PECS II block for cardiac implantable electronic device insertion: A pilot study.

AIM: Some truncal blocks could provide adequate surgical anesthesia and postoperative analgesia in cardiac implantable electronic devices (CIED) insertion. The aim of this study was to evaluate the feasibility of the pectoral nerves (PECS) II block for CIED insertion. METHODS: PECS II blocks were performed on the left side using the ultrasound-guided single injection technique in all patients. The primary outcome for feasibility was the percentage of the cases completed without intraoperative additional local anesthesia. Secondary outcomes were the amount of intraoperative additional local anesthetic, intraoperative opioid requirement, postoperative pain scores, first requirement for postoperative analgesia, postoperative analgesic consumption, patient satisfaction, and block-related complications. RESULTS: Of the total 30 patients, 19 (63.3%) required intraoperative additional local anesthetic. The median (IQR [range]) volume of the additional local anesthetic used was 7 (4-10 [2.5-12]) mL. Two patients needed additional IV analgesics in the first 24 h postoperatively. No statistically significant differences were determined between the patients requiring and not requiring intraoperative additional local anesthetic in respect of age, gender, duration of surgery, block performance time, and hospital stay. A total of 26 (86.6%) patients reported a high level of satisfaction with the procedure. CONCLUSIONS: PECS II block for cardiac electronic implantable device insertion provides effective postoperative analgesia for at least 24 h. Although PECS II block alone could not provide complete surgical anesthesia in the majority of the patients, when combined with supplementary local anesthetic, contributes to a smooth intraoperative course for patients.

The nerve supply to the pectoralis major: An anatomical study and clinical application of the denervation in subpectoral breast implant surgery.

BACKGROUND: Using the subpectoral approach, animation deformity or breast distortion due to pectoralis muscle contraction is common. Although the anatomy of the pectoral nerves has been extensively studied, only few studies have related the location of these nerves to bony landmarks. OBJECTIVE: Our aim is to clarify the anatomy and possible variations of the innervation of the pectoralis major in relation to bony landmarks useful for surgery and to identify the preferred level for (selective) denervation by 1) transecting the nerves and 2) splitting the muscle in subpectoral breast implant surgery in cadavers. METHODS: Fourteen pectoral regions (both left and right side) were dissected on 7 formaldehyde-fixed cadavers. The origin, locations, and course were mapped and (distances to) landmarks were reported. RESULTS: The lateral pectoral nerve, medial pectoral nerve, and ansa pectoralis were identified in all cadavers. Nerve branches pierce the pectoralis minor or run along its upper or lower border. The piercing nerves vary from one to three branches and were consistently located lateral to the midclavicular line. The horizontal and vertical distances to bony landmarks varied greatly and depended on the size and location of the pectoralis minor, except for the nerve running along the upper border of the PMin, which was located consistently around 30% of the clavicular line from the acromioclavicular joint to the sternoclavicular joint. CONCLUSION: We were unable to define a fixed landmark to mark pre- or peroperatively. However, we could define guidelines that help to identify and excise or preserve nerves of interest.

Effect of balanced anaesthesia with and without modified pectoralis nerve block on postoperative analgesia after breast surgeries: A randomised controlled trial.

BACKGROUND AND AIMS: Modified pectoral nerve block (PEC) has been reported to have variable effects on perioperative pain in patients undergoing surgery for carcinoma breast. This randomised controlled trial was conducted to study the effect of modified PEC on postoperative pain relief in patients undergoing breast surgery. METHODS: Fifty patients with carcinoma breast undergoing breast surgery were randomised to receive a modified PEC block consisting of 30 ml of ropivacaine 0.2% after induction of anaesthesia (PEC group) or no block (GA group) in this prospective randomised trial. Time to first rescue analgesia was recorded as primary outcome. Other secondary outcomes recorded were postoperative visual analogue scale (VAS) scores, number of rescue boluses and 24-h fentanyl consumption. RESULTS: There was no significant difference in time to first rescue analgesia between the two groups, with mean difference (95% confidence interval) of 22.91 (-6.8 to 52.69) min. Amount of fentanyl required to keep pain VAS less than 3 was also comparable between the two groups, mean (standard deviation) of 42.0 µg (17.42) in GA group versus 43.24 µg (17.22) in PEC group; P = 0.830.20/25 patients required rescue analgesia in GA group as compared to 17/25 in PEC group (P = 0.334). The postoperative VAS scores were also comparable between the groups at all time intervals. CONCLUSION: Balanced anaesthesia supplemented with modified PEC block performed after general anaesthesia did not improve the postoperative pain in patients undergoing modified radical mastectomy.

