Thoracic paravertebral block performance for modified radical

mastectomy in a geriatric patient

I. INTRODUCTION
Carcinoma mammae is a malignant tumor that starts in the cells of the breast. A
malignant tumor is a group of cancer cells that can grow into (invade)
surrounding tissues or spread (metastasize) to distant areas of the body.
Carcinoma mammae is usually treated with surgery (mastectomy), which may be
followed by chemotherapy or radiation therapy, or both.
There are 3 types of mastectomy (Hirshaut & Pressman, 1992) :
Modified Radical Mastectomy, the surgical removal of the entire breast,
the breast tissue in the sternum, collarbone and ribs, and lump around the
armpit.
Total (Simple) Mastectomy, the surgical removal of the entire breast, but
not the glands in the armpit.
Radical Mastectomy, the surgical removal of part of the breast. Usually
called a lumpectomy, the removal only in tissues that contain cancer cells,
instead of the whole breast. This operation is always followed by
administration of radiotherapy. Lumpectomy is usually recommended in
patients with large tumor less than 2 cm and located at the edge of the
breast.

Modified radical mastectomy (MRM) is a procedure that usually performed

under general anesthesia and necessitates endotracheal intubation. We
report here the use of paravertebral block (PVB) as a primary anesthetic
technique in a geriatric patient undergoing MRM.

From a chronological viewpoint, medical treatment of the elderly (geriatrics) starts

from the age of 65 years old. In addition to chronological age, other factors must
be considered in order to define the elderly patient. Functional reserves decrease
with age, which leads to increased vulnerability. Frailty as a term describes this
situation and can be defined pathophysiologically by a mainly subclinical
inflammatory state. Therefore, in 2007 the German Society of Geriatrics (DGG),
the German Society of Gerontology and Geriatrics (DGGG), and the German
Group of Geriatric Institutions (BAG) have jointly developed a definition of the
geriatric patient.
In many elderly patients may be manifested as exaggerated drops in blood
pressure during induction of general anesthesia. A prolonged circulation time
delays the onset of IV drugs, but speeds induction with inhalational agents. Aging
decreases elasticity of lung tissue, allowing overdistention of alveoli and collapse
of small airways. Residual volume and the functional residual capacity increase
with aging. Airway collapse increases residual volume and closing capacity. Even
in normal person, closing capacity exceeds functional residual capacity at age 45
years in the supine position and age 65 years in sitting position. Liver mass and
hepatic function declines in proportion to the decrease in liver mass.

Paravertebral block
Paravertebral blocks provide surgical anesthesia or postoperative analgesia for
procedures involving

II. CASE REPORT

 A 65-year-old, 50 kg, 160 cm woman, with American Society of Anesthesiology
(ASA) physical status II was scheduled for left MRM with axillary lymph node
dissection for infiltrating ductal carcinoma. The blood test revealed :
Hemoglobin : 11,3
Hematokrit : 31,9
Leukosit : 3.800
Trombosit : 404.000
Glucose : 111
Albumin : 3,5
Ureum :6
Creatinin : 0,6
Natrium : 140,1
Kalium : 4,1
Chlorida : 107,3
PPT/PPTK : 13,6 / 11,5
PTT/APTTK : 18,1 / 34,0
Patient was monitorized and sedated with 2 mg intravenous (IV) midazolam. The
initial blood pressure, heart rate and peripheral oxygen saturation were 132/89
mmHg, 68 beats/min and 98 %, respectively. Paravertebral injection were
performed with the patient in the sitting position by using the technique described
by Moore and Katz. The superior aspects of spinous processes of C7 Th6 were
marked. The skin and subcutaneous tissue were anesthetized with 5 ml Lidocain
(10 mg/ml). The skin entry points were 2,5 cm lateral to the marks. A 22 gauge
Quincke spinal needle attached via extension tubing to syringe containing local
ansthetic was utilized. The needle was inerted perpendicular to the skin until the
transverse process was contacted. The needle was then withdrawn and reangled
inferiorly and advanced further 1,5 cm. After careful aspiration, 5 ml per segment
0,5 % bupivacaine with 1:10 epineprine was admmistered. Following the PVB the
patient was placed in the supine position with a right lateral tilt and superficial
nerve block was performed using 5 ml of the same local anesthetic. This was
done to Hock the supraclavicular nerves that provide sensation to uperior aspect
of the breast. Onset of sensory loss accured 10 minutes after injection with
surgical anesthesia ensuing 30 minutes after injection.
Prior to incision, a blood pressure decreased to 116/70 mmHg. Intraoperative
sedation was provided with IV 2 mg midazolam and 50 mcg fentanyl. There was
no evidence of epidural spread or pneumothorax. Surgery lasted 150 minutes
and the patient remained comfortable during the procedure.
MRM was complited without any complication and the patient was returned to the
ward. In the ward her initial pain assesment wich was assessed with by verbal
analogue scale (VAS) was zero. Nausea and vomiting were not seen in ward.
She did not require any analgesic medication for 30 hours. After 30 hours her
VAS score was 2, ketorolac 30 mg IV was administered and also prescribed as 3
times a day. Continued with 1000 mg paracetamol infusion 2 times a day the day
after, followed by administration of 1000 mg paracetamol PO, 3 times a day.
During her hospitalization, no opioid medication was needed and the patient was
discharged on the third postoperative day.

III. DISCUSSION
In this case, we reported the use of PVB in a patient undergoing MRM with
axillary lymph node disection. MRM can be performed under different anesthetic
techniques including general anesthesia, thoracic epidural anesthesia or PVB.
Regarding to our patients anesthestic plan, we had two objectives: primary
objective was avoiding intubation and mechanical ventilation because of foreseen
postoperative respiratory failure. Secondary objective was avoiding severe
 hypotension, not to hasten the heart failure. As a result, we decided to perform
thoracic PVB.
PVB can offer several advantages for patients. By administering local anesthetic
near the somatic roots, unilateral anesthesia was provided without bilateral
sympathectomy. So this technique could facilitate maintenance of the normal
haemodynamic status.
PVB can provide profound, long-lasting sensory deafferentation. The resulting
greater attenuation of the surgical stress response may translate into reduced
inotropic stimulation of the heart. Additionally, unlike general anesthesia, PVB can
provide superior postoperative analgesia and less nausea and vomiting, shorter
recovery time, require fewer analgesic, earlier mobilization, and earlier home
readiness for discharge.

IV. CONCLUSION
PVB has been shown to provide improved acute postoperative pain management
following breast surgery. Recent studies suggest additional benefits to this
procedure, including decreased development of chronic pain and decreased
cancer reccurence.
In this patient use of thoracic PVB provided hemodynamic and respiratory
stability, excellent unilateral anesthesia and high patient satisfaction. In a geriatric
patient, thoracic PVB can be performed as an efficient and good anesthetic
technique for MRM surgery.

REFERENCES

1. http://www.ncbi.nlm.nih.gov/pubmed/17934704