|LETTER TO EDITOR
|Year : 2019 | Volume
| Issue : 2 | Page : 199-200
Perioperative and postoperative pain relief in a reduction mammoplasty using ultrasound-guided pectoral nerve block: A firsthand experience by a young anesthetist
Sandhya Ghodke1, Ravishekar N Hiremath2, A Banerjee3, Sanjay Maurya4
1 Department of Anaesthesia, MH Kirkee, Pune, Maharashtra, India
2 OC, SHO (L), Bangalore, Karnataka, India
3 Department of Anaesthesia, Command Hospital, Udhampur, Jammu and Kashmir, India
4 Senior Advisor (Surgery and Reconstructive Surgery), Command Hospital, Pune, Maharashtra, India
|Date of Web Publication||07-Oct-2019|
Capt (Dr) Sandhya Ghodke
MH Kirkee, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ghodke S, Hiremath RN, Banerjee A, Maurya S. Perioperative and postoperative pain relief in a reduction mammoplasty using ultrasound-guided pectoral nerve block: A firsthand experience by a young anesthetist. J Mar Med Soc 2019;21:199-200
|How to cite this URL:|
Ghodke S, Hiremath RN, Banerjee A, Maurya S. Perioperative and postoperative pain relief in a reduction mammoplasty using ultrasound-guided pectoral nerve block: A firsthand experience by a young anesthetist. J Mar Med Soc [serial online] 2019 [cited 2020 Jul 15];21:199-200. Available from: http://www.marinemedicalsociety.in/text.asp?2019/21/2/199/268621
We encountered a case of a 47-year-old female weighing 77 kg posted for bilateral reduction mammoplasty. The patient had cervical spondylosis for the last 10 years but was not on any medication for that. She had undergone total abdominal hysterectomy 16 years back under general anesthesia. The patient was accepted for surgery in the American Society of Anesthesiologists Class II in view of obesity and difficult airway. The patient was given diazepam tablet 5 mg HS on the night prior to surgery. Preoperatively, the patient's blood sugar was 112 mg/dl and serum electrolytes were within normal limits. Monitoring was started with electrocardiogram (ECG), SpO2, noninvasive blood pressure (NIBP), end-tidal CO2 (EtCO2), and skin probe for temperature. Premedication given was injection glycopyrrolate 0.2 mg intravenously (IV), injection ondansetron 4 mg IV, injection midazolam 1 mg IV, and injection fentanyl 60 mcg IV. Preoxygenation was done with 100% oxygen for 3 min. Induction was done with injection propofol 140 mg IV. After confirming ventilation, injection rocuronium 70 mg IV was given. Intubation was possible in the second attempt with the help of a bougie (Cormack–Lehane class III) using no. 7.5 endotracheal tube (ETT). After confirming equal air entry on both sides of the chest, the ETT was fixed at the right angle of the mouth. Maintenance of anesthesia was done with O2, N2O, sevoflurane, and atracurium.
Ultrasound-guided PECS I and II blocks were performed thereafter. Taking strict aseptic precautions and after preparation of skin with 0.5% chlorhexidine, a high-frequency linear ultrasound probe was placed below the right clavicle at the midclavicular line and angled inferolaterally; the axillary artery and vein were first located. Immediately under the axillary artery, the 2nd rib was located. With movement of the probe little laterally, the 3rd rib was counted and with further movement the 4th rib was also located. Initially, the pectoralis major and minor muscles were identified along with pectoral branch of thoracoacromial artery. When the probe was moved laterally at the level of the 3rd and 4th ribs, the serratus anterior muscle was identified below the pectoralis minor muscle. Using an in-plane approach, a 21G 10-cm sonoplex needle was inserted from the superomedial aspect and guided to the fascial plane between pectoralis minor and serratus anterior muscles, and 20-ml local anesthesia (LA) was injected after negative aspiration at this level. The needle was then withdrawn to reach the fascial plane between the pectoralis major and minor muscles, and further 10-ml LA was injected after negative aspiration at this level. The same procedure was repeated at the left side of the chest, and further 30-ml LA (20 ml LA in PECS II block + 10 ml LA in PECS I block) was injected on the left side of the chest as well. Drug used for the block was 0.25% ropivacaine.
