American Society of Regional Anesthesia and Pain Medicine May 2018 - 19
Sensory innervation of the axilla is supplied by the lower brachial
plexus (C8-T1-medial cutaneous nerve of the arm) and may not be
covered with a paravertebral block, although it is not uncommon
for cervical spread of local anesthetic with a paravertebral block
as evidenced by frequent development of Horner syndrome. The
medial arm/axilla is also supplied by the intercostobrachial (T2)
nerve, which should be covered with a paravertebral block. A PECS
II block can usually cover the intercostobrachial nerve successfully,
but a brachial plexus block that covers the medial cord is necessary
to block the medial cutaneous nerve of the arm. The superficial
cervical plexus (supraclavicular nerves) may also contribute to
sensory innervation of the axilla and anterior chest. I would consider
performing additional blocks to cover what might have been missed.
Pawa: I would take a pain history and examine the patient to
assess the cause of pain. I would also ask for a surgical consult.
The possible differential diagnoses for pain would be surgical
site pain because of inadequate scar analgesia in axilla (PECS
block was not performed), pain from transection or electrocautery
to intercostobrachial nerve, acute hematoma formation, and
nonsurgical site pain from excessive shoulder abduction. If a PECS
block had not been performed, I would clamp the drains for 30
minutes and perform bilateral PECS II blocks. If a PECS block had
been performed, I would attempt to administer small intravenous
boluses of ketamine or to instill local anesthesia via the drains.
cover the medial cutaneous nerve of arm, although I would be
wary of causing phrenic nerve paresis in an obese patient with
obstructive sleep apnea (interscalene and infraclavicular blocks). An
infraclavicular block is also challenging in morbidly obese patients.
Alternatively, I could have done bilateral PECS II/intercostobrachial
nerve block to cover the axilla or possibly bilateral superficial
cervical plexus blocks.
Pawa: Depending on the cause, a number of options are available.
Insertion of preemptive PECS blocks would be my first choice.
The other potential strategies are preoperative administration
of a gabapentin, not cutting the intercostobrachial nerve, or
infiltrating the axillary wound with local anesthesia as the surgeons
suggested.
Feinstein: In our experience, the PECS and serratus blocks enable
better axillary analgesia. These interfascial plane blocks provide
brachial plexus blockade that is missed when a paravertebral or
epidural is used.
REFERENCES
1.
Abdallah FW, Morgan PJ, Cil T, et al. Ultrasound-guided multi-level
paravertebral blocks and total intravenous anesthesia improve the quality
of recovery after ambulatory breast tumor resection. Anesthesiology.
2014;120:703-713.
2.
Wu J, Buggy D, Fleischmann E, et al. Thoracic paravertebral regional anesthesia
improves analgesia after breast cancer surgery: a randomized controlled
multicentre clinical trial. Can J Anesth. 2015;62:241-251.
3.
Pawa A, Wight J, Onwochei DN, et al. Combined thoracic paravertebral and
pectoral nerve blocks for breast surgery under sedation: a prospective
observational case series. Anaesthesia. 2018;73(4):438-443.
What could you have done to prevent the patient's significant
axillary pain?
4.
Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. Can anesthetic
technique for primary breast cancer surgery affect recurrence or metastasis?
Anesthesiology. 2006;105:660-664.
Warren: I could have performed a low-dose brachial plexus block
(low interscalene, supraclavicular, or infraclavicular approach) to
5.
Woodworth GE, Ivie RM, Nelson SM, et al. Perioperative Breast Analgesia. A
qualitative Review of Anatomy and Regional Techniques. Reg Anesth Pain Med.
2017;42:609-631.
Feinstein: After evaluating the patient at bedside and confirming
the bilateral axillary pain, we would order PRN opioids as well as a
single-dose intravenous ketorolac.
American Society of Regional Anesthesia and Pain Medicine
2018
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