In centers with high turnover of breast surgeries, pectoral nerve block Pec II is time-consuming and requires ultrasound familiarity for administration. We decided to block the same nerves under vision after resection to evaluate postoperative analgesic effects.
Sixty patients scheduled for modified radical mastectomy were enrolled in this prospective, randomized, placebo-controlled, triple-blinded study. All patients received standardized general anesthesia. After surgical resection, infiltration of either ropivacaine Group A or saline Group B was given under vision at two points: 20 ml in the fascia over serratus anterior and 10 ml in the fascia between pectoralis major and minor at the level of the third rib.
The primary outcomes measured were the time to first request for analgesia after extubation and total dose of analgesics needed, and secondary outcome included pain scores using the Numerical Rating Scale over 24 h. Analgesics used postoperatively were fentanyl citrate and paracetamol. We used Student's t -test to analyze quantity of analgesics needed, the nonparametric Mann—Whitney U -test for time to first request of analgesic, and Fisher's exact test for pain scores.
No patient in Group A required fentanyl. The mean time to first request for analgesia and mean dose of paracetamol required was Significantly more patients in Group A had mild pain scores compared to Group B. Pec II block with ropivacaine delivered under vision reduced analgesic requirement and pain scores significantly. Perioperative analgesia for surgery in carcinoma breast utilizes significant quantities of opioids as compared to cosmetic breast surgeries. Ultrasound-guided modified pectoral nerve block Pec initially described for cosmetic breast surgeries provides excellent analgesia, but is resource-intensive in terms of trained manpower and equipment.
This prospective, randomized, placebo-controlled, triple-blinded, parallel group, single-center trial was conducted from January to June after approval of the Institutional Review Board and Ethics Committee in our hospital. Patients with local anesthetic allergy, locally advanced breast malignancies with skin ulceration or infiltration of chest wall, bleeding dyscrasias, patients on anticoagulants, and deranged liver function tests were excluded from the study.
After overnight fasting patients were premedicated with alprazolam 0. All patients received standardized general anesthesia with intravenous IV propofol for induction of general anesthesia, nitrous oxide — oxygen — sevoflurane for maintenance along with IV vecuronium for neuromuscular blockade. Supraglottic airway device I-gel was used to secure the airway.
The drug used for the study was 0. The placebo solution, 0. Study and placebo trial solutions were colorless, 30 ml in volume and were presented identically in 50 cc syringes. The patients were randomly allocated into two groups using computer-generated random numbers. The group allocation numbers were kept in a sealed envelope which was opened by investigator A first author after the patient was taken up for surgery.
Investigator A prepared 30 ml of either 0. Group A received 0. Investigator A did not participate in subsequent clinical care or outcome assessment of the patients. The filled syringe was handed over to investigator B second author in the operation theatre who conducted the anesthesia for the patient.
After completion of the surgery and wash of the area of dissection, investigator C third author injected 20 ml of the solution in the syringe beneath the pectoralis minor so as to infiltrate under the fascia, over serratus anterior [ Figure 1 ] Injection between Pectoralis Minor and fascia over Serratus Anterior and 10 ml between the pectoralis major and pectoralis minor infiltrating under the fascia at the level of the third rib [ Figure 2 ].
Participants patients and investigating personnel second and third authors did not know whether the syringes contained ropivacaine or saline. Postoperative analgesia regimen was standard in both groups. After reversal from anesthesia patients were extubated and shifted to the recovery room. When awake patients were asked to evaluate their pain intensity according to NRS scale by the second author. If it was more than 3 IV fentanyl citrate, 0. NRS was reassessed after 10 min. One hour after surgery, patient was shifted to postoperative ward for overnight monitoring and received IV pantoprazole and domperidone as per hospital protocol.
Pain was assessed and treated according to NRS at rest and movement pain on moving the ipsilateral arm 1 hour from the time patient woke up after surgery and thereafter every 6 h for the next 24 h by investigator B.Until recently, patients having anterior chest procedures involving the pectoral muscles such as breast reconstruction had only two regional anesthetic choices for intraoperative and postoperative pain control.
