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      Pectoralis Plane Block for Pacemaker Insertion: A Successful Primary Anesthetic

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          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.

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          Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery.

          The Pecs block (pectoral nerves block) is an easy and reliable superficial block inspired by the infraclavicular block approach and the transversus abdominis plane blocks. Once the pectoralis muscles are located under the clavicle the space between the two muscles is dissected to reach the lateral pectoral and the medial pectoral nerves. The main indications are breast expanders and subpectoral prosthesis where the distension of these muscles is extremely painful. A second version of the Pecs block is described, called "modified Pecs block" or Pecs block type II. This novel approach aims to block at least the pectoral nerves, the intercostobrachial, intercostals III-IV-V-VI and the long thoracic nerve. These nerves need to be blocked to provide complete analgesia during breast surgery, and it is an alternative or a rescue block if paravertebral blocks and thoracic epidurals failed. This block has been used in our unit in the past year for the Pecs I indications described, and in addition for, tumorectomies, wide excisions, and axillary clearances. The ultrasound sequence to perform this block is shown, together with simple X-ray dye images and gadolinium MRI images to understand the spread and pathways that can explain the benefit of this novel approach. Copyright © 2012 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.
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            The 'pecs block': a novel technique for providing analgesia after breast surgery.

             Raul Blanco (2011)
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              Pectoral nerves (PECS) and intercostal nerve block for cardiac resynchronization therapy device implantation

              A 71-year-old man was scheduled to undergo cardiac resynchronization therapy device (CRTD) implantation. He was combined with severe chronic heart failure due to ischemic heart disease. NYHA class was 3 to 4 and electrocardiogram showed non-sustained ventricular. Ejection fraction was about 20% revealed by transthoracic echocardiogram. He was also on several anticoagulation medications. We planned to implant the device under the greater pectoral muscle. As general anesthesia was considered risky, monitored anesthesia care utilizing peripheral nerve block and slight sedation was scheduled. Pectoral nerves (PECS) block and intercostal block was performed under ultrasonography with ropivacaine. For sedation during the procedure, continuous infusion of dexmedetomidine without a loading dose was performed. The procedure lasted about 3 hours, but the patient showed no pain or restlessness. Combination of PECS block and intercostal block may provide effective analgesia for CRTD implantation.

                Author and article information

                Front Surg
                Front Surg
                Front. Surg.
                Frontiers in Surgery
                Frontiers Media S.A.
                20 November 2019
                : 6
                Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami , Miami, FL, United States
                Author notes

                Edited by: Massimo Bonacchi, University of Florence, Italy

                Reviewed by: Michael Hofmann, University of Zurich, Switzerland; Gabriella Di Lascio, Hospital Universitario Careggi, Italy

                *Correspondence: Ana C. Mavarez ana.mavarez@ 123456jhsmiami.org

                This article was submitted to Heart Surgery, a section of the journal Frontiers in Surgery

                Copyright © 2019 Mavarez, Ripat and Suarez.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                Page count
                Figures: 2, Tables: 0, Equations: 0, References: 8, Pages: 4, Words: 2188
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