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Abstract
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Background and Aims The axillary region has always been a challenge for anesthesiologists. Brachial plexus, paravertebral and intercostal blocks achieve only partial anesthetic coverage. Pecto-serratus plane block technique showed to be effective as an analgesic technique for axillary node dissection during breast surgery. We modified the method in order to enhance local anesthetic spread to the axillary region and achieve surgical anesthesia even for more destructive surgical procedures.
Methods For the modified-pecto-serratus-plane block (m-PSP) we use a 100 mm short beveled echogenic needle (Stimuplex Ultra 360 – Bbraun – Melsungen – Germany) and perform the injection in the fascial plane between the pectoralis minor and serratus muscle in a medial to lateral direction above the third rib instead of the fourth as described by Blanco in his original PECS 2 block.
Modified-Pecto-Serratus-Plane block: needle over the 3rd rib, medic-lateral spread of local anesthetic (LA) along the plane between pec minor and serrates anterior muscles, toward the axillary region
Infra-Clavicular Brachial plexus block: needle below the axillary artery; local anesthetic spread forming the double-bubble sign and involving the tunica adventitia of the artery and the cords of the brachial plexus
Results We applied the m-PSP in several surgeries involving the axillary region as a single block or in combination with other techniques to achieve surgical anesthesia. For example, we managed a case of a true axillary aneurysm (consent obtained) requiring an ipsilateral cephalic vein-graft, with the combination of m-PSP and infra-clavicular brachial plexus block (ICB). The m-PSP covered skin (T2-T4 lateral-cutaneous branches; intercostobrachial nerve; medial-cutaneous nerve of the arm) and soft tissues of the axilla for the surgical access; the ICB with the double-bubble sign (direct perivascular local anesthesia; complete coverage of arm and forearm) allowed the axillary artery surgical manipulations and the vein-graft harvesting.
Surgery: under mild sedation and collaborating patient, resection of the axillary aneurysm (AAA) and harvesting of ipsilateral cephalic vein in the forearm (VGHS: Vein-Graft Harvest Site)
Conclusions For axillary surgeries, adequate knowledge of anatomy allows regional techniques to be adapted and combined covering all surgical maneuvers.