pecs, spb, literature review, KSP 2018 ultrasound workshop

1. Pecs block, Serratus Plane Block with
Literature review : When & How?
홍부휘 MD PhD , koho0127@gmail.com
2018. 04

2. • Dr. Rafael Blanco
• Department of Anaesthesia, Corniche
Hospital, Abu Dhabi, United Arab
Emirates
• Thoracic Interfascial Nerve Blocks
• Pectoralis and Serratus Plane Block

3. 0.4 mL/kg or approximately 20–30 ml
0.25% levobupivacaine
Between the pectoralis major & minor muscle
Aiming : medial and lateral pectoral nerves
50-mm block needles
5 ml/hr infusions of levobupivacaine 0.25%
for up to 7 days to be effective
probe position : similar infraclavicular
brachial plexus block.
Anaesthesia, 2011, 66, pages 848

4. First puncture is a Pecs I block with 10 ml of local anesthetic injected between the
pectoralis muscles
Second puncture gives 20 ml of local anesthetic between the Pmm and the serratus
muscle.
Lateral & medial pectoral nerve
lateral branches of the intercostal nerves (T2 to T6)
long thoracic and the thoracodorsal nerve

7. 0.4 mL/kg of local anesthetic
Between the latissimus dorsi and the serratus anterior muscle
more posteriorly and at the level of the fifth rib
Lateral cutaneous branches of the second to ninth intercostal nerves and possibly the long
thoracic and thoracodorsal nerves.
long-lasting paraesthesia (750–840 min)

10. There is no difference if the point of injection is between serratus anterior and
either pectoralis minor or the external intercostal muscle
pecs I is the easiest block to perform,
pecs II the most effective and the
Serratus plane block somewhere between the other two, but with better
spread towards the lower thoracic dermatomes.
The choice of block will therefore depend on where analgesia is required.

11. Below the outer third of the clavicle
transverse to the axis of the body Mario Fajardo Pérez
Servicio de Anestesia, Hospital
Universitario del Tajo,
Aranjuez, Madrid, Spain

12. Anterior approach
= Fajardo´s Pec´s approach
Lateral approach
Levobupivacaine 0.375%
16hr lasting

15. Innervation of the breast.
Anterior and lateral
branches of intercostal nerves (yellow)
Supraclavicular nerves (orange)
Lateral pectoral nerve (brown)
Medial pectoral nerve (pink)
Long thoracic nerve (blue)
Thoracodorsal nerve (green)
Intercostobrachial (purple).

17. Chest wall innervation, breast surgeries, and analgesic procedures

18. Atlas of Sonoanatomy for Regional
anesthesia and pain medicine. Karmakar et al.

20. 립 카운트 립 사
진

22. Atlas of Sonoanatomy. Karmakar et al.

23. Atlas of Sonoanatomy. Karmakar et al.

24. Atlas of Sonoanatomy. Karmakar et al.

25. Atlas of Sonoanatomy. Karmakar et al.

26. Atlas of Sonoanatomy. Karmakar et al.

27. Atlas of Sonoanatomy. Karmakar et al.

28. Atlas of Sonoanatomy. Karmakar et al.

29. Atlas of Sonoanatomy. Karmakar et al.

30. Atlas of Sonoanatomy. Karmakar et al.

33. SPB Position direction

34. 등 배
머리
다리

40. Subpectoral plexus
Two pectoral nerves,
Three terminal branches

41. Superior branch travelled in a
straight course to the pectoralis major
to innervate the clavicular aspect.
Middle branch coursed on the under-
surface of the pectoralis major near
the pectoral branch of the thoraco-
acromial artery to innervate the
muscle’s sternal aspect.
Inferior branch passed
beneath the pectoralis minor muscle
to innervate the pectoralis minor
muscle and the costal aspect of the
pectoralis major muscle.

42. Deep and lateral aspect of the
pectoralis minor muscle (3.3
mL)
Between the pectoralis major
and minor muscle (3.3 mL)
Superficial to the posterior
fascia of the pectoralis major
muscle (3.4 mL)

43. Superficial SAM vs Deep SAM
• Spread more extensively,
Duration longer,
• Deep plane : axillary crux
missed by Blanco
• Thin pt : SAM is not very
prominent. Deep plane more
easily identified
• Good anterior distribution

45. 25-gauge, 1.5-inch Quincke needle
10 mL of 0.25% bupivacaine

46. Volume 40, Number 6, November-
December 2015 p 729
Block the intercostal nerves just after emerging
from the external intercostal muscle
Greater spread within the serratus intercostal
fascial plane caudally because the injection is
located within a confined and poorly distensible
space, through which the intercostobrachial and
the perforating lateral intercostal cutaneous
branches run, and respiratory movements allow the
LA to be dispersed
LTN may be injured in axillary dissection during
surgery, causing winged scapula syndrome, and
injecting LA above the SAM may produce
temporary palsy of the LTN. We believe that this is
not an objective but an adverse effect that we can
avoid by performing the injection below the
muscle. The LTN is a purely motor nerve and
should not be blocked.

47. RAPM

48. Anterior-Approach SIFP Block clavipectoral fascia (CPF),
pectoralfascia (PF)
10 min following the injection

53. Inferior to thoracic paravertebral block

54. PIFB SIFB was Inferior to thoracic paravertebral block

55. 1: TPVB vs 2 : PECS
T2의 차이?
Medial & lateral pectoral nerve 의 차이?
LTN DSN 의 차이?

56. Between
Pmm & SAm
The modified PEC2 block provided better
analgesia, with local anesthetic spread
towards the axilla.
Between
PMm & Pmm

57. combination of both pre-incisional PECs blocks
and postoperative LA infusion

60. The Pecs block reduces postsurgical
opioid consumption during the PACU
stay time for patients undergoing breast
surgery.

61. Reduced the requirement for propofol
but not that for remifentanil,
due to the inability of the PECS block to reach
the internal mammary area.
Improved postoperative pain
but not the postoperative QoR-40 score due
to the factors that cannot be measured by
analgesia immediately after surgery, such as
rebound pain.

63. 3.7 vs 3.6 hours
Dermatomes Cold test
4 [3–4] vs 6 [5–7]

65. case series of 16
one conversion to general anaesthesia
all patients experienced either no or minimal
intra-operative pain , choose this anaesthetic
technique again.
Surgeon :
‘indistinguishable from general anaesthesia’
‘extremely satisfied’ or ‘satisfied’

72. 82-year-oldman fell onto a table
fracturing right ribs 4-9.
65-year-old woman struck by a car while riding a
bicycle, resulting in left 5-7 rib fractures.

77. Article in press

81. PECS type I (ropivacaine 0.375% 10 ml), PECS II (ropivacaine 0.375% 20 ml) and
serratus plane block (ropivacaine 0.25% 30 ml)
Remifentanil (0.025 μg/kg/minute)
Procedure Time :15 minutes.
Venturi mask
800 ml of pleural effusion fluid was evacuated and multiple pleural biopsies were performed
OP time : 90 minutes
NRS pain score : 2 during the whole procedure.
During the subsequent 24 hours the patient required no rescue analgesic.
Postoperative NRS score was 2 (interquartile range, IQR 1–3).
R. M. Corso, S. Maitan, V. Russotto, C. Gregoretti , Italy

82. koho0127@gmail.com