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

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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

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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

Summary:

  • 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

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Overview with quiz

Youtube video of ultrasound-guided ACB – Nov 2014

Youtube video of ultrasound-guided ACB – Apr 2014

Ultrasoundblock.com: Ultrasound-guided ACB with pics and video

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
From NYSORA

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: