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Abstract
Background and Aims Sensory innervation of the breast is complex1, what makes general anaesthesia the most suitable anaesthetic technique. Nonetheless, patients with major cardiovascular diseases may be in high risk for complications2. The advance of ultrasound guided regional anaesthesia made possible general anaesthesia-free procedures, as Pawa et al . 3 demonstrated. This case report describes a successful case of breast surgery under sedation in a patient with major cardiovascular disease.
Methods A 31 years old female diagnosed with interatrial communication and severe pulmonary hypertension (PSAP 117 mmHg), treated with sildenafil 150 mg daily, presented on NYHA class II and proposed for right modified radical mastectomy. Paravertebral block was performed at 2 levels (T3/T5, levobupivacaine 0,3% + epinephrine 1:200.000 10 cc/level, T5 catheter insertion), plus PECS II (levobupivacaine 0,25% + epinephrine 1:200.000 30 cc) and superficial cervical plexus (levobupivacaine 0,25% + epinephrine 1:200.000 7 cc). Sedation provided with dexmedetomidine and propofol TCI (bispectral index monitoring, target > 60). ASA standard monitoring plus invasive arterial and central venous blood pressure. Emergency drugs were prompt available. Supplementary oxygen through non-rebreather face mask.
Transthoracic echocardiogram, apical view.
T5 paravertebral block
Results Surgery lasted 90 minutes and was successfully performed under light sedation. Spontaneous ventilation and hemodynamic stability preserved. Analgesia provided through paravertebral catheter during 36 hours (ropivacaine 0,2% 5 cc/h) with insignificant pain. Hospital discharge on postoperative day 2.
Intra operative view
Conclusions Ultrasound guided regional anaesthesia is a game changer technique for breast surgery cases where general anaesthesia effects are undesirable, potentially mitigating risks in patients with major cardiovascular disease.