PECS 2 vs serratus plane for breast sx pain relief

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turnupthevapor

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Have had success with PECS2 for our breast cases the past two years. It seems Serratus Plane Block offers equal or better distributions

Has anyone started doing SPB for breast surgery?Are you doing them supine or lateral?

I was thinking of young 35ML .25 ropi each side.

Any thought on the matter?

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Serratus all the way! 25-30cc of 0.25-0.5% ropi per side sounds good. It is sort of a volume block (think TAP), so look for that good spread across multiple ribs (either between serratus and lat or serratus and ribs- I prefer the former).
 
I've not had great succes with these blocks (maybe because i'm not doing them right), do you block both sides for unilateral procedures?
 
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What is the benefits of doing these blocks if the surgeon infiltrates with exparel (no block)? Want to see if we can convince them to let us do paravertebral vs pec over them injecting, so we can increase billing volume for blocks
 
I've not had great succes with these blocks (maybe because i'm not doing them right), do you block both sides for unilateral procedures?
Block for the side the operation is on
 
What is the benefits of doing these blocks if the surgeon infiltrates with exparel (no block)? Want to see if we can convince them to let us do paravertebral vs pec over them injecting, so we can increase billing volume for blocks
Where is the surgeon infiltrating the exparel? I’ve been using exparel as well for serratus blocks and found that it has worked quite well
 
Where is the surgeon infiltrating the exparel? I’ve been using exparel as well for serratus blocks and found that it has worked quite well

They usually inject in skin preincision, muscle and fascia. Our surgeons claim patients do well and that they have minimal to no pain. Hard to argue with that...
 
Have used serratus blocks for a year now with a denser block than the PEC 2 block. From the package insert on Exparel, it seems if you are using ropivacaine, the surgeon should not be injecting Exparel. Only bupivacaine is compatible with Exparel.
 
Have used serratus blocks for a year now with a denser block than the PEC 2 block. From the package insert on Exparel, it seems if you are using ropivacaine, the surgeon should not be injecting Exparel. Only bupivacaine is compatible with Exparel.
If using exparel for a block, I use 0.25% bupi with it. If I’m not using exparel, I use ropi (with some dexamethasone).
 
We recently got a new dedicated breast surgeon who is fully onboard with us doing some form of regional for her cases. Our initial plan was Pecs v. Serratus blocks, but she expressed concern over being able to monitor the long thoracic nerve during axillary node dissections (seems like just about every case involves at least a SNB). From what I’ve been able to dig up, it does seem like both pecs 2 and serratus blocks can take out the LTN. What’s been everyone else’s experience with this? At this point we’re thinking of just doing ESP’s instead.
 
PECS2? Serratus Plane? What in tarnation you talkin' bout?! You'll get a GA and a "good luck" from The Kid and that's about it.
 
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PECS2? Serratus Plane? What in tarnation you talkin' bout?! You'll get a GA and a "good luck" from The Kid and that's about it.

Ya, but I like poking needles in people and the insurance companies will pay me more to do it.
 
Fresh out of residency and at my new job I'm the first person to do these blocks at my place. Surgeons don't mind me doing them and are kind of intrigued, especially the younger ones. Here's the routine I typically do:

If performing bilateral mastectomy, intubate patient with 100 mcg fentanyl then perform bilateral pecs II blocks using 10 mL for superficial, then 20 or 25 mL for the deep injection. Use 0.2% ropi with 2.5 mcg/mL epinephrine and this should total about 1.5 mg/mL (toxic dose 3 mg/mL with epi). This should give enough room for surgeon to give local too. After this, give 1 mg hydromorphone up front and that should be enough opioid for the whole case.

If unilateral mastectomy, intubate patient with 100 mcg fentanyl then perform a pecs II block and consider using 0.5% ropi with 2.5 mcg/mL. With axilla dissection, consider supplementing with intercostobrachial block.

I've played around with using (SAB + PECS1) vs PECS2. The SAB doesn't really seem to make a big difference IMHO, plus it requires 2 more needle pokes for bilateral breasts.

My technique is to prep all 4 needle poke spots (PECS1 sites and mid-axillary line SAB sites) with arms out at 90d, I then do both the PECS1's then reach over further and do the SABs, again mid axillary line in plane with needle tip angling cephalad entering skin at about the 5th or 6th rib targeting the plane at about the 4th rib.
 
What’s the point of the PECS 1 for a simple mastectomy? If they’re not working under the muscle it doesn’t really do anything for you correct?
 
What’s the point of the PECS 1 for a simple mastectomy? If they’re not working under the muscle it doesn’t really do anything for you correct?
If I remember right, it's to decrease associated muscle spasm from Pec major/minor that can contribute to pain.

For all those interested in comparing/contrasting the blocks in breast analgesia, this is a great article with a super nice chart reviewing the nerve coverage. Well worth the read of the full article:

Woodworth G, Ivie R, Nelson S, Walker C, Maniker R. Perioperative Breast Analgesia: A qualitative Review of Anatomy and Regional Techniques. Reg Anesth Pain Med 2017;42: 609–631
 
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