Regional Anesthesia and Pain Medicine • Volume 40, Number 2, March-April 2015
Letters to the Editor
Benjamin Fox, FRCA Anaesthesia Department Norfolk and Norwich University Hospital Norwich, United Kingdom
The authors declare no conflict of interest.
REFERENCES 1. Lie J, Letheren M. “Wrong side” sticker/dressing to help reduce wrong-sided nerve blocks. Reg Anesth Pain Med. 2014;39:441–442. 2. The Royal College of Anaesthetists, 2010. Stop Before You Block. Available at: http://www.rcoa. ac.uk/standards-of-clinical-practice/wrong-siteblock. Accessed April 25, 2014. 3. Safe Anaesthesia Liaison Group, 2010. Wrong Site Blocks During Surgery. Available at: http://www.aagbi.org/sites/default/files/ SALG_statement_WSB_10_11_10.pdf. Accessed April 25, 2014. 4. NHS England. Never Events Update 2013/14. Available at: http://www.england.nhs.uk/wpcontent/uploads/2013/12/nev-ev-list-1314-clar. pdf. Accessed April 27, 2014. 5. Al-Nasser B. Unintentional side error for continuous sciatic nerve block at the popliteal fossa. Acta Anaesthesiol Belg. 2011;62:213–215. 6. Cohen SP, Hayek SM, Datta S, et al. Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. Anesthesiology. 2010;112:711–718.
Thoracic Paravertebral Block and Its Effects on Chronic Pain and Health-Related Quality of Life After Modified Radical Mastectomy Accepted for publication: October 30, 2014. To the Editor: e congratulate Karmakar and colleagues1 for their thoughtful study about the importance of postoperative pain relief and chronic pain prevention after breast cancer surgery. Women undergoing breast cancer surgery may benefit from increased attention to protocols promoting enhanced recover after surgery.2 Our department is also striving to improve regional techniques to provide analgesia quality after breast cancer surgery. We think the serratus-intercostal plane block3 could become an effective alternative to paravertebral block. Although clinical trials are needed, preliminary published studies are promising.
W
FIGURE 1. The picture shows a 100 mm 21G needle inserted with an in‐plane approaching the mid-axillary line in a woman during the serrato‐intercostal ultrasound block performance and corresponding ultrasound image.
In our experience, this new block offers advantages. It can be safely performed under general anesthesia, helping us decrease patients’ anxiety. In contrast to the paravertebral block, these interfascial thoracic blocks can be safely used in the presence of coagulation disorders and have fewer complications, promoting hospital discharge and decreased costs. We can use a single-shot technique or in conjunction with a continuous infuser pump. A remarkable point is how useful the serratusintercostal plane block single shot can be when the axillary area is included in the surgery. We have noticed that if we administer the local anesthetic between the anterior serratus muscle (ASM) and the external intercostal muscle, at the level of the fourth to sixth rib in the midaxillary line in the long axis of the body with an in-plane approach from caudal to cranial direction, instead of the double injection suggested by Blanco et al,4 there is a greater likelihood of good
© 2014 American Society of Regional Anesthesia and Pain Medicine
analgesia in the axillary region and we avoid blocking the long thoracic nerve. The block’s effectiveness in the axillary region is also better than the modified Pecs block because the 3-headed form of the ASM prohibits the correct local anesthetic distribution when administered below the minor pectoral muscle. At this level, in the midaxillary line, the ultrasound image is simple to recognize (Fig. 1): We see subcutaneous tissue, ASM, the ribs with the intercostal muscles, and pleura. The serratus-intercostal plane block is of moderate complexity, reducing performance time. This block helps ensure the distribution of the local anesthetic along the hemithoracic wall in every direction along the interfascial plane, blocking the lateral cutaneous intercostal nerve branches responsible for innervation of the mammary glands. Although paravertebral block is a widely studied regional technique block, we must remain open to new techniques that may be useful when a paravertebral block has failed, is
177
Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
contraindicated, or is impossible to perform in a given patient. Patricia Alfaro-de la Torre, MD Department of Anesthesiology Hospital del Tajo Aranjuez, Madrid, Spain
Mario Fajardo-Pérez, MD Department of Anesthesiology Hospital de Móstoles Madrid, Spain
178
Regional Anesthesia and Pain Medicine • Volume 40, Number 2, March-April 2015
The authors declare no conflict of interest. REFERENCES 1. Karmakar MK, Samy W, Li JW, et al. Thoracic paravertebral block and its effects on chronic pain and health-related quality of life after modified radical mastectomy. Reg Anesth Pain Med. 2014;39:289–298. 2. Arsalani-Zadeh R, ElFadl D, Yassin N, MacFie J. Evidence-based review of enhancing
postoperative recovery after breast surgery. Br J Surg. 2011;98:181–196. 3. De la Torre PA, García PD, Alvarez SL, Miguel FJG, Pérez MF. A novel ultrasound-guided block: a promising alternative for breast analgesia. Aesthet Surg J. 2014;34: 198–200. 4. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013;68:1107–1113.
