Anaesthesia 2015, 70, 502–510
References 1. Pandit JJ, Andrade J, Bogod D, et al. The 5th national audit project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Anaesthesia 2014; 69: 1089–101. 2. Nightingale CE. NAP5- death knell for the anaesthetic room. Anaesthesia 2015; 70: 108–9. 3. Lawrence M, Ball DR. Why use anaesthetic rooms? Anaesthesia News 2015; 330: 24. doi:10.1111/anae.13050
Death of the anaesthetic room II Induction of general anaesthesia has taken place in the operating theatre rather than separate anaesthetic rooms at our hospital since 1995, without detriment to efficiency or patient safety, even when managing high-risk cases [1]. Reasons for this move were described in a letter to Anaesthesia in 2001 [2], in response to an editorial by Professor Harmer [3] and comments by Diana Brahams, Barrister-at-Law, who described the practice of moving unmonitored, disconnected, anaesthetised patients as ‘clumsy and ill conceived’ [4]. In our minds, there is no sensible, considered reason why induction should take place in the anaesthetic room. In-theatre induction allows uninterrupted monitoring and self-positioning of patients, with reduced risks of accidental awareness and manual handling injuries, during the early, more hazardous and unstable stages of general anaesthesia. From a trainee’s perspective, in-theatre induction inculcates safe practice in the delivery of anaesthesia from the outset of one’s profes508
Correspondence
sional career. It would be interesting to undertake further research about trainees’ comparative experiences of adapting to anaesthetic rooms when they move to other hospitals that do not currently employ this method. R. Morris J. Broadway Ipswich Hospital NHS Trust, Ipswich, UK Email: james.broadway@ ipswichhospital.nhs.uk No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References
1. Nightingale CE. NAP 5 – death knell for the anaesthetic room? Anaesthesia 2015; 70: 108–9. 2. Broadway JW, Smith MG, Archer TJ. Anaesthesia without induction rooms. Anaesthesia 2001; 56: 82–3. 3. Harmer M. ‘For the times they are achanging’ – or are they? Anaesthesia 2000; 55: 735–6. 4. Brahams D. Series of errors which culminated in death. Anaesthesia 1990; 45: 332–3. doi:10.1111/anae.13058
Yet more on Pecs block nomenclature Blanco et al. have usefully proposed superficial nerve block for analgesia after breast surgery as an alternative to paravertebral block [1–3]. The nomenclature of such techniques remains confusing [4]. I would like to suggest a clarification, by proposing that the term ‘Pecs block’ should be limited to injec-
tion between the major and minor pectoralis muscles, in order to block the lateral and medial pectoral nerves [1]. These innervate both the pectoralis major and minor muscles, and despite the numerous anatomical variations of the medial pectoral nerve [5], appear to be of most use during the insertion of breast expanders beneath the pectoralis muscles [1], when co-administered with a paravertebral block [6]. The thoracic intercostal nerves T2-T6 innervate the breast. In the mid-axillary line, these nerves cross serratus anterior and innervate the lateral aspect of the breast. In the axilla, these nerves follow the long thoracic nerve, supplying serratus anterior and latissimus dorsi (as the thoracodorsal nerve). All of these nerves may be involved in breast surgery. For example, thoracodorsal innervation is important in latissimus dorsi flap creation during breast reconstruction. Both Pecs II [2] and serratus plane block [3] affect all these nerves in the axilla. I propose naming the injection of local anaesthetic into this area an ‘axillary compartment block. In my daily practice, I inject 20 ml local anaesthetic under ultrasound guidance superficially to serratus muscle, cranially directed and in the mid-axillary line. Although further investigation is needed, axillary compartment block appears to provide a suitable alternative to paravertebral block, particularly as surgical dissection of fascia may allow the spread of local anaesthesia between intrapectoral and axillary compartments, facilitating the effects of continuous postoperative infiltration [7].
© 2015 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
Anaesthesia 2015, 70, 502–510
R. Fuzier Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthe siacorrespondence.com.
References 1. Blanco R. The ‘pecs block’: a novel technique for providing analgesia after breast surgery. Anaesthesia 2011; 66: 847–8. 2. Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): a novel approach to ~ola de breast surgery. Revista Espan n 2012; 59: Anestesiologia y Reanimacio 470–5. 3. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013; 68: 1107–13. 4. Sebastian MP. Pecs II or serratus plane block? Anaesthesia 2014; 69: 1173. 5. Porzionato A, Macchi V, Stecco C, Loukas M, Tubbs RS, De Caro R. Surgical anatomy of the pectoral nerves and the pectoral musculature. Clinical Anatomy 2012; 25: 559–75. 6. Bouzinac A, Tournier JJ, Delbos A, Berot JE. Interest of ultrasound-guided lateral pectoral nerve block associated with paravertebral block for complete mastectomy pain management. Annales sie et de Re animaFrancaises d’Anesthe tion 2014; 33: 548–50. 7. Wallaert M, Courivaud P, Mati EH, Shiniara M, Guilbert JM. Catheter for continuous interpectoral block and postoperative pain relief in breast surgery. Annales Francaises sie et de Re animation 2014; d’Anesthe 33: 269–71. doi:10.1111/anae.13039
A reply Fuzier’s reclassification of three thoracic wall blocks (Pecs I [1], Pecs II [2] and serratus plane blocks [3])
into two major compartment blocks (pectoral and axillary) is interesting. The Pecs I block provides similar analgesia to the pectoral compartment block, for the apex of the axilla and for superficial dissections. Unless dissection is deep and posterior, this is sufficient without additional axillary compartment infiltration. I agree with Fuzier that there must be a communication between the two compartments, but there might also be heterogeneity of the nerve supply, and it will be difficult to compare Pecs I with pectoral compartment blocks until these anatomical issues are resolved. The Pecs II block provides a similar effect to combined pectoral and axillary compartment blocks, because is performed at two levels (between the pectoralis muscles, and between pectoralis minor and serratus anterior muscles) and was designed to reach the lower segments of the hemithorax. The serratus plane block was never designed to affect the pectoral compartment, which is why its name was changed from Pecs III to serratus plane block. I agree that anaesthetising the chest wall is complex both conceptually and in performance. Anything that helps clinicians understand the importance of there being two main compartments is important, and Fuzier’s simple classification reinforces this idea. R. Blanco Corniche Hospital, Abu Dhabi, UAE Email: [email protected] No external funding and no competing interests declared. Previously
© 2015 The Association of Anaesthetists of Great Britain and Ireland
posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. Blanco R. The pecs block: a novel technique for providing analgesia after breast surgery. Anaesthesia 2011; 66: 847–8. 2. Blanco R, Fajardo M, Parras T. Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast ~ola de Anestesisurgery. Revista Espan ologˇ a y Reanimacion 2012; 59: 470– 5. 3. Blanco R, Parras T, McDonnell JG, PratsGalino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013; 68: 1107–13. doi:10.1111/anae.13057
Joseph Snape and electroanaesthesia In their admirable paper on the history of electroanaesthesia [1], the authors describe its local use in dentistry around 1950 as ‘very early’. In fact, Joseph Snape, a dentist on the staff of the Liverpool Royal Infirmary, published a monograph on this subject in 1858 [2]. He described his apparatus and technique and claimed much success, quoting testimonials from many satisfied patients. His main problem was insulating his instruments from contact with the surrounding tissues. To emphasise the safety of his method, he mentioned a death under chloroform in Epsom in 1858, the dentist being one of his own students, a Mr Keeling [3]. He also wrote a letter to The Times on the safety of his method [4]. He continued to use the technique, described in two further editions of his book (the last published in 1874). In 1881, after his 509
References 1. Pandit JJ, Andrade J, Bogod D, et al. The 5th national audit project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Anaesthesia 2014; 69: 1089–101. 2. Nightingale CE. NAP5- death knell for the anaesthetic room. Anaesthesia 2015; 70: 108–9. 3. Lawrence M, Ball DR. Why use anaesthetic rooms? Anaesthesia News 2015; 330: 24. doi:10.1111/anae.13050
Death of the anaesthetic room II Induction of general anaesthesia has taken place in the operating theatre rather than separate anaesthetic rooms at our hospital since 1995, without detriment to efficiency or patient safety, even when managing high-risk cases [1]. Reasons for this move were described in a letter to Anaesthesia in 2001 [2], in response to an editorial by Professor Harmer [3] and comments by Diana Brahams, Barrister-at-Law, who described the practice of moving unmonitored, disconnected, anaesthetised patients as ‘clumsy and ill conceived’ [4]. In our minds, there is no sensible, considered reason why induction should take place in the anaesthetic room. In-theatre induction allows uninterrupted monitoring and self-positioning of patients, with reduced risks of accidental awareness and manual handling injuries, during the early, more hazardous and unstable stages of general anaesthesia. From a trainee’s perspective, in-theatre induction inculcates safe practice in the delivery of anaesthesia from the outset of one’s profes508
Correspondence
sional career. It would be interesting to undertake further research about trainees’ comparative experiences of adapting to anaesthetic rooms when they move to other hospitals that do not currently employ this method. R. Morris J. Broadway Ipswich Hospital NHS Trust, Ipswich, UK Email: james.broadway@ ipswichhospital.nhs.uk No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References
1. Nightingale CE. NAP 5 – death knell for the anaesthetic room? Anaesthesia 2015; 70: 108–9. 2. Broadway JW, Smith MG, Archer TJ. Anaesthesia without induction rooms. Anaesthesia 2001; 56: 82–3. 3. Harmer M. ‘For the times they are achanging’ – or are they? Anaesthesia 2000; 55: 735–6. 4. Brahams D. Series of errors which culminated in death. Anaesthesia 1990; 45: 332–3. doi:10.1111/anae.13058
Yet more on Pecs block nomenclature Blanco et al. have usefully proposed superficial nerve block for analgesia after breast surgery as an alternative to paravertebral block [1–3]. The nomenclature of such techniques remains confusing [4]. I would like to suggest a clarification, by proposing that the term ‘Pecs block’ should be limited to injec-
tion between the major and minor pectoralis muscles, in order to block the lateral and medial pectoral nerves [1]. These innervate both the pectoralis major and minor muscles, and despite the numerous anatomical variations of the medial pectoral nerve [5], appear to be of most use during the insertion of breast expanders beneath the pectoralis muscles [1], when co-administered with a paravertebral block [6]. The thoracic intercostal nerves T2-T6 innervate the breast. In the mid-axillary line, these nerves cross serratus anterior and innervate the lateral aspect of the breast. In the axilla, these nerves follow the long thoracic nerve, supplying serratus anterior and latissimus dorsi (as the thoracodorsal nerve). All of these nerves may be involved in breast surgery. For example, thoracodorsal innervation is important in latissimus dorsi flap creation during breast reconstruction. Both Pecs II [2] and serratus plane block [3] affect all these nerves in the axilla. I propose naming the injection of local anaesthetic into this area an ‘axillary compartment block. In my daily practice, I inject 20 ml local anaesthetic under ultrasound guidance superficially to serratus muscle, cranially directed and in the mid-axillary line. Although further investigation is needed, axillary compartment block appears to provide a suitable alternative to paravertebral block, particularly as surgical dissection of fascia may allow the spread of local anaesthesia between intrapectoral and axillary compartments, facilitating the effects of continuous postoperative infiltration [7].
© 2015 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
Anaesthesia 2015, 70, 502–510
R. Fuzier Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthe siacorrespondence.com.
References 1. Blanco R. The ‘pecs block’: a novel technique for providing analgesia after breast surgery. Anaesthesia 2011; 66: 847–8. 2. Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): a novel approach to ~ola de breast surgery. Revista Espan n 2012; 59: Anestesiologia y Reanimacio 470–5. 3. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013; 68: 1107–13. 4. Sebastian MP. Pecs II or serratus plane block? Anaesthesia 2014; 69: 1173. 5. Porzionato A, Macchi V, Stecco C, Loukas M, Tubbs RS, De Caro R. Surgical anatomy of the pectoral nerves and the pectoral musculature. Clinical Anatomy 2012; 25: 559–75. 6. Bouzinac A, Tournier JJ, Delbos A, Berot JE. Interest of ultrasound-guided lateral pectoral nerve block associated with paravertebral block for complete mastectomy pain management. Annales sie et de Re animaFrancaises d’Anesthe tion 2014; 33: 548–50. 7. Wallaert M, Courivaud P, Mati EH, Shiniara M, Guilbert JM. Catheter for continuous interpectoral block and postoperative pain relief in breast surgery. Annales Francaises sie et de Re animation 2014; d’Anesthe 33: 269–71. doi:10.1111/anae.13039
A reply Fuzier’s reclassification of three thoracic wall blocks (Pecs I [1], Pecs II [2] and serratus plane blocks [3])
into two major compartment blocks (pectoral and axillary) is interesting. The Pecs I block provides similar analgesia to the pectoral compartment block, for the apex of the axilla and for superficial dissections. Unless dissection is deep and posterior, this is sufficient without additional axillary compartment infiltration. I agree with Fuzier that there must be a communication between the two compartments, but there might also be heterogeneity of the nerve supply, and it will be difficult to compare Pecs I with pectoral compartment blocks until these anatomical issues are resolved. The Pecs II block provides a similar effect to combined pectoral and axillary compartment blocks, because is performed at two levels (between the pectoralis muscles, and between pectoralis minor and serratus anterior muscles) and was designed to reach the lower segments of the hemithorax. The serratus plane block was never designed to affect the pectoral compartment, which is why its name was changed from Pecs III to serratus plane block. I agree that anaesthetising the chest wall is complex both conceptually and in performance. Anything that helps clinicians understand the importance of there being two main compartments is important, and Fuzier’s simple classification reinforces this idea. R. Blanco Corniche Hospital, Abu Dhabi, UAE Email: [email protected] No external funding and no competing interests declared. Previously
© 2015 The Association of Anaesthetists of Great Britain and Ireland
posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. Blanco R. The pecs block: a novel technique for providing analgesia after breast surgery. Anaesthesia 2011; 66: 847–8. 2. Blanco R, Fajardo M, Parras T. Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast ~ola de Anestesisurgery. Revista Espan ologˇ a y Reanimacion 2012; 59: 470– 5. 3. Blanco R, Parras T, McDonnell JG, PratsGalino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013; 68: 1107–13. doi:10.1111/anae.13057
Joseph Snape and electroanaesthesia In their admirable paper on the history of electroanaesthesia [1], the authors describe its local use in dentistry around 1950 as ‘very early’. In fact, Joseph Snape, a dentist on the staff of the Liverpool Royal Infirmary, published a monograph on this subject in 1858 [2]. He described his apparatus and technique and claimed much success, quoting testimonials from many satisfied patients. His main problem was insulating his instruments from contact with the surrounding tissues. To emphasise the safety of his method, he mentioned a death under chloroform in Epsom in 1858, the dentist being one of his own students, a Mr Keeling [3]. He also wrote a letter to The Times on the safety of his method [4]. He continued to use the technique, described in two further editions of his book (the last published in 1874). In 1881, after his 509