These included the thoracic epidural and, more commonly the thoracic paravertebral block. Since many of these reconstructive cases are done on an outpatient basis, the epidural approach is considerably less desirable and may pose significant risk to the patient. The alternative approach for analgesia pertaining to outpatient breast reconstruction cases is the thoracic paravertebral block PVB. While less risky and having a longer duration, it is often less than effective in producing the desired analgesia.
The reconstructive breast procedures have considerable pain arising directly from the pectoral muscles themselves. This can be because many surgeons find it desirable to place breast implants under the pectoral muscles. This produces pain and pressure sensations by the pectorals. Spasm of the pectoral muscles during the immediate and more distant post operative period is also an issue that patients and surgeons struggle with.
The pain response from the pectoral muscles, not the skin, fascia and mammary tissue, makes the thoracic PVB less or ineffective for reconstructive cases. This is sensible because the block essentially doesn't match the surgery. The likely reason for this fact is that the pectoral muscles simply aren't innervated by the spinal afferents carried under the ribs.
A new procedure targeting the innervation of the pectoral muscles for breast reconstruction has recently been explored. This new approach is called the median and lateral pectoral nerve blocks. This approach is safe, simple and effective- although it is so new it hasn't been investigated to any great extent. This novel approach takes advantage of the superficial nature of the target nerves and no requirement to image the nerves themselves.
The pectoral muscles themselves are superficial structures and image well with even poor ultrasound equipment.
The block involves both the medial and lateral pectoral nerves. The median pectoral nerve arises from the brachial plexus. Specifically the medial cord of the plexus.
It derives spinal contributions from C8-T1. After leaving the plexus it runs between the pectoralis major and the pectoralis minor muscle. It sends off about three additional branches into the pectoralis major muscle as well. The lateral pectoral nerve arises from the lateral cord of the brachial plexus.
It derives spinal contributions from C5-C7. It leaves the brachial plexus and also runs between the pectoralis major and minor muscles. It innervates solely the pectoralis major muscle. The path that these two nerves share is the space between the pectoralis major and minor muscles.Plast Reconstra Surg Glob Open. This site is for informational purposes only and is intended to address medical questions from healthcare professionals in the United States.
To report an adverse event, email drugsafety pacira. EXPAREL is indicated for single-dose infiltration in adults to produce postsurgical local analgesia and as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Safety and efficacy have not been established in other nerve blocks.
Please refer to full Prescribing Information. Skip to main content. Consider the neuroanatomy to target the appropriate nerves for a PECS block. Internal sagittal view of where to inject local anesthetic PECS I block 2 Injection between pectoralis major and minor muscles PECS II block 2 Injection between the pectoralis muscles and a second injection between the serratus anterior and pectoralis minor muscles.
Performing a PECS II block for more extensive pectoral and breast procedures PECS II block The goal is to infiltrate 2 fascial compartments by dividing the dose and injecting 3 Between the pectoral nerves the pectoral fascia and clavipectoral fascia Under the pectoralis minor muscle between the clavipectoral fascia and the superficial border of the serratus muscle Nerves involved 4 : Long thoracic nerve nerve to serratus anterior Thoracic intercostal nerves from T2 to T6 Thoracodorsal nerve nerve to latissimus dorsi.
Images 2 and 3 courtesy of Jacob Hutchins, MD. Important Notice This site is for informational purposes only and is intended to address medical questions from healthcare professionals in the United States. References Blanco R.
Multimodal analgesia in breast surgical procedures: technical and pharmacological considerations for liposomal bupivacaine use. Plast Reconstr Surg Glob Open. Blanco R, Barrington MJ. Pectoralis and serratus plane blocks. Accessed April 4, Gonzales J. Indication EXPAREL is indicated for single-dose infiltration in adults to produce postsurgical local analgesia and as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia.
See More EXPAREL is indicated for single-dose infiltration in adults to produce postsurgical local analgesia and as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia.Breast cancer surgery can rid your body of cancer, but leave you with weeks of recovery time and plenty of pain. However, a relatively new procedure called a pecs block procedure has been effective at preemptively blocking pain related to breast cancer surgery. Patients wake up from surgery feeling significantly less pain as well as a shortened recovery time.
