What type of block can be given for axillary lymph node excision?

Regional Anesthesia Options for Axillary Lymph Node Excision

For axillary lymph node excision, a paravertebral block is the recommended regional anesthesia technique, providing optimal pain control and reduced opioid requirements. 1

Primary Anesthetic Options

Major Breast Surgery with Axillary Node Dissection

1. Paravertebral Block (First Choice) 1

   • Provides superior postoperative analgesia
   • Associated with lower pain scores and reduced systemic analgesic consumption
   • Reduces postoperative nausea and vomiting
   • Can shorten hospital stay
   • Can be performed as single-injection or continuous technique

2. PECS Block (Alternative Option) 1

   • Consider when:
     • No axillary node dissection is planned
     • Paravertebral block is contraindicated
   • Provides interfascial plane blockade

3. Axillary Brachial Plexus Block 2

   • Effective for anesthesia of the axillary region
   • Median onset of sensory block ranges from 10-45 minutes depending on nerve
   • Duration ranges from 3.7-8.7 hours
   • Success rates of 56-86% with 0.5% ropivacaine
   • Can use 0.75% ropivacaine (40mL/300mg) for improved quality and duration

Multimodal Analgesia Protocol

Pre/Intraoperative Medications

• Paracetamol (Grade B) 1
• NSAIDs or COX-2 inhibitors (Grade A/B) 1
• Gabapentin (Grade A) - reduces postoperative pain and opioid consumption 1
• Dexamethasone (Grade B) - provides additional pain relief and reduces PONV 1

Local Anesthetic Options

• Local anesthetic wound infiltration can be added to regional techniques 1
• Ropivacaine 0.5-0.75% is effective for brachial plexus blocks 2

Postoperative Management

• Continue paracetamol and NSAIDs/COX-2 inhibitors 1
• Opioids as rescue only when needed 1
• Consider continuous paravertebral block if catheter placed 1

Nerve Preservation Considerations

Careful attention to nerve preservation during axillary lymph node dissection is crucial to reduce postoperative morbidity:

• The intercostobrachial nerve and long thoracic nerve are at high risk of damage during axillary lymph node dissection 3
• Damage can result in sensory loss, paresthesia, persistent pain syndromes, and shoulder dysfunction 3
• Complications after axillary dissection include numbness (35%), pain (30%), arm swelling (15%), and limitation of arm movement (8%) 4

Surgical Context

The anesthetic approach should consider the specific surgical procedure being performed:

• Sentinel lymph node biopsy is the preferred method for axillary staging in early breast cancer 1
• Axillary lymph node dissection is performed when sentinel nodes are positive for metastasis 1
• The extent of surgery influences the choice of anesthetic technique 1

Pitfalls and Caveats

• High doses of gabapentin may cause side effects (dizziness, blurred vision, sedation) that are concerning in ambulatory patients 1
• Continuous paravertebral blocks are more resource-intensive and costly than single-injection techniques 1
• Failure rates for axillary blocks (14-44%) are higher than for supraclavicular approaches (8%) 2
• Nerve injury during block placement is a potential complication that must be weighed against the benefits of regional anesthesia

Regional anesthesia techniques significantly improve pain control and reduce opioid requirements following axillary lymph node excision, with paravertebral blocks offering the most comprehensive coverage for this procedure.