Comparison of pectoral Nerve (PECS1) block with combined PECS1 and transversus thoracis muscle (TTM) block in patients undergoing cardiac implantable electronic device insertion – A pilot study

Abstract

Background: Pectoral nerve (PECS1) block has been used for patients undergoing cardiac implantable electronic device (CIED) insertions, however, PECS1 block alone may lead to inadequate analgesia during tunneling and pocket creation because of the highly innervated chest wall. Transversus thoracis muscle plane (TTM) block targeting the anterior branches of T2-T6 intercostal nerves can be effectively used in combination with PECS1 for patients undergoing CIED insertion. The present study hypothesized that combined PECS1 and TTM blocks would provide effective analgesia for patients undergoing CIED insertion compared to PECS1 block alone. Materials and Methods: Thirty adult patients between the age group of 18–85 years undergoing CIED insertion were enrolled in the study. A prospective, randomized, comparative, pilot study was conducted. A total of 30 patients were enrolled, who were randomized to either Group P: PECS1 block ( n = 15) or Group PT: PECS1 and TTM blocks ( n = 15). The intraoperative requirement of midazolam and local anesthetic and level of sedation by Ramsay sedation score were noted. The pain was assessed by visual analog scale (VAS) at rest and during a cough or deep breathing at 0 h, 3 h, 6 h, 12 h, and 24 h after the procedure. Results: VAS scores at rest were significantly lower in group PT at 0, 3, 6, and 12 h postprocedure, and during cough at 0, 6, and 12 h after the procedure ( P < 0.05). At 24 h, VAS scores were comparable between both groups. Intraoperative midazolam consumption was higher in group P compared to group PT ( P = 0.002). Fourteen patients in group P received local anesthetic supplementation in comparison to only one patient in group PT ( P = 0.0001). Thirteen patients in group P received the first rescue analgesia in comparison to three patients in group PT ( P = 0.0003). Conclusion: Combined PECS1 and TTM blocks provide superior analgesia, reduced net consumption of local anesthetic, sedative agents, and rescue analgesics compared to PECS1 block alone in patients undergoing CIED insertion.

PECS II block for cardiac implantable electronic device insertion: A pilot study

“…However, as the innervation of the chest wall is very complex, PECS I block alone may not provide complete analgesia. Arasu et al 4 reported that PECS I block alone may be insufficient for analgesia, especially during tunneling and pocket creation, and the combination of PECS I and transversus thoracic muscle plane block provided superior analgesia than PECS I block alone. However, visualization of the transversus thoracic muscle by ultrasound may be difficult because of its thin structure.…”

“…It has been reported in a few studies and case reports that some truncal blocks could provide adequate surgical anesthesia and postoperative analgesia in CIED insertion. [3][4][5][6][7][8][9] Pectoral nerve (PECS) blocks (PECS I and PECS II) were introduced by Blanco and were seen to provide effective analgesia after breast surgery. 10,11 The PECS I block is a single plane block that provides analgesia of the lateral surface of the breast and chest wall after local anesthetic applied between the fascia of the pectoralis major and minor muscles.…”

“…Peripheral nerve block techniques may be considered for CIED insertion because the patients requiring CIED are usually high‐risk for general anesthesia and therefore, the possible adverse effects of general anesthesia may need to be avoided. It has been reported in a few studies and case reports that some truncal blocks could provide adequate surgical anesthesia and postoperative analgesia in CIED insertion 3–9 …”

Efficacy and safety of supraclavicular and pectoralis nerve blocks as primary peri‐procedural analgesia for cardiac electronic device implantation: A pilot study

“…Among the patients enrolled in the BRUISE CONTROL‐ 1 and 2 trials ( n = 1308), 26.8% of patients had moderate pain (VAS score 4−6), while 26.6% had severe pain (VAS score 7−10) 13 . PECs blocks were initially developed for thoracic and breast procedures and have now shown promise when used for CIED implantation in several case series 9–12,14 . The utilization of nerve blocks in CIED implantation has multiple benefits.…”

“…Recently, nerve blocks have been used to reduce periprocedural pain, intravenous sedation requirements, and possibly length of stay 8–14 . The PECS1 nerve block has previously been reported for CIED implantation.…”