The procedure works by honing in on specific nerve endings within the chest that cause the most pain and numbing them before surgery even begins. A pecs block procedure targets groups of pectoral and intercostal nerves in the chest. Using an ultrasound to guide the placement of a needle, a local anesthetic is injected between the thoracic wall muscles. The pecs I block anesthetizes the medial and lateral pectoral nerves. The pecs II block does the same as the pecs I block, only with an additional injection between the pectoralis minor and serratus anterior muscles that will numb the upper intercostal nerves.
By targeting the nerves before the pain fibers are even stimulated, both post-surgery pain and recovery time are lessened. The traditional practice for surgery is to prescribe strong opioids like hydrocodone, which are highly addictive and can also come with side effects like constipation and dizziness. Doctors are now under mounting pressure to limit opioid prescriptions because of the opioid epidemic, making the pecs block procedure is even more promising.
PECS Block With Bupivacaine Vs Bupivacaine and Dexmedetomidine in Modified Radical Mastectomy
The procedure is being used more frequently all across the United States, but some states have been slower than others in adopting the new technique. For example, Dr. Phillip Ley is currently the only surgeon in Mississippi who is regularly using the pecs block procedure.
Watch the video below to see the procedure explained in real time by Dr. Thomas McClellan, a plastic surgeon. Get the latest from The Breast Cancer Site in your inbox every morning! All rights reserved. Owned and operated by CharityUSA. Share on Facebook. Sign up for news and offers! I approve storage of my email by GreaterGood. Visit The Breast Cancer Site to fund mammograms.Many types of regional nerve blocks have been used during anesthesia for modified radical mastectomy.
In recent years, the use of pectoral nerve PECS block has gained importance in postoperative analgesia, but there are still controversies regarding its efficacy. There is especially no consensus on the optimal type of PECS block to be used. Herein, we attempt to evaluate the analgesic efficacy of the PECS block after radical mastectomy.
Outcome measures such as intra- and postoperative consumption of opioids, postoperative nausea and vomiting PONVneed for postoperative rescue analgesia, and pain scores were analyzed.
After quality evaluation and data extraction, a meta-analysis was performed using Review Manager 5.
A total of 8 RCTs and 2 cohort studies involving patients were eligible. However, subgroup analysis showed that PECS I block did not have a significant advantage in reducing the intra- and postoperative consumption of opioids.
Results for each outcome indicator were confirmed as having a high or moderate level of evidence. Breast cancer is the most common malignancy in women; surgery is one of the mainstays of treatment of breast cancer, and modified radical mastectomy is one of the standard treatments.
Thoracic paravertebral, thoracic epidural, intercostal nerve, and interscalene brachial plexus blocks have been used for anesthesia and abirritation during modified radical mastectomy, but their applications are limited by the complicated nature of the procedures and severe complications. PECS I block is an interfascial plane block administered between the pectoralis major and the pectoralis minor muscles. However, 2 recent studies indicated that the PECS block does not effectively block the sensory nerves nor does it exert additional analgesic effects.
Therefore, there is some uncertainty about the clinical utility of the PECS block. The search strategy was designed according to the searching criteria issued by the Cochrane Collaboration. In addition, we manually searched journals and reference lists for articles related to this study.
All analyses were based on previous published studies; thus, no ethical approval and patient consent are required. Eligible studies were required to meet all of the following criteria:. Studies were considered ineligible and were excluded if they met the following criteria:.
Two reviewers the first and second authors independently assessed the quality of the included literature. The 2 reviewers the first and second authors independently extracted data from all available studies in accordance with the standard form of data extraction.
If disagreements occurred, the decision regarding data extraction was done by the third reviewer the corresponding author. For incomplete data, the reviewers tried to contact the authors of the original articles by email to request the original data, but did not receive a response. In some cases, the standard deviations SD that were not presented in the original reports could be estimated based on the range or median [ 19 ] or based on the confidence interval CI as described in the Cochrane Handbook for Systematic Reviews of Interventions.