A randomised trial: effects of different anesthesia methods on early perioperative pain sensitivity and cellular immune function in patients undergoing radical mastectomy.

BACKGROUND: This study sought to investigate the effects of transversus thoracic muscle plane-pectoral nerves (TTP-PECS) block combined with propofol anesthesia on early perioperative pain sensitivity and cellular immune function in patients undergoing radical mastectomy. METHODS: A total of 115 patients who underwent radical mastectomy for breast cancer at our hospital from January 2019 to January 2021 were selected as the study subjects. The patients were allocated to the control group (n=57) or observation group (n=58) using a random number method. The control group was given simple general anesthesia, and the observation group was given TTP-PECS block combined with propofol anesthesia. The recovery time, pain [visual analogue scoring (VAS)] scores, and incidences of adverse reactions were compared between the 2 groups. Hemodynamic indicators [i.e., heart rate (HR), mean arterial pressure (MAP)], stress indicators [i.e., blood glucose (GLU), epinephrine (E), cortisol (Cor)], and the cellular immune function ofthe2 groups before anesthesia (T0), at the end of operation (T1), 1day after operation (T2) and 3days after operation (T3) were recorded. RESULTS: The spontaneous respiration recovery time, time to full wakefulness and the extubation time of the observation group were shorter than those of the control group (P<0.05). The observation group had lower VAS scores than the control group at 2, 8, 12, and 24 h after operation (P<0.05). The levels of MAP, HR, GLU, E and Cor in the observation group at T1, T2, and T3 were lower than those in the control group (P<0.05). Compared to the control group, the observation group had increased cluster of differentiation (CD)3+, CD4+, and CD4+/CD8+ cells (P<0.05), but there were no significant differences in CD8+ and natural killer (NK) cells between the 2 groups (P>0.05). The incidence of adverse reactions in the observation group was lower than that in the control group (8.62% vs. 24.56%) (P<0.05). CONCLUSIONS: TTP-PECS block combined with propofol anesthesia can relieve pain, shorten the recovery time, stabilize the hemodynamic level, and alleviate the stress responses of patients undergoing radical mastectomy with a slight suppression of cellular immune function and high safety. TRIAL REGISTRATION: Chinese Clinical Trial Registration Center ChiCTR2100048438.

The Analgesic Efficacy of Pecto-Intercostal Fascial Block Combined with Pectoral Nerve Block in Modified Radical Mastectomy: A Prospective Randomized Trial.

