S1:E6 "Keeping A-breast of Chest Wall Blocks: Regional Anesthesia for Breast Surgery"

Are you down with TTP or having issues with gumph and a wet axilla? Maybe it's time to talk about pecs, baby. I'm Amit Pawa. Oh, you don't think your patient needs blocks for mastectomy? Bless your heart. We've got news for you. I'm Jeff Gadsden, and this is Block it like it's hot.

Hey, Amit. We're back for more episode six. How you been, man? 

Listen. I've been great. I I mean, I guess time must be flying when you're having fun. How do we get to six already? Totally. 

I've been pretty good. I I reckon, you know what? I've been thinking a lot about chuff levels. You've kind of taken over my life with this chuff level thing, and I reckon I've been rocking a steady eight over the last two weeks. That's a that's a That's good. 

Pretty good place to be averaging. Right? Have you charted it? No. No. 

That that's you know, we're trying to we're trying to save paper, and so I don't wanna waste paper. And I haven't got enough whiteboards to access that. But maybe when we get our new electronic patient record system, which is we I just come back from some training from Oh. Maybe I can ask them to add in the chuff chart in the block area. How about that? 

That would be great. Right? Yeah. Epic, if you're listening, add a chuff chart. Do you know? 

I think there's something in that. And and then maybe we could correlate chuff levels with block success and patient reported outcome measures. Listen. I'm going off tangent here, but I'll tell you what. You you asked me about, how I've been. 

I've started to get a little bit nervous. I'll tell you why I'm getting nervous is because we've got a couple of meetings coming up. So we've got Azra Spring in Hollywood, Miami. We've got Ara UK in Newcastle in The UK, and I'm doing virtual talk for the ANSCA meeting in Down Under. And I haven't written any of my talks yet, and I'm starting to get nervous. 

There's that accent again. No. No. That wasn't that was just the way I speak then. So so I'm I haven't written my talks. 

I'm getting nervous. But apart from that, I'm excited. Are are you all ready for for your meetings? You must have written your talks. Oh, so what you're saying is you haven't written your pro con debate yet against yours truly? 

Yeah. Yeah. So the pro con debate against you Don't even bother. Just concede. I was hoping I was gonna I was gonna extract some, some some nuggets from you to incorporate in the pro con during the during the process of recording this podcast. 

That's what I was hoping for. Okay. Guys, in case you're wondering what we're talking about, Jeff and I are, have a date on the stage at REUK fourth and fifth of May this year. We've got a pro con debate, about the use of nerve stimulation for regional anesthesia. I'm just gonna leave it there. 

Check out the program, and you'll see who's talking about which side. But, yeah, I'm a bit nervous about that. It's gonna be a great meeting. I can't I can't wait. No. 

Absolutely. And I'll you what I'll tell you what else I've done. Just to round off the what I've been up to, I I got back, in Sunday, we had a whole day of clothes shopping with my three ladies. That's my wife and my two girls. Okay. 

And I was getting dragged around the shops. I mean, I tell you what, I lead a glamorous lifestyle. Yeah. The kind of shops you go to I don't really wanna them because we're not getting sponsorship, really. That's right. 

Yeah. It's true. But is there a, like, what I call the husband chair where you can, like, sit down, nice nice comfy chair, sit back, take pull your phone out, just say, I'll be right here, honey. Collect me on the way out. Well, so usually, I that's the first thing I look for, but then they're like, oh, no. 

But we want you to can you come and have a look at this? Or what do you think about this? So, actually, I should be grateful that my wife and my daughters care what I think. Unfortunately, we're now getting to the stage when most of the time I'm saying, no. I don't like it, and they don't listen to me anyway. 

So, you know, that's kind of I'm I'm kind of marginalized. But, no, it's all good. It's all good. This is I I'm very blessed to have a a beautiful wife and lovely daughter. Exactly. 

For sure. You know, it's it's all good, man. It's all good. Listen. How have you been, buddy? 

I've I've told you a lot about what I've been up to. Tell me what you've been up to. Oh, it's it's been good. Good couple weeks. Got some skiing in there, actually, which is nice. 

Yeah. Skiing? Oh my goodness. With the family out to, Colorado. That was fun. 

Lots lots and lots of snow. Nobody got injured. Yes. That's always how we mark success. Yeah. 

Yeah. Come come back with all bones intact. No no blocking opportunities for broken bones. Yeah. No. 

But, yeah, man. It's been good. Hey. We've had some great questions and interaction online. Shall we do some shout outs? 

For show, bro. First of all, I've gotta give a shout out to one of our Australian, listeners. We got a lot of shout outs from the Australian guys. They've been really engaging. So this is Andrew Lovett. 

Oh, yeah. Now now, Andrew, first of all, he commented on our first episode. He said his favorite Disney princess is somewhere between Moana and Raya, one of the new princesses. So that was cool. Wait. 

Who's Raya? Did I miss You've not heard of Raya? No. Oh my god. Yeah. 

Raya that she's like a dragon princess type thing. I've seen it. I've I've seen it. That's you've not heard of Raya? You gotta do some homework. 

I'm still back on Little Mermaid. That's how much I've caught up. Yeah. Well, listen. Well, let's let's put that to one side. 

But, you know, Andrew didn't stop his engagement there. He's got some more stuff for us. He Andrew's daughter, Genevieve, has got a joke for us. Are you ready for this? Hit me. 

Why don't you trust atoms? Why? Because they make up everything. Come on, Genevieve. I love it. 

Genevieve. Nice. Nice one. Fist bump for Genevieve. Definitely a fist bump for Genevieve. 

Andrew also suggested that we talk about two subjects. Number one was nerve injury, and number two was additives. And I think we're probably gonna have that covered. Right? For sure. 

Yeah. That's gonna be great. Both of those. So, Jeff, have you got any shout outs? Yeah. 

Well, it's so funny you say that. As one of our friends from Twitter, Bob Funacutter, says, quote, even though he's not a regionalist, he still enjoys a good axillary block, but he does fear the complications, especially nerve damage. So he wants us to discuss avoidance, detection, and management of nerve damage. That fits in with what Andrew said as well. So it's a biggie. 

It's a good it's a good topic. So we'll we'll definitely cover that. You know what? On the subject of jokes, I've just whilst, we were thinking about these whilst I was listening to us, thinking about these jokes that we gotta tell. So first of all, this is the joke that I tell to all of my patients who are having a weight breast surgery. 

Okay? Are you ready for this? Okay. K. Is there no aspirin in the jungle? 

Don't no aspirin in the jungle. Because the paracetamol paracetamol paracetamol acetaminophen. That's that's not bad. That's not if that if that works transatlantically. Do you guys know what paracetamol is? 

I know you do, but do you think that one? I I yeah. It's, it might be lost in some people. Well, in that case independence. Yeah. 

I've got another one. I've got another one. This is the other joke I tell when that if that one doesn't go down so well. Why did why did the banana go to the hospital? Because it wasn't peeling well. 

Oh god. So how how deep is your joke list when you have an awake patient? Like, I I I'm imagining imagining that you get to these two, and there's still some, like See, the the the problem is, do you not remember what my New Year's resolution was? My New Year's resolution was to get better remembering some dudges. Remember jokes. 

That's because these are the only two that I could remember. Now the beauty of using a tiny bit of propofol sedation, even if it's, like, five mils an hour, is that patients don't remember laughing to these jokes. I can recycle these same two jokes the whole way through the list, and every time I get a different reaction. It's brilliant. Throughout the case. 

That's amazing. Yeah. I find that that with a just a little bit of purple fall, I am at my most charming. Definitely. Yeah. 

Definitely. Patients patients love me. I just yeah. They laugh at everything I say. Well, speaking of jokes, I my my bartender son Yes. 

Who's 10, Holt, has has a joke, and he wants to share it with you. Would that be okay if Holt told a joke? I I cannot believe it. Holt, come and join us. I wanna hear this joke. 

Let let's hear what you got. Okay. Alright. Here's Holt. Hi, Amit. 

Hey, Holt. How are doing? Good. Good. How are you? 

I'm very good. Thank you. I wanna hear this joke. I wanna hear this joke. What's the difference between a piano, tuna, and glue? 

What is the difference between a tuna, piano, and glue? I don't know, Holt. Tell me what is the difference between a tuna, a piano, and glue? You can tune a piano, but you can't piano a tuna. Oh god. 

That is that is terrible and very deserving of this podcast. But what what's what about the glue, though? I knew you'd get stuck there. Oh, no. A double whammy? 

That is terrible. Very good. Thank you, Holt. Now off to bed. Off to bed. 

Okay. Bye. Thanks for having me. Alright. Amit. 

So with that with that out of the way, what do we have for our listeners today? Well, you know what, Jeff? We're gonna talk about a subject that is very close to my heart, and that is, of course, regional anesthesia for breast surgery. I have been doing regional anesthesia for breast surgery for about fourteen years. And before we get into the nuts and bolts of this, I really wanna give a shout out to some of my early inspirations in this area. 

I've got doctor Rafa Blanco and Theresa Paris, two of the first people to describe the PEX block, and, both of them I work very closely with. Rafa was my mentor. So I wanna big big shout out to them. John McDonald who I got a lot of tips and he taught me how to do paravertebral blocks and, of course, doctor Manuj Kamarco. So those are the four breast inspirations that I have. 

I just wanna give a shout out to them before we get into it. Oh, it's gonna be fine. Okay. Let's do this. Okay. 

So, Jeff, you know, when I first started as a consultant anesthetist, I worked with some breast surgeons who said, breast surgery isn't painful. I'm cutting the nerves. Said, you know, don't worry about doing these flashy blocks. Do you have any experience of that, and how did you deal with that? I do. 

It's funny you say that. I had a I had a surgeon in New York. You know, she just started as as faculty. Just finished fellowship. So fairly fairly green. 

And, you know, introducing myself and saying, this is my plan for for your patient this morning. We're gonna do the block, and then we'll and she says, oh, woah. That's okay. I don't I don't need a block for this patient. And I was like, what? 

What? And she goes, oh, no. No. Because breast surgery doesn't hurt because I cut the nerves. And jaw on the floor, I didn't know how to respond to that. 

If that occurred down here in the South, we would have said, bless her heart. That's do know do you know what that means? Do you know the implication of Bless someone saying bless your heart. Bless the heart. You know, she doesn't know any better kind of thing, or, I I don't know. 

What does that mean? Bless your heart is basically, the middle finger. Oh, no. I did not know that. Yeah. 

Okay. It's like a very polite southern way of saying Oh, shove off. Oh, man. Okay. Well, I've gotta be careful. 

I do sometimes say bless. I've gotta be careful with them. Make sure they don't take from the South. Okay. That's it's context dependent. 

Yeah. For sure. You see the thing yeah. I so clearly, that's not something that just happens on one, you know, one part of the world. So I I've heard that in the in various hospitals in The UK. 

But the thing is, you know, breast surgery, has many sort of complex inputs of pain. Right? Because this is the first time I learned about the petrol nerves, which I'd never even thought of before. And I'd always thought about just the intercostal nerves, and I kind of focused my attention on the lateral cutaneous branches of the intercostal nerves, and I kept forgetting that there are anterior cutaneous branches that come up paracernally, and that's important for a later part of the discussion. Yeah. 

I remember some of my early slides on breast surgery. I used to talk about the lateral and anterior cutaneous branches. Used talk about the supraclavicular nerves from the cervical plexus, you know, the superior part of the chest wall, which very rarely form parts of of skin innovation. Then I used to talk about thoracodorsal, the long thoracic, intercostal brachial. But, you know, what's important? 

If if we were trying to think about what's what are the important nerves to think about when when we're performing these blocks for for breast surgery, what are the important nerves to think about? So, you know, I think part of this has to start with what are your goals for your blocks? And if your goal is awake breast surgery, I'm making sparkling conversation with the patient during that procedure, which I've done. Yes. In cases where patients tell me there's no way I want to be sedated. 

I I hate that feeling. I don't want fentanyl. You know, We can do that. But that requires, you know, the full Monti of blocks or or some combination that gets everything. But that's a diff that's a different level. 

Right? That's a different level. Yeah. For sure. And we don't do that very often. 

But, usually, they're either getting decent propofol sedation, your your GAWA Yeah. If you would, or an LMA or, you know, some sort of airway device. So that becomes a different threshold for success, and I can omit some of those or the surgeon can do the bit of infiltration depending on how important I think those are. So do you do you have a similar sort of framework that you Yeah. I do. 

