Fascial Plane Blocks Combination for Breast Surgery in Obese Patients With Difficult Airway Management: Insidious or a Valid Alternative

Obesity poses several challenges for anesthetists. The several comorbidities associated with obesity can result in very complex management, which requires a multimodal and reasoned approach. The possible difficult airways are, certainly, the obstacle that most can put the anesthetist to the test. From this point of view, regional anesthesia (RA) can be a valid alternative to general anesthesia (GA) in selected patients. The possibility of performing an anesthetic block allows the fulfilment of the surgical act. We present the case of a 56-year-old woman, with a BMI of 43. In her medical history, she has obstructive sleep apnea syndrome (OSAS) on home-oxygen therapy without continuous positive airway pressure (CPAP) therapy. The patient reported probable airway difficulties in previous breast surgery, and the preoperative evaluation highlighted and confirmed the high risk. For this reason, in agreement with the surgeons and the patient, we decided to perform RA. Forty minutes before the start of the surgery, a deep anesthetic ultrasound-guided serratus anterior plane (US-SAP; branches of the intercostal nerves in the middle axillary line [BRILMA]) was performed, followed by a right ultrasound-guided erector spinae plane (US-ESP) block. Mild sedation with propofol 1 mg/kg/h was administered and SpO₂ always remained above 97% with nasal oxygen at 3 l/min. The surgery was completed in 35 minutes, the patient complained of no pain, and received opioid rescue therapy during the post-operative period. This case presents clinical evidence that RA can help in avoiding some dreadful complications that can occur during GA in obese patients. In any case, the anesthetic management choice must be carefully reasoned, considering the patient's clinical conditions, surgical needs, and, not least, the skills of the anesthetist.