Ultrasound guided serratus anterior plane block for thoracic analgesia in a patient with multiple rib fractures
Mbuvah F, Garzon-Serrano J. Ultrasound guided serratus anterior plane block for thoracic analgesia in a patient with multiple rib fractures. Regional Anesthesia and Pain Medicine 2017; 42(6).
Regional Anesthesia and Pain Medicine
Introduction Multiple rib fractures are associated with multiple complications, with pneumonia occurring in up to 30% of elderly patients . Adequate pain control is fundamental in improving patient tolerance for deep breathing, which in turn decrease the risk of respiratory complications. We report a case of an elderly patient with multiple rib fractures post fall and severe kyphoscoliosis, whose pain was safely and adequately managed with a serratus anterior plane block (SAP). Results/Case report A 94 year old female patient with dementia was admitted with right rib fractures (ribs 7 through 10) post fall. She was alert and oriented x 0 at baseline, making an accurate assessment of her pain challenging. However she was hypertensive, tachycardic and appeared uncomfortable. She was initially started on Acetaminophen 650 mg orally every 6 hrs as needed, Fentanyl 12 mcg/hr patch, Hydrocodone -acetaminophen 5-325 mg 2 tablets every 6 hrs as needed and Morphine 6 mg orally every 2 hrs as needed. She did not seem to tolerate the use of the incentive spirometer despite escalating doses of the above medications. A regional technique was considered as an adjunct to her multimodal pain regime. However her severe kyphoscoliosis made a thoracic epidural technically challenging. Therefore, we decided to perform a right serratus anterior plane continuous block. With the patient in slight left lateral decubitus position, the right hemithorax was prepped in a sterile fashion. A high frequency linear probe was placed in a sagittal plane along the mid axillary line. The skin was then infiltrated with 5 cc of 1 % lidocaine and then a 17 G, 89 mm Tuohy needle was advanced in-plane to the plane below the serratus anterior muscle (Fig 1). 30 cc of 0.2% Ropivacaine was then injected with direct visualization of spread of local anesthetic. A 19G catheter was then placed into this plane through the Tuohy needle and secured at 22 cm at the skin (Fig 2). A continuous infusion of 8 cc/hr of 0.2% Ropivacaine was started thereafter via an elastomeric pump. The patient's tachycardia and hypertension significantly improved a few hours later and the patient appeared subjectively more comfortable. The patient was able to better tolerate breathing exercises and the catheter was removed after 5 days without any complications. Patient consent for submission of the case report for publication/presentation has been obtained. Discussion Adequate pain control improves respiratory mechanics in patients with thoracic pain, reducing the risk of pulmonary complications . The SAP is an ultrasound-guided nerve block used to anesthetize the hemithorax by blocking the lateral branches of the intercostal nerves as they traverse the plane below serratus anterior muscles . The SAP has been used to provide thoracic analgesia is patients with multiple rib fractures and post thoracotomies  and is a safe and simple alternative to a thoracic epidural in patients with contraindications to thoracic epidurals such as severe kyphoscoliosis. This technique can be used as part of a multimodal analgesia regime or as the sole technique for pain control in patients in whom narcotics are better avoided.