Anesthesia for Latissimus Dorsi Flap for Breast Reconstruction

What is a latissimus dorsi flap?

From MDAnderson.org

Latissimus Dorsi Flap in Breast Reconstruction. Cancer Control. 2018 Jan-Dec; 25(1): 1073274817744638.

A Retrospective Study of Latissimus Dorsi Flap in Immediate Breast Reconstruction. Front. Oncol., 04 November 2021. https://doi.org/10.3389/fonc.2021.598604

Anesthetic Techniques

Regional Anesthesia For Breast Reconstruction. [Updated 2022 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

Anaesthesia for breast surgery. BJA Education, 18(11): 342e348 (2018).

Anaesthesia for free flap breast reconstruction. BJA Education, Volume 16, Issue 5, May 2016, Pages 162–166.

Paravertebral Analgesia with Levobupivacaine Increases Postoperative Flap Tissue Oxygen Tension after Immediate Latissimus Dorsi Breast Reconstruction Compared with Intravenous Opioid Analgesia. Anesthesiology February 2004, Vol. 100, 375–380.

Treatment of Post-Latissimus Dorsi Flap Breast Reconstruction Pain With Continuous Paravertebral Nerve Blocks: A Retrospective Review. Anesth Pain Med. 2016 Oct; 6(5): e39476.

Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives. J Pain Res. 2018;11:1567-1581.

Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis. J Clin Anesth. 2021 Sep;72:110274.

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials. Can J Anaesth. 2022 Apr;69(4):527-549.

Efficacy of erector spinae plane block for analgesia in breast surgery: a systematic review and meta-analysis. Anaesthesia. 2021 Mar;76(3):404-413.

Erector Spinae Plane Block Similar to Paravertebral Block for Perioperative Pain Control in Breast Surgery: A Meta-Analysis Study. Pain Physician. 2021 May;24(3):203-213.

Erector Spinae Plane Block for Mastectomy and Breast Flap Reconstructive Surgery: A Three Case Series. Open Journal of Anesthesiology
Vol.10 No.01(2020), Article ID:97889,8 pages.

Fascia Iliaca block for hip surgery

Why place regional blocks for surgery?

JNYSORA Volume 10 March 2009: Nerve Blocks For Postoperative Analgesia: Choices After Common Lower Extremity Procedures.

What is it?

NYSORA description

From Starship Child Health

NYSORA video describing the block

Academic Life in EM. Aug 21, 2019. Fascia iliaca nerve block: A hip fracture best-practice

EM St. John. Fascia Iliaca Nerve Block. .

From Starship Child Health

How to do it?

Suprainguinal Fascia Iliaca Plane block

MySigRA Suprainguinal Fascia Iliaca Plane block

From Highland EM Ultrasound

Literature says:

Journal of Orthopaedic Trauma: January 2020 – Volume 34 – Issue 1 – p 49-54. Fascia Iliaca Block Decreases Hip Fracture Postoperative Opioid Consumption: A Prospective Randomized Controlled Trial.

Eur J Emerg Med. 2016 Feb;23(1):12-8. Fascia iliaca compartment block for hip fractures: experience of integrating a new protocol across two hospital sites.

BJA VOLUME 120, ISSUE 6, P1368-1380, JUNE 01, 2018. Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation.

Fascia iliaca block in the emergency department for hip fracture: a randomized, controlled, double-blind trial. BMC Geriatr 19, 180 (2019).

Anesthesiology September 2018, Vol. 129, 536–543. Preoperative Fascia Iliaca Block Does Not Improve Analgesia after Arthroscopic Hip Surgery, but Causes Quadriceps Muscles Weakness: A Randomized, Double-blind Trial.

J Surg, Volume 16:2, 2020. Peripheral Nerve Blocks in Hip Arthroscopy.

Am J Orthop (Belle Mead NJ).  2018 Jun;47(6). Outcomes After Peripheral Nerve Block in Hip Arthroscopy.

Transversus Abdominis Plane (TAP) block

Indications and Technique

Figure 1. Biomed Res Int. 2017; 2017: 8284363.
Figure 1. Anesthesiol Res Pract. 2012; 2012: 731645.
Figure 5. Anesthesiol Res Pract. 2012; 2012: 731645.
Figure 6. Biomed Res Int. 2017; 2017: 8284363.

Pros & Cons

The Effect of Transversus Abdominis Plane Blocks on Postoperative Pain in Laparoscopic Colorectal Surgery: A Prospective, Randomized, Double-Blind Trial. Diseases of the Colon & Rectum: November 2014 – Volume 57 – Issue 11 – p 1290-1297


How to perform a TAP block?

YouTube: U/S guided TAP block

YouTube: RAUKvideos U/S guided TAP block Fast forward to 0:39

YouTube: 3D How-To U/S Guided TAP block Fast forward to 1:00

YouTube: 2012 ISURA TAP block lecture Fast forward to 16:55 for summary.

YouTube: ASRA Society Fast forward to 0:55. Sound off.

YouTube: Pajunk TAP block


Current mix:

  • July 2020
    • 0.25% bupi + epi + 1 mcg/kg dexmedetomidine (roughly 30 ml per side)

Erector Spinae Plane Block

After speaking to a colleague of mine regarding regional anesthesia for thoracotomy and mastectomy, I am reading up on Erector Spinae Plane (ESP) block.

**Updated May 2022**

Indications:

The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019 Jun; 72(3): 209–220.

Other regional blocks

Continuous ESP block catheter (my current regimen and what I’m able to get at my institution):

  • Braun Periflex catheter through 17g epidural needle
  • Cranial-to-caudal approach @ T5 (mastectomy, vats, rib fractures)
  • 20ml 0.25% bupi + epi prior to catheter
  • Catheter 5cm in space
  • 5 ml 0.25% bupi + epi after catheter placed
  • Mix: 0.125% bupi + fentanyl @ 10 ml/hr
  • If PCEA available, bolus 15ml every 3 hours; continuous as mix above.

Traveling with an Infant

We took our first trip as a family of 3 to Maui (or should I say 4 since I’m 14 weeks pregnant).  Granted, it’s a roughly 6 hour/5 hour plane ride to/back.  I had read up on multiple blogs regarding what to bring, how to travel, what to expect, etc.  I’ve created a bullet list of must-have things to travel with or pack for your little one (ours was 7 months old at the time of travel) Continue reading “Traveling with an Infant”