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Anesthesia: PECS blocks

In breast surgery, field block infiltration or fascial plane infiltration can be an effective technique in a multimodal analgesia strategy^1,2

A PECS (ultrasound-guided medial and lateral pectoralis nerve) block is a less invasive technique for providing analgesia after breast surgery compared with standard approaches such as thoracic epidural, paravertebral, intercostal nerve, and interpleural blocks.^2,3

PECS blocks are applied in the pectoral and axillary regions, with the muscles in both regions innervated by the brachial plexus.³

In PECS I and PECS II field infiltration, ultrasound guidance can be used to identify the appropriate fascial plane(s) and to deposit local anesthetic to provide regional analgesia.²

These techniques provide effective analgesia after breast surgery and, unlike thoracic paravertebral and epidural blocks, are not associated with sympathetic blocks.²

PECS blocks with EXPAREL
PECS I block
PECS II block

PECS blocks can be administered by the anesthesiologist or surgeon;
direct injection during open surgery is also possible²

Areas covered by a PECS I or PECS II block

externalAnteriorNew

Interior View

External anterior view of areas covered by PECS I and PECS II block

PECS I block³ (red area)Devised to anesthetize the medial and lateral pectoral nerves, which innervate the pectoralis muscles

Supraclavicular nerves

PECS II block³ (light blue area)Extends the block to provide blockade of the upper intercostal nerves

Anterior cutaneous nerve
Lateral cutaneous nerve

Consider the neuroanatomy to target the appropriate nerves for a PECS block

InteriorViewNew

Interior View

Interior view of nerves to target with a PECS block

PECS I block²The lateral and medial pectoral nerves lie in the fascial plane between the pectoralis major and minor muscles

PECS II block²Spinal nerves T2-T4 lie in the fascial plane between the pectoralis minor and serratus anterior muscles

Dorsal nerve
Anterior scalene muscle
Brachial plexus
Axillary artery
Medial pectoral nerve
Lateral pectoral nerve
Musculocutaneous nerve
Thoracodorsal nerve
Latissimus dorsi muscle
Long thoracic nerve

internalSagittalNew

Internal sagittal view of where to inject local anesthetic

PECS I block²Injection between pectoralis major and minor muscles

Pectoralis major
Pectoralis minor
Serratus anterior
Rib 4
Rib 3

PECS II block²Injection between the pectoralis muscles and a second injection between the serratus anterior and pectoralis minor muscles

Rib 2
Rib 1
Coracoid process
Clavicle

LEARN ABOUT EXPAREL IN ABDOMINAL FIELD BLOCKS LEARN ABOUT EXPAREL IN INTERSCALENE BRACHIAL PLEXUS NERVE BLOCK

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Important Notice

This site is intended to provide medical and product information to health care professionals in the United States.

To report an adverse event, email drugsafety@pacira.com or call 1-855-793-9727.

For medical inquiries related to EXPAREL, submit a request to Medical Information or call 1-855-793-9727.

These are not all of the potential important safety considerations for EXPAREL; please see the full Prescribing Information.

References

Blanco R. The ‘pecs block’: a novel technique for providing analgesia after breast surgery. Anaesthesia. 2011;66(9):847-848.
Afonso AM, Newman MI, Seely N, et al. Multimodal analgesia in breast surgical procedures: technical and pharmacological considerations for liposomal bupivacaine use. Plast Reconstr Surg Glob Open. 2017;5(9):e1480. doi:10.1097/GOX.0000000000001480.
Blanco R, Barrington MJ. Pectoralis and serratus plane blocks. New York School of Regional Anesthesia (NYSORA). http://www.nysora.com/pectoralis-serratus-plane-blocks. Accessed Aug 25, 2020.

Indication

EXPAREL is indicated for single-dose infiltration in patients aged 6 years and older to produce postsurgical local analgesia and in adults as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information

EXPAREL is contraindicated in obstetrical paracervical block anesthesia.
Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via interscalene brachial plexus nerve block were nausea, pyrexia, and constipation.
Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritus, and tachycardia.
If EXPAREL and other non-bupivacaine local anesthetics, including lidocaine, are administered at the same site, there may be an immediate release of bupivacaine from EXPAREL. Therefore, EXPAREL may be administered to the same site 20 minutes after injecting lidocaine.
EXPAREL is not recommended to be used in the following patient populations: patients <6 years old for infiltration, patients younger than 18 years old for interscalene brachial plexus nerve block, and/or pregnant patients.
Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.

Warnings and Precautions Specific to EXPAREL

Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL.
EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, or intravascular or intra-articular use.
The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.

Warnings and Precautions for Bupivacaine-Containing Products

Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression.
Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability, which may lead to dysrhythmias, sometimes leading to death.
Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients.
Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use.
Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.

Please refer to full Prescribing Information.

EXPAREL is indicated for single-dose infiltration in patients aged 6 years and older to produce postsurgical local analgesia and in adults as an interscalene brachial plexus nerve block to produce postsurgical regional analgesia. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information