Mastectomy is a common surgical procedure for breast malignancies. General anesthesia is traditionally favored for the operation. However, there are situations when general anesthesia may be considered unsuitable. Regional anesthesia was chosen for mastectomy in our patients due to compromised pulmonary status, resulting from widespread malignant infiltrations of the lungs.
Although intercostal nerves block has been used for minor breast procedures, its use for major breast surgery is not common. The block, alone, cannot guarantee adequate anesthesia for surgical excision of the entire breast, as in simple mastectomy. Intercostal nerves block was combined with blockade of the supraclavicular branches of the superficial cervical plexus, which provide sensation to the upper part of the breast and the intercostal nerve supply from the contra-lateral side. These combinations provided a complete block of the sensory supply to the breast. The technique thus provided optimal surgical condition with stable hemodynamics, in the absence of sympathetic blockade that often complicates alternative techniques, such as paravertebral and thoracic epidural blocks. Intercostal nerves block is credited with a higher risk of local anesthetic toxicity compared with paravertebral or epidural blocks. This is because the absorption kinetics of local anesthetics in the intercostal space is comparably more rapid than in any of these less vascularized sites. However, none of our patients exhibited any evidence of local anesthetic toxicity. This was probably due to the small volume of local anesthetic used (4 ml) at each intercostal space. Furthermore, the addition of a vasoconstrictor (epinephrine) to limit absorption and the use of low concentration of the local anesthetic agent to limit total dose, no doubt, assisted in preventing a large bolus of local anesthetic being delivered into the blood stream within a short time. The actual amount of bupivacaine delivered into the intercostal spaces in any of the two patients was less than the maximum recommended dose (2-3 mg/kg1). Pleural puncture with subsequent development of pneumothorax is another potential complication of intercostal nerves block. However, the incidence of this complication is extremely low, and it’s claimed to be less than 1%. Neither of the two patients in this report experienced pneumothorax. viagra plus
Although all patients are candidates for intercostal nerves block, it is known that as patients become more obese, the blocks may be technically more difficult to carry out. This was the situation with our first patient, in whom the mid-axillary approach had to be abandoned for a posterior approach, which was found easier for the block in the obese patient.