in multiple rib fractures: a case report Continuous serratus anterior plane block providesanalgesia DEANESTESIOLOGIA REVISTABRASILEIRA

RevBrasAnestesiol.2019;69(1):87---90

REVISTA

BRASILEIRA DE

ANESTESIOLOGIA

CLINICAL INFORMATION

Continuous serratus anterior plane block provides analgesia in multiple rib fractures: a case report

Fernando Calado de Oliveira Camacho

, Elena Segura-Grau

aCentroHospitalardeSãoJoão,Servic¸odeAnestesiologia,Porto,Portugal

bCentroHospitalardeTondelaeViseu,Servic¸odeAnestesiologia,Viseu,Portugal

Received22December2017;accepted30March2018 Availableonline7May2018

KEYWORDS Regionalanesthesia;

Serratusplaneblock;

Ribfractures

Abstract Thoracictraumawithribfracturesisachallengingconditionduetothesevereasso- ciatedpain.Uncontrolledpainimpairsbreathingandanadequatepaincontrolisnecessaryto providecomfortandtoavoidfurthercomplications.SerratusAnteriorPlaneblockisaprocedure safeandeasytoaccomplish.Theauthorsdescribeacaseofthoracictraumawithribfractures andrespiratorycompromise.PaincontrolwasonlyachievedafterperformingaSerratusAnte- riorPlaneblock.Thetechniquewasdoneasdescribedinthemedicalliteraturewithplacement ofacatheter.Painreliefwasachievedwithalowconcentrationinfusionoflocalanesthetic.

©2018SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by- nc-nd/4.0/).

PALAVRAS-CHAVE Anestesiaregional;

Bloqueiodoplano serrátil;

Fraturasdecostelas

Obloqueiocontínuodoplanoserrátilanteriorforneceanalgesiaemfraturas múltiplasdecostelas:relatodecaso

Resumo Otraumatorácicocomfraturas decostelaséumacondic¸ãodesafiadora devidoà dorintensaassociada.Onãocontroledadorprejudicaarespirac¸ãoenquantooseucontrole adequadoénecessárioparaproporcionarconfortoeevitarmaiorescomplicac¸ões.Obloqueio doplanoserrátilanterioréumprocedimentoseguroefácilderealizar.Descrevemosumcaso detraumatorácicocomfraturasdecostelasecomprometimentorespiratório.Ocontroleda dorsófoiobtidoapósarealizac¸ãodobloqueiodoplanoserrátilanterior.Atécnicafoirealizada conforme descritonaliteraturamédica comacolocac¸ãode umcateter.Oalíviodadorfoi obtidocomumainfusãodeanestésicolocalembaixaconcentrac¸ão.

©2018SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigo OpenAccess sobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by- nc-nd/4.0/).

∗Correspondingauthor.

E-mail:fcamacho00@gmail.com(F.C.Camacho).

https://doi.org/10.1016/j.bjane.2018.04.005

0104-0014/©2018SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

88 F.C.Camacho,E.Segura-Grau

Introduction

Thoracicblunt trauma, especiallywhen multiple ribfrac- turesareassociated,ischallenging tomanageandcauses significantmorbidityduetotheseverepainimplied.¹

Patientscanpresentwithrespiratorycompromiseastheir capacitytoexpandthethoraxislimitedbypain.Asaresult, smallertidalvolumes areaccomplishedand theability to coughandclearsecretionsis impaired,possiblyleadingto atelectasisandanincreasedriskofrespiratoryinfections.²

Althoughmultipletherapeuticoptionsareavailable,pain managementcan be difficult.³ Intravenous analgesia with opioidsiscommonlyused,butitisassociatedwithmultiple sideeffects,suchassuppressionofthecoughreflex,respi- ratorydepression, nausea,vomitingandpruritus. Epidural analgesiaprovides goodanalgesia, but can betechnically difficultat thethoracic leveland hasseveralimplications andrisks.Paravertebralandintercostalblockscanalsobe performed,butarechallengingtodoandnotwithoutrisk.

