Refining a great idea: the consolidation of PECS I, PECS II and serratus blocks into a single thoracic fascial plane block, the SAP block

2019 ◽  
pp. rapm-2019-100745 ◽  
Author(s):  
Carlo D Franco ◽  
Konstantin Inozemtsev
Keyword(s):  
Brachial Plexus ◽  
Chest Wall ◽  
Mechanism Of Action ◽  
Sensory Innervation ◽  
Common Mechanism ◽  
Nerve Blocks ◽  
Intercostal Nerves ◽  
Lateral Branches ◽  
Fascial Plane Block ◽  
Fascial Plane

The popularity of ultrasound-guided nerve blocks has impacted the practice of regional anesthesia in profound ways, improving some techniques and introducing new ones. Some of these new nerve blocks are based on the concept of fascial plane blocks, in which the local anesthetic is injected into a plane instead of around a specific nerve. Pectoralis muscles (PECS) and serratus blocks, most commonly used for post op analgesia after breast surgery, are good examples. Among the nerves targeted by PECS/serratus blocks are different branches of the brachial plexus that traditionally have been considered purely motor nerves. This unsubstantiated claim is a departure from accepted anatomical knowledge and challenges our understanding of the sensory innervation of the chest wall. The objective of this Daring Discourse is to look beyond the ability of PECS/serratus blocks to provide analgesia/anesthesia of the chest wall, to concentrate instead on understanding the mechanism of action of these blocks and, in the process, test the veracity of the claim. After a comprehensive review of the evidence we have concluded that (1) the traditional model of sensory innervation of the chest wall, which derives from the lateral branches of the upper intercostal nerves and does not include branches of the brachial plexus, is correct. (2) PECS/serratus blocks share the same mechanism of action, blocking the lateral branches of the upper intercostal nerves, and so their varied success is tied to their ability to reach them. This common mechanism agrees with the traditional innervation model. (3) A common mechanism of action supports the consolidation of PECS/serratus blocks into a single thoracic fascial plane block with a point of injection closer to the effector site. In a nod to transversus abdominus plane block, the original inspiration for PECS blocks, we propose naming this modified block, the serratus anterior plane block.

The analgesic effects of combined pectoral nerve blocks versus combined serratus anterior plane block and pecto-intercostal fascial plane block in breast surgery

QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
Hany Mohamed Mohamed ElZahaby ◽  
Sahar Mohamed Talaat ◽  
Mohamed Mohamed Abd El FattahGhoneim ◽  
Manar Mohsen Ahmed Matared
Keyword(s):  
Breast Surgery ◽  
P Value ◽  
Serratus Anterior ◽  
Nerve Blocks ◽  
Rescue Analgesia ◽  
Analgesic Effects ◽  
Pectoral Nerve ◽  
Fascial Plane Block ◽  
Anterior Plane ◽  
Fascial Plane

Abstract Background Poorly controlled acute pain after breast surgery is associated with a variety of unwanted post-operative consequences, including patient suffering, distress, respiratory complications, prolonged hospital stay and increased likelihood of chronic pain. The analgesic regimen used for postoperative pain control needs to meet the goals of providing safe, effective analgesia, with minimal side effects for the patient. Objective The aim of this study is to compare the intra-operative and the post-operative analgesic effects of the thoracic interfascial plane blocks (serratus anterior plane block in combination with pecto-intercostal fascial plane block) and pectoral nerve blocks (PECS I and II)in patients undergoing non-reconstructive breast surgeries. Patients and Methods The study was conducted on 50 randomly chosen patients in Ain Shams University General Surgery Hospital after approval of the medical ethical committee. They were allocated in two groups of 25 patients each. The two groups were compared regarding analgesic outcome by using the visual analogue scaling system in the first 24 hours postoperative and the patients' satisfaction using verbal rating scale and this was the primary outcome of our study. The amount of fentanyl consumed intra-operative, time for first call for rescue analgesia and the frequency of using it were recorded and compared to achieve the secondary outcome of the study which included reducing opiods requirements and avoiding their side effects. Results The study found that the total amount of intra-operative fentanyl consumption was significantly higher in the SAPB and PIFB group than the Pecs group with the range of 100-150 versus 100-200 micg fentanyl respectively, and the VAS was significantly higher in the combination of serratus anterior plane block and pecto-intercostal fascial plane block compared to Pecs I and II at 8th, 12th and 24th hours post operatively with p value 0.018, 0.022 and 0.032 respectively, also the frequency of administration of rescue analgesia was higher in the SABP and PIFB group with the range of (2 to 3) times in PECS I and II group versus (2 to 5) in SABP/PIFB group. Besides, the first request of post-operative morphine was significantly delayed in the pectoral nerve blocks than the SABP and PIFB group with the p value (0.020). Conclusion The present study found that Pecs I and II group provided superior intra-operative and post-operative analgesic control compared to the serratus and PIFB group in patients undergoing non-reconstructive breast surgeries.