BACKGROUND: Pectoral nerve (Pecs) block is one of the most promising regional analgesic techniques for breast surgery. However, Pecs II block may not provide analgesia of the medial aspect of the breast or the entire nipple-areolar complex. OBJECTIVES: The aim of the present study was to investigate the efficacy of combining the pecto-intercostal fascial block (PIFB) and Pecs II block for perioperative analgesia following modified radical mastectomy (MRM). STUDY DESIGN: A prospective randomized study. SETTING: An academic medical center. METHODS: Sixty women undergoing unilateral MRM were randomly divided into 2 groups. The Pecs II group received Pecs II block using 20 mL bupivacaine 0.25% between the serratus anterior and the external intercostal muscles, and 10 mL bupivacaine 0.25% between the pectoralis major and minor muscles, together with sham PIFB using 15 mL normal saline solution in the interfascial plane between the pectoralis major muscle and the external intercostal muscle. PIFB-Pecs II group received the same Pecs II block combined with PIFB using 15 mL bupivacaine 0.25%. RESULTS: The median (interquartile range [IQR]) time to the first morphine dose was significantly longer in the PIFB-Pecs II group (327.5 [266.3-360.0] minutes) than the Pecs II group (196 [163.8-248.8] minutes) (P < 0.001, 95% confidence interval [CI] 79.98, 150.00).The median (IQR) cumulative morphine consumption was higher in the Pecs II group (14.0 [11.0-18.0] mg) than the PIFB-Pecs II group (8.0 [7.0-9.0] mg) (P < 0.001; CI, 4.0-8.0). Intraoperative consumption of fentanyl was significantly lower in PIFB-Pecs II group with a median (IQR) of 0 (0-15 mu g) than the Pecs II group median 57.5 (0-75 mu g) (P = 0.022, CI; 0-60). The Visual Analog Scale scores for the first 12 postoperative hours were lower in the PIFB-Pecs II group than the Pecs II group at rest and on moving the ipsilateral arm (P < 0.001). The dermatomal block on the lateral chest wall was comparable between the 2 studied groups. PIFB-Pecs II provided extensive sensory block on the anterior chest wall, whereas Pecs II block failed to achieve any sensory block. LIMITATIONS: This study was limited by its small sample size. CONCLUSIONS: The combination of Pecs II and PIFB provide better perioperative analgesia for MRM than Pecs II alone.

Modified Pectoral Nerve Block versus Serratus Block for Analgesia Following Modified Radical Mastectomy: A Randomized Controlled Trial.

BACKGROUND: Modified pectoral nerves (PECSII) and serratus blocks have been recently used for analgesia in breast surgery, but evidence comparing their analgesic benefits is limited. This prospective randomized, controlled study aims to examine the analgesic efficacy and safety profile of ultrasound-guided PECSII versus serratus blocks in patients undergoing modified radical mastectomy (MRM) for breast cancer. PATIENTS AND METHODS: One-hundred and eighty adult females scheduled for MRM were randomly allocated to three groups. PECS group patients received a PECSII block with 30mL of bupivacaine 0.25%, whereas SAPB group received a serratus anterior plane block (SAPB) using the same volume of bupivacaine 0.25% before induction of anesthesia. The control group received general anesthesia alone. Outcomes included 24 hours morphine consumption, intraoperative fentanyl requirements, visual analogue scale (VAS) scores for pain at rest and during movement, time to first rescue analgesia, postoperative nausea and vomiting (PONV), and sedation scores. RESULTS: Both PECSII and serratus blocks were associated with reduced postoperative morphine consumption compared to the control group (p<0.001). Both blocks were associated with reduced intraoperative fentanyl requirements, VAS scores, and PONV as compared with the control group. Also, they were associated with prolonged time to first rescue analgesia and better sedation scores in comparison with the control group. However, there were no differences between both blocks for all outcomes. CONCLUSION: PECSII and serratus blocks provide similarly adequate analgesia following modified radical mastectomy. CLINICAL TRIAL REGISTRATION: NCT02946294.

The brachial plexus - explaining its morphology and variability by a generic developmental model.