Ultrasound-guidedSerratusAnteriorPlane(SAP)blockis arecenttechnique,firstdescribedbyBlancoetal.in2013, that provides analgesia for the thoracic wall by blocking thelateral branches of the intercostalnerves fromT2 to L2.Itisasafe,simpletoperformblockwithnosignificant contraindicationsorsideeffects.⁴

Wepresentacase reportofapatientwithmultiple rib fractureswhohadsevere,refractorypain.Thepatientwas successfullytreated witha SAPblock andplacementof a catheterfor continuous analgesia ona low concentration infusionoflocalanesthetic.

Written consentfor the publicationof thiscase report wasobtainedfromthepatient.

Case report

A 36-year-old male, ASA I, presented to the Emergency Department (ED) with right-sided thoracic trauma in the settingofasixmetersheightfall.

OnarrivaltotheEDthepatientwasalertandoriented, butcomplainedofsevereright-sidedthoracicpain.HisGlas- gowComaScalescorewas15withnoneurologicaldeficits.

Hisoxygensaturationwas94%onroomairbuthehadmild respiratorydistress.Thepatientwashemodynamicallysta- ble,withanormalheartrateandbloodpressure.

On physical examination hehad severe pain onpalpa- tionoftherighthemithoraxandslightlydiminishedbreath soundsonthesameside.Theremainingoftheexamination wasunremarkable.

His blood test results were normal. Radiological eval- uation was obtained. Head and cervical spine Computed Tomography(CT)werenegativeforinjuries.Chestradiogra- phyandthoraxCTshowedribfracturesofthefirstthrough theeighth ribs andconcomitant ipsilateralpneumothorax andpleuraleffusion.

A 24 Fr tube was inserted, with drainage of hematic contentinsmallquantity.

Nosurgical intervention wasindicated, but due tothe severe thoracic injuries he was admitted to the surgical intermediate care unit for clinical observation and pain control.

Hewasprescribed systemicintravenous analgesiawith Paracetamol, NSAID’s and IV opioids. His pain, however, remained severe, located on the right hemithorax, pre- ventinghimfrommovingandbreathingadequately.Onthe fifth day, due to the inadequate pain control, the Anes- thesia Acute Pain Service was consulted. Medication was reviewedanda morphinePCAwasaddedtohistherapeu- tics. Amild initialimprovement wasreported,butby the eightday the patientwasagainunder severepain witha Numerical Rating Scale (NRS) score of 8. He was bedrid- den, uneasy,didnot toleratemobilizationsandpresented withpainrelatedimpairedbreathing.Duetothetherapeu- ticfailure,hislungfunctionwasdeteriorating,withclinical andradiologicalworsening(Fig.1).Afterdiscussion,itwas decidedtoperformaSAPblockwithplacementofacatheter forcontinuousanalgesia.

The patient was monitored with pulse oximetry, ECG andnon-invasivebloodpressure.Withthepatientinsupine position,weusedalinearultrasoundtransducer (SonoSite M-Turbo) toscan over the right hemithorax tolocate the fifthribatthemidclavicularline.Wedislocatedtheprobe laterally,identifyingtheserratusanteriormuscleover the fifthrib.Afteranesthetisingtheskinwith2mLoflidocaine 2%, an 18 gauge Touhy needle was introduced in-plane, underdirectvisualization, totheplane immediatelydeep totheserratusanteriormuscle.Afternegativeaspiration, 20mLoflevobupivacaine0.25%wereinjected.Afterwards, a 20gauge peripheralnerve catheterwaseasilythreaded intothespace.Theneedlewasremovedandthecatheter securedwithadhesive(Fig.2).FiveminutesaftertheLocal Anesthetic(LA)administration, thepatientstartedfeeling asignificantreliefofpain.Afterafewmoreminutesheno longer had difficulty breathing and reported almost com- plete cessation of pain at rest. A levobupivacaine 0.12%

infusionatarateof5mL.h⁻¹byaDrugInfusionBalloon(DIB) wasstarted,andthepatientremainedunderobservationat the intermediatecare unit. On the following day, hewas abletostandupandsitonthebedsidechairandreporteda NRSscoreof0atrest,withaNRSscoreof3withmobiliza- tion.Onthe3rddayafterplacementofthecatheter,due tohisfavorableoutcome,hewastransferredtothesurgical

Figure1 Clinicalandradiologicalworsening.

