PEC 1 & 2 Blocks, Serratus Anterior Block

I’ve been hearing more and more about PEC 2 block for mastectomy.  What’s wonderful about this block is that it seems that the risk of pneumothorax is lower than for a paravertebral block.

Egyptian Journal of Anaesthesia; April 2014. Thoracic Paravertebral Block vs. Pectoral Nerve Block for Analgesia after Breast Surgery

SlideShare powerpoint: PEC 1 & 2 and Serratus Anterior Blocks


Current Anesthesiol Rep, 2015. Regional Anesthesia for Breast Surgery: Techniques and Benefits.

Rev Esp Anesthesia Reanim; 2012: Ultrasound Description of PECS 2 (modified PECS 1): A Novel Approach to Breast Surgery

Poster Summary of PECS 2


TAP, PEC 1, & PEC 2 Blocks PPT

Anaesthesia, 2013. Serratus Plane Block: A Novel Ultrasound-Guided Thoracic Wall Nerve Block.

NYSORA 2014: Update on truncal blocks


  • U/S guidance: probe position similar to infraclavicular block. Find 3rd, 4th rib.
  • Pt position: Head away from side of block. Ipsilateral arm abducted.
  • PEC 2: Inject 20 ml 0.25% bupi between pec minor and serratus.
  • PEC 1: Inject 10 ml 0.25% bupi between pec major and pec minor.
  • Serratus: 5th rib, mid-axillary line. Inject 30 ml 0.125% bupi along top (superficial) and bottom (deep) of serratus muscle (which is just deep to the latissmus dorsi).

YouTube: PECS 1&2 Block

YouTube: Serratus plane block

Adductor Canal Blocks #adductor #regional #anesthesia #femoral #blocks

What is the adductor canal?

Why all this talk about an adductor canal block (ACB)?

For years, femoral nerve blocks (FNB) have been the gold standard for pain control in more invasive knee/lower leg surgeries (total knees, ACLs, etc.).  More recently, adductor canal blocks have been gaining in popularity over femoral nerve blocks because there seems to be less motor blockade from ACB than FNB.  This is important because it decreases fall risk and allows earlier patient ambulation while also providing adequate analgesia.

Anesthesiology Mar 2014. Kim et al. Adductor Canal Block versus Femoral Nerve Block for Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial.

From the ASA 2017:

Virtual Anatomy lab for regional:

  • Femoral nb: fem art, Top of iliacus muscle, within fasc iliaca. Flat nerve. Want local anesthesia (LA) spread going under femoral artery (FA). Does hip joint capsule > Adductor CB (hip fractures, not THA). Catheters to POD3. Fascia iliaca more cranial than inguinal crease to get hip jt nerves. Do inplane to avoid bowel.
  • Adductor Canal block: nerve sits on lateral side of FA. Want FA when dives under Sartorius muscle. Aim for bottom of FA to get under membrane. Block the Nerve to Vastus medialis nerve also (not effect motor). Nerve bt vastus med and sartorius. Looks like it’s in the membrane bt muscles. Want proximimal sartorius (pain and strength better)


How to place an adductor canal block


Overview with quiz

Youtube video of ultrasound-guided ACB – Nov 2014

Youtube video of ultrasound-guided ACB – Apr 2014 Ultrasound-guided ACB with pics and video

****** Updated January 2023*****

Effective dose for adductor canal block

Comparison of two different volumes of 0.5%, ropivacaine used in ultrasound-guided adductor canal block after knee arthroplasty: A randomized, blinded, controlled noninferiority trial.  2022 Jan-Mar; 38(1): 84–90.

Determination of ED50 and ED95 of 0.5% Ropivacaine in Adductor Canal Block to Produce Quadriceps Weakness: A Dose-Finding Study.

Adductor Canal block with 0.5% ropivacaine for postoperative pain relief in lower limb surgeries performed under spinal anesthesia. Bali J Anaesthesiol 2020;4:49-52.