In classic anatomy teaching, the brachial plexus generally features as an enigmatic rote-learned structure, leaving the student with a feeling of complexity. The notion of complexity may increase in dissections, where plexuses significantly differing from the standard plexus model are readily found. This raises questions: what determines the existence and prevalence of variants and to what degree should they be considered anomalous? A model linking brachial plexus morphology and its variability to causative morphological parameters which would also standardize plexus description and teaching would be beneficial. The present study aims to provide such a model by analyzing the context of plexus development and applying this model in the analysis of plexus variability in anatomical specimens. Based on a thorough literature review, a generic developmental model was formulated and different factors of variability defined. In 56 plexuses, the proposed generic principles of plexus variability were found consistent with the variations encountered. Summarized, the modeled generic principles are as follows. Brachial plexus axon bundles grow out into an environment of chemical tracer paths in which constraints and obstacles are present: the geometry of the arm bud, cartilaginous bone precursors and vessels. The overall constancy of these factors generates a gross plexus outline, while the variability in these factors gives rise to typical plexus variations. The usefulness of the model derives from the fact that the variability of the main morphologically determining factors is not random but is the expression of the possibilities of the embryological substrate. Within the model, the major plexus morphological determinant is the segmental position of the subclavian artery, which is determined by the segment level of the intersegmental artery from which it develops. Normally, the subclavian artery develops from intersegmental artery i7. However, the subclavian artery can develop from inferior or superior segmental levels, from intersegmental artery i8 or i6, and possibly also from i9 or i5. Each of these arterial variants creates a typical, morphologically distinct, predictable plexus configuration. Superimposed on these basic plexus configurations, the underlying embryological substrate may develop further variability by integrating remnants of other intersegmental arteries into the arterial network. The resulting plexus configurations are further modified by local factors, e.g. the splitting of outgrowing axon bundles around vessels. A large split in the lateral cord around a large vein or veins crossing from lateral to medial, tangentially cranially over the subclavian artery was found in 54% of the 56 investigated BP and therefore might be added to plexus teaching. The distinct plexus morphologies associated with the subclavian artery segmental levels were further found associated with, among others, typical variations in the pectoral nerves and their ansas; these associations were also modeled. The presented models could allow brachial plexus rote learning to be replaced by a more insightful narrative of formative principles suitable for teaching. Clinically, improved understanding of the relationship between plexus variability and the local anatomical environment should be relevant to brachial plexus surgery and reconstruction.

The efficacy of ultrasound-guided type-I and type-II pectoral nerve blocks for postoperative analgesia after breast augmentation: A prospective, randomised study.

PURPOSE: The present study was planned to evaluate the efficacy and safety of ultrasound-guided Pecs I and II blocks for postoperative analgesia after sub-pectoral breast augmentation. METHODS: Fifty-four adult female patients undergoing breast augmentation were randomly divided into two groups: the control group (Group C, n=27) who were not subjected to block treatment and Pecs group (Group P, n=27) who received Pecs I (bupivacain 0.25%, 10mL) and Pecs II (bupivacain 0.25%, 20mL) block. Patient-controlled fentanyl analgesia was used for postoperative pain relief in both groups, and the patients were observed for the presence of any block-related complications. RESULTS: The 24-h fentanyl consumption was smaller in Group P [mean±SD, 378.7±54.0µg and 115.7±98.1µg, respectively; P<0.001]. VAS scores in Group P were significantly lower at the time of admission to the post-anaesthetic care unit and at 1, 2, 4, 8, 12, and 24h (P<0.001). The rates of nausea and vomiting were higher in Group C than in Group P (9 vs 2, P=0.018). Hospital stay duration was shorter in Group P than in Group C (24.4±1.2h vs 27.0±3.1h, P<0.001). No block-related complications were recorded. CONCLUSIONS: Combine used of Pecs I and II blocks provide superior postoperative analgesia in patients undergoing breast augmentation and shortens hospital stay.

Comparison of the Efficacy of Ultrasound-Guided Serratus Anterior Plane Block, Pectoral Nerves II Block, and Intercostal Nerve Block for the Management of Postoperative Thoracotomy Pain After Pediatric Cardiac Surgery.

