Bilateral PECS II Blocks with Continuous Local Analgesia for Traumatic Sternal and Bilateral Rib Fractures
impaired ventilation predisposing to pneumonia
Overall mortality for isolated sternal fractures is 3.5%1
With concomitant injuries as high as 22%1
blunt cardiac injury
Adequate analgesia is key to recovery. Reduction of opioid burden rapidly becoming a focus across the country
Side effects of pain medications present high risk for complications, especially with the elderly
73 year old Female admitted to the Trauma ICU after MVC
sternal fracture, retrosternal hematoma
rib fractures (1-9 Right side, 3-9 left side)
left distal radius fracture, left 4th & 5th metacarpal fracture
grade 2 splenic laceration
right pelvic sidewall hematoma
scalp laceration x2
Coronary Artery Disease with Myocardial Infarction x3, s/p Percutaneous Coronary Intervention (PCI) x (last PCI 8 years prior, on Plavix)
Lung Ca s/p partial resection (in remission)
Severe pain interspersed between periods of oversedation and respiratory depression while on a patient-controlled opioid infusion
Bilateral PECS II blocks with continuous infusion catheters placed
20mL of 0.2% ropivacaine initially
infusion of 0.2% ropivacaine at 6 mL/hr titrating for pain control
Pre- and post-procedure pain, demand opioid use, and incentive spirometer volumes are listed in Table 1.
The rest of her hospital course was uncomplicated. The Left catheter was removed on day 6 and the Right catheter was removed on day 7 without issue.
The PECS block, initially described for analgesia after breast surgery, attempts to block sensation and alleviate muscle spasm in the upper chest. Among the modifications, the PECS II block attempts to target the pectorals, the intercostobrachial, intercostals 2-6, and the long thoracic nerves, additionally covering the axilla.2
In this block, ultrasound guidance is used to localize the plane just lateral to the pectoralis minor between the serratus anterior and ribs 2-4, and local anesthetic is deposited. As initially described, the effect typically lasts approximately 8 hours.2
In this case we placed catheters for continuous local anesthetic infusions, which provided analgesia over the following week. SubpectoralInterfascial plane and Serratus plane blocks were either made difficult by habitus or would not cover enough of the injured area.
Our case also showed not only improved analgesia for multiple rib fractures but also decrease of sternal fracture pain, something not previously described.3 To date, no published studies describe a PECS II block with catheter for continuous analgesia in this fashion, our case showed adequate analgesia and reduced opioid requirement over 7 days. As such, this block represents a potent tool to treat pain in a multimodal analgesia regimen when other methods of regional anesthesia are contraindicated or otherwise unavailable.