SAPblockformultipleribfractures 89

Figure2 Theneedlewasremovedandthecathetersecured withadhesive.

ward.TheLAinfusionwasmaintainedforatotaloffivedays, afterwhichitwasremoved.HewaskeptonParacetamoland NSAID’s,butdidnotrequireopioidtherapyaftertheplace- mentofthecatheter.Thepatientremainedcomfortableat alltimesandabletomobilizeaswell.Onthethirddaypost removalofthecatheter,hewasdischargedhome,without painorothercomplicationswhatsoever.

Discussion

Thiscasereportintendstodemonstratethecomplexityof pain management in thoracic trauma with associated rib fractures.

Currentgold standardfor managementofpaininblunt thoracic trauma is the placement of a thoracic epidural catheter.However,manypatientsareelderly,withmultiple comorbidities,andareonanticoagulantorantiplateletther- apy, limitingitsfeasibility.The riskof hypotensiondueto thebilateralthoracicsympathectomyisalsoaconcern,and itcanbetechnicallydifficulttoplaceanepiduralcatheter atathoraciclevel.Developmentofnovelapproaches,such as SAP block, is promising, as it carries fewer risks and contraindications; it is easy to perform under ultrasound guidance and provides adequate analgesia. In our case, a multimodal intravenous analgesia protocol was imple- mented initially, with no success after several days of treatment,henceourchoicetoplaceaSAPcatheter.

This atechniquefirstdescribedbyBlancoetal.⁴Inthe originalstudy,theyadministered0.4mg.kg⁻¹oflevobupiva- caine0.125%underultrasoundguidancetofourvolunteers, achieving analgesia from T2 to T9. It evolved from the Pecs I and II blocks described by the same authors, and wasintendedtoprovideanalgesiafor patientsundergoing surgery involving thethoracic wall, specifically for breast surgery. It has since been described in the medical liter- ature for other purposes, such as providing analgesia in thoracic traumapatients, particularlythosewithmultiple ribfractures.⁵

In this case report, we chose not to place a thoracic epiduralcatheterduetothefactthatthepatientwasunder severepainanditwouldbedifficulttopositionhimforthe procedure.Aparavertebralblockcouldpossiblyworsenthe

respiratoryfunctionintheeventofaniatrogenicpneumoth- orax.Asso,weoptedtoperformaSAPblockwithplacement ofacatheterforprolongedanalgesiceffect,althoughthere arefewstudiesinthemedicalliteratureforthecontinuous techniquein thesetting of thoracic traumawithribfrac- tures. After the LA administration, the patient improved inamatterofminutes,asdescribedinotherreports.⁵He couldagainbreathe deeply without painand mobilize his rightarm.Hismood improvedinstantly.Heremainedpain freeforthedurationoftheLAinfusionandwasabletoper- formphysicalrehabilitation, whichwherethegoalsofour treatment.

Althoughthepatientwashealthy,hisprolongedbedrid- den status was starting to take a toll, as he was having difficultyto adequatelybreathe, cough and mobilize sec- retions.His serial chest radiography’s showed developing opacitiesin both lungfields, suggestiveof atelectasis.He hadrepeatedachesttomographyat the8daypost hospi- taladmissionthatconfirmedthediagnosis.Paincontrolwas necessarytopreventfurthercomplications,suchasrespira- toryinfectionandfailure.

Ultrasound-guided continuous SAP block is a relatively recenttechniquetoprovideanalgesiaincasesofmultiplerib fractures.Theoptimalanalgesicregimenisnotwelldefined, butwechoseaninfusionofalowconcentrationofLA,min- imizingpotentialrisksassociatedtoLAtoxicity,while still providingadequateanalgesia.

Thiscasereportandthecurrentliteraturesuggestthat continuousSAPblockis an effectivemethod foranalgesia incasesofmultipleribfractures.Itisatechniquethatcan easily be accomplishedat bedside, inclusively at the ED.

Webelieveitisan option totake intoaccountin difficult casessuchasthis,beingabletoprovideadequate analge- siawithminimalcomplications.However,morestudiesare requiredtohelpascertaintheidealsitefortheplacement of thecatheter, the optimalconcentration and dosage of theLAandtocompareitsefficiencywithothermethodsof analgesia.

Conflicts of interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgments

Theauthors wouldliketoacknowledgeDoctorJosé Pedro Assunc¸ão,ChiefoftheAnesthesiologyDepartmentofCentro HospitalardeTondelaeViseu.

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