OBJECTIVE: The aim of this study was to compare the relative efficacy of ultrasound-guided serratus anterior plane block (SAPB), pectoral nerves (Pecs) II block, and intercostal nerve block (ICNB) for the management of post-thoracotomy pain in pediatric cardiac surgery. DESIGN: A prospective, randomized, single-blind, comparative study. SETTING: Single-institution tertiary referral cardiac center. PARTICIPANTS: The study comprised 108 children with congenital heart disease requiring surgery through a thoracotomy. INTERVENTIONS: Children were allocated randomly to 1 of the 3 groups: SAPB, Pecs II, or ICNB. All participants received 3 mg/kg of 0.2% ropivacaine for ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal and fentanyl was used for rescue analgesia. MEASUREMENTS AND MAIN RESULTS: A modified objective pain score (MOPS) was evaluated at 1, 2, 4, 6, 8, 10, and 12 hours post-extubation. The early mean MOPS at 1, 2, and 4 hours was similar in the 3 groups. The late mean MOPS was significantly lower in the SAPB group compared with that of the ICNB group (p < 0.001). The Pecs II group also had a lower MOPS compared with the ICNB group at 6, 8, and 10 hours (p < 0.001), but the MOPS was comparable at hour 12 (p = 0.301). The requirement for rescue fentanyl was significantly higher in ICNB group in contrast to the SAPB and Pecs II groups. CONCLUSION: SAPB and Pecs II fascial plane blocks are equally efficacious in post-thoracotomy pain management compared with ICNB, but they have the additional benefit of being longer lasting and are as easily performed as the traditional ICNB.

Evaluation on analgesic effect of the single-injection technique of pectoral nerves Ⅰ and Ⅱ in patients undergoing modified radical mastectomy / 临床麻醉学杂志

Objective To investigate the efficacy of the single-injection technique of PECS Ⅰ and Ⅱ blocks for postoperative analgesia in patients undergoing modified radical mastectomy. Methods Sixty female patients who would undergo elective unilateral modified radical mastectomy, aged 30-65 years, falling into ASA physical status Ⅰ or Ⅱ, were selected and randomly divided into PECS group (group P) or control group (group C), 30 cases in each. After induction, patients in group P underwent ultrasound-guided combined PECS Ⅰ and Ⅱ blocks in a single-injection technique before surgery, 30 ml of 0.5％ ropivacaine was given to these patients. Patients in group C received general anesthesia alone. Anesthesia maintenance was performed by total intravenous anesthesia. The dosage of intraoperative propofol and remifentanil, postoperative recovery time, the requirement of sufentanil at 48 h after operation and the first time pressing the analgesic pump button, rescue analgesic requirements at 48 h after operation and the pressing frequency of analgesic pump were recorded in the two groups. Results The usage of propofol and remifentanil in group P were significantly less than those in group C (P ＜ 0.05). The recovery time after operation was significantly shorter than that in group C (P ＜ 0.05). The total consumption of sufentanil after 48 h was significantly less than that in group C (P ＜ 0.05). The first pressing time of the analgesic pump in group P was significantly later than that in group C (P ＜ 0.05).The rescue analgesic requirements in group P at 48 h were lower than those in group C (P ＜ 0.05).The pressing frequencies of analgesic pump in group P at 24 h were less than those in group C (P ＜ 0.05). Conclusion For patients undergoing modified radical mastectomy, ultrasound-guided combined PECS Ⅰ and Ⅱ blocks in a single-injection technique can reduce the dosage of opioid drugs in the perioperative period, and can provide better analgesic effect after operation.

Pectoral nerve block as a single anesthetic technique for breast surgery and sentinel lymph node investigation. / Bloqueo de nervios pectorales como técnica anestésica única para cirugía mamaria con biopsia de ganglio centinela.

Breast cancer surgery is usually performed under general anesthesia or, more recently, combined with conventional regional techniques. Pectoral nerves (PECs) block appears as an analgesic alternative in these procedures, but few studies refer to it as a single anesthetic technique1-3. In this case report, we describe a 56-year-old female patient, BMI 31kg/m2, ASA IV, admitted for elective tumorectomy of the left upper quadrant of the breast and sentinel node investigation. Given the multiple comorbidities and the high anesthetic and surgical risk, the anaesthetic plan consisted in ultrasound guided PECs II block as a single anesthetic technique. The authors report a successful anesthetic and pain management without complications in breast surgery. PECs block, as a single anesthetic technique, may be safe, advantageous and effective with haemodynamic stability and few side effects in high risk cardiac patients.

Advances in regional anaesthesia: A review of current practice, newer techniques and outcomes.