I mean, know, before I have to I have to be honest. If I look at what happened during my training when I first started, I learned paravertebral blocks. I did paravertebral blocks for as many patients as I could. And I have to be honest, the quality of pain relief I got in that one period of about it's about about a year and a half when I was doing, you know, all the patients having breast cancer surgery. I did paravertebral blocks for those patients because I felt I could justify it, but also because I wanted to get, you know, decent results. 

Those patients got amazing analgesia, and that was the the one It's the king of blocks. It's the king of blocks. And and absolutely and I got the the most cards and thank you letters and boxes of chocolate that I've ever got in my career in that one year and a half that I was doing para virtual blocks for everybody. But then, of course, in the Wait. Wait. 

You get you get boxes of chocolate from patients? Yeah. If we do a good job. It's not the norm, but that's what I'm saying. And that Maybe if I had maybe if I had your smooth talking ways, I could get some some more chocolate. 

Okay. That's a new goal. New goal for 2023. I even got a pair of socks once. Backflip? 

Did get a pair of socks. Socks. So you're you're getting clothing and chocolate. What is it? Is it, like, always Valentine's Day when it when you're on at power? 

Well, it feels like that sometimes. But you know what? But you but the truth is I'm Hashtag jealous. Yeah. Well, listen, man. 

It's it goes both ways. It goes both ways. But but then but then, you know, in The UK, we don't routinely not in all hospitals have a block remodel. So one now has to be a little bit sensible when so now when I'm planning what type of, regional anesthetic I'm gonna give the patient depends upon patient factors. It depends on what their expectations are, their comorbidities, the degree of tissue disruption. 

Because, you know, if they're doing a lumpectomy versus a mastectomy, they will have a different pain trajectory or different pain profile. If they're doing a mastectomy and that's it or a mastectomy and just an isolated sentinel lymph node biopsy, that's different from a mastectomy and auxiliary, node dissection. And, also, you gotta add the implant reconstruction component onto that. So it gets a bit more complex. And even with implant reconstruction, they might do a prepectral or a subpectral implant reconstruction. 

So Sure. Yeah. We kinda gotta understand that what we're dealing with before we make those decisions, I think. And we're not really even talking about we're we're talking about oncologic surgery Yeah. For the most part. 

But there's also cosmetic surgery that shares a lot of the same, obviously, principles. Yeah. I mean so we we very rarely well, we don't do pure cosmetic surgery in the National Health Service. Of course, that happens a lot in the private sector here. But there may be some patients who have had ipsilateral mastectomy and implant reconstruction, and we offer symmetrization Wait. 

Procedures on the NHS where we do something to the other side to match it, and that might be a breast reduction or or breast augmentation. Wait. What what was that word? Symmetrization. Okay. 

I looking Symmetrization. I mean, it's I I You've not you've not heard that? I I mean, I hope listen. Oh my goodness. Don't tell me I've been making out words. 

I'm really good at making out words, by the way. And in my head, they make sense. It sounds it sounds impressive. I wanna be the director of symmetrization. We do symmetrization. 

Do That thing. Contralateral symmetrization. Is is that a word? No. I get it. 

I I I get what you know, symmetry. Yeah. I know. I I you said it. I knew exactly what you Holy moly. 

I hope I haven't made up a word. I've never heard that word. Okay. No. It's perfect. 

I love it. I'm gonna Google this as soon as I get off this. In fact, I might Google it now. No. Wait. 

I won't. Okay. Okay. Well, listen. So so if, you know, go so we so I talked about pain trajectory, and I think there are some operations, and I'm gonna play devil's advocate here. 

There are some operations where they make a small, incision. They remove for example, very occasion, we'll do an isolated sentinel lymph node biopsy. Now in those cases, they make a small incision over the axilla. They use a gamma probe or sometimes dye to find one lymph node and then they close things up. Now I don't think you can justify, in my opinion, doing a block for that was actually surgeon can put in local anesthetic, and it's gonna hurt for, like, twenty four hours, and they can manage with local infiltration Yeah. 

And normal oral multimodals afterwards. Right? So that's one thing. Yeah. Totally agree. 

The only time when I have used regional anesthesia is if the patient has said that they don't want to have a general anesthetic. And, actually, then I've done, a pector serratus and or serratus anterior plane block. I've got the surgeon to mark where they're gonna be making their incision. I just infiltrate the incision with local anesthetic, and essentially, you can have they can have that surgery without going to sleep. So that would be the only time when I would do regional anesthesia for the smaller cases. 

Sure. Yeah. But, you know, what about in the old days? In the old days, didn't they used to do thoracic epidural for everyone? How old do you think I am? 

No. I mean, I don't I mean, I'm I'm I'm taking the mickey here because, actually, if I'm being honest, during my training, which was and I was a trainee from, say, 2002 to 2009 in anesthesia, I never saw anybody do blocks for breast surgery. Can you believe that? I literally didn't. I learned as a consultant because they weren't doing it. 

I understand that paravertebral is landmark guided paravertebral was popular in the old days. And maybe for some cases where there was high risk, they might have attempted to do an epidural if if paravertebral wasn't in their skill set. But actually, during my training, I never saw anything. How about you? A bit a bit of variety, but I I have as you know, I was fortunate to train at both University of Toronto and then at NYSORA in New York. 

So that was very, very block forward Uh-huh. As it were. And so paravertebral was the was the default. However, we were doing them landmark based at the time. So we'd go in, you'd hit the transverse process Boom. 

Grab the needle a centimeter out, come back, angle slightly cut out, and and then advance until your fingers hit the skin. And the assumption was you'd be a centimeter past the teepee and hopefully in the right place. And so and, you know, for the majority of time, they worked. That does give me the heebie jeebies, though, because I've seen heebie jeebies. It's heebie jeebies central. 

Yeah. Because you don't know. You've got no idea. You might be too far. And, actually, what you think you're hitting, when you think you're hitting transverse process, actually could be the superior aspects of the of the rib. 

Right? So Yeah. There's a lot of assumptions there. And that does that make me feel a bit nervous. Totally. 

And and not to mention, like, the parts when, you know, you get a fairly deep back you're you're pushing in, you're going in, you're going in, and and wait. Maybe I'm am I between two Oh gosh. Two levels, and I'm just gonna go right into the soft tissue and, not confidence inspiring. But then when it did work and and you managed to nail each transit process, it was it was a good feeling. High fives all around. 

