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Pectoral Fascial (PECS) I and II Blocks for Post-Operative Analgesia following Median Sternotomy
Historically, opiates have served as the primary modality for controlling post-operative pain following median sternotomy . Because of the morbidity associated with opioid use, administration of local anesthetics at the surgical site via single injection or placement of a continuous catheter has become more common. Unfortunately, the utility of sternal local anesthetic infiltration appears to be limited . This case highlights the potential of a PECS I and II block in providing effective analgesia following median sternotomy. IRB approval was obtained prior to the submission of this case report.
We present a 52 year old male with history of coronary artery disease requiring 3-vessel coronary artery bypass grafting. Given anecdotal observation of higher opiate requirements in younger median sternotomy patients and the questionable utility of sternal local anesthetic infiltration, the decision was made to perform bilateral pectoral fascial (PECS) I and II blocks for post-operative analgesia. Sixty mL of 0.25% bupivacaine with 1:400,000 epinephrine was injected via ultrasound-guided PECS I and II blocks. 20 mL was deposited between the pectoral minor and serratus anterior muscle, while 10 mL was deposited between the pectorals major and the pectoralis minor muscles bilaterally.
The patient received a total of 500 mcg of intravenous fentanyl intra-operatively and was successfully extubated within 3 hours of ICU arrival. He reported no pain for the first 8 hours following extubation, requiring only 0.5 mg of IV hydromorphone for the first 18 hours of his ICU stay. His pain scores began to increase approximately 24 hours after the blocks were placed. The patient was transferred out of the ICU on post-operative day (POD) 1 and discharged home on POD 5 after an uneventful hospital stay.
To date, studies have shown limited efficacy in sternal infiltration of local anesthetic for post-operative pain control in cardiac surgery patients. We present the first case report of bilateral ultrasound guided PECS I and II blocks for successful analgesia after median sternotomy.
The appeal of the PECS block lies in its technical simplicity, as it is a simple fascial plane block with a low risk profile. Medial and lateral pectoral nerves are targeted by PECS I, providing analgesia to the pectoralis major and minor muscles while PECS II targets blockade of the lateral intercostal nerves resulting in anterolateral chest analgesia. Although these blocks have been described in reconstructive breast surgery, and more recently, as a rescue modality after minimally invasive cardiac surgery, our case highlights the successful utilization of this regional technique for analgesia after median sternotomy .
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