Transthoracic AV Graft Repair, Utilizing The PECS I and II Nerve Block
In 2012 Blanco et al described a novel regional anesthetic called the PEC I and II nerve block, which aimed at anesthetizing the branches of the brachial plexus that supply the major and minor pectoral muscles1. Sylvain et al has described the anatomy of the pectoral region, which include three main branches of the pectoral nerves that if anesthetized correctly could cover dermatomes T2-T6 including the axillary region2. Two recent randomized clinical trials have shown that the PEC I and II blocks in addition to GA for breast cancer surgery significantly lowered pain scores, as well as post-operative opioid consumption.3,4. Surprisingly, there have not been many publications that describe the use of the pectoral nerve blocks for other surgical procedures in the same geographical region. Therefore, the authors of this case report were interested in the efficacy of the pectoral nerve block as an alternative to the intercostal, paravertebral or epidural for chest wall surgeries. In this case report we used the PECS I & II block with IV sedation as the sole anesthetic for the repair of a malfunctioning AV graft that was tunneled across the patient’s chest wall. Our goal was to avoid general anesthesia, minimize opioid use and to provide long lasting post-operative pain control. This successful attempt at minimizing a patient’s intraoperative and post-operative pain after chest wall surgery using the PEC I and II block will hopefully open the gateway to performing this block more frequently in other types of chest wall surgeries, both for intraoperative and post op analgesia.
59-year-old male with a PMH of HTN, CHF, and ESRD on hemodialysis. His only working AVG was one that spanned from his right axillary artery to the collateral vein on the left chest wall and it was currently occluded, requiring emergent revascularization. Due to the patient’s poor functional status and multiple co-morbidities, regional anesthesia was chosen as the anesthetic of choice. Under ultrasound guidance a total of 15 ml’s of 2% Lidocaine with 1:200K epi + 30ml’s of 0.25% Bupivacaine was deposited between the pectoralis major, minor and serratus anterior at the level of the fourth rib in the midclavicular line. A total of 2mg of Midazolam and 25mcg of fentanyl were used for the block placement and a low dose propofol infusion was used for the duration of the case. The patient tolerated the procedure well, and denied any pain at the surgical site for 12 hrs post op.
The PECS block is an easy and reliable superficial block that targets the pectoral nerves at the interfascial plane between the pectoralis major, minor and serratus anterior muscles. Anesthetic coverage includes dermatomes T2-T6 which make it an ideal block for chest wall surgery. A recent 2016 study showed that the PECS block was more efficacious for postoperative pain control after radical mastectomy than the thoracic paravertebral block4. Given the recent advent and success of this regional technique, the authors surmise that the PEC block can be extended to various other intra-op or post-operative situations in which the pectoral nerves might be involved, including breast surgeries, thoracotomies, and even pace maker insertions.
1. Blanco R, et al. Ultrasound description of Pecs II (modified Pecs I): A novel approach to breast surgey. Rev EspAnestesiol Reanim.2012.
2. David, SylvainTrial." British Journal of Anaesthesia Br. J. Anaesth. 117.3 (2016): 382-86. Web. , et al. "The Anatomy of the Pectoral Nerves and Its Significance in Breast Augmentation, Axillary Dissection and Pectoral Muscle Flaps." Journal of Plastic, Reconstructive & Aesthetic Surgery 65.9 (2012): 1193-198. Web.
3. Bashandy G, Abbas D. Pectoral Nerves I and II Blocks in Multimodal Analgesia for Breast Cancer Surgery A randomized clinical trial.2015.
4. Kulhari, S., "Efficacy of Pectoral Nerve Block versus thoracic Paravertebral Block for Postoperative Analgesia after Radical Mastectomy: A Randomized Controlled