But in in those days, would you have done multiple level landmark guided paravertebral blocks for for a mastectomy, say? Mostly. Yeah. Yeah. We were mostly doing every level. 

So it's like giving yourself five five chances or six chances for pneumothorax. Right? Well, I I it's interesting you bring this up, the five versus six, because I do t 23456. Uh-huh. Is that what you do? 

Well, this is I'm happy you brought this up. So there was a really nice, paper that was written by, Vishal Uppal and colleagues. And, actually, that I was already doing this practice, but it kinda made me feel a little bit more justified for it. So if I'm doing an analgesic block, which I do which I cite prior to a general anesthetic, I do a single level paravertebral block for mastectomy. And, you know, this paper by Vishal and his team showed that single level versus multilevel, they actually got a similar level of dermatomal involvement. 

And I remember there were some old papers that were looking at nerve stimulator guided paravertebral blocks, and they talked about how a single level versus multilevel, you know, there was no difference. So based upon that, I've always done a single level for analgesia. I used to do a single level combined with some of the fascial plane blocks for awake surgery, But every now and then, we'd come across a patient where the quality of of anesthesia wasn't perfect. So now for awake surgery, I do multiple levels, but I don't do as many levels as you. I probably do between three to four levels of maximum for awake surgery. 

You know, it's interesting to see how, you know, different approaches, but we'll probably get into that in a second. So I think for single level, I do a single level for analgesia, but you would still do multiple levels for analgesia, would you? Well Or or are you doing your MAC cases as part of this? No. So to be fair, if it's if it's just my hands and I've I'm by myself, which isn't very often, and it's and I'm and I know I'm gonna put the patient to sleep anyway, so this is an analgesic block. 

I might do two. Okay. I'll do two levels. So I'll do, like, t three and t five. Okay. 

But if it's, you know, back to MFB, want that maximum fellow benefit. Yes. So five chances to to get procedures in there. So but I wanted what I wanted to talk about too is other levels. So there are I'm aware of people that that go after t one. 

Yeah. And what are your thoughts on that? So, actually, so I have done this. And so I have when I'm doing when I've got a patient who's having an axillary node dissection, they're deep into the axilla, and they're gonna be going to that territory, which intercostal brachial, medial cutaneous nerve, the arm, all of that sort of area, and involving the petrol nerves, I generally add in a pector serratus or an, an interpetral nerve block. And some of my colleagues think Stuart Grant is one of them, and Iwana Costash is another. 

And they both said, well, why don't you just do a t one, a t two paravertebral because you'll get high up and you'll get all the you'll get all of the the the innovation that you require if you get that high. Number one, I don't think it's always that easy to identify and perform a block that high. For sure. It very much depends on the patient's, body habitus. And, actually, I think sometimes those high blocks can be tricky, and you might be making things more complicated than you need to. 

And, actually, sometimes even though I've done that, I still don't get complete anesthesia of the axilla because axilla is a tough area to anesthetize. So I would say if I was doing it for analgesia, I don't think I it's not something I do. How about you? No. Same. 

And I you know, as I've thought more and more about this as a young as a young consultant back in the old days, you know, think about the innovation of the That sounded like another character from Mary Poppins, like the guys that were in the bank. Yeah. Anyway, sorry. Oh, it's a jolly holiday with So as an old consult as a you would say as a young consultant. As a yeah. 

In the beginning right. Beginning to think about, like, the innovation of the Agzilla. And so, you know, my understanding is that's that's t two and t three. Yeah. And I and so and I get trainees coming up and say, well, I wanna a t one, two, four, five, six for parapertib. 

Said, well, tell me where c five innervates. And they point to sort of their shoulder. And then where does c six go? And then c seven. And then where does c eight? 

And they're now they're they're at the pinky. And I said, does t one innervate? And they sort of point to their, medial forearm. And I said, how about t two? And then they go up to intercostal brachial area and axilla. 

And so they begin to realize, oh, yeah. T one is a brachial plexus nerve that innervates the upper limb. It's not a chest nerve. And if you look at and we pull out the atlas and have dermatomes and just go, see, here's your neck, supraclavicular nerves, c three, c four, and then it jumps to t two. Yep. 

Yep. Just below the clavicle. So when you're doing a a t one nerve root block, you're helping that patient have forearm anesthesia, not necessarily anything to do with breast or or axilla. So now I will admit, I have seen and this is interesting. If anybody has any thoughts on this, I didn't mean to bring this up today, but it's something that rattles around in my brain sometimes. 

I've seen other dermatomal charts that include t one right at at about the clavicle, but I don't think that that so maybe there's some variation there. I've never found it to be important. We we wrote a paper very recently on this for awake, breast surgery and BJ education. And I have to be honest, getting the diagram for that right was so complicated because if you consult multiple anatomical references, there is no consistency into how they demonstrate dermatome innovation. And I've seen some really bizarre ones to some that kind of vary very slightly. 

So, I mean, we all know the human body varies anyway, but you're right. I haven't seen t one demonstrated on the chest, as you said, that you may see in some in some textbooks. Okay. So we agree that paravertebral is gold standard, probably. Right? 

Yep. For for unilateral chest surge or even bilateral chest surge for that may for that point. Yes. How important is it to add the PEX blocks, the interpectoral pectoserratus? Well, okay. 

I don't we're we're you people will hopefully notice that we're intentionally using the preferred terminology, although I saw a slide on Twitter today from the inventor of the PEX, but Raf Blanca still Blanca is still talking about PEC one and PEC two because it's kind of his baby. But yes. So Do want my hot take on that? Okay. Let's go. 

I I'm a PEX. It'll always be PEX to me. It's like I'm I'm Raf and I are into this romance movie, and like, I always always to call it pecs for you. I I just need to remember. Gonna stop you there. 

Listen. I didn't wanna get into this. Pectoserratus. I didn't wanna go there because we've gonna have a whole podcast on the. But hold on. 

The thing that I spent most of my early consultant career doing is saying to people, they were like, did you do, like, a PEX one or did you do a PEX two? And I was like, no. No, guys. A PEX two involves the PEX one injection plus the second endpoint. They're like, yeah. 

I know. But did you do a PEX one or a PEX two? And I was oh, no. No. No. 

