American Society of Regional Anesthesia and Pain Medicine May 2018 - 16

What regional anesthesia technique would accompany your
planned anesthetic?
Warren: Given the patient's size, an ultrasound-guided
paravertebral block may be challenging, although I would attempt
it depending on the anatomy visualization. If paravertebral block
anatomy is not favorable, then I would perform ultrasound-guided
PECS blocks (I, II, serratus plane).
I would use bilateral, ultrasound-guided paravertebral blocks with an
in-plane transverse intercostal approach (linear probe 6-13 mHz),
depositing bupivacaine 0.5% with 1:400,000 epinephrine, 20 mL
each side (total 40 mL volume). I typically perform only a singlelevel block between T2-T4. If the plan is to conduct surgery under
a sole regional anesthetic technique, I would probably perform two
level injections bilaterally at T2-T3, T5-T6 with bupivacaine 0.375%
with epinephrine 1:400,000, with 10-12 mL at each site (total
of 40-48 mL). If visualization is difficult, I would attempt a more
oblique ultrasound probe position or consider a sagittal paramedian
approach. Recognizing that analgesia may be incomplete for the
axillary dissection, I might also consider the addition of a PECS II
block (ie, ultrasound-guided PECS I, II, serratus plane block using
either bupivacaine 0.25% or 0.375% with 60-70 mL volume).

potential blockade of the long thoracic nerve when using PECS
and serratus blocks, but our breast surgeons feel comfortable
proceeding with the block. Additionally, PECS blocks are arguably
easier to perform, faster, and safer than paravertebral blocks.
Would you consider insertion of a thoracic epidural as an
alternative to paravertebral or pecs blocks?
Warren: Certainly, a mid- to high-thoracic epidural would be a good
alternative to a paravertebral or PECS block; however the incidence
of hypotension, motor weakness, and urinary retention is much
greater than with a more peripheral approach. Pneumothorax is
usually the risk that pushes many to prefer thoracic epidural over
paravertebral block, but the incidence of pneumothorax, or clinically
significant pneumothorax, is exceedingly low with a paravertebral
block at my institution. Furthermore, recent publications have
supported the low incidence of pneumothorax with ultrasoundguided paravertebral block.
Pawa: I would not consider siting a thoracic epidural in these
patients for a number of reasons. First, I am an ultrasound convert,
and it is difficult to site thoracic epidurals in real time with

Pawa: My practice is largely based on anesthesia for breast
cancer. The block I site the most for mastectomy surgery is the
thoracic paravertebral, and I routinely site bilateral blocks for
bilateral surgery. I occasionally supplement with a PECS I or II
block, depending on the surgery and the patient. It is my standard
practice to site paravertebrals preoperatively under a small amount
of sedation, usually a bolus dose of midazolam (1-2 mg), possibly
with a small amount of intravenous fentanyl (25-75 mcg). All of my
paravertebrals are ultrasound guided, and with patients of this size,
I position patients in the semiprone position and use a transverse,
in-plane approach to the paravertebral space with an 18g Tuohy
needle. If performing analgesic blocks, I usually use weightappropriate doses of 0.25-0.5% levobupivacaine.
Feinstein: PECS blocks are offered preoperatively as our primary
postoperative analgesic. The injection used for this block is 25
mL of bupivacaine 0.25%, with 2 mg of dexamethasone per side.
One-third of the injectate is given between the pectoralis major and
minor and two-thirds between the pectoralis minor and serratus
anterior.
In our institution, patients receiving these blocks are routinely able
to avoid intravenous opioids and often require minimal oral opioids
in the first 24 hours. PECS and serratus blocks may offer improved
analgesia, compared to other blocks for mastectomy, because
of the unique blockade, which includes both lateral cutaneous
branches of the intercostal nerves and some terminal branches
of the brachial plexus. Some concern has been raised about the

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American Society of Regional Anesthesia and Pain Medicine
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