Intraoperative Placement of Pectoral Nerve Block Catheters

Abstract

Regional and neuraxial anesthesia for pain management after breast surgery is not widely used despite data showing improved postoperative pain control and patient satisfaction scores. We report a case of a 61-year-old woman who underwent bilateral mastectomies, and received postoperative analgesia via pectoral nerves 1 and 2 nerve blocks. This case highlights a previously undescribed technique of prolonged postoperative pain control by intraoperative placement of pectoral nerves 1 and 2 regional anesthesia catheters under direct visualization. Intraoperative placement has the potential benefits of more accurate plane targeting, time saving, and widening the scope of use to practitioners are not trained in the ultrasound guided technique. We also present a review of the regional block techniques and present a preliminary algorithm for the selection of block method in breast surgery.

<p>Establishing a Technique for Pectoral II–Block Catheter Insertion with Ultrasound Guidance: A Randomized Controlled Trial</p>

“…The technique requires ultrasound-trained personnel. Moreover, it is a common practice to inject a single dose of local anesthetic without leaving a catheter in the site for continuous injection, 9 though Blanco et al 8 described catheter insertion in the original technique. In the current study, a catheter was left in place to enable continuous infusion of local anesthetics, thereby providing longer duration and better control of postoperative analgesia.…”

“…7,8 Pectoral I block provides blockade to the medial and lateral pectoral nerves, while pectoral II block additionally targets the long thoracic nerve, thoracodorsal nerve, and anterior divisions of the thoracic intercostal nerves from T2 to T6. [8][9][10] Pectoral blocks gained wide acceptance among anesthesiologists, as they are superficial, simple, effective, and relatively safe procedures that provide adequate postoperative analgesia (as evidenced by decreased pain scores and reduced need of postoperative pain medications). [11][12][13] Several studies have reported the use of pectoral blocks in conjunction with superficial chest-wall surgeries.…”

Comparing the quality of analgesia with ultrasound-guided pectoral nerve block and serratus anterior plane block II in patients undergoing modified radical mastectomy: a randomised clinical trial

“…Therefore, Blanco et al [15] concluded that the serratus block produced better axillary analgesia than PECS II. Wang et al [14] supposed that SAP could paralyse a large number of intercostal nerves, which may innervate the mammary gland and the lateral and anterior cutaneous branches of the second to sixth thoracic intercostal nerves [30,31]. However, Bakeer et al [25] compared SAP, PECS II, and no blockade in 180 women following MRM.…”

Continuous Pectoral Nerve Block Compared With Continuous Thoracic Paravertebral Block and Intravenous Opioid Analgesia for the Postoperative Analgesic Efficacy in Patients Undergoing Modified Radical Mastectomy

“…Placement of the blocks under direct visualization, as described in this article, addresses these limitations and allows more accurate plane targeting. 13 Continuous Pecs block was evaluated in some case reports. 13,33,34 Wallaert et al 33 placed a catheter between the pectoralis minor and the pectoralis major under ultrasound guidance in 4 patients scheduled for breast surgery and they documented that the continuous interpectoral block provided excellent postoperative analgesia.…”

“…In group III, after tissue resection, ipsilateral Pecs block catheters were placed intraoperatively under direct visualization by the surgical team with anesthesia assistance. 13 Separate catheters were placed into the Pecs I and II tissue planes. After an initial bolus dose of 10 mL of 0.125% bupivacaine, a continuous infusion of 5 mL/h was started in each catheter (Fig.…”