A PEX two is a PEX one. And so I spent my and then, you know, when people write papers on it, I don't know whether when they say they did a PEX block, what they did. So, actually, I found I I found that element confusing. And, I think when he did the description, he initially described the interpetual injection and said this is the PEX block. And when he modified it and actually made the modified PEX block, he called it the PEX two, but he definitely described it as two endpoints. 

And for that reason alone, I think it's worthwhile separating them. And, of course, just because there are two endpoints doesn't necessarily mean the block should be linked because there may be some indications when you don't need to do the interpectoral. Totally agree. Yeah. But when we talk about PEX two, we bring them all together, and that's probably confusing. 

Yeah. I totally agree. And and I think that, I think what's if what's happened in my mind, I think a lot of people's minds, maybe at least on this side of the of the ocean is that PEX one equals blockade of the pectoral nerves. PEX two is the lateral cutaneous branches of two three four five six. So, and and fully admitting that when Rafa described it, it was both for that second one. 

But, anyway, so let's talk about the these blocks. So I so I was taught these as an alternative to performing paravertebral blocks. So when Rafa told me about them just ahead of publishing about them, I started using these for patients having more minor surgery, though as an alternative to paravertebral blocks. And, you know, my analgesic outcomes were definitely not as good as paravertebral in my hand, but it's interesting because I always considered them as being one entity. So I do the interpectral. 

I do the pet dysrators, and I consider it as one entity. And then there was a really interesting daring discourse. I believe it was Carlo Franco who who wrote this talking about nomenclature again and saying, well, actually, we don't need to do petrol nerve blocks for analgesia. They're playing no role. But I would say, I I don't agree with that because I've seen patients who having a weight breast surgery, and they're doing diathermy on the chest wall. 

You know, they're buzzing pec major. Yeah. The patient feels no susceptive inputs. They feel something. So if they're innovated by the petrol nodes, I think they have a role. 

But so I I think they're I think they're a good alternative, but I don't think they're as good. And I think I made a really big mistake when I first started doing these blocks is I didn't necessarily pay attention to where the incision was. And if the surgical incision crossed, I'm gonna make up another phrase now, crossed the midnippillary line. So so, basically, it was was medial to the nipple. It was medial to the nipple. 

Therefore, in the territory of the anterior cutaneous branches of the intercostal nerves, clearly, a block that targets the latched cutaneous branches is not gonna be sufficient. So I sometimes find it lacking, but that was my poor understanding of when to use certain blocks because I hadn't heard of the alternative blocks to help that. Okay. So what I'm hearing from you is pervertebral. And then if they're gonna do pectoral work, either boving down onto the pec muscle or placing a submuscular implant or tissue expander, you'll add a interpectoral Yep. 

Aka PEX one. Yep. Is that fair? That is fair. That is fair. 

So you're so you're no longer using PEX. And that's exactly what we do too. Yeah. Or what I do. Yeah. 

Parativo to me, gold standard. And if there's pectoral work to be done, I think a PEX one solves that issue. So now what about if either you don't think the risk of doing a paravertebral is justified, or, you don't think maybe the surgery requires something so dense, or there may be some other reason why you're you're not prepared to perform a block at the back. What alternatives? We talked about PEX blocks, but, you know, what can we add in, Jeff, to cover the medial chest wall innovation? 

So, yeah, different ways to skin that cat. You can do just infiltration. I've taken a a ten mil syringe of local anesthetic and just went Yep. Up the up the sternal, you know, border on that side just to get the cutaneous nerves. Surgeon can do it themselves, his or herself as they're as they're dissecting down. 

And by the way, the same for the supraclavicular nerve that comes out of the clavicle. My old recipe was PVB. Yeah. And then I did a little l shape across the clavicle Mhmm. And then down along the sternal border with subcutaneous local to cover those cutaneous branches. 

That was before I really understood about pectoral nerves. But Yeah. But or you could do a a fancy parasternal intercostal block like the TTP or the PIFB. I just like to call them parasternal blocks. Was it and, this this is an output of the of the other nomenclature work that's come up that we did for the work, for regional anesthesia and pain medicine. 

Right? Because there used to be the parasternal intercost no. Petro intercostal fascial plane block. The fact that I can't even remember what the acronym stands for tells you what the problem is. It was one of the most awkward acronyms, the PIFBA. 

Yeah. PIFBA versus the t t p p b versus the transversus thoracis plane block. Come on, guys. Can we up our acronym game here? Transversus thoracis muscle was a muscle I didn't know about until I started reading about this stuff. 

And, actually, that's the medial component of the, the innermost intercostal muscle. Right? So, actually, that block has created a little bit of a division amongst some of our regional friends. There are some people that like to go deep, and do these TTPB, but right in that deep plane between the internal intercostal membrane or muscle and the and the transverse thoracic muscle. Deep to that is the internal mammary arteries. 

Right? So why would you take a needle down that low? It's a pretty good sized artery. Yeah. I think, the arguments I've heard and I've I've done both. 

Yeah. You you're gonna find this surprising, but I had a TTP done on myself. My. Again, I was curious about what we were actually leading up to do a study in patients, we suddenly, as we're writing the IRB, we're like, wait, do we need one block at sort of three four, or is that gonna cover it all? That it's gonna spread up and down up to the manubrium and then down to the xiphoid. 

So we did a little pilot experiment and figured out that actually two well, at least in me, two blocks. And it's because of my massive pecs. That's what was preventing the spread. But two two blocks on each side did a much better job of covering than one at one single sort of in the middle block. But that was a TTP. 

Oh, yeah. So the argument I've heard about TTP versus the deep versus the shallow Yes. Better spread with the deep because there's less sort of compressive intermuscular force. I have not found that, especially because I do two blocks on each side. So so my take on that so, again, in case people are wondering what on earth are they talking about, we're talking about blocking the anterior cutaneous branches of the intercostal nerves that come off, from the sternum, either side of the sternum depending on which side you're you're looking at. 

I have found the superficial parasternal intercostal block, which is between pec major and intercostal muscles. I found that safer to teach, but it doesn't necessarily always present the way it's shown in videos and textbooks. So in an ideal world, you'd pass a needle through skin, subcutaneous tissue, through the pep major. You'd find that plane between pep major and intercostals near the ribs or the costal cartilages depending upon how medial you're doing the block. You get local anesthetic, and you get multilevel spread. 

