Revista EspañoladeAnestesiología Reanimación - CSEN

1 +Model REDAR-167; No. of Pages 6 ARTICLE IN PRESS. Rev Esp Anestesiol Reanim. 2012;xxx(xx):xxx---xxx Revista Espa ola de Anestesiolog a y reanimaci n ORIGINAL. Ultrasound description of Pecs II (modi ed Pecs I): A novel approach to breast surgery R. Blanco a, , M. Fajardo b , T. Parras Maldonado c a Department of Anaesthesiology and Pain Therapy, Hospital Abente y Lago, Complexo Hospitalario Universitario A Coruna, Spain b Department of Anaesthesiology and Pain Therapy, Hospital del Tajo, Madrid, Spain c Department of Anaesthesiology and Pain Therapy, Hospital Universitario Ciudad de Jaen, Jaen, Spain Received 3 May 2012; accepted 11 July 2012. KEYWORDS Abstract Ultrasound; Objective: The Pecs block (pectoral nerves block) is an easy and reliable super cial block Infraclavicular nerve inspired by the infraclavicular block approach and the transversus abdominis plane blocks.

2 Block; Once the pectoralis muscles are located under the clavicle the space between the two muscles Pectoral nerves; is dissected to reach the lateral pectoral and the medial pectoral nerves. The main indica- Regional anaesthesia; tions are breast expanders and subpectoral prosthesis where the distension of these muscles is Transversus extremely painful. abdominis plane Material and methods: A second version of the Pecs block is described, called modi ed Pecs block; block'' or Pecs block type II. This novel approach aims to block at least the pectoral nerves, the Fascial block; intercostobrachial, intercostals III-IV-V-VI and the long thoracic nerve. These nerves need to be Pectoral nerves blocked to provide complete analgesia during breast surgery, and it is an alternative or a rescue block; block if paravertebral blocks and thoracic epidurals failed.

3 This block has been used in our unit Anatomy: axilla in the past year for the Pecs I indications described, and in addition for, tumorectomies, wide excisions, and axillary clearances. Results and conclusions: The ultrasound sequence to perform this block is shown, together with simple X-ray dye images and gadolinium MRI images to understand the spread and pathways that can explain the bene t of this novel approach. 2012 Sociedad Espa nola de Anestesiolog a, reanimaci n y Terap utica del Dolor. Published by Elsevier Espa a, All rights reserved. Corresponding author. E-mail address: (R. Blanco). 0034-9356/$ see front matter 2012 Sociedad Espa . nola de Anestesiolog a, reanimaci n y Terap utica del Dolor. Published by Elsevier Espa a, All rights reserved.

4 Please cite this article in press as: Blanco R, et al. Ultrasound description of Pecs II (modi ed Pecs I): A novel approach to breast surgery. Rev Esp Anestesiol Reanim. 2012. +Model REDAR-167; No. of Pages 6 ARTICLE IN PRESS. 2 R. Blanco et al. PALABRAS CLAVE Descripci n de la ecograf a de los pectorales II (pectorales I modi cados): un nuevo Ecograf a; enfoque de la cirug a mamaria Bloqueo del plexo Resumen braquial Objetivo: El bloqueo Pecs es un bloqueo regional super cial sencillo que se inspira en el abor- infraclavicular;. daje del bloqueo infraclavicular y en el bloqueo TAP (plano del transversus abdominis). Una Nervios pectorales;. vez identi cados los m sculos pectorales distales a la clav cula disecamos el plano fascial entre Anestesia regional.

5 Ambos para alcanzar los nervios pectorales lateral (LPM) y medial (MPN). La indicaci n prin- Bloqueo del plano del cipal del bloqueo Pecs es para expansores subpectorales y en pr tesis submamarias donde la m sculo transverso distension muscular produce un dolor extremo. del abdomen;. Material y m todo: En este art culo describimos una segunda modi caci n del bloqueo Pecs. Bloqueo fascial;. Lo llamamos bloqueo Pecs modi cado o bloqueo Pecs II. Es un abordaje original que pretende Bloqueo de los alcanzar los nervios pectorales, nervios intercostobraquial, intercostales III-IV-V-VI y el tor cico nervios pectorales;. largo. Estos nervios son esenciales a la hora de proporcional analgesia completa en la cirug a Anatom a: axila oncol gica de mama y se posiciona como una alternativa o un bloqueo de rescate de los bloqueos paravertebrales y epidurales tor cicas.

