Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

To Evaluate the Efficacy of Ultrasonography Guided

Pectoral Nerve Block for Postoperative Analgesia in
Breast Surgeries
First Author Second Author (Correspondent Author)
Dr. Samreen Shaikh (Senior Resident) Dr. Pushpa Agrawal (Professor & HOD)
Department of Anaesthesiology, Dr. Vaishampayan Memorial Department of Anaesthesiology, Dr. Vaishampayan Memorial
Govt Medical College, Solapur, Maharashtra Govt Medical College, Solapur, Maharashtra

Dr. Nilambaree Adke (Associate professor) Dr. Pallavi Bhagwat (Junior resident-3)
Department of Anaesthesiology, Dr. Vaishampayan Memorial Department of Anaesthesiology, Dr. Vaishampayan Memorial
Govt Medical College, Solapur, Maharashtra Govt Medical College, Solapur, Maharashtra

Dr. Monica Kandi (Junior resident-3) Dr. Ashit Mehta (Associate professor)
Department of Anaesthesiology, Dr. Vaishampayan Memorial Department of Anaesthesiology, Dr. Vaishampayan Memorial
Govt Medical College, Solapur, Maharashtra Govt Medical College, Solapur, Maharashtra

Dr. Manjiri Deshpande (Associate professor) Dr. Praveen Jadhav (Associate professor)
Department of Anaesthesiology, Dr. Vaishampayan Memorial Department of Anaesthesiology, Dr. Vaishampayan Memorial
Govt Medical College, Solapur, Maharashtra Govt Medical College, Solapur, Maharashtra

Dr. Sachin Swami (Assistant professor)

Department of Anaesthesiology, Dr. Vaishampayan
Memorial Govt Medical College, Solapur, Maharashtra

Abstract:- Present study aim was to study the potential the global breast cancer burden. Among the Indian
advantages of pectoralis nerve block for providing population, it has surpassed that of cervical cancer and has
analgesia in postoperative mastectomy surgery period by become the most common cancer with 25.8 per 100,000 and
assessing reduction in pain, improved analgesia in the mortality of 12.7 per 100,000. Despite the improved
axilla and upper limb and for reduced morphine efficiency in surgical treatment of breast cancer, peri
consumption, besides being less invasive, easier and safer mastectomy pain syndrome remains a persistent challenging
to perform as it is done under ultrasound guidance. concern.
Total 30 ASA I, II and III patients of age between 18 to
80 years were included in this study. All patient received The standard of anaesthetic care for patients
10ml inj. Bupivacaine 0.25% for pectoral nerve block undergoing mastectomy or breast surgery is general
under USG guidance, under all aseptic precautions. The anaesthesia or with a multimodal approach for analgesia,
results of my study by using 0.25% of 10ml injection of such as opioids, paracetamol and, NSAIDs.2 Excessive
bupivacaine is supportive, in proving, the two-level morphine consumption is an additional concern in the
PECS block is safe, effective, reliable, easy to perform, management, as there is growing evidence of an increase in
decreases opioid consumption, improves postoperative recurrence with the use of morphine.3 Advances in
pain, provides patient satisfaction and psycological relief anaesthesia in the previous two decades have given rise to
in breast cancer related surgery. regional anesthesia techniques, such as thoracic epidural and
paravertebral block which are now considered as ‘gold
Keywords:- Ultrasonography, Pectoral Nerve Block, Breast standard’ regional anaesthetic techniques for these patients.
Surgeries. Although evidence shows that they are effective, associated
significant complications have been reported with these
I. INTRODUCTION procedures.4

Breast cancer is the most common cancer among Blanco R in 2011, illustrated the procedure of Pectoral
women and its incidence is on the rise. According to Nerve (PECS) block and its effectiveness in reducing pain
GLOBOCAN statistics, there are 1.7 million women locally over the serratus anterior area during breast
diagnosed with breast cancer and 522,000 related deaths. reconstruction surgeries.5 With limited studies showing
American cancer society reports that one in eight women positive results of PECS, this study was initiated to provide
will develop breast cancer in her lifetime.1 India along with further evidence to the efficacy and safety of this recently
United States of America and China account for one-third of introduced technique towards pain management in

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Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Mastectomy surgeries. Our aim was to study the potential to allow in-plane needle trajectory from medical to lateral
advantages of pectoralis nerve block for providing analgesia side. The proper fascial plane was confirmed by
in postoperative mastectomy surgery period by assessing hydrodissection with saline to open the space between the
reduction in pain, improved analgesia in the axilla and upper pectoral muscles. First the plane between serratus anterior
limb and for reduced morphine consumption, besides being and pectoralis minor, was identified and 0.2ml/kg ,10ml of
less invasive, easier and safer to perform as it is done under bupivacaine was instilled, followed by the plane and
ultrasound guidance. between pectoralis major and minor 0.2ml/kg of 10ml drug
was instilled as the needle was withdrawn.
II. MATERIALS AND METHODS
After surgery, patients were transferred to post-
 Source of data: Patients admitted for breast surgeries in anaesthesia care unit (PACU), Pain score was documented
our hospital against Numeric Rating Scale every 2 hours for the initial
 Study Period : December 2019 to July 2021 8hrs at PACU then continued at the ward. The Numerical
 Study Design : A Prospective Observation Study Rating Scale has shown a high correlation as compared to
 Study Sample : 30 patients other pain-assessment tools. The patients were asked to
circle the number between 0 and 10, zero representing “no
A. Inclusion Criteria : pain at all” whereas the upper limit represents “the worst
 Patient undergoing breast surgeries pain possible”
 Patient of age between 18 to 80 yrs. of female
 Patient with ASA grade 1,2,3 III. OBSERVATIONS AND RESULTS