In reality, we find that we have to do at least two separate injections to get it to spread. Sometimes you get to beautifully run over the over the costal cartilage or the rib, but not always. And I just you know, I don't teach my trainees to do the TTPB or the deep parasternal intercostal plane block because I'm doing a breast list for, for goodness sake, guys, and I don't wanna be calling any cardiac surgeons in. So that's kind of my rationale behind it. Yeah. 

I I totally agree. I mean, if if I'm doing a sternotomy, that's different. Yeah. But, you know, doing breast surgery really involves skin, subcutaneous, and breast tissue, which on that medial part can just be done with a subcutaneous injection. So Now listen. 

Just to to to finish up the conversation on the fascial plane blocks. So we've got the antramedial and the anterolateral fascial plane blocks. We've we haven't talked about the serratus anterior plane block. Now how is this different from the pectoseratus? Because Age old question. 

Yeah. Is it it's kinda the same plane, really. It's the same thing, man. Yeah. It's the same thing. 

I I mean, the way I try to break this down for trainees and and workshops is that PEX two, maybe a little more concentrated in the for breasts like t two to six, whereas serratus with bigger volume and maybe you're getting t two to t nine ish. We usually use serratus for rib fractures Yeah. Yeah. And or thoracoscopic stuff. I'm gonna give you my my secret now. 

Oh. For a patient who's not having, a paravertebral block. So if they're having a mastectomy, not having a paravertebral block, I do a superficial parasternal intercostal plane. I do a serratus anterior plane, and I might add in an interpetual injection. So I don't do a pector serratus. 

I basically take the probe out laterally because I find it's easier to find that plane. Because sometimes when you're trying to find a pector serratus plane or what would have been the the previous PEX two, your needle can get lost in that in that fascia of the axilla. And, actually, you think you're opening up the plane over serratus, then you end up opening up this weird gump into all this fat. So, actually, I think, well, you know what? I'm gonna do a parasternal, I'm and gonna do interpetual and I'll do the serratus laterally. 

So that's my secret when I can't do a paravertebral. I'm still stuck in the word gump. Yeah. But I totally agree. Another word. 

Yeah. You know, you and I should make a list of blocks, a fascia plane blocks that open up beautifully, unzipper like butter, and then there's ones that are tough. Serratus plane block to me always opens up nicely versus pectosoritis, maybe not so nice. So I think that's another good reason. And the other thing is you're you're like out of the way of the breast itself. 

And I I get a bit talking about heebie jeebies, I don't like sticking a needle through a breast that I hear you. Especially if it's an oncologic indication and there's I'm about you know, am I gonna be seeding cancers? I have you know, I have heard this. My my breast surgeons haven't been uncomfortable about this, but I have heard people being worried about this, before. But it's, yeah, something to think about. 

Maybe I'm just being extra cautious. But I but for that reason, I do like the serratus because you can sort of just push, the soft tissue medially and then come down on the side of the chest wall. There is one thing we do have to talk about, Jeff, and that is the problem of the wet axilla. Have you heard about the wet axilla problem? Ugh. 

I hate a wet axilla. So they they are you know, I I'm very fortunate in that the surgeons that I operate with have got used to, have trained on me doing, local anesthetic in the axilla, and they say, look. This this axilla looks wet. It's a dermatitis, but actually, they've got used to operating it. And often, they find it useful because as they're dissecting, they track the local anesthetic, and they can make sure they're going in the right place. 

But I have had some surgeons who said, please don't put anything in the axilla. Number one, it disrupts my landmarks, my anatomy. And number two, I've had a complaint slash concern that it would affect their ability to stimulate the nerves with diathermy. So if they're doing an auxiliary node dissection and they wanna use electrostimulation to identify the, the long thoracic or the thoracodorsal nerves, they say that it interferes with that process. And in fact, you know, I've I've got videos showing the nerves bathed in local anesthetic, but when you do direct simulation, it still works. 

But, you know, there there is a concern about the wet axilla. Yeah. I haven't heard of the term that quite that way. But No. I just made that up right now. 

You heard it here first, folks. Wet axilla. Sounds sounds icky. But yeah. The no. 

Same thing. We have had when we get a new breast surgeon come on, and I'm discussing with her or him about what blocks they would like or any concerns they have, that frequently comes up. And I do have a surgeon that I don't do PEX blocks for Yeah. For that reason. Yeah. 

Well, it's an you know, it's it's a collaborative approach. Right? We've gotta make sure we're all looking after the patient, but at the same time Yeah. We've gotta work in harmony with with the teams. Everyone's gotta be on board. 

Everyone's gotta be on the same page. So it's you know, I I believe it or not, even I compromise sometimes. PVB in harmony. Oh my god. This is amazing. 

We need to come up with all these random songs and keep a list of them because that will contribute to our rap at the end of the show. Okay. So now just when you thought it was safe to escape ESP, power breath. Okay. So smashed PVB king of blocks. 

We got that. We're here for the breast. We've talked about fascial playing blocks. Does the erector spinae playing block have a role in breast surgery? I have my opinion. 

I have a thought process about that, but I wanna hear yours. I wanna so I want you to tell me about ESP and breast surgery. Then I want you to tell me about what you think about the crossover blocks, the retro lamina blocks. There's some other blocks at the back, the rhomboid intercostal sub serratus blocks, and then the MTP slash ITP. So shoot over to you, and then I'll tell you what I think. 

Okay. ESP, not a bad plan b. If I wasn't excited for whatever reason about doing a PVB or if you were a person that didn't want to do a PVB because it's just that's not something that you're happy with or comfortable with. I think ESP is a fine second option. Keeps a local back in the back. 

There's no wet axilla Yeah. Or, you know, inter interpectoral plane that they open up and they go, what the heck is all this stuff in my plane? We've used it. We've had good success actually on the times that we have used it. I think so I think but definitely a plan b block. 

And for those other ones you're talking about, I'm just gonna lump them all into Yeah. I call those plan c. Like, I just why bother? I don't mean to disrespect the the risk block or whatever it is, but but, I I think choice a, PVB. Choice b, a set of pectoral slash serratus anterior blocks that, you know, meet your needs. 

And if not that, ESP. I don't know. You're okay. I wanna hear your thoughts. Okay. 

