Anyone doing Pecs 2 blocks for outpatient breast surgery?

[BLADEMDA]

Reg Anesth Pain Med. 2015 Jan-Feb;40(1):68-74. doi: 10.1097/AAP.0000000000000163.
Pectoral Nerves I and II Blocks in Multimodal Analgesia for Breast Cancer Surgery: A Randomized Clinical Trial.
Bashandy GM1, Abbas DN.
Author information

Abstract
BACKGROUND:
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.

METHODS:
One hundred twenty adult female patients scheduled for elective unilateral modified radical mastectomy under general anesthesia were randomly allocated to receive either general anesthesia plus Pecs block (Pecs group, n = 60) or general anesthesia alone (control group, n = 60).

RESULTS:
Statistically significant lower visual analog scale pain scores were observed in the Pecs group than in the control group patients. Moreover, postoperative morphine consumption in the Pecs group was lower in the first 12 hours after surgery than in the control group. In addition, statistically significant lower intraoperative fentanyl consumption was observed in the Pecs group than in the control group. In the postanesthesia care unit, nausea and vomiting as well as sedation scores were lower in the Pecs group compared with the control group. Overall, postanesthesia care unit and hospital stays were shorter in the Pecs group than in the control group.

CONCLUSIONS:
The combined Pecs I and II block is a simple, easy-to-learn technique that produces good analgesia for radical breast surgery.

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[BLADEMDA]

The block is technically easy to do but is even the slightest risk of pneumo worth it in this patient population?

I'm thinking that Exparel (diluted to a volume of 40 mls) would be best suited for this type of block as that ensures a minimum of 24 hours of efficacy.

 

[GA8314]

Reg Anesth Pain Med. 2015 Jan-Feb;40(1):68-74. doi: 10.1097/AAP.0000000000000163.
Pectoral Nerves I and II Blocks in Multimodal Analgesia for Breast Cancer Surgery: A Randomized Clinical Trial.
Bashandy GM1, Abbas DN.
Author information

Abstract
BACKGROUND:
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.

METHODS:
One hundred twenty adult female patients scheduled for elective unilateral modified radical mastectomy under general anesthesia were randomly allocated to receive either general anesthesia plus Pecs block (Pecs group, n = 60) or general anesthesia alone (control group, n = 60).

RESULTS:
Statistically significant lower visual analog scale pain scores were observed in the Pecs group than in the control group patients. Moreover, postoperative morphine consumption in the Pecs group was lower in the first 12 hours after surgery than in the control group. In addition, statistically significant lower intraoperative fentanyl consumption was observed in the Pecs group than in the control group. In the postanesthesia care unit, nausea and vomiting as well as sedation scores were lower in the Pecs group compared with the control group. Overall, postanesthesia care unit and hospital stays were shorter in the Pecs group than in the control group.

CONCLUSIONS:
The combined Pecs I and II block is a simple, easy-to-learn technique that produces good analgesia for radical breast surgery.

What about paravertebrals for radical mastectomies? I've had excellent results but n=2...... Really, though, I'm going to be doing them for this procedure.

 

[BLADEMDA]

The idea behind Pecs 1 and Pecs is that these blocks are safer for outpatient surgery than Paravertebral blocks with similar efficacy.

 

[Urzuz]

Can't access the full article so can't accurately critique it, but I have a feeling that this may be a case where statistical significance =/= clinical significance. Would love to see the full article with all the numbers though.

 

[Planktonmd]

Anyone cares to elaborate on the technique?
And anyone has experience doing interscalene blocks for breast surgery?

 

[deleted162650]

And anyone has experience doing interscalene blocks for breast surgery?

You're gonna have to educate me on this one. ISB commonly misses C8 let alone the T2-5 you're gonna need to achieve any breast analgesia.

Toward the end of residency I spent a couple weeks with the regional fellows learning paravertebrals. I walked away with the impression that the pneumo risk was unacceptably high for this population. I'll have to research the PECS blocks a little bit but I don't think the breast surgeons at my gig are gonna be overly keen on the idea.

 

[BLADEMDA]

Patient demographics and duration of surgery for both groups were comparable (Table 1). Statistically significantly lower VAS pain scores were observed in the Pecs group compared with the control group in all test time periods (Fig. 6). In comparing perioperative opioid needs, the intraoperative fentanyl requirements were found to be lower in the Pecs group than in the control group (115 ± 28.56 μg and 252.5 ± 44.352 μg, respectively, with P < 0.001). In addition, the total amount of postoperative morphine needed to keep VAS pain scores less than 3 was 2.9 ± 1.714 mg and 6.9 ± 1.861 mg in the Pecs and control groups, respectively, and the difference was found to be statistically significant (P < 0.001). The patients in the Pecs group used less morphine in the first 12 hours postoperatively than did the control group patients, but the morphine needs of the 2 groups were comparable in the succeeding 12 hours (Table 2). Only 12 of 60 patients in the Pecs group required morphine PCA based on the protocol of the study, where an adequate VAS pain score of less than 3 was maintained only by paracetamol and nonsteroidal anti-inflammatory drug that were given to all patients in our study. Conversely, 36 of 60 patients in the control group required PCA morphine administration.