Statistical analysis was performed using RevMan 5. The chi-square test was used to assess heterogeneity. Relative risk RR was used as the combined effect indicator for dichotomous variables; standardized mean differences were used for continuous variables.
For the outcome indicators with significant heterogeneity, a sensitivity analysis was conducted by removing the included studies one at a time to determine the sources of heterogeneity.
Pecs Block Procedure Reduces Surgery Pain
A publication bias assessment using forest plots was intended to be conducted if no less than 10 studies were included. There were 8 high quality and 2 low quality studies. Six high-quality RCTs were double-blind studies.
A total of 9 studies that included patients reported on the use of intraoperative opioids. No source of heterogeneity was found in the sensitivity analysis.The PECS block is a newer regional anesthesia technique that works by injecting long-acting anesthetics, guided by ultrasound, to numb the front of the chest wall before surgical incision.
Zhou, M. Our study found women who received a PECS block prior to surgery had significantly less total opioid consumption, from the start of surgery to the first day after surgery, compared to patients who did not receive the block.
Breast cancer is one of the most common cancers affecting women, with an incidence of 1 in 8 women in the United States. Mastectomy is often performed for treatment of breast cancer; however, many patients experience severe acute postsurgical pain. The acute pain is typically treated with opioids, which have many side effects including nausea, constipation, sleepiness, respiratory depression, and can eventually lead to dependence and addiction. Mastectomy patients are also at high risk of developing chronic pain pain lasting three months or morewhich can impair quality of life.
Any perioperative interventions performed by physician anesthesiologists to reduce acute pain after surgery, including the use of regional anesthesia and opioid sparing techniques, have the potential to decrease the risk of chronic post-mastectomy pain, the researchers note.
In the study, researchers examined patients who had unilateral or bilateral mastectomy between and Ninety-eight patients received a PECS block prior to general anesthesia, while 54 patients received general anesthesia only. Opioid consumption was collected at multiple time points — during surgery, in the post-anesthesia care unit PACU and on the first day after surgery.
Researchers found a statistically significant reduction in opioid consumption during surgery 20 percent and on the first day after surgery 36 percent in patients who received a PECS block, compared to those who did not.
PACU opioid consumption was not significantly different between the groups. PECS blocks have several advantages over other blocks used to reduce postsurgical pain after mastectomy such as thoracic paravertebral nerve blocks, which numb the spinal nerve, in that they are less invasive, have less risk of nerve injury, are easier to administer and have fewer potential complications.
Founded inthe American Society of Anesthesiologists ASA is an educational, research and scientific society with more than 52, members organized to raise and maintain the standards of the medical practice of anesthesiology. ASA is committed to ensuring physician anesthesiologists evaluate and supervise the medical care of patients before, during and after surgery to provide the highest quality and safest care every patient deserves.
For more information on the field of anesthesiology, visit the American Society of Anesthesiologists online at asahq. To learn more about the role physician anesthesiologists play in ensuring patient safety, visit asahq.
Back Standards and Guidelines. Back Education and Career. Back Events. Back In the Spotlight. Back Podcasts. Back Quality and Practice Management.Pectoralis nerve Pecs and serratus plane blocks are newer ultrasound US -guided regional anesthesia techniques of the thorax. The increasing use of ultrasonography to identify tissue layers and, particularly, fascial layers has led to the development of several newer interfascial injection techniques for analgesia of the chest and abdominal wall.
Intraoperative pectoral nerve block (Pec) for breast cancer surgery: A randomized controlled trial
For instance, the Pecs I block was devised to anesthetize the medial and lateral pectoral nerves, which innervate the pectoralis muscles. This is accomplished by an injection of local anesthetic in the fascial plane between the pectoralis major and minor muscles. The Pecs II block which also includes the Pecs I block is an extension that involves a second injection lateral to the Pecs I injection point in the plane between the pectoralis minor and serratus anterior muscles with the intention of providing blockade of the upper intercostal nerves.
