Pectoralis Plane Block for Pacemaker Insertion: A Successful Primary Anesthetic

Abstract

Effective anesthesia, analgesia, and hemodynamic stability is important to maintain during pacemaker implantation surgery, especially in the elderly population and patients with compromised cardiac function. As a strategy to avoid the need for intravenous (IV) anesthetics, peripheral nerve block techniques may be used in these specific cases. We report a case of successful pacemaker implantation surgery in a patient with severe Aortic Stenosis (AS) and Sick Sinus Syndrome (SSS) using unilateral pectoralis plane block for surgical anesthesia. Since general anesthesia was considered risky, monitored anesthesia care utilizing peripheral nerve block was planned. A single shot left side pectoralis plane block (PECS II) was done under ultrasound guidance injecting a total of 20 mL of 0.5% Ropivacaine with 1% Lidocaine. No sedation was needed. The patient tolerated the procedure with no significant hemodynamic changes. Patient did not require opioids post-operative and was discharged home in stable condition the next day. This case highlights that PECS block can also provide effective surgical anesthesia for relatively long procedures avoiding the risk of complications associated with IV anesthesia in high risk cardiovascular patients. Additionally, these blocks can provide an opioid sparing option for post-operative management in pacemaker implantation surgeries.

Evaluation of the Effectiveness of Modified Pectoral Nerve Blocks Type II (PECS II) for Vascular Access Port Implantation Using Cephalic Vein Venesection

“…Mavarez et al [22] described the use of PECS I and PECS II compartmental blocks for implantation of electronic cardiac devices (pacemakers, implantable cardioverter-defibrillators (ICDs), cardiac resynchronisation therapy (CRT) pacemakers, and others) with good results [23]. Electrodes were implanted transvenously by venipuncture of the subclavian vein or venesection of the left cephalic vein in the region of the deltopectoral groove [22]. Ince et al and Munshey et al [24] also described the successful use of PECS I and PECS II blocks for vascular access port implantation and vascular catheter implantation in children and adults [25].…”

“…The PECS compartmental blocks were introduced into clinical practice by Rafael Blanco [20,21], mainly for perioperative analgesia in breast surgery, but over time, the use of these methods has been extended to various thoracic procedures. Mavarez et al [22] described the use of PECS I and PECS II compartmental blocks for implantation of electronic cardiac devices (pacemakers, implantable cardioverter-defibrillators (ICDs), cardiac resynchronisation therapy (CRT) pacemakers, and others) with good results [23]. Electrodes were implanted transvenously by venipuncture of the subclavian vein or venesection of the left cephalic vein in the region of the deltopectoral groove [22].…”

Ultrasound-Guided Regional Anesthesia Under Sedation for Radical Mastectomy in an SAS Patient: A Case Report

“…Furthermore, the use of muscle relaxant drugs and positive airway pressure in the intubated patient could theoretically cause an even greater hemodynamic change, deleterious to the patient with AS ( 7 ). Neuraxial anesthesia is rarely used for patients with SAS, owing to its sympathetic blockade effect that can potentially cause loss of vascular tone and cardiac output ( 8 ). Regional anesthesia, such as TPVB, is a popular technique in breast surgery.…”

Regional Analgesia for Cardiac Surgery. Part 2: Peripheral Regional Analgesia for Cardiac Surgery

“…PECS blocks had been successfully utilized for providing anesthesia for the insertion of a CRTD. Mavarez et al 38 reported the use of PECS 2 block as a sole anesthetic for pacemaker insertion in a patient with severe aortic stenosis and sick sinus syndrome. The patient required no additional intraoperative sedatives nor any postoperative opioids for 24 hours.…”

“…Kulhari et al 37 used a single bolus dose of 25 mL of ropivacaine 0.5% for PECS block. Mavarez et al 38 used a total of 20 mL of 0.5% ropivacaine with 1% lidocaine. Fujiwara et al 39 used 10 mL of 0.375% ropivacaine into the interfascial plane between pectoralis major and minor muscles.…”