Postanesthesia care unit stay was statistically shorter in the Pecs group than in the control group (14 ± 11 minutes and 28 ± 12 minutes, respectively, where P = 0.012). This finding may be explained in part by lower VAS pain scores in the Pecs group, as well as lower PONV scores (0.15 ± .366 vs 1.65 ± 0.875, with P < 0.001). The reported lower sedation scores in the Pecs group compared with those in the control group are an alternative explanation of shorter PACU stay in the Pecs group (2.10 ± 0.308 vs 3.20 ± 0.523, respectively, with P < 0.001).

Postsurgical hospital stay was shorter in the Pecs group than that in the control group (P < 0.001). All patients in the Pecs group were discharged from the hospital within 24 hours, whereas in the control group, only 12 patients left within 24 hours, 42 patients were discharged within 48 hours, and 6 patients stayed in the hospital for more than 48 hours.

 

[BLADEMDA]

What about paravertebrals for radical mastectomies? I've had excellent results but n=2...... Really, though, I'm going to be doing them for this procedure.

The whole point of this thread is that for radical mastectomies the Pecs blocks are as good as Paravertebral blocks with lower risk of pneumothorax; this study showed significant pain score reduction and decreased length of stay in the PECS Group vs Control.

 

[Planktonmd]

Anyone cares to elaborate on the technique?
And anyone has experience doing interscalene blocks for breast surgery?

Both pectoral nerves are branches of the brachial plexus, so blocking the plexus should provide similar analgesia but it also involves the whole upper extremity.
There was a study confirming this 2 years ago:
http://www.researchgate.net/publica...fficacy_of_interscalene_brachial_plexus_block

 

[sevoflurane]

What's your experience blade? I'm curious. We have a full on pain service and this is being done. I have little experience with this block. I typically do a paravertebral for these cases.

 

[somedumbDO]

Just started doing them n=4 on bilat radical breast. One had zero pain 2 had 2/10 pain and one lady didn't work at all. Our plastics surgeon wants a block so it was an easy sell.

 

[spike7585]

Bump. Any more experiences to share with these blocks? Suitable alternative to paravertebrals?

 

[Mman]

Postsurgical hospital stay was shorter in the Pecs group than that in the control group (P < 0.001). All patients in the Pecs group were discharged from the hospital within 24 hours, whereas in the control group, only 12 patients left within 24 hours, 42 patients were discharged within 48 hours, and 6 patients stayed in the hospital for more than 48 hours.

Nearly 100% of ours are done outpatient surgery center with overnight stay for observation and home at 7 AM the next day. Why do they have so many staying for so long?

 

[GatorBait1548]

We do this routinely at my place

 

[somedumbDO]

I have been doing them for last 6 months. All but one breast surgeon actually requests them. Even one of the plastics surgeon wants them for their sub muscular augs. They work much like a tap block for the abdomen. They pay well, we bill 64421 x 2 with good reimbursement. I use 0.25 % marcaine w decadron +/- clonidine. 20cc imbetwen SA/Pm and 10 cc Pm/PM half of the time you can see the pectoral nerve.

 

[Hoya11]

Not enough evidence, im my mind, to start talking these already sensitive patients into blocks. just give the extra 100mcg of fentanyl and other non-opiates. i believe the study with the 12 people remaining hospitalized is underpowered and misleading, and unlikely to be duplicated. if i were having the surgery, i would personally prefer the extra 15 mins in pacu, the extra 100mcg of intraop fent, and the extra few mg of moprhine than be poked with a needle and experimented on in my chest. i think these studies are put on by those interested in doing blocks for monetary reasons alone. until further evidence i remain skeptical.

 

[aneftp]

The block is technically easy to do but is even the slightest risk of pneumo worth it in this patient population?

I'm thinking that Exparel (diluted to a volume of 40 mls) would be best suited for this type of block as that ensures a minimum of 24 hours of efficacy.

Exparel way too expensive. If I am surgery center owner. It's going to eat into my profit margin.

 

[Winged Scapula]

Exparel way too expensive. If I am surgery center owner. It's going to eat into my profit margin.

Yep, only one of the hospitals/surgery centers I go to allows us to use it. Interestingly, its one of the smaller community hospitals rather than the fancier places.

I find that Exparel (when available) coupled with 50 units of Botox into each pec muscle works best and is much longer lasting. These operations really shouldn't be that painful given the newer data almost relegating axillary node dissection to the history books (excepting the young and anxious types for whom a week long chemically induced coma would still lead them to claim they had pain that week). No recon goes home the same day, with recon the next morning.