Advances in ultrasound guided regional anaesthesia and introduction of newer long acting local anaesthetics have given clinicians an opportunity to apply novel approaches to block peripheral nerves with ease. Consequently, improvements in outcomes such as quality of analgesia, early rehabilitation and patient satisfaction have been observed. In this article we will review some of the newer regional anaesthetic techniques, long acting local anaesthetics and adjuvants, and discuss evidence for key outcomes such as cancer recurrence and safety with ultrasound guidance.

The usefulness of interpectoral block as an analgesic technique in breast cancer surgery. / Utilidad del bloqueo interpectoral continuo como técnica analgésica en cirugía oncológica de mama.

OBJECTIVE: To compare the analgesic efficacy of continuous interpectoral block (CIPB) compared to intravenous analgesia (IV) after breast surgery. MATERIAL AND METHOD: A prospective, comparative and randomised study of women aged from 18-75years, ASAI-III, operated for breast cancer. In group1 (CIPB) after general anaesthetic, an ultrasound-guided interpectoral catheter was placed and 30mL of 0.5% ropivacaine was administered through it. In the event of an increase in heart rate and blood pressure >15% after the surgical incision, intravenous fentanyl 1µg·kg-1 was administered, repeating the dose as necessary. In the postoperative period, perfusion of ropivacaine 0.2% 5mL·h-1; with PCA bolus 5mL/30minutes was administered through the catheter for 24hours and rescue analgesia prescribed with 5mg subcutaneous morphine chloride. In group2 (IV), after induction of general anaesthesia, intravenous fentanyl was administered in the same way as in the other group. The patients received metamizole 2g with dexketoprofen 50mg and ondansetron 4mg postoperatively followed by perfusion of metamizole 4%, tramadol 0.2% and ondansetron 0.08% 2ml·h-1; with PCA bolus 2mL/20min for 24hours. The same rescue analgesia was prescribed. The principal variables recorded were pain at rest and during movement, according to a simple verbal scale (VAS 0-10) and the rescue analgesia required on discharge from recovery, at 12 and at 24hours. RESULTS: 137 patients were included: 81 in group1 (59.12%) and 56 in group2 (40.87%). No significant differences were observed in the analgesia between either group, but differences were observed in the dose of intraoperative fentanyl (P<.05). Differences that were not significant were observed in the rescue analgesia required on recovery (10% fewer on group1). CONCLUSIONS: Both techniques provided effective postoperative analgesia, but the CIPB group required significantly less intraoperative fentanyl.

Pectoral nerve block (Pecs block) with sedation for breast conserving surgery without general anesthesia.

Most regional anesthesia in breast surgeries is performed as postoperative pain management under general anesthesia, and not as the primary anesthesia. Regional anesthesia has very few cardiovascular or pulmonary side-effects, as compared with general anesthesia. Pectoral nerve block is a relatively new technique, with fewer complications than other regional anesthesia. We performed Pecs I and Pec II block simultaneously as primary anesthesia under moderate sedation with dexmedetomidine for breast conserving surgery in a 49-year-old female patient with invasive ductal carcinoma. Block was uneventful and showed no complications. Thus, Pecs block with sedation could be an alternative to general anesthesia for breast surgeries.

Prospective double blind randomized placebo-controlled clinical trial of the pectoral nerves (Pecs) block type II.

