472 | Correspondence

exclusion, while the total success range was 37–98%. Including References
all VLs, the view was excellent in only 60% of patients, and the
1. Kleine-Brueggeney M, Greif R, Schoettker P, Savoldelli GL,
time for intubation ranged from 47 to 93 s, including the ‘I can
Nabecker S, Theiler LG. Evaluation of six videolaryngoscopes
see but I can’t intubate’ scenario. Injury to soft tissue and bleed-
in 720 patients with a simulated difficult airway: a multi-
ing occurred in 5–36% of the patients.
centre randomized controlled trial. Br J Anaesth 2016; 116:
Given that the study setting could not reflect real difficult
670–9
situations, let us project these data to the number of worldwide
2. Welsler TG, Regenbogen SE, Thompson KD, et al. An estima-
anaesthetic procedures performed in the estimated 230 million
tion of the global volume of surgery: a modelling strategy
major surgeries annually worldwide,2 including 60 000 anaes-
based on available data. Lancet 2008; 372: 139–44
thetics each day in the USA3 and 2.9 million annually in the UK.4
3. NIH. Waking up to Anesthesia, Learn More Before You Go Under.
Admitting a 2–2.4% failure rate, millions of (unexpected) difficult
NIH- News in Health. April 2011. Available from https://newsin
intubations should occur annually. These figures remain diffi-
health.nih.gov/issue/apr2011/feature1 (accessed 24.01.17)
cult to accept, and we could not be satisfied even with 98% VL
4. Cook TM, Woodall N, Frerk C; Fourth National Audit Project.
success, which is the best performance from the study.1
Major complication of airway management in the UK: results
The most efficient VLs certainly represent progress in com-
of the Fourth National Audit Project of the Royal College of
parison to direct laryngoscopy, but clearly they do solve the
Anesthetists and the Difficult Airway Society. Part 1: anes-
problem of difficult unforeseen intubation or decrease the need
thesia. Br J Anaesth 2011; 106: 617–31
for bronchoscope use,5 and therefore they cannot be the Holy
5. Thomas G, Kelly F, Cook T. Introduction of videolaryngo-
Grail of difficult airways. We need further studies to solve the
scopy has not reduced rates of fibreoptic intubation. Br J
new questions that these new devices bring up, with correct in-
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struments and specific end points, not simply of laryngeal view
6. Cortellazzi P, Caldiroli D, Byrne A, Sommariva A, Orena EF,
(using tools such as Freemantle score or POGO—as the authors
Tramacere I. Defining and developing expertise in tracheal
correctly did—and not only Cormack–Lehane), but also of intub- R
intubation using a GlideScopeV for anaesthetists with ex-
ation feasibility, time, and side-effects. We need to define precise
pertise in Macintosh direct laryngoscopy: an in-vivo longitu-
learning curves (and they are probably steeper for VLs than for
dinal study. Anaesthesia 2015; 70: 290–5
MacIntosh).6 We need taxonomic classification of VLs (e.g. chan-
7. Gruppo di Studio SIAARTI Vie Aeree Difficili. Raccomanda-
nelled, unchannelled, hybrid, or based on blade angles/thickness
zioni per il controllo delle vie aeree e la gestione delle
or field of view), clearly stating potential indications and
difficolt? Minerva Anestesiol 2005; 71: 617–57
limitations for each device; we probably also need to define new
8. Sgalambro F. Unexpected difficult intubation: many algo-
VL-specific difficult airway prediction parameters. Only there-
rithms, many devices, many techniques, the best choice
after might we succeed in proposing the appropriate place for
would be not having to choose. Is it utopian? Br J Anaesth
these devices in any airway algorithm.
2016 Nov; 117: 672–4
The bronchoscope is still considered the gold standard7 for
9. Lenhardt R, Burkhart MT, Brock GN, Kanchi-Kandadai S,
anticipated difficulties for use in awake or sedated patients; an
Sharma R, Akça O. Is video laryngoscope-assisted flexible
interesting alternative could be represented by the combination
tracheoscope intubation feasible for patients with predicted
of bronchoscope with Macintosh8 or with VL,9 even in unex-
difficult airway? A prospective, randomized clinical trial.
pected difficult intubation, not forgetting awake VL use.10 But be-
Anesth Analg 2014; 118: 1259–65
fore claiming them as the new gold standard in difficult airway
10. McGuire BE. Use of the McGrath video laryngoscope in awake
management, we should improve our understanding of their
patients. Anaesthesia 2009; 64: 912–4
roles. New devices require a rigorous learning curve and evalu-
ation; the only Holy Grail in airway management is patient
oxygenation, which should remain the key point in any device-
based algorithm. doi: 10.1093/bja/aex022

Declaration of interest
None declared.

Surgery of the axilla with combined brachial plexus and

intercostobrachial nerve block in the subpectoral intercostal plane
R. Seidel1,*, A. T. Gray2, A. Wree3, M. Schulze3
1
Schwerin, Germany, 2San Francisco, CA, USA and 3Rostock, Germany
*E-mail: ronald-seidel@t-online.de

Editor—The axilla has the shape of a pyramid, with walls formed skin above the armpit (dermatomes). Both the brachial plexus
by muscles (and the axillary fascia) innervated by the brachial and the lateral cutaneous branches of the upper intercostal
plexus (myotomes). The base of the pyramid is formed by the nerves (intercostobrachial nerve T2–T3) are involved in the