© 2014 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
Benjamin Fox, FRCA Anaesthesia Department Norfolk and Norwich University Hospital Norwich, United Kingdom
The authors declare no conflict of interest.
REFERENCES 1. Lie J, Letheren M. “Wrong side” sticker/dressing to help reduce wrong-sided nerve blocks. Reg Anesth Pain Med. 2014;39:441–442. 2. The Royal College of Anaesthetists, 2010. Stop Before You Block. Available at: http://www.rcoa. ac.uk/standards-of-clinical-practice/wrong-siteblock. Accessed April 25, 2014. 3. Safe Anaesthesia Liaison Group, 2010. Wrong Site Blocks During Surgery. Available at: http://www.aagbi.org/sites/default/files/ SALG_statement_WSB_10_11_10.pdf. Accessed April 25, 2014. 4. NHS England. Never Events Update 2013/14. Available at: http://www.england.nhs.uk/wpcontent/uploads/2013/12/nev-ev-list-1314-clar. pdf. Accessed April 27, 2014. 5. Al-Nasser B. Unintentional side error for continuous sciatic nerve block at the popliteal fossa. Acta Anaesthesiol Belg. 2011;62:213–215. 6. Cohen SP, Hayek SM, Datta S, et al. Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. Anesthesiology. 2010;112:711–718.
Thoracic Paravertebral Block and Its Effects on Chronic Pain and Health-Related Quality of Life After Modified Radical Mastectomy Accepted for publication: October 30, 2014. To the Editor: e congratulate Karmakar and colleagues1 for their thoughtful study about the importance of postoperative pain relief and chronic pain prevention after breast cancer surgery. Women undergoing breast cancer surgery may benefit from increased attention to protocols promoting enhanced recover after surgery.2 Our department is also striving to improve regional techniques to provide analgesia quality after breast cancer surgery. We think the serratus-intercostal plane block3 could become an effective alternative to paravertebral block. Although clinical trials are needed, preliminary published studies are promising.
W
FIGURE 1. The picture shows a 100 mm 21G needle inserted with an in‐plane approaching the mid-axillary line in a woman during the serrato‐intercostal ultrasound block performance and corresponding ultrasound image.
In our experience, this new block offers advantages. It can be safely performed under general anesthesia, helping us decrease patients’ anxiety. In contrast to the paravertebral block, these interfascial thoracic blocks can be safely used in the presence of coagulation disorders and have fewer complications, promoting hospital discharge and decreased costs. We can use a single-shot technique or in conjunction with a continuous infuser pump. A remarkable point is how useful the serratusintercostal plane block single shot can be when the axillary area is included in the surgery. We have noticed that if we administer the local anesthetic between the anterior serratus muscle (ASM) and the external intercostal muscle, at the level of the fourth to sixth rib in the midaxillary line in the long axis of the body with an in-plane approach from caudal to cranial direction, instead of the double injection suggested by Blanco et al,4 there is a greater likelihood of good
© 2014 American Society of Regional Anesthesia and Pain Medicine
analgesia in the axillary region and we avoid blocking the long thoracic nerve. The block’s effectiveness in the axillary region is also better than the modified Pecs block because the 3-headed form of the ASM prohibits the correct local anesthetic distribution when administered below the minor pectoral muscle. At this level, in the midaxillary line, the ultrasound image is simple to recognize (Fig. 1): We see subcutaneous tissue, ASM, the ribs with the intercostal muscles, and pleura. The serratus-intercostal plane block is of moderate complexity, reducing performance time. This block helps ensure the distribution of the local anesthetic along the hemithoracic wall in every direction along the interfascial plane, blocking the lateral cutaneous intercostal nerve branches responsible for innervation of the mammary glands. Although paravertebral block is a widely studied regional technique block, we must remain open to new techniques that may be useful when a paravertebral block has failed, is
177
Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
contraindicated, or is impossible to perform in a given patient. Patricia Alfaro-de la Torre, MD Department of Anesthesiology Hospital del Tajo Aranjuez, Madrid, Spain
Mario Fajardo-Pérez, MD Department of Anesthesiology Hospital de Móstoles Madrid, Spain
178
Regional Anesthesia and Pain Medicine • Volume 40, Number 2, March-April 2015
The authors declare no conflict of interest. REFERENCES 1. Karmakar MK, Samy W, Li JW, et al. Thoracic paravertebral block and its effects on chronic pain and health-related quality of life after modified radical mastectomy. Reg Anesth Pain Med. 2014;39:289–298. 2. Arsalani-Zadeh R, ElFadl D, Yassin N, MacFie J. Evidence-based review of enhancing
postoperative recovery after breast surgery. Br J Surg. 2011;98:181–196. 3. De la Torre PA, García PD, Alvarez SL, Miguel FJG, Pérez MF. A novel ultrasound-guided block: a promising alternative for breast analgesia. Aesthet Surg J. 2014;34: 198–200. 4. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013;68:1107–1113.
© 2014 American Society of Regional Anesthesia and Pain Medicine
Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
