Gonzales, Jeffery, MD, MA Pectoral Blocks

Home , Lateral cord, Lateral pectoral nerve, Long thoracic nerve, Medial cord, Medial pectoral nerve, Thoracodorsal nerve

Jeff Gonzales MD, MA  Discuss value and use of PECS I and II University of Colorado Hospital CRASH 2016  Overview of involved anatomy

 Briefly describe cytokine issues with general anesthesia

 Risks and benefits of adding a PEC block with ultrasound guidance

 First described in 2012 at the ESRA Spain Congress by Blanco et al.

 Also know as PECS I, PECS II (Serratus‐ intercostal plane block (SIP))

 PECS I: median and lateral pectoral nerves

 PECS II: Long thoracic, Intercostal nn. (T2‐ T6) and thoracodorsal nerve

Cephalad Caudad Pec. Major m. Gonzales, Jeffery, MD, MA Pectoral Blocks

M. pectoralis n.

L. pectoralis n.

M. pectoralis n.

Lateral Pectoral N.(C5‐C7) off lateral cord, innervates pec major

Medial Pectoral N. (C8‐T1) off medial cord, innervates pec minor and major

Long Thoracic N. (C5‐C7) off proximal brachial plexus, innervates Serratus Anter

 medial and lateral pectoral nerves (mid‐clavicle) pec minor

 Medial Pectoral nerve (C8, T1): immediately from Medial Cord (late anterior division).

. Innervates Pec minor and Pec major(lower 1/3) pec major Medial Pectoral Nerve  Lateral Pectoral nerve (C5, C6, C7): immediately from Lateral Cord

. Innervates Pec Major

Pec Major L.PEC n.

Lat. Pectoral N. Pec Major M.PEC n. Clavicular Gonzales, Jeffery, MD, MA Pectoral Blocks

 Infiltration technique under ultrasound guidance  Head turned opposite side.  Shoulder abducted and elbow flexed  Similar probe position as Infraclavicular  Linear probe  Technique for muscle related pain

c Pec Major e p h l pec minor a d SA

c c injection e e p p pectoralis maj. h h l l cephlad pectoralis minor. a a d d Ax. a. PECs I SCAN Gonzales, Jeffery, MD, MA Pectoral Blocks

 Target: fascial plane between Pec major and pec  Additive technique for PECS I and breast Minor. (L. and M. pectoral nn. branches) surgery   Vascular concern is branches from thoracoacromial Long thoracic, Intercostal nn. (T2‐T6) and artery and vein. thoracodorsal nerve  analgesic benefit for WLE, mastecomies, and  Analgesic technique. axillary dissection

 Lower Concentration and Higher volume

(0.25% LA, 20cc Volume)

 Infiltration technique under ultrasound guidance

Pec minor  Head turned opposite side. subscapularis

Thoracodorsal n.  Shoulder abducted and elbow flexed

 Similar probe position as Infraclavicular along breast toward latissimus dorsi m.

S.A.  Linear probe

Lat. dorsi  Technique for muscle and dermatomal analgesia S.A.

2. Gonzales, Jeffery, MD, MA Pectoral Blocks

anterior‐lateral

injection

SA rib3 rib4

Intercostal m. PEC’s3 cephald 5th rib 4th rib pec maj

pec min

Pleura Serr Ant PECs II SCAN

4th Rib

 Target: fascial plane between Pec minor and serratus ant. m.  Inject PECs II, then or superficial to serratus anterior m. (T3‐T6) PECs I to preserve anatomy/view  Long Thoracic nerve is immediately superior‐posterior along Latissimus dorsi and serratus  Excellent alternative to paravertebral for  Analgesic technique. breast surgery

 Lower Concentration and Higher volume  Similar to TAP block, PECs are High Volume (0.25% LA, 20cc Volume) blocks!