Fig 1 Subpectoral intercostal plane block in the second intercostal space.
Top panel, sonographic representation (right side, in-plane approach). 1,
pectoralis major muscle; 2, pectoralis minor muscle; 3, intercostal muscle;
4, third rib; 5, pleural line; 6, needle; 7, serratus anterior muscle vs axillary
tissue. Bottom panel, schematic representation (right side). r1–r4, rib 1–4;
2nd/3rd ics, second/third intercostal space; black cross, injection site;
dashed line, thoracodorsal nerve; icbn, intercostobrachial nerve (continu-
ous lines represent two separate contributions from T2 and T3); ldm, latis-
simus dorsi muscle; ltn, long thoracic nerve (dotted line); PMiM, pectoralis
minor muscle; vertical thin line, medioclavicular line; sm, serratus anter-
ior muscle.
sensory innervation.1–4 This requires a combined regional anaes-
thesia technique for more extensive surgical interventions in the
axillary region. We present an ultrasound-guided subpectoral
intercostal plane block as a simple and promising technique to
anaesthetize the intercostobrachial nerve selectively. This is
documented by an anatomical case series. In combination with a
brachial plexus block (segments C5–T1), the anaesthetic field is
expanded to include segments T2–T3.
Several blocking techniques have been described for the inter-
costobrachial nerve.5–11 The traditional procedure is a subcutane-
ous ring infiltration on the dorsomedial upper arm (brachial
branches). Alternatives are a thoracic paravertebral block (second
and third intercostal nerve) or a thoracic wall block (brachial and
axillary branches).
Dissections were performed at the Institute of Anatomy,
University of Rostock, Germany. We used a 38 mm (6–13 MHz)
linear transducer (Sonosite EDGETM, Bothell, WA, USA).
V R
Injections were performed with a SonoPlex 21 gauge 100 mm
single-injection cannula from Pajunk (Geisingen, Germany).
Nine ultrasound-guided subpectoral intercostal plane injections
were carried out in six unembalmed cadavers with methylene
blue 20 ml. First, a sagittal scanning plane at the level of the
second intercostal space in the midclavicular line was chosen.
The transducer was then moved laterally until the pectoralis
minor muscle became visible. Next, the cranial end of the probe
was rotated laterally on the second intercostal space. The injec-
tion site (in-plane technique from medial to lateral) was superfi-
cial to the external intercostal muscle (Fig. 1). In six out of
six preparations without prior surgical intervention in the
Correspondence | 473
infraclavicular region, the injected dye stained the intercosto-
brachial nerve in the intercostal plane. In addition, two out
of three cadavers were stained in a similar manner after im-
plantation of a pacemaker or a venous port. In these situations,
thoracic paravertebral block might provide an alternative
approach.7
For brachial plexus block (C5–T1), the puncture site should be
far enough proximal to reach thoracic branches (pectoral, long
thoracic, and thoracodorsal nerves). In three cadavers, an add-
itional supra- (n¼3) or infraclavicular (n¼2) injection of the bra-
chial plexus was performed with methylene blue 20 ml. The
thoracodorsal nerve (from the posterior cord) was reliably stained
by dye from the brachial plexus injection (at the level of the pos-
terior cord), but not with the intercostal plane block (thoracic
level). The long thoracic nerve (derived from roots C5–C7) was not
stained with the subpectoral injections (thoracic level). Here, the
axillary fascia acted as an effective barrier that prevented spread
of injected dye towards the lateral chest wall. With brachial
plexus block, staining of this nerve is dependent on its level of ori-
gin from the brachial plexus and the volume of local anaesthetic
administered. We found staining by dye solution only for supra-
clavicular blocks (two of three cadavers).
In contrast to the ‘PECS II block’ (subpectoral serratus plane
block), we chose an injection site over the external intercostal
muscle (subpectoral intercostal plane block) in the second inter-
costal space.5 The potential advantages are simplification and
more options in the choice of the injection site. We conclude that
the volume of local anaesthetic should suffice to cover at least
two intercostal interspaces (T2–T3). At present, there are no clin-
ical trials addressing this regional anaesthesia technique.
Declaration of interest
A.T.G. receives consulting fees from Smiths Medical. Other
authors declared no conflicts of interest.
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474 | Correspondence

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Erector spinae plane block for pain relief in rib fractures

D. L. Hamilton* and B. Manickam
Darlington, UK
*E-mail: duncanleehamilton@nhs.net

Editor—We report a case of successful erector spinae plane (ESP)
block using a continuous catheter technique for pain relief in a
patient with multiple unilateral rib fractures.
A 50 year old male was thrown from a heavy vehicle sustain-
ing multiple unilateral right sided rib fractures in the T6–T9
area. He had no other injuries. Thirty six hours post injury he
was complaining of severe pain in the right hemithorax, was un-
able to move from his bed, and could not sleep as a result of pain.
He was unable to take a deep breath or cough. On examination
there was bruising and exquisite tenderness over the right lateral
chest wall, and very poor air entry bilaterally on auscultation
over the mid and lower zones. He reported numerical rating scale
(NRS) pain scores of 6/10 at rest, and 10/10 on the slightest move-
ment, despite oral Paracetamol (Acetaminophen), Diclofenac,
topical Lidocaine patches, and a patient controlled analgesia
(PCA) Morphine infusion. The pain was particularly severe on the
posterior aspect of the chest around the T6 level relatively close
to the midline, and anteriorly along the right costal margin.
After informed consent and application of standard monitor-
ing, a right sided ultrasound guided (Sonosite S-Nerve, Sonosite

A B

C D

Fig 1 (A and B) Sonographic anatomy for Erector Spinae Plane (ESP) block: Trapezius muscle (Tm), Rhomboid Major muscle (Rm), Erector Spinae muscle (Es), TV4 &
TV5: Transverse process of the fourth & fifth thoracic vertebrae respectively. (C and D) Ultrasound guided ESP block showing location of needle (arrows) and Local
Anaesthetic (LA) deposited deep to the Erector Spinae muscle.