During the surgery, breast tissue excision followed by liposuction of the lateral thoracic wall and axillary region was done on both sides. No LA infiltration was done by the surgeon for liposuction; only adrenaline 1 in 200,000 was used for infiltration. The surgery lasted for 195 min, and throughout the surgery, the patient's vitals were monitored with ECG within normal limits, NIBP reading – SBP range 116-122 mmHg, DBP range 72 – 78 mmHg, HR 78-84 per Min and SpO299%.
No further analgesics were given during the surgery. After the surgery, reversal was done with injection neostigmine 3.5 mg and injection glycopyrrolate 0.6 mg IV, and the patient was extubated. Recovery was complete, and blood loss was minimal. The patient did not complain of any pain at the surgical site after extubation. She was kept in the intensive care unit (ICU) for 24 h postsurgery. She did complain of pain at the surgical site after shifting to ICU which was managed with injection paracetamol 1 g IV. After that, the patient was comfortable and did not require any further analgesics till the next day morning.
Visual Analog Scale evaluation for pain severity management was done for the initial 24 h postsurgery every 2 h. Only twice the score was 6 and 7 which was managed with injection paracetamol 1 g IV. The postoperative period was almost uneventful. The patient started accepting oral feeds after 6 h of the surgery and was later on shifted to the ward after the initial 24 h in the ICU.
Recently, Blanco et al. reported PECS block as a newer analgesic technique for breast surgeries., In comparison with the paravertebral and thoracic epidural blocks, PECS block is a safe, easy, reliable, and less invasive technique which can be performed in a patient in supine position after giving general anesthesia.
Interestingly, PECS block was able to reduce intraoperative and postoperative opioid requirement, postoperative pain, and postoperative nausea and vomiting in patients undergoing breast surgery., In our case, injection fentanyl 60 mcg was given as premedication. Thereafter, no analgesics were given in the intraoperative period. Even in the immediate postoperative period, breakthrough pain was managed with injection paracetamol. No opioid injections were required in the postoperative period, thus avoiding side effects such as nausea, vomiting, respiratory depression, and constipation.
Further, paravertebral, thoracic epidural, intercostal, and intrapleural block require multiple injections, repeated boluses or continuous infusion, or larger doses of LAs, which may lead to problems such as LA systemic toxicity (LAST), risk of pneumothorax or pulmonary damage, and sometimes impairment of respiratory muscle function. Such problems can be avoided with a successful PECS block. PECS block does not require multiple injections or repeated bolus doses, thereby reducing chances of local anaesthetic toxicity and as it is performed under real time ultrasound, chances of pneumothorax or pulmonary damage can also be avoided. It can be performed on both sides of chest wall simultaneously. In our case, 0.25% ropivacaine 30 ml was used on each side, which is well below the maximum recommended dose of ropivacaine.,,
The only prerequisite for this block is an ultrasound machine with a linear array probe. It cannot be performed with blind or landmark techniques nor is a nerve stimulator of any help as this block is given in myofascial plane.
However, PECS block being a newer technique, more studies need to be conducted and guidelines should be drawn to establish the efficacy of PECS block over the other established techniques of providing analgesia in breast surgery. Nevertheless, its safety and simplicity make PECS block a better approach for perioperative and postoperative analgesia for breast surgeries. Like transversus abdominis plane block is intended for the abdomen, PECS block is intended for the chest surgeries, with their introduction being facilitated by the availability of a portable ultrasound machine.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): A novel approach to breast surgery. Rev Esp Anestesiol Reanim 2012;59:470-5.
Blanco R. The 'pecs block': A novel technique for providing analgesia after breast surgery. Anaesthesia 2011;66:847-8.
Bashandy GM, Abbas DN. Pectoral nerves I and II blocks in multimodal analgesia for breast cancer surgery: A randomized clinical trial. Reg Anesth Pain Med 2015;40:68-74.
Morioka H, Kamiya Y, Yoshida T, Baba H. Pectoral nerve block combined with general anesthesia for breast cancer surgery: A retrospective comparison. JA Clin Rep 2015;1:15.
Rosenberg PH, Veering BT, Urmey WF. Maximum recommended doses of local anesthetics: A multifactorial concept. Reg Anesth Pain Med 004;29:564-75.
Kimura Y, Kamada Y, Kimura A, Orimo K. Ropivacaine-induced toxicity with overdose suspected after axillary brachial plexus block. J Anesth 2007;21:413-6.
Ala-Kokko TI, Löppönen A, Alahuhta S. Two instances of central nervous system toxicity in the same patient following repeated ropivacaine-induced brachial plexus block. Acta Anaesthesiol Scand 2000;44:623-6.