Gonzales, Jeffery, MD, MA Pectoral Blocks 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 anterior 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. 1 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!.