Ultrasound-assisted Upper Thoracic Epidural Anaesthesia in Awake Breast Surgeries: A Case Series

Abstract

Carcinoma of the breast is a leading cause of hospitalisation in elderly women and the most common surgery performed in Surgical Oncology and General Surgery Departments. Traditionally, General Anaesthesia (GA) was used for patients undergoing modified radical mastectomy. However, GA is not an ideal choice for patients with restrictive pulmonary diseases, obesity, or Chronic Obstructive Pulmonary Disease (COPD), as it is associated with increased intraoperative and postoperative complications. Regional anaesthesia is a suitable alternative, as it has the advantages of reduced sympathetic stimulation, no airway manipulation, and avoids polypharmacy, thereby reducing the hospital stay. A series of 10 female patients were presented, who were scheduled for modified radical mastectomy surgery under ultrasound-assisted thoracic epidural anaesthesia, and the patients were awake and conscious throughout the surgery. The ultrasound-assisted upper thoracic epidural was performed with a 100% success rate, and the mean procedure time taken was 238.5 seconds (ultrasound examination plus needle placement). Out of the 10 patients, one patient had two needle punctures. The needle redirections were absent in three patients, two times in three patients, and one time in four patients. Except for one patient, the epidural was successfully placed on the first attempt. Patient comfort was assessed based on the Modified Comfort Scale, with Grade-1 in five patients, Grade-2 in four patients and Grade-3 in one patient. No complications such as dural puncture or bloody tap were reported. In patients scheduled for modified radical mastectomy, performing an upper thoracic epidural using a landmark-guided technique is challenging, as the thoracic spines are very acutely angulated (T3-T6). Therefore, the ultrasound-assisted thoracic epidural technique is a safe and effective bedside tool that can be used to identify the epidural space without any side effects for the patients.