YouTube: Practical anesthesia techniques: Adductor canal block U/S demo

YouTube: Sonosite: adductor canal block U/S 3d

Quicker spinals:

MedicationDosageSensory Regression to S1
Chloroprocaine 3%30mg40-60 min
45mg45-70 min
60mg60-90 min
Mepivacaine 2%30mg120-160 min1
45mg140-180 min1
60mg120 > min
Ref: Basics of Anesthesia ch. 17 table 17.3, BJA 19(10): 321-328 (2019)

1Motor regression typically occurs 30-40 minutes prior to sensory regression

Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation: A Randomized Controlled Trial. Anesthesiology October 2020, Vol. 133, 801–811.

-mepivacaine 1.5% (3.5 ml, 52.5 mg), hyperbaric bupivacaine 0.75% (1.5 ml, 11.25 mg) or isobaric bupivacaine 0.5% (2.5 ml, 12.5 mg). Early ambulation predicts successful same-day discharge,6  which is consistent with our results. The earlier return of motor function likely allowed patients who received mepivacaine to meet physical therapy milestones sooner, contributing to a faster discharge. 

Time of return of neurologic function after spinal anesthesia for total knee arthroplasty: mepivacaine vs bupivacaine in a randomized controlled trial. Arthroplast Today. 2019 May 3;5(2):226-233.

Spinal anesthetic dosing.

Patient heightaBupivacaine 0.75% doseMepivacaine 2% dose
Between 4′10″ and 5′7″1.4 mL10.5 mg3 mL60 mg
Greater than 5′7″1.6 mL12 mg3.4 mL68 mg

No additives (fentanyl, epinephrine) were added to any spinal dose.

aPatients under 4′10″ were excluded from the study (none were encountered).

All patients were compliant with a standardized multimodal perioperative pain and nausea protocol. Patients were given sustained-release morphine 15 mg, meloxicam 15 mg, and gabapentin 300 mg. Dexamethasone 8 mg was given intravenously after anesthetic induction for nausea and pain control. Patients were asked to urinate prior to transfer to the operating room and Foley catheters were not utilized. Intraoperatively, a periarticular injection of 120 mL of diluted ropivacaine 300 mg with epinephrine 1 mg and ketorolac 30 mg was used for local administration. Intraoperative surgeon-delivered adductor canal blockade with 20 mL of the cocktail was added as previously described [24]. The postoperative pain regimen consisted of sustained-release morphine 15 mg every 8 hours for 24 hours, meloxicam 15 mg daily, gabapentin 300 mg twice daily, scheduled oral acetaminophen 975 mg every 8 hours, scheduled tramadol 50 mg every 6 hours, and oxycodone 5-10 mg as needed with morphine 1-2 mg intravenously for breakthrough pain. A repeat dose of dexamethasone 8 mg intravenously was also given the morning after surgery. All patients were mobilized immediately after surgery when physical therapy was available and neurologic function was sufficient.

Postoperative outcomes of mepivacaine vs. bupivacaine in patients undergoing total joint arthroplasty with spinal anesthesia. Arthroplasty. 2022 Jul 13;4(1):32

Postoperative Pain Management in Total Knee Arthroplasty. Orthop Surg. 2019 Oct;11(5):755-761.

Paravertebral block basics and cancer recurrence #paravetebral #block #regional #ultrasound #anesthesia #cancer

From J Anaesthesiol Clin Pharmacol. 2011 Jan-Mar; 27(1): 5–11.
Why do paravertebral blocks?
Paravertebral blocks and decreased cancer recurrence
Paravertebral block techniques

But wait… what about the potential side effects/adverse events from a paravertebral block?

Why not do a TIVA with propofol and dexmetetomedine and local anesthesia via surgeon?  Where’s that study to compare?

** Update **  July 20, 2016 –> What about the PEC 1&2 Blocks as well as Serratus block?

Prolonging blockade with adjuvants: