Anatomical Evaluation of a Conventional Pectoralis II Versus a Subserratus Plane Block for Breast Surgery.

BACKGROUND: Pectoralis I and II (Pecs I/Pecs II) blocks are modern regional anesthetic techniques performed in combination to anesthetize the nerves involved in breast surgery and axillary node dissection. Pecs II spread and clinical efficacy is thought to be independent of whether injection occurs between pectoralis minor and serratus anterior or deep to serratus anterior. Injecting deep to serratus anterior onto the rib may be technically easier; however, our clinical experience suggests that this approach may be less effective for axillary dissection. We undertook a cadaveric study to evaluate a subserratus plane approach for use in breast and axillary surgery. METHODS: Ultrasound-guided blocks using methylene blue dye were performed on 4 Genelyn-embalmed cadavers to assess and compare dye spread after a conventional Pecs II and a subserratus plane block at the third rib. RESULTS: Conventional Pecs II injection demonstrated staining of the intercostobrachial nerve, third intercostal nerve, thoracodorsal nerve, long thoracic nerve, medial pectoral, and lateral pectoral nerve. The subserratus plane produced significantly less axillary spread, incomplete staining of the medial pectoral, and very minimal staining of the lateral pectoral nerve. Dye spread was limited to the lateral cutaneous branches of the intercostal nerves in both injections. CONCLUSIONS: In our cadaveric study, injecting deep to serratus plane produced significantly less axillary spread. For breast surgery excluding the axilla, both techniques may be effective; however, for axillary dissection, the conventional Pecs II is likely to produce superior analgesia and additionally may help achieve complete coverage of the deeper pectoral nerve branches.

Ambulatory anesthetic care in children undergoing myringotomy and tube placement: current perspectives.

PURPOSE: Myringotomy and tube placement is one of the most frequently performed ear, nose and throat (ENT) surgeries in the pediatric population. Effective anesthetic management is vital to ensuring successful ambulatory care and ensuring child and parental satisfaction. RECENT FINDINGS: This review summarizes recently published studies about the long-term effects of general anesthesia in young children, novel approaches to preoperative fasting and simplified approaches to the assessment and management of emergence delirium (ED) and emergence agitation (EA). New developments in perioperative ambulatory care, including management of comorbidities and day care unit logistics, are discussed. SUMMARY: Long-term follow-up of children exposed to general anesthesia before the age of 4 years has limited impact on academic achievement or cognitive performance and should not delay the treatment of common ENT pathology, which can impair speech and language development. A more liberal approach to fasting, employing a 6-4-0 regime allowing children fluids up until theater, may become an accepted practice in future. ED and EA should be discriminated from pain in recovery and, where the child is at risk of harm, should be treated promptly. Postoperative pain at home remains problematic in ambulatory surgery and better parental education is needed. Effective ambulatory care ultimately requires a well-coordinated team approach from effective preassessment to postoperative follow-up.