B. Exclusion Criteria: This Prospective study of 30 patients was performed to

evaluate the effects of the recently introduced, regional
 Non-consenting patients
anaesthesia technique, the two-level PECS block, in the
 ASA GRADE 4 physical status management of breast surgery at our hospital.
 Allergy to local and general anaesthetic drugs
 Chest wall anatomical abnormality The following intra operative and post-operative
 Presence of infection parameters were measured as outcome variables: The
 Patients on anti-coagulants or anti-platelet drugs primary outcome was the safety and efficacy of PECS block.
/coagulopathy This was supported with the following variables.
a) Intra-operative heart rate and blood pressure
The study included patients who fulfilled the inclusion b) Intra and post-operative opioid consumption
criteria. Before proceeding with the study, a written and c) Post-operative pain assessment and management
informed consent was taken from these patients. The same d) Post-operative heart rate and blood pressure
was explained to their bystanders. The confidentiality of the
patient was maintained. Patients underwent routine pre- Total 30 ASA I, II and III patients of age between 18 to
anesthetic evaluation and all patients recruited were either 80 years were included in this study. All patient received
ASA 1 or 2 or 3. Fasting protocols were followed. All 10ml inj. Bupivacaine 0.25% for pectoral nerve block under
patients were kept nil per oral (NPO) for 6 hours for solids USG guidance, under all aseptic precautions. Mean age
and milk; 2 hours for clear fluids like coconut water, or includes in the study was 36.03±14.60 years.
water. On the morning of surgery, patients were reassessed
and taken in. The anaesthesia machine, emergency oxygen Intra operatively there was no significant changes
source, pipeline oxygen supply, working laryngoscope were noted in systolic and diastolic blood pressure, pulse rate and
checked. Working suction apparatus with suction catheter, respiratory rate in any of the patients.
airway equipment, intravenous fluids and all emergency
drugs were kept ready for emergency resuscitation. Time taken for procedure is time taken from the
insertion of block needle to the end of local Anesthetic
All patients received general anaesthesia. After injection and needle withdrawal in minutes. The mean time
establishing intravenous access in the operation theatre, taken for the procedure to administer a block is 10.45± 3.32
routine monitors were established (ECG, pulse oximetry, min.
noninvasive BP). Intraoperative vitals were monitored on
an interval of 5 ,15 30, 60, 90,120min. Systolic and Completeness of block was considered when block
Diastolic blood pressure along with heart rate ETCO2 and provided solid analgesia with no need of supplemental
saturation was recorded. Total morphine and fentanyl analgesia. Out of 30 patients no one required of supplement
consumption was also recorded. analgesia.

No complications were noted following block. Hence

The block was performed with the patient in supine in our study there was 100% success rate with average 7hrs
position and the arm abducted 90 degrees. The landmarks and 31 min of preoperative analgesia with no incidence of
under US was identified that is the Pectoralis major, complications such as vessel puncture, nerve injury,
Pectoralis minor and the pectoral branch of the
thoracoacromial artery. The transducer was rotated slightly

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Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
hematoma which reflects the safety of ultrasound guided IV. DISCUSSION
pectoral nerve block.
Effective control of the postoperative pain can prevent
the negative physiological and psychological consequences
that can occur if it is badly managed. Furthermore, this
control can protect immunity by suppressing the stress
response to surgery and reducing the need for opioid.
Chronic postmastectomy pain can be developed from poorly
managed acute postomastectomy pain. The severity of acute
pain can be modified by the use of regional anesthesia
techniques, like PECS block and this leads to less chronic
pain. The time for performing the block varied from 5 min
to 20 min. The mean time taken for the procedure to
administer a block is 10.45±3.32 min.

Present study shows that average duration of

postoperative analgesia was 7 hrs and 31 min which is
Fig 1Intra-operative heart rate and blood pressure comparable with Blanc’s study. PECS I and PECS II blocks
were initially introduced by Blanco et al in 20115 claiming
its advantages in pain management during perioperative of
reconstructive breast surgery. Their study was performed in
50 patients undergoing mastectomy surgery and reported
good post operative analgesia for 8 hours. Since then, there
have been multiple studies showing mixed results of the
block.

Present study shows that there was considerable

difference as regards to HR and BP during operation after
giving block, on arrival to PACU and at 1,2,3,4,6,8 hrs
postoperatively.

