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

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          Abstract

          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.

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

          R. Blanco, M. FAJARDO, T. Parras Maldonado (2012)
          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)
            Article 0 comments Cited 138 times – based on 0 reviews     Review now
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              Surgical anatomy of the pectoral nerves and the pectoral musculature.

              Andrea Porzionato, Raffaele De Palma, Raymond R. Tubbs … (2012)
              The pectoral nerves (PNs) may be selectively injured through various traumatic mechanisms such as direct trauma, hypertrophic muscle compression, and iatrogenic injuries (breast surgery and axillary node dissection, pectoralis major muscle transfers). The PN may be surgically recovered through nerve transfers. They may also be used as donors to the musculocutaneous, axillary, long thoracic, and spinal accessory nerves and for reinnervation of myocutaneous free flaps. Thus, in this article, we reviewed the surgical anatomy of PN. A meta-analysis of the available literature showed that the lateral pectoral nerve (LPN) arises most frequently with two branches from the anterior divisions of the upper and middle trunks (33.8%) or as a single root from the lateral cord (23.4%). The medial pectoral nerve (MPN) usually arises from the medial cord (49.3%), anterior division of the lower trunk (43.8%), or lower trunk (4.7%). The two PN are usually connected immediately distal to the thoracoacromial artery by the so-called ansa pectoralis. The MPN may also show communications with the intercostobrachial nerve. In 50%-100% of cases, it may pass, at least with some branches, through the pectoralis minor muscle. The LPN supplies the upper portions of the pectoralis major muscle; the MPN innervates the lower parts of the pectoralis major and the pectoralis minor muscle. Among the accessory muscles of the pectoral girdle, the LPN may also innervate the tensor semivaginae articulationis humero-scapularis, pectoralis minimus, sternoclavicularis, axillary arch, sternalis, and infraclavicularis muscles; the MPN may innervate the pectoralis quartus, chondrofascialis, axillary arch, chondroepitrochlearis, and sternalis muscles. Copyright © 2011 Wiley Periodicals, Inc.
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                Author and article information

                Contributors
                Atsushi Fujiwara: heiheiheifuji@gmail.com
                Nobuyasu Komasawa: ane078@poh.osaka-med.ac.jp
                Toshiaki Minami: ane022@poh.osaka-med.ac.jp
                Journal
                Journal ID (nlm-ta): Springerplus
                Journal ID (iso-abbrev): Springerplus
                Title: SpringerPlus
                Publisher: Springer International Publishing (Cham )
                ISSN (Electronic): 2193-1801
                Publication date (Electronic): 5 August 2014
                Publication date PMC-release: 5 August 2014
                Publication date Collection: 2014
                Volume: 3
                Electronic Location Identifier: 409
                Affiliations
                Department of Anesthesiology, Osaka Medical College, Daigaku-machi 2-7, Takatsuki, Osaka, 569-8686 Japan
                Article
                Publisher ID: 1103
                DOI: 10.1186/2193-1801-3-409
                PMC ID: 4128952
                PubMed ID: 25120950
                SO-VID: 8c4d99c2-ed3c-46b1-8bbc-52e373e414e3
                Copyright © © Fujiwara et al.; licensee Springer. 2014
                License:

                This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.

                History
                Date received : 15 July 2014
                Date accepted : 29 July 2014
                Categories
                Subject: Case Study
                Custom metadata
                issue-copyright-statement © The Author(s) 2014

                ScienceOpen disciplines: Uncategorized
                Keywords: cardiac resynchronization therapy device implantation,pectoral nerves (pecs) block,intercostal nerve block
                Data availability:
                ScienceOpen disciplines: Uncategorized
                Keywords: cardiac resynchronization therapy device implantation, pectoral nerves (pecs) block, intercostal nerve block

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