2023 FSA Podium and Poster Abstracts

P066: BILATERAL PNEUMOTHORAX AFTER ULTRASOUND-GUIDED PECTORALIS BLOCK
Gianfranco Molfetto, DO¹; Johnathan Bishop²; Grace Chalhoub, DO¹; Benjamin Houseman, MD¹; ¹Memorial Healthcare System; ²Virginia College of Osteopathic Medicine

INTRODUCTION: Pneumothorax is a rare but serious complication of breast reconstruction with an estimated incidence between 0.04% and 0.55% (1,2). The cause of pneumothorax is often difficult to determine, but may include intraoperative laceration of the pleura, injury due to local anesthetic injection, ruptured pulmonary blebs during or after the procedure, and high ventilation pressure (3). Here we report an unusual case of bilateral pneumothorax following ultrasound-guided pectoralis plane block under general endotracheal anesthesia.

CASE REPORT: A 68-year-old female with an unremarkable past medical history presented for bilateral mastectomy and reconstruction. Following induction of general anesthesia and endotracheal intubation, bilateral pectoralis nerve blocks were performed using ultrasound guidance. Shortly after the blocks were completed, increased peak airway pressures were observed and decreased breath sounds were noted on the left. The patient remained hemodynamically stable. Thoracic surgery placed a 28 Fr chest tube on the left. A smaller right-sided pneumothorax was noted chest x-ray, and an 8 Fr pigtail catheter was placed. Following these interventions, the breast reconstruction was safely completed. Both the chest tube and pigtail were removed on postoperative day 1 and the patient was discharged home on postoperative day 3.

DISCUSSION: One study of over 34,000 breast reconstructions estimated an incidence of pneumothorax of 0.55% (1), while a second review of over 9000 reconstruction / expander placements found an incidence of 0.04% (2). The latter study proposed that surgery could safely proceed once the pneumothorax was treated and the patient was hemodynamically stable. Consistent with this approach, we completed the procedure following placement of a chest tube and pigtail catheter.

Several factors increase risk for the development of pneumothorax during breast surgery. These include prior pneumothorax, smoking history, and injection of local anesthesia without the use of ultrasound (3). While ultrasound guidance reduces the risk of block-related complications, it does not eliminate the risk of intravascular injection or pneumothorax, particularly in individuals with challenging anatomy or increased baseline risk.