So I, of course, like everybody else, when I heard about the erector spani plane block, I tried it for I wouldn't say I tried it for everything, but I tried it for breast surgery because I wanted to see what it was like. So my first trial of using this, I did it preemptively. So the same way that I would do a PEX block, I did an ESP block and then gave them a general anesthetic, and I was meh when it came to results. So I was like, kind of, yeah. Well, you know, was it great? 

I don't know. Sometimes it's okay. Sometimes it wasn't. When I had really good results was when I did it as a rescue block. So a patient maybe had no block or or had a a PEX block or interpetrol, petrol serratus for surgery and in recovery on PACU was in pain. 

So in those situations, I wanna use, ESP as a rescue block. Boy, oh, boy. I was really impressed. In the similar way that you'd be impressed if you use it for, for rib fractures and you got that sort of relatively early onset. Now some of that, of course, could be placebo effect. 

I you know, I'm not I'm not in denial about that. But when I use it in that manner, it worked well. And it may have had something to do with the fact that the tissue damage or the, you know, the nervous system was already wound up. I don't know. It seemed to work well in those circumstances. 

I I don't doubt that, actually. I think it's interesting, and that supports an observation that I've always had, which is if you do a block for a patient prior to surgery and it's not a complete block, right? They wake up in the PACU, they're having some pain and that pain is aggravating and it's gonna be, I 'm gonna call that a five or mid range pain, but you to try to explain to the patient, you don't know what you're not feeling because I've blocked 85% of the rest of those nerves if you only knew. And so I think the delta between what they were feeling and the relief they feel from your, let's call it incomplete Yes. ESP or maybe not quite as good ESP is so much is so appreciable They, they have they love it. 

I I think that's right. In fact, somebody should probably do a study whereby they, they put a catheter in, preemptively, but don't put anything down it or or put, you know, randomized controlled trial where they put placebo versus drug and then see what happens when they bolus the catheter impact you. And I bet you'll find that's when it has a role. I'm I'm sure it will. So funny. 

We actually did that study, not for ESP. We did it for for femoral. Actually, I know that study. I read that study. Yeah. 

Totally patients that got the adductor canal block and all the all the usual stuff we do. Yes. I know that study. And it was it was sort of in response to is adductor canal the same as ephemeral? Well, if it is if it is the same, then a supplemental femoral on top of it shouldn't do anything. 

Right? So we did they randomized patients in the PACU to get femoral or sham femoral, and there was a huge there was a huge difference as you might expect. So so there may well be something in that. You know, I don't know if anyone if anyone's planning on doing that, I'd be I'd be really interested to hear about that. And I so what I have done so when I was disappointed with my preemptive preoperative ESP, I I decided to modify, and that's why I do the supercharged ESP. 

So I do the ESP block, at one level, I kinda make an extra hole. I do I do that pepper potting, but it's actually just one hole in into transverse space, and I inject about five five to 10 cc's at the point of maximum dermatomal involvement. And I put, like, yeah, five to 10 cc's there, and I come out. Now I know Iwana Costash react reacted to our first podcast and said, well, if you're gonna do a hybrid ESP, why not just do, you know, just do only ITP blocks or MTP blocks? Why do the two? 

And it's mainly because I wanna keep a depot of local anesthetic in the Eritzmani plan. I wanna get that breadth of spread, but I know I really want it work specifically at one level. But, yes, she may she raises a valid point. So I think ESP has a role exactly as you say, probably as a plan c. Plan a paravertebral, plan b, PEX, you know, parasternal intercostal, and plan c ESP. 

Here we go. Okay, Jeff. I mean, I guess, let's finish it. Finish up talking about awake mastectomy. So, you know, this is something that you know, why do we learn all these blocks? 

Well, because number one, we wanna do the best for our patients, but, actually, it does also give us the options to do something different. So I've got a specific, recipe for a weight mastectomy. I've kind of alluded to it. Let's hear it. Okay. 

You wanna hear about it? I'm ready. Okay. So ninety five percent of the success for a weight mastectomy is all to do with patient preparation. So we're gonna imagine this patient is called Henrietta. 

So Henrietta comes to her pre op assessment clinic, and she's got a whole host of medical issues. And someone's identified that she is pretty high risk for general anesthesia. And so they just said, you know what? We have this option for you, and then you can avoid a general anesthetic. And they go through the process. 

They consent her for the blocks. They explain the risk. They set her expectations so she knows what to expect because what we don't wanna be doing is speaking to a patient on the morning of surgery and telling them we're not gonna give them a general anesthetic for the first time. So patient preparation is key. We talk about the fact that they won't that they don't have to be completely wide awake. 

We can use elements of sedation. We also ask them about music. So we we use a lot of music and, you know, so they know what to expect. And, actually, when I see patients in the morning of surgery before awake surgery, when they've been consented and prepared properly, I talk to them. They go, yep. 

That's exactly what the doctor told me in the pre assessment clinic. I know what to expect. Sure. So I see them in the morning of surgery. Yeah. 

I, again go through the process, talk about the risks about the the injections I'm gonna do, and then we bring them into our anesthetic room or your block holding bay. We make sure we keep them nice and warm. We check them in, check the correct site of surgery. And, course, if you're doing blocks at the back, I need to make sure I'm I'm I'm blocking the correct side, and then I make sure I play some music for them. Oh. 

Get some music that they like. I like that. I say, say, what music do you like? The idea is just to drop that tension and that anxiety. We cannulate them. 

We make sure and I use a small amount of midazolam. What do you guys call midazolam? We call it midazolam. Okay. You you don't don't you have one of those funny names like, relaxotral? 

Or or now they're calling it relaxotral. That sounds amazing. Okay. So so I tend to give them a little bit of midazolam, and fentanyl, and I do, a multilevel paravertebral block. Now get ready. 

I don't just use bupivacaine. Okay. I mix lidocaine with bupivacaine. Oh. Okay. 

So we're not gonna talk about that now. Alright. Different episode. But I will work out the maximum allowable of dose that I can give the patient of lidocaine with epinephrine, for example, and I reduce that by 50%. And I do the same for the maximum allowable dose of bupivacaine. 

