The Complete Abstract: Liposomal Bupivacaine and Cryoneurolysis for Mastectomy

Abstract: 1254

Medically Challenging Cases

INTERCOSTAL INFILTRATION WITH LIPOSOMAL BUPIVACAINE AND PERCUTANEOUS CRYONEUROLYSIS FOR MASTECTOMY

Mike Guzman

Community Surgery Center East

Introduction

Multimodal pathways using a variety of pain blocks and medicines have been previously described for mastectomy surgery. Single injection blocks can possibly have a 24 hour duration. Mastectomy pain can persist past the few days after surgery. Extending pain relief with continuous nerve block catheters and a local anesthetic pain pump may allow longer relief. Pain catheters require skilled providers. The catheters may migrate out of exact position or inadvertently be pulled out. Ultrasound guided liposomal bupivacaine infiltration into specific intercostal spaces can provide pain relief for 36-48 hours and avoid pain catheters and a pump. Breast surgeons typically leave drains in place for 7-10 days. Many patients complain the pain irritation from their drain is worse than the original mastectomy. Enclosed are details of a 55 year old female that had a mastectomy and axillary node dissection. Pain control was with intercostal liposomal bupivacaine infiltration and percutaneous cryoneurolysis.

Materials and Methods

There was no IRB approval obtained at Community Health Network for this case study because there is no identifiable information and is exempt from IRB review requirements.

The 55 year old female underwent a single sided mastectomy and axillary node dissection for breast cancer. There was no breast reconstruction. Preoperatively, the patient was sedated with midazolam 2 mg IV and received acetaminophen 1000 mg IV. The patient was monitored and prepped using sterile techniques. Liposomal bupivacaine 133 mg (10 ml), bupivacaine 75 mg (30 ml) and normal saline 60 ml made a mixture total of 100 ml. A 4 inch ultrasound needle was used for infiltration of the mixture into the intercostal spaces. The patient was placed in a lateral decubitus position. The patient received ultrasound guided intercostal infiltration in the posterior mid axillary line from T1 to T6. Approximately, 10 ml of the mixture was infiltrated below the outer intercostal membrane at each level T1-T6. Another 10 ml of the mixture was infiltrated below the serrated anterior plane at each level from T1-T6. The patient also received percutaneous cryoneurolysis in the posterior mid axillary line from T2-T5. Cryoneurolysis was performed using a hand held cryoneurolysis device that delivered cold temperatures at the distal tip of a 3 prong needle. The cryoneurolysis consisted of one minute treatment freeze cycles. The patient received a general anesthetic with propofol and sevoflurane. The patient was given ketorolac 15 mg every 6 hours and one additional dose of acetaminophen 1000 mg intravenously.

Results/Case Report

The patient emerged from anesthesia with a pain score of 0/10. The patient did not request any additional pain medications for her 20 hour outpatient surgery stay. The patient was contacted after her surgery and reported the only pain medicines she had taken for 3 weeks was 2 acetaminophen 500 mg tablets.

Discussion

Remarkable postoperative pain control synergy is possible when combining infiltration of liposomal bupivacaine and percutaneous cryoneurolysis for mastectomy patients.