In agreement with our study, Fujiwara et al. found that

Fig 2 Intra and post-operative opioid consumption PECS produces hemodynamic stability in his research on the
effect of intercostal nerve block and PECS block for cardiac
resynchronization therapy device. This can be explained by
the fact that PECS is a nerve block without sympathetic
affection and hemodynamic changes.6

In agreement with our results, Sopena - Zubiria et al. in

their study on the reconstructive breast surgery found that
the PECS has a good hemodynamic stability when added to
the paravertebral block compared to the TPVB alone.
Moreover, they considered it as a good, simple, and safe
anesthetic and analgesic technique block; further, they
consider it better than PVB and the thoracic spinal
anesthesia where it provided satisfactory surgical anesthesia
Fig 3 Post-operative pain assessment and management with prolonged duration of postoperative analgesia. 7

Present study shows that there were highly significant

changes in the pain score on arrival to PACU, and at 2, 4, 6,
8 h postoperatively. In agreement with our study, Hala in
their study on the anesthesia for conservative breast surgery
in breast found that in PECS groups, VAS throughout
surgery and during the first 24 h postoperative was better
than that in the thoracic spinal anesthesia.8

Present study showed that post operative rescue

analgesia required in our study was minimal. In agreement
with our results, Bashandy et al. during their study on the
effect of PECS on breast cancer excision found that the total
Fig 4Post-operative heart rate and blood pressure morphine consumption dose during the first 24 h

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Volume 8, Issue 4, April – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
postoperatively was considerably lower in the PECS group [5]. Blanco R. The “pecs block”: a novel technique for
than that in the PVB group.9 providing analgesia after breast surgery. Anaesthesia.
2011 Sep;66(9):847–8.
Kulhari et al., during their study on the effect of PECS [6]. Fujiwara A, Komasawa N, Minami T. Pectoral nerves
block versus TPVB using ropivacaine 0.5% for (PECS) and intercostal nerve block for cardiac
postoperative analgesia after radical mastectomy, found that resynchronization therapy device implantation.
the 24 h morphine consumption was also less in the PECS-II Springerplus. 2014;3:409.
block group (3.90±0.79 vs. 5.30±0.98 mg in PECS-II and [7]. Sopena-Zubiria LA, Fernández-Meré LA, Valdés Arias
TPVB group, respectively; P < 0.0001) and found that the C, Muñoz González F, Sánchez Asheras J, Ibáñez
duration of analgesia was significantly longer in patients Ernández C, et al. Thoracic paravertebral block
who received the PECS versus those who received TPVB compared to thoracic paravertebral block plus pectoral
(197.5±31.35 vs. 294.5±52.76 min in the TPVB group and nerve block in reconstructive breast surgery. Rev Esp
the PECS-II, respectively; P < 0.0001).10 Anestesiol Reanim. 2012;59:12–7.
[8]. Hala MS. Ultrasound guided pectoral nerve blockade
Furthermore, Chakraborty et al. in their study on a versus thoracic spinal blockade for conservative breast
single injection of PECS block showed that the pain-free surgery in cancer breast: A randomized controlled trial.
duration extended to 24 h after PECS injection.11 Pedrosa in Egypt J Anaesth. 2016;32:29–35.
his study showed that the PECS block is an effective [9]. Bashandy GM, Abbas DN. Pectoral nerves I and II
analgesic technique for breast reconstructive surgery and blocks in multimodal analgesia for breast cancer
allows reduction of opioid (tramadol) consumption and its surgery: A randomized clinical trial. Reg Anesth Pain
undesirable effects and he mentioned that it should be Med. 2015;40:68–74.
considered as an alternative to conventional analgesia.12 [10]. Kulhari S, Bharti N, Bala I, Arora S, Singh G. Efficacy
of pectoral nerve block versus thoracic paravertebral
V. CONCLUSION block for postoperative analgesia after radical
mastectomy: A randomized controlled trial. Br J
USG guided PEC-I and PEC-II block together Anaesth. 2016;117:382–6.
provided good analgesia post operatively in all ca breast [11]. Chakraborty A, Khemka R, Datta T, Mitra S.
patients and it also decreases need of analgesic drugs like COMBIPECS, the singleinjection technique of pectoral
opioids and NSAIDS postoperatively. Because of good nerve blocks 1 and 2: A case series. J Clin Anesth.
analgesia all patients were satisfied and definitely there was 2016;35:365–8.
psychological relief in breast cancer related surgery. Inj. [12]. Pedrosa F. PECS block as a post-operative analgesic
Bupivacain 0.25% of 10ml for PEC I and 10 ml for PEC II strategy for reconstructive breast surgery: Preliminary
was sufficient without any toxicity. results. ESRA Acad. 2016:138532.

Thus, we conclude that USG guided PEC-I and PEC -

II block together with total 0.25% Bupivacain 20cc is safe,
supportive, effective, reliable technique for post operative
pain relief in patients of Carcinoma breast. It should be
considered as an adjuvant therapy in multimodal analgesic
technique to General Anaesthesia for Carcinoma breast.

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