American Society of Regional Anesthesia and Pain Medicine August 2016 - 42

Figure 1:

Figure 2:

may determine the quality of spread in the segmental regions both
cephlad and caudad to the initial injection site.14,15

(0.75%). A nerve stimulator also can be applied to identify a
paresthesia or motor response along the intercostal nerve. The
use of a nerve stimulator may increase the incidence of anterior
placement of local anesthetic to the endothoracic fascia; this
may result in a greater incidence of multilevel spread of the local
anesthetic.15

Technique. For either the landmark or US technique, patients can
be positioned in the sitting or the lateral position with the operative
side up. With the US technique, some practitioners may position
patients in the prone position for block placement. Figures 1 and 2
provide images of the landmarks typically visualized when using US
for a PVB. Both in- and out-of-plane needle advancement have been
used. Commonly, one can identify the transverse process about
2.5 cm lateral to the spinous process, and the visualization of the
anterior border (parietal pleura) and the medial border (transverse
process) are utilized to guide the injection. The intercostal muscle
is also visualized (Figure 1). When scanning in the transverse plane,
the ribs can be identified superiorly and inferiorly. The ribs produce
a shadow effect as the US beam is attenuated by bone, while the
pleura will not have the same attenuation effect. Both the ribs and
pleura will appear as hyperechoic structures under US. The ribs will
also be more superficial.
Local anesthetic is placed with a blunt-tipped needle following
sterile technique. During the in-plane approach, the needle is
directed from lateral to medial in the transverse scan and, usually,
from superior to inferior in the sagittal scan (Figure 2). Once the
posterior border is passed, there may be a sensed "pop" and
loss of resistance to injection during the placement of the local
anesthetic. The spread of local anesthetic will be seen spreading
over the anterior border (the pleura) to confirm appropriate
placement. Because this is similar to an intercostal nerve injection,
consideration must be given to the potential rapid uptake of local
anesthetic. Therefore, it is recommended that lower concentrations
(0.5% equivalent or less) be used rather than higher concentrations

42
2

PECTORAL BLOCKS
Recently, the PEC I, PECS II, and Serratus Plane blocks have
been described as fascial plane blocks that work as potential
analgesic adjuvants for both major and minor breast surgery
with or without axillary lymph node dissection.16-19 The block
was originally described as an infiltration technique between the
pectoralis major and minor muscles (PEC I). This placement targets
the innervation to the pectoralis muscles, namely, the lateral and
medial pectoral nerves. Since then, local anesthetic placement
to target the pectoral nerves as well as the thoracic dermatomal
innervation, is mainly, but not limited, to T2-T6.19 The techniques
were originally described by Blanco et al. The exact location of
placement of the local anesthetic is what will differentiate the PEC
I, PECS II, and serratus plane block. Chest wall blocks are relatively
easy to perform under direct US guidance.16-18 Combinations of
these blocks have been shown to be useful in both minor and
major breast surgery, including mastectomy with temporary and
permanent implant placement. Chest wall blocks have been
associated with decreased opioid consumption and increased
patient satisfaction.16,19
When compared to PVBs, PECS blocks could eliminate the risk of
posterior midline spread and subsequent hypotension, which can
be seen with epidurals and PVBs.16 The risks include anesthesia of
the long thoracic nerve, nerve injury to the thoracodorsal and long

American Society of Regional Anesthesia and Pain Medicine
2016



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