STUDY OBJECTIVE: The aim of this clinical trial was to test the hypothesis whether adding the pectoral nerves (Pecs) block type II to the anesthetic procedure reduces opioid consumption during and after breast surgery. DESIGN: A prospective randomized double blind placebo-controlled study. SETTING: A secondary hospital. PATIENTS: 140 breast cancer stage 1-3 patients undergoing mastectomy or tumorectomy with sentinel node or axillary node dissection. INTERVENTIONS: Patients were randomized to receive either a Pecs block with levobupivacaine 0.25% (n=70) or placebo block with saline (n=70). MEASUREMENTS: The pain levels were evaluated by Numeric Rating Scale (NRS) pain scores at 15-minute intervals during the post anesthesia care unit stay time (PACU), at 2-hour intervals for the first 24h on the ward and at 4-hour intervals for the next 24h. Intraoperative and postoperative opioid consumption were recorded during the full stay. Patient satisfaction was evaluated upon discharge using a 10-point scale. MAIN RESULTS: Intraoperative sufentanil requirements were comparable for the Pecs and placebo group (8.0±3.5µg and 7.8±3.0µg, P=0.730). Patients in the Pecs group experienced significantly less pain than patients in the control group (P=0.048) during their PACU stay. Furthermore, patients in the Pecs group required significant less postoperative opioids (9.16±10.15mg and 14.97±14.38mg morphine equivalent, P=0.037) and required significant fewer postsurgical opioid administration interventions than patients in the control group (P=0.045). Both patient-groups were very satisfied about their management (9.6±0.6 and 9.1±1.8 on a 10-point scale, P=0.211). CONCLUSIONS: The Pecs block reduces postsurgical opioid consumption during the PACU stay time for patients undergoing breast surgery.

Unusual Branching Pattern of the Lateral Cord of the Brachial Plexus Associated with Neurovascular Compression: Case report.

The brachial plexus consists of a network of nerves that innervates the upper limbs and its musculature. We report a rare formation of the lateral cord of the brachial plexus observed during the dissection of a 47-year-old male cadaver at the Department of Anatomy, Vardhman Mahavir Medical College, New Delhi, India, in 2016. The lateral cord was exceptionally long with twin lateral pectoral nerves and twin lateral roots of the median nerve. The proximal lateral root of the median nerve was thin in comparison to the medial root of the median nerve. The distal lateral root of the median nerve was thicker and followed an unusual course through the coracobrachialis muscle. In the lower third of the arm, the median nerve and the brachial artery-along with its vena comitans-spanned through the brachialis muscle. Surgeons, anaesthesiologists, radiologists and anatomists should be aware of such anatomical variations as they may result in neurovascular compression.

Analgesic and Sensory Effects of the Pecs Local Anesthetic Block in Patients with Persistent Pain after Breast Cancer Surgery: A Pilot Study.

BACKGROUND: Persistent pain after breast cancer surgery (PPBCS) develops in 15% to 25% of patients, sometimes years after surgery. Approximately 50% of PPBCS patients have neuropathic pain in the breast, which may be due to dysfunction of the pectoral nerves. The Pecs local anesthetic block proposes to block these nerves and has provided pain relief for patients undergoing breast cancer surgery, but has yet to be evaluated in patients with PPBCS. METHODS: The aim of this pilot study was to examine the effects of the Pecs block on summed pain intensity (SPI) and sensory function (through quantitative sensory testing [QST]) in eight patients with PPBCS. SPI and QST measurements were recorded before and 30 minutes after administration of the Pecs block (20 mL 0.25% bupivacaine). Pain intensity and sleep interference were measured daily before and after the block for 7 days. RESULTS: Patients experienced analgesia (P = 0.008) and reduced hypoesthesia areas to cold (P = 0.004) and warmth (P = 0.01) after 30 minutes. The reported pain relief (P = 0.02) and reduced sleep interference (P = 0.01) persisted for 7 days after the block. CONCLUSIONS: This pilot study suggests that the pectoral nerves play a role in the maintenance of pain in the breast area in PPBCS and begs for further research.

Pectoral nerve block (Pecs block) with sedation for breast conserving surgery without general anesthesia

Most regional anesthesia in breast surgeries is performed as postoperative pain management under general anesthesia, and not as the primary anesthesia. Regional anesthesia has very few cardiovascular or pulmonary side-effects, as compared with general anesthesia. Pectoral nerve block is a relatively new technique, with fewer complications than other regional anesthesia. We performed Pecs I and Pec II block simultaneously as primary anesthesia under moderate sedation with dexmedetomidine for breast conserving surgery in a 49-year-old female patient with invasive ductal carcinoma. Block was uneventful and showed no complications. Thus, Pecs block with sedation could be an alternative to general anesthesia for breast surgeries.