These interfascial injections were developed as alternatives to thoracic epidural, paravertebral, intercostal, and intrapleural blocks, primarily for analgesia after surgery on the hemithorax.
Initially, Pecs blocks were intended for analgesia after breast surgery; however, case reports have also described the use of Pecs and serratus plane blocks for analgesia following thoracotomy and rib fracture.
Information from the currently published literature on Pecs and serratus plane blocks in peer-reviewed journals is summarized in Table 1. Pecs blocks have also been proposed in letters to the editor as alternative techniques to anesthetize operative regions such as the axilla, proximal medial upper arm, and posterior shoulder, which are not innervated by the brachial plexus Figure 1.
Pecs blocks are applied in the pectoral and axillary regions, with the muscles in both regions innervated by the brachial plexus. The pectoral region overlies the pectoralis major muscle and is limited by the axillary, mammary, and inframammary regions Figure 2.
The axillary region is lateral to the pectoral region and consists of the area of the upper chest that surrounds the axilla. In both regions, there are muscles, nerves, and vessels within the fascial layers Figure 3.
In the pectoral region, there are four muscles relevant to Pecs blocks: the pectoralis major, pectoralis minor, serratus anterior, and subclavius muscles.
The pectoralis major and minor muscles are innervated by the lateral and medial pectoral nerves; the serratus anterior is innervated by the long thoracic nerve C5, C6, and C7 ; and the subclavius is innervated by the upper trunk of the brachial plexus C5 and C6. The axillary region is a pyramidal structure with four borders: 1. The apex or axillary inlet, formed by a lateral border of the first rib, superior border of the scapula, and the posterior border of the clavicle 2.
The anterior border, formed by the pectoralis major and minor muscles 3. The lateral border, formed by the humerus 4. The posterior border, formed by the teres major, latissimus dorsi, and subscapularis muscles.
Figure 2the muscles, nerves, and vessels relevant to Pecs and serratus plane blocks are summarized in Tables 2, 3 and 4 respectively. The pectoral and axillary regions are separated by fascias.
In the pectoral region, there are two main fascias: the superficial fascia and the deep thoracic fascia. The deep thoracic fascia divides into three separate fascias: the pectoral superficialclavipectoral intermediateand exothoracic deep.
The clavipectoral fascia stretches between the clavicle and the pectoralis minor Figure 4 and encloses the pectoralis minor with a thin layer of fascia. Between the pectoralis minor and subclavius muscles, the two layers of the clavipectoral fascia fuse. Caudal to the pectoralis minor, the clavipectoral fascial layers rejoin to form the suspensory ligament of the axilla, which is joined to the axillary fascia Figure 5.
At the pectoral level, the fascias create four potential compartments for the injection of local anesthetic:. The first two compartments are in the pectoral region, but the third and fourth communicate with the axillary region. The nerves and vessels in this region create communications by crossing the compartments. The nerves of the pectoral region are mainly the lateral and medial pectoral nerves, but there is also an important innervation from the supraclavicular nerve and from the lateral and anterior branches of the intercostal nerves.
The lateral pectoral nerve crosses the axillary artery anteriorly and pierces the clavipectoral fascia in close relationship with the thoracoacromial artery on the undersurface of the upper portion of the pectoralis major muscle, which it supplies with lateral cord fibers from C5—C7 Figure 6. The lateral pectoral nerve is medial to the pectoralis minor before entering the pectoralis major muscle; it communicates across the axillary artery with the medial pectoral nerve and, through this communication via ansa pectoralissupplies the pectoralis minor.
The medial pectoral nerve arises from the medial cord fibers from C8—T1, behind the axillary artery at the level below the clavicle, and passes through the deep surface of the pectoralis minor, which is perforated and then enters and innervates pectoralis major. Both pectoral nerves enter the deep surface of the pectoralis major, and neither has a cutaneous branch.
The nerves of the axillary region are the intercostobrachialis, intercostal T3—T9, long thoracic, and thoracodorsal. It crosses the serratus anterior muscle in the midaxillary line to innervate the axilla. The intercostobrachialis nerve is a vital nerve if regional anesthesia of the axilla is required.