6 En el ultimo a no hemos estado us ndolo en nuestro centro en tumorectomias, ampliaciones de bordes y para vaciamientos axilares adem s de las indicaciones del Pecs I. Resultados y conclusiones: Mostraremos la secuencia ecogr ca para poder realizar este blo- queo junto con im genes con contraste radiogr co y resonancia magn tica con gadolinium para poder entender los bene cios de este bloqueo. 2012 Sociedad Espa nola de Anestesiolog a, reanimaci n y Terap utica del Dolor. Publicado por Elsevier Espa a, Todos los derechos reservados. Introduction reported over the serratus muscle area. The Pecs II aims to block this region, together with the lateral branches of the The neural supply of the anatomical structures involved intercostal nerves that exit at the level of the mid-axillary in breast surgery is not well understood when it comes line to innervate the mammary gland and the skin from T2.

7 To providing analgesia for perioperative pain relief. Tho- to T6. racic epidural1 and paravertebral2---4 blocks became the gold To understand the theory and practice of the Pecs blocks standard techniques to achieve this goal, but not every anes- we must rst make a detailed review of the anatomy thesiologist is comfortable performing these procedures. As involved in this region. The pectoral nerves are major an alternative for these techniques we designed a novel nerves arising from the brachial plexus innervating the pec- series of blocks: Pecs I and Pecs II. toral muscles. The lateral pectoral nerve most commonly The Pecs block type I5---7 is a recently described, easy and arises from C5, C6 and C7, and the median pectoral nerve reliable super cial block that targets the lateral and median from C8 and lateral pectoral nerve is the bigger of pectoral nerves at an interfascial plane between the pec- the two and runs between the major and minor pectoral toralis major (PMm) and minor (Pmm) muscles.

8 It can be muscles in a fascial plane in close proximity to the pec- used for different breast operations, but we mainly use it for toral branch of the thoracoacromial artery and innervates the insertion of breast expanders and subpectoral prosthe- the PMm. sis. Other potential indications are traumatic chest injuries, The medial pectoral nerve runs under the Pmm. It crosses iatrogenic pectoral muscle dissections, pacemakers, Port-a- the muscle to reach the lower third of the PMm in the pec- caths and chest drains. toral region after piercing the two layers of the clavipectoral In this paper we describe a second version of the Pecs fascia. Various groups agree that the medial pectoral nerve block type I. We call it modi ed Pecs's block'' or Pecs block crosses Pmm in 62% of the patients, while in the remainder type II.

9 This novel approach aims to block the axilla that it is located on its lateral is vital for axillary clearances and the intercostal nerves, A second set of nerves involved are the anterior divisions necessary for wide excisions, tumorectomy, sentinel node of the thoracic intercostal nerves from T2 to T6. They lie at exeresis and several types of mastectomies. the back between the pleura and the posterior intercostal To perform the Pecs II block or modi ed Pecs's block'' membrane and run in a plane between the intercostal mus- we use two needle approaches instead of one. The rst punc- cles as far as the sternum. The intercostal nerves give off ture is a Pecs I block with 10 ml of local anesthetic injected lateral and anterior branches.

10 Lateral branches: the nerves between the pectoralis muscles, and the second puncture pierce the intercostalis externi and the serratus anterior gives 20 ml of local anesthetic between the Pmm and the ser- muscles at the mid-axillary line to give off anterior and pos- ratus muscle. This will break through the axillary door' and terior terminal branches. The lateral cutaneous branch of will reach the long thoracic nerve and reliably at least two the second intercostal nerve does not divide in anterior and intercostal nerves. We designed this block because, although posterior branches and it is called the intercostobrachialis during breast expander and subpectoral prosthesis insertions nerve. Anterior branches: the nerves cross in front of the the PMm is mainly affected, there is still signi cant pain internal mammary artery, pierce the intercostalis interni Please cite this article in press as: Blanco R, et al.