Depositing User:	Dr Muhamad Rasydan Abdul Ghani
Date Deposited:	21 Dec 2021 09:22
Last Modified:	21 Dec 2021 09:22
URI:	http://irep.iium.edu.my/id/eprint/95008

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