I reduce that by 50%. The work course of my technique is a paravertebral block. So I will do three to four paravertebral injections with three to five cc's of local anesthetic covering from probably t two down to wherever I can get decent spread. Once I've done that, I lay the patient supine, and I supplement. So I do supplementary chest wall blocks, especially if they're doing exudino clearance. 

And this is because I'm doing the belt and braces approach. So I will add in a parasternal plus or minus into petrol, pector serratus, or serratus. The idea is I do whatever local I've got left. I dilute that down. So I've got, you know, 10 to fifteen cc's for the midline or for the parasternal blocks and the balance volume about 20 to 30 cc's for the lateral component. 

I do those blocks and then I wait. Now I never used to wait. So actually, when I'm good, I do these fast. Actually, it doesn't take me that long to do the blocks, but I wait for the blocks to cook. And I check them because actually, it really makes a difference if you can demonstrate that difference to the patient before you go into theater. 

Sure. Yeah. I was called out. I had to anesthetize, a member of staff once, and I did the block, the blocks and the and the the patient said to me, Amit, I don't feel any difference. And I said, just wait. 

Just wait. And it wasn't until that particular patient was able to detect a difference, and she was using touch. She was like, oh my goodness. It feels different. Okay. 

Let's go. It wasn't until she was able to feel the difference that we went to theater. Sure. Yeah. So, yeah, so making, making sure you've covered the full extent of the chest wall, making sure they're nice and numb. 

Then we go into theater. We play music. We use a little bit more sedation. Sometimes I might use propofol sedation. I've heard people use interrupted boluses of ketamine. 

Mhmm. We give supplementary oxygenation. We make sure we apply the the drapes. We make sure the patient knows the drape's gonna be close to the face so they don't get surprised, and we lift them up out of the way. It's all about being calm, and communicative. 

You wanna make sure we communicate with the patients. And then last but not least, I wanna make sure I have a plan for backup. What happens if the patient feels pain? Do I have room for supplementary local anesthetic? Do I have what rescue analgesic am I gonna use? 

And I often use dilute doses of either opiate or ketamine. We have the ability to increase sedation. So it's kind of a multimodal thing. That's amazing, man. That that's a really comprehensive and thoughtful set of steps that you've developed there. 

And I know you've got a lot of experience, so that's, that's awesome. Hey. I had a question for you. What's the concentration you're using with your mixture? So so again, depending on patient weight, but I usually use zero point five percent levobupivacaine in the back Okay. 

And then one or two percent lidocaine depending upon what how much weight allowance I have and how many blocks I'm gonna do. Sure. If it's a if it's a lumpectomy, then I don't necessarily bother with supplementary blocks, and we can just work with just doing the paravertebral. Okay. I know some people do these just under the fascial plane blocks, but I think the paravertebral is so predictable. 

That's why I like to do that. And do you do you find that the the addition of that dilute serratus saves you sometimes? I think well, I'll tell you when it really made a difference. It really made a difference when I used to do a single level block in the parabirtual space. Uh-huh. 

Sure. Of course, I'm I'm hedging my bets. I'm hoping that it spread you can often watch the spread in real time. But I think it saves me in a couple of situations sometimes when they bring the chest drain out and the chest drain comes out, although yeah. Much lower than when you may may be blocked. 

But I think it just I think it is I we call it belts and braces. It's just doing that a little bit extra. Is it essential? Yeah. I think probably as I get older and a bit maybe a bit wiser, I I might drop it in some circumstances. 

I don't do for everyone. You're doing a ring block of the chest? Effectively. And you know what? There are some patients where we have no option to give a general anesthetic. 

And in those cases where I really, really, really don't wanna give a GA, I'll throw everything at there at at it. Whereas actually where where Yeah. You know, where there's it wouldn't be a disaster. It's more patient preference. Well, you know, we'll make a value call on that. 

Well, that's great, man. I love to I love to hear that. You do anything similar or just there's anything very different? Sort sort of. A lot of the initial steps you described are are common. 

We'll do a paravertebral at every level. So t two, three, four, five, six. We use, we don't mix our local anesthetics. Different episode, we'll get into why that's extremely wrong to In in your opinion. Just kidding. 

Just kidding. Well, kidding. Not kidding. No. We so we'll use a higher a high concentration of, typically, the rapivacaine half percent or something similar. 

And then it depend if they're gonna do muscular work. So, you know, modified radical mastectomy where they're gonna be stripping the fascia off the pec muscle or submuscular implant or tissue expander, I'll do a PEX one as well or pecto intrapectoral block. And if it's if it's awake, I'll still do that little L shape. So you're getting the supraclaviculars. Yeah. 

Yes. Right on the clavicle and then down the side of the sternum just to get all that. But it's interesting about the serratus. That's, I think maybe because we do every level I think that I think that's probably yeah. Maybe the t two, t three is is not as much of an issue. 

That may that may be well, that may well be why. I mean, the other thing we didn't mention that I think is worthwhile mentioning is every now and then, patients start complaining of pain intraoperatively, but it's not due to the surgical site. It's due to the somebody leaning on an arm or leaning on a leg or doing something. And if you use use a bit of sedation, you don't necessarily get to to identify that. So preparing the team as well for what you're doing is really important. 

So please remember the patient's awake. But yeah. Really important. Yeah. That's really interesting. 

Listen. Yeah. I've as always, I learned a lot from, from this conversation, Jeff. So thank you so much for taking me through. Oh, me too. 

Yeah. Thank you. That was that was great. Appreciate it. Alright, man. 

I think we pretty much covered it. What do you think? Yeah. I know. I think I think, I'm sure that at least a couple of the things would generate some discussion. 

Maybe the symmetrization phrase, maybe relax a troll. I I I don't know. But I I think we've covered it all. We're all good, man. Well, why don't we wrap it up and, give the listeners a chance to hit us up on social media if you have any thoughts or questions or concerns. 

Where can they find us? Okay. Well, everybody you guys can find us at Twitter at at block it underscore hot underscore pod on YouTube at at block it like it's hot, and on Instagram. What's the Instagram tag, Jeff? Yeah. 

Block underscore it underscore like underscore it underscore hot. And don't forget the hashtag hashtag block it like it's hot, no apostrophes, and get involved in the conversations. We'd love to hear from you. And if you are enjoying this show, it would be awesome if you could please rate us wherever you get your podcasts. It really helps to push the podcast to the top of the algorithm and, give other people who who might enjoy it a chance to listen. 

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