Tackling the axillary blind spot with PECS II

Abstract

We read Blanco et al.'s description of the PECS II and serratus plane blocks 1, 2 with great interest. We would like to describe a possible new role of this novel interfascial plane block in vascular access creation. In our institution, axillo-brachial arteriovenous graft creation is usually performed under regional anaesthesia in order to avoid the risks of general anaesthesia in this group of patients with significant co-morbidities. We routinely administer an ultrasound-guided supraclavicular block together with superficial local anaesthetic infiltration near the axilla to block the intercostobrachial nerve. However, we have observed that this technique is frequently inadequate for extensive axillary dissection, requiring either intra-operative local anaesthetic supplementation or conversion to general anaesthesia. Recently, we started performing a variation of Blanco et al.'s PECS II block technique 3, 4 in combination with a supraclavicular block for upper limb vascular access creation that extends to the axilla. The results so far have been encouraging, and we would like to share our experience. We used ultrasound (FUJIFILM SonoSite M-Turbo®), with a linear array transducer (13-6 MHz) and 22-G, 50-mm Stimuplex® needle (B. Braun Medical Inc., Melsungen, Germany). The patients were placed in the supine position with standard monitoring. The ultrasound probe was placed below the outer third of the clavicle, in a sagittal plane, with pectoralis major and minor, serratus anterior muscles and thoracic rib in view. The needle was inserted in-plane from medial to lateral, in a cephalo-caudad fashion, targeting the fascial plane between the pectoralis minor and serratus anterior muscles at the third rib, taking care to avoid puncturing the thoracoacromial artery and pleura. We used a variation of local anaesthetic volumes from 10 ml to 20 ml ropivacaine 0.5%, with a further 15–20 ml to block the brachial plexus via a supraclavicular approach under real-time ultrasound guidance. This alternative technique provided satisfactory anaesthesia in our very limited case series of three patients, with surgical duration varying from 2 h to 5 h. No additional local anaesthetic supplementation by the surgeon was required despite significant dissection into the axillary fossa. The procedure was well received by both patients and surgeons. Our initial experience with this interfascial plane block for anaesthesia in the axillary fossa has been promising. We are in the midst of conducting a randomised controlled trial to determine the efficacy of the modified PECS II block in patients undergoing arteriovenous graft creation surgery.