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LETTER TO THE EDITOR
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Dexmedetomidine-based conscious sedation combined with erector spinae plane block for patients undergoing accelerated partial breast irradiation


 Department of Onco-Anesthesiology and Palliative Medicine, Dr. BRA-IRCH, AIIMS, New Delhi, India

Date of Submission05-Jun-2019
Date of Decision15-Oct-2019
Date of Acceptance22-Sep-2019

Correspondence Address:
Nishkarsh Gupta,
Department of Onco-Anesthesiology and Palliative Medicine, Dr. BRA-IRCH, AIIMS, Ansari Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_155_19



How to cite this URL:
Sirohiya P, Gupta N, Kumar V, Bhopale S. Dexmedetomidine-based conscious sedation combined with erector spinae plane block for patients undergoing accelerated partial breast irradiation. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Mar 2]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=309942



Sir,

The literature on the anesthetic considerations for accelerated partial breast irradiation (APBI) in breast cancer patients is very scarce. We present a case of rapid recovery and better postprocedural analgesia after APBI using erector spinae plane (ESP) block and conscious sedation with dexmedetomidine. Postprocedural recovery was smooth and uneventful. A 63-year-old female, weight 75 kg and height 163cm, with no previous history of medical comorbidities, addiction, and malignancy in family, was posted for multicatheter interstitial brachytherapy (type of APBI) for carcinoma right breast. Right breast conservation surgery was done before 3 weeks; margins and sentinel lymph nodes were free of tumor on specimen histopathology. As per patient records, she had fluctuating blood pressure intraoperatively and increased pain scores postoperatively; hence, we decided to do the procedure under ESP block and sedation. This technique is a myofascial plane block performed at T5 transverse process below the erector spinae muscle (ESM).[1] We chose this technique instead of paravertebral block or other thoracic wall blocks because of its ease to perform and safer profile.[2] In the operation theater, the patient was monitored and placed in left lateral position. A linear probe (Micromaxx ultrasound system, Micromaxx® L38e/10-5Mhz, SonoSite, Inc, Bothell, Wa 98021, USA) was placed transversally on the T5 vertebra spinous process, and its ultrasonographic image was identified. Then, the probe was moved laterally, and the laminae, the zygapophyseal articulation, and the transverse process (TP) of T5 were scanned. When the T5 TP was visualized and centered, the probe was rotated 90° clockwise. In this view, we were able to recognize the subcutaneous tissue on the top than three muscle layers, namely, the trapezius muscle above, the rhomboid major muscle in the middle, and the ESM on the bottom. A mixture of ropivacaine 112.5 mg in 30 mL of total volume was prepared for injecting the ESP plane. A 2.125” 18G block needle (Contiplex® D, B. Braun Melsungen AG 34209 Melsungen, Germany) was inserted in a caudal-to-cephalad direction until the tip contacted the T5 transverse process. Depth was achieved at 4 cm. 30 ml of the drug was injected in the plane below the ESM and confirmed by visualization of local anesthetic spreading in a longitudinal pattern [Figure 1]. At this point, we inserted a 20G catheter (transparent polyamide catheter) 8 cm into the ESP to facilitate a course of intermittent boluses of local anesthetic. Within 20 min of injection, sensory block over the T2–T9 dermatomes and complete analgesia were obtained. For sedation, bolus of dexmedetomidine 75 mg over 10 min was given, and then 15–50 μg/h to keep the optimum sedation level (Ramsay Sedation Score[3] −2 or 3). An oxygen mask was connected to the patient. APBI catheters were inserted by a radiation oncologist [Figure 2]. At the end of the procedure, dexmedetomidine was disconnected. The procedure lasted 20 min and was uneventful. After recovery from anesthesia, the patient was shifted to recovery room where pain was monitored using a 10-point Numeric Pain Rating (NRS) scale with four evaluations every 30 min. The NRS score was <3/10 in all the four measurements. The patient was discharged in the radiotherapy ward where she had never requested for rescue analgesics, and the NRS score was maintained at <3/10 on that day. The next morning when patient complained of pain (NRS = 5/10), injection ropivacaine 0.125% 15 ml was given through a catheter. Single daily bolus required till postprocedural day 3. On day 5, the catheter was removed as NRS <3/10 for >24 h. The ESP block was previously described by Forero et al.[1] in video-assisted thoracoscopic surgery and in laparoscopic ventral hernia repair.[4] The peculiarity of this block is the simple identification of the ultrasound landmark and the likely safe procedure.[2] APBI is a painful procedure usually done either in general anesthesia or local anesthesia.[5] To our knowledge, this is the first reported case of APBI under ESP block and conscious sedation with dexmedetomidine.
Figure 1: Ultrasound image showing local anesthetic spread

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Figure 2: Patient with accelerated partial breast irradiation catheters

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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.
Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med 2016;41:621-7.  Back to cited text no. 1
    
2.
El-Boghdadly K, Pawa A. The erector spinae plane block: Plane and simple. Anaesthesia 2017;72:434-8.  Back to cited text no. 2
    
3.
Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J 1974;2:656-9.  Back to cited text no. 3
    
4.
Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair. Anaesthesia 2017;72:452-60.  Back to cited text no. 4
    
5.
Skowronek J, Wawrzyniak-Hojczyk M, Ambrochowicz K. Brachytherapy in accelerated partial breast irradiation (APBI) – Review of treatment methods. J Contemp Brachytherapy 2012;4:152-64.  Back to cited text no. 5
    


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