Fascial plane blocks and peripheral nerve blocks: two planets not so far apart

2019 ◽  
Vol 85 (10) ◽  
Author(s):  
Pierfrancesco Fusco ◽  
Eugenio Di Martino ◽  
Giuseppe Paladini ◽  
Francesca De Sanctis ◽  
Stefano Di Carlo ◽  
...  
Keyword(s):  
Peripheral Nerve ◽  
Nerve Blocks ◽  
Peripheral Nerve Blocks ◽  
Fascial Plane

Eight years and already a classic: marking the rise of ultrasound‐guided fascial plane blocks for chest wall surgery

Anaesthesia ◽  
2021 ◽  
Vol 76 (8) ◽  
pp. 1129-1133
Author(s):  
A. H. Kumar ◽  
E. Sultan ◽  
E. R. Mariano
Keyword(s):  
Chest Wall ◽  
Ultrasound Guided ◽  
Fascial Plane

Ultrasound‐guided fascial plane blocks of the chest wall: a state‐of‐the‐art review

Anaesthesia ◽  
2021 ◽  
Vol 76 (S1) ◽  
pp. 110-126 ◽  
Author(s):  
K. J. Chin ◽  
B. Versyck ◽  
A. Pawa
Keyword(s):  
Chest Wall ◽  
State Of The Art ◽  
Ultrasound Guided ◽  
Fascial Plane

scholarly journals Bacteriophage-derived CHAP domain protein, P128, kills Staphylococcus cells by cleaving interpeptide cross-bridge of peptidoglycan

Microbiology ◽  
2014 ◽  
Vol 160 (10) ◽  
pp. 2157-2169 ◽  
Author(s):  
Sudarson Sundarrajan ◽  
Junjappa Raghupatil ◽  
Aradhana Vipra ◽  
Nagalakshmi Narasimhaswamy ◽  
Sanjeev Saravanan ◽  
...  
Keyword(s):  
Staphylococcus Aureus ◽  
Mechanism Of Action ◽  
Catalytic Domain ◽  
Antibiotic Sensitivity ◽  
High Sensitivity ◽  
Common Mechanism ◽  
Cross Bridge ◽  
Sensitivity Pattern

P128 is an anti-staphylococcal protein consisting of the Staphylococcus aureus phage-K-derived tail-associated muralytic enzyme (TAME) catalytic domain (Lys16) fused with the cell-wall-binding SH3b domain of lysostaphin. In order to understand the mechanism of action and emergence of resistance to P128, we isolated mutants of Staphylococcus spp., including meticillin-resistant Staphylococcus aureus (MRSA), resistant to P128. In addition to P128, the mutants also showed resistance to Lys16, the catalytic domain of P128. The mutants showed loss of fitness as shown by reduced rate of growth in vitro. One of the mutants tested was found to show reduced virulence in animal models of S. aureus septicaemia suggesting loss of fitness in vivo as well. Analysis of the antibiotic sensitivity pattern showed that the mutants derived from MRSA strains had become sensitive to meticillin and other β-lactams. Interestingly, the mutant cells were resistant to the lytic action of phage K, although the phage was able to adsorb to these cells. Sequencing of the femA gene of three P128-resistant mutants showed either a truncation or deletion in femA, suggesting that improper cross-bridge formation in S. aureus could be causing resistance to P128. Using glutathione S-transferase (GST) fusion peptides as substrates it was found that both P128 and Lys16 were capable of cleaving a pentaglycine sequence, suggesting that P128 might be killing S. aureus by cleaving the pentaglycine cross-bridge of peptidoglycan. Moreover, peptides corresponding to the reported cross-bridge of Staphylococcus haemolyticus (GGSGG, AGSGG), which were not cleaved by lysostaphin, were cleaved efficiently by P128. This was also reflected in high sensitivity of S. haemolyticus to P128. This showed that in spite of sharing a common mechanism of action with lysostaphin, P128 has unique properties, which allow it to act on certain lysostaphin-resistant Staphylococcus strains.

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