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      Combined ultrasound-guided Pecs II block and general anesthesia are effective for reducing pain from modified radical mastectomy

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          Abstract

          Purpose: Combined regional and general anesthesia are often used for the management of breast cancer surgery. Thoracic spinal block, thoracic epidural block, thoracic paravertebral block, and multiple intercostal nerve blocks are the regional anesthesia techniques which have been used in breast surgery, but some anesthesiologists are not comfortable because of the complication and side effects. In 2012, Blanco et al introduced pectoralis nerve (Pecs) II block or modified Pecs block as a novel approach to breast surgery. This study aims to determine the effectiveness of combined ultrasound-guided Pecs II block and general anesthesia for reducing intra- and postoperative pain from modified radical mastectomy.

          Patients and methods: Fifty patients undergoing modified radical mastectomy with general anesthesia were divided into two groups randomly (n=25), to either Pecs (P) group or control (C) group. Ultrasound-guided Pecs II block was done with 0.25% bupivacaine (P group) or 0.9% NaCl (C group). Patient-controlled analgesia was used to control postoperative pain. Intraoperative opioid consumption, postoperative visual analog scale (VAS) score, and postoperative opioid consumption were measured.

          Results: Intraoperative opioid consumption was significantly lower in P group ( P≤0.05). VAS score at 3, 6, 12, and 24 hrs postoperative were significantly lower in P group ( P≤0.05). Twenty-four hours postoperative opioid consumption was significantly lower in P group ( P≤0.05). There are no complications following Pecs block in both groups, including pneumothorax, vascular puncture, and hematoma.

          Conclusion: Combined ultrasound-guided Pecs II block and general anesthesia are effective in reducing pain both intra- and postoperatively in patients undergoing modified radical mastectomy. Ultrasound-guided Pecs II block is a relatively safe peripheral nerve block.

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          Most cited references 19

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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 I and II blocks in multimodal analgesia for breast cancer surgery: a randomized clinical trial.

              The pectoral nerves (Pecs) block types I and II are novel techniques to block the pectoral, intercostobrachial, third to sixth intercostals, and the long thoracic nerves. They may provide good analgesia during and after breast surgery. Our study aimed to compare prospectively the quality of analgesia after modified radical mastectomy surgery using general anesthesia and Pecs blocks versus general anesthesia alone.
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                Author and article information

                Journal
                J Pain Res
                J Pain Res
                JPR
                jpainres
                Journal of Pain Research
                Dove
                1178-7090
                26 April 2019
                2019
                : 12
                : 1353-1358
                Affiliations
                [1 ]Department of Anesthesiology and Intensive Care, Sanglah Hospital, Faculty of Medicine, Udayana University , Denpasar, Bali, Indonesia
                Author notes
                Correspondence: A A Gde Putra Semara JayaDepartment of Anesthesiology and Intensive Care, Sanglah Hospital, Faculty of Medicine, Udayana University , Diponegoro Street, Denpasar, Bali80114, IndonesiaTel +628 191 624 1248Fax +6 236 123 5980Email gungthey84@ 123456yahoo.com
                Article
                197669
                10.2147/JPR.S197669
                6497844
                © 2019 Senapathi et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 2, Tables: 4, References: 23, Pages: 6
                Categories
                Original Research

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