PECS II Block Combined with Supraclavicular Brachial Plexus Block Allows Anesthesia for Transaxillary Thoracic Outlet Syndrome Decompression Surgery

Thoracic outlet syndrome (TOS) is a group of disorders that usually involves compression the brachial plexus, and, less frequently, subclavian vein or artery, often caused by supernumerary rib. The main symptoms are upper extremity pallor, venous thrombosis, paresthesia, weakness, muscle atrophy, and pain.1Barkhordarian S. First rib resection in thoracic syndrome.J Hand Surg Am. 2007; 32: 565-570Abstract Full Text PDF PubMed Scopus (31) Google Scholar When conservative therapy fails, first surgical definitive treatment.2Jones MR Prabhakar A Viswanath O et al.Thoracic syndrome: comprehensive review pathophysiology, diagnosis, treatment.Pain Ther. 2019; 8: 5-18Crossref (42) procedures involving ribs carried out under general anesthesia, perioperative pain managed with systemic opioids, epidural paravertebral block;3D'Ercole F Arora H Kumar PA Paravertebral block for surgery.J Cardiothorac Vasc Anesth. 2018; 915-927Abstract (64) although they may lead to complications, such as pneumothorax, hematoma, accidental dural puncture.4Pace MM Sharma B Anderson-Dam J al.Ultrasound-guided blockade: retrospective study incidence complications.Anesth Analg. 2016; 122: 1186-1191Crossref (89) We considered combination supraclavicular plexus (SBP) PECS II feasible alternative anesthesia postoperative analgesia. efficacy blocks, together other wall analgesia breast surgery have been described widely.5Grasso Orsaria P Costa interfascial plane blocks non-anesthesiologists cancer surgery: Functional outcomes benefits.Anticancer Res. 2020; 40: 2231-2238Crossref (4) Scholar, 6Versyck van Geffen GJ Chin KJ Analgesic Pecs block: systematic meta-analysis.Anaesthesia. 74: 663-673Crossref (49) 7Costa Caruso S Pascarella G al.Sternotomy debridement critical patient difficult predicted airway: Can regional be labyrinth exit?.Minerva Anestesiol. 86: 462-463Crossref (2) In past few years, become safer more complex block,8Costa Strumia Remore LM al.Breast analgesia: Another perspective PROSPECT guidelines.Anaesthesia. 75: 1404-1405Crossref without any decreasing analgesic effect. present successful series five patients TOS eligible (together rib, when present), scalene muscle's insertion stenting costoclavicular junction stenosis via axillary access. Written informed consent publication case was obtained all patients. Patient characteristics resumed Table 1.Table 1Summary Patients’ Characteristics Main OutcomesPatient #12345Age3023242143SexFemaleMaleMaleFemaleFemaleWeight (kg)6375815874ResectionRight ribRight ribLeft ribProcedure's length (min)8885959287NRS recovery room00202NRS 2 hours22023NRS6 hours30000NRS12 hours20000Post-operative opiatesNoneNoneNoneNoneNoneAbbreviation: NRS, Pain numeric rating scale (0-10). Open table new tab Abbreviation: preoperative room, supine position, vital parameters (peripheral oxygen saturation (SpO2), electrocardiogram, non invasive blood pressure (NIBP)) were monitored, 50 µg fentanyl plus mg intravenous midazolam administered. For SBP block, region scanned using high-frequency linear-array transducer (M-Turbo, Fujifilm-Sonosite); arteries over identified; 100-mm needle (Stimuplex Ultra 360, B. Braun, Germany) inserted anteromedially targeting “corner pocket” (the angle between artery rib)9Morfey DH Brull R. Finding corner pocket: Landmarks ultrasound-guided block.Anaesthesia. 2009; 64: 1381Crossref (11) Scholar; then 10 mL 2% mepivacaine injected. (three patients), altered normal anatomy, it lay lateral below plexus; consequently, reached easily medial-to-lateral approach (Fig 1). aligned deltoid pectoralis major muscles order identify major, minor, serratus anterior third two different planes—the minor second anterior.10Blanco R Fajardo M Parras Maldonado T Ultrasound description (modified I): novel surgery.Rev Esp Anestesiol Reanim. 2012; 59: 470-475Crossref (302) each injection, 0.375% ropivacaine Ice test on ulnar confirmed onset ready within 20 minutes. Surgery sedation propofol 2%, target-controlled-infusion (Perfusor Space infusion system – at 1.5 µg/mL, effect-site concentration, spontaneous breathing, 40% administration through venturi mask. Thirty milligrams Ketorolac, 1 g acetaminophen, 4 dexamethasone administered before incision. No additional opiates implies opening pleura, pleural drainage necessarily performed. Opening pleura while breathing spontaneously leads lung collapse pneumothorax. According what surgeons reported, absence ventilating facilitated maneuvers, reducing procedure risk injuries. iatrogenic along phrenic nerve palsy related excluded respiratory pathologies from being suitable receive this technique; moreover, included reports, we planned rescue strategy manage airways if imbalance occurred during surgery. Intraoperative hemodynamic remained stable every cases. no received medication; NRS score (0-10) always three Postoperative consisted 1g oral acetaminophen x 3/day 100 tramadol dose; doses, nor killers requested Pleural removed day one discomfort; discharged two. At three-weeks follow-up, reported complications. our effectively covered following10: nerves, facilitating use retractors muscles; clavipectoral fascia, providing inferior border clavicle fascia itself, involved manipulations; intercostobrachial cutaneous branch fourth intercostal covering skin incision parietal opening; thoracodorsal retraction latissimus dorsi muscle. tube into same exits about cm caudally incision, T3 dermatome, still block. performed numb bundles proximity avoid reflexes resection; innervation comes T1 root, not reliably proximal techniques. addition, injection provides sort local infiltration periosteum, insertion, artery. Our experience showed could promising technique surgery, allowing avoidance addition control opioid sparing. Large studies needed confirm real its impact patients’ outcome satisfaction, especially compared anesthesia.