Thoraxic Wall Nerve Block

Author - dr. Resa Putra Adipurna

Supervisor :
dr. Taufiq Agus Siswagama SpAn KMN
Overview
• Peripheral nerve blocks of the thoracic region are used
are used for operative anesthesia and/or postoperative
analgesia for a variety of surgeries of the chest and
upper abdomen.
• In some cases, peripheral nerve blocks of the thoracic
region also provide analgesia for acute pain due to rib
fracture or another chest trauma.
Thoraxic Region Nerve Block

• Intercostal nerve blocks

• Thoracic paravertebral blocks (TPVB)
• Interfascial blocks of the thoraxic region
• Pecs I - Pecs II Block
• Seratus Anterior Plane Block
Intercostal Nerve Block
I C B N
Intercostal Nerve Block
• The intercostal nerves (ICNs) innervate the major parts
of the skin and musculature of the chest and abdominal
wall.
• ICNB is used in a variety of acute and chronic pain
conditions affecting the thorax and upper abdomen,
including breast and chest wall surgery.
• Introduction of ultrasound guidance to the practice of
regional anesthesia further facilitates its practice.
Intercostal Nerve Block
INDICATIONS
• ICNB provides excellent analgesia
in patients with :
• rib fractures
• postsurgical pain after chest and
upper abdominal surgery such as
thoracotomy, thoracostomy,
mastectomy, gastrostomy, and
cholecystectomy.
CONTRAINDICATION
• Disorders of coagulation, although
this is not an absolute
contraindication
• Local infection, lack of expertise
and resuscitating equipment
ANATOMY
INNERVATION
SONOANOTOMY
 TECHNIQUE
• ICNB can be performed with the patient in the
prone, sitting, or lateral position (block side up).
• The position of the arm in either position is to pull
the scapulae laterally and facilitate access to the
posterior rib angles above T7.
• Run scanning first.
• Under aseptic conditions, the block sites are
identified guided by ultrasound.
• Inferior borders of the ribs to be blocked are
palpated, scanned, and marked.
• The needle entry sites are infiltrated with
lidocaine 1%–2%.
• Needle introduced through ultrasound guided - in
plane.
LOCAL ANESTHESIA DOSE
• The choice of local anesthetic for single-shot ICNB includes
bupivacaine 0.25%–0.5%, lidocaine 1%–2% with epinephrine
1/200,000–1/400,000, and ropivacaine 0.5%.
• Three to 5 mL of local anesthetic is injected at each level
during a multiple-injection ICNB. The duration of action is
usually 12 ± 6 h.
• Addition of epinephrine to bupivacaine or ropivacaine does not
significantly prolong the duration of the block but may slow the
systemic absorption and increase the maximum allowable dose
with a single shot by 30%.
COMPLICATIONS

• The foremost concern is a pneumothorax, which

may occur in about 1%.
• The peritoneum and abdominal viscera are at risk
of penetration when lower ICNs are blocked.
•LA S T
Thoracic Paravertebral Blocks
TPVB
Overview
• Thoracic paravertebral block (TPVB) is the technique of
injecting local anesthetic alongside the thoracic vertebra
close to where the spinal nerves emerge from the
intervertebral foramen.
• This produces unilateral, segmental, somatic, and
sympathetic nerve blockade, which is effective for
anesthesia and in treating acute and chronic pain of
unilateral origin from the chest and abdomen.
 INDICATION &
CONTRAINDICATION
SONOANOTOMY

Thoraxic
Paravertebral
Block
T E C H N I Q U E
• Place the US probe in a caudocranial orientation
about 5 cm from midline at the level where
anaesthesia/analgesia is to be achieved.
• At this point identify the ribs on sonography. Next
identify the pleura deep to the ribs. Deep to
pleura, the pulmonary tissue is not seen due to
its air content.
• Continuing to manoeuvre the probe medially,
look for the transition of ribs to transverse
processes marked by a change in shape and a
slight step-up of bony image.
• Slide the transducer cranially, such that the
targeted paravertebral space lies towards one
side of the US screen.
• This produces a steep needle insertion angle
LOCAL ANESTHESIA DOSE
• Since TPVB does not result in motor weakness of the
extremities, long-lasting analgesia is nearly always desirable
with TPVB.
• Consequently, long-acting local anesthetic drugs are typically
used. These include bupivacaine or levobupivacaine 0.5%
and ropivacaine 0.5%.
• For single-injection TPVB, 20–25 mL of local anesthetic is
injected in aliquots, whereas for multiple-injection TPVB, 4–5
mL of local anesthetic is injected at each level planned.
• The maximum dose of local anesthetic must be adjusted in
the elderly, poorly nourished, and frail patients.
COMPLICATIONS
• US guidance has the potential of increasing safety for PVBs
compared to traditional landmark technique. There are limited
data on US-based complications.
• In a retrospective study at Massachusetts General Hospital over
a 4-year period of US-guided thoracic PVB in breast surgery, 6
complications were documented in over 1400 blocks performed.
• These included bradycardia with hypotension, a vasovagal
episode, and possible local anaesthetic toxicity but no
incidence of accidental pleural puncture or pneumothorax.1 See
Table 3 for general and specific complications of PVB.
Interfascial Block of
Thoraxic Region
Pecs I - Pecs II Block
Seratus Anterior Plane Block
What’s the differences ?
Peripheral Nerve Block
• The endpoint of a peripheral nerve
block procedure is the deposition
of local anesthetic around a
peripheral nerve, causing a nerve
conduction blockade.
• One target
• Higher risk of nerve injury
• Low volume : low risk LAST
Interfascial block
• The endpoint of the ultrasound-
guided procedure is the spread of
local anesthetic on the target
fascial plane
• Multiple target
• Low risk of nerve injury
• High volume : high risk LAST
O v e r v i e w (1)
• Pectoralis nerve (Pecs) and serratus plane nerve blocks are
newer ultrasound (US)-guided regional anesthesia techniques
of the thorax.
• Pecs I block is accomplished by an injection of local anesthetic
in the fascial plane between the pectoralis major and minor
muscles.
• The Pecs II nerve block (which also includes the Pecs I nerve
block) is an extension that involves a second injection lateral to
the Pecs I injection point in the plane between the pectoralis
minor and serratus anterior muscles with the intention of
providing blockade of the upper intercostal nerves.
O v e r v i e w (2)
• Further modification is the serratus plane
nerve block, in which local anesthetic is
injected between the serratus anterior and
latissimus dorsi muscles.
 ANATOMY

The pectoralis major and minor muscles are innervated by the lateral and medial pectoral nerves;
the serratus anterior is innervated by the long thoracic nerve (C5, C6, and C7);
and the subclavius is innervated by the upper trunk of the brachial plexus (C5 and C6).
INNERVATION
SO
NO
AN
OT
OM
Y
Pe
cs
I-II
Blo
ck
SONOANOTOM
Y
SAP Block
Pecs I Block
• The nerve block is performed with the patient supine, either with the arm
next to the chest or abducted 90 degrees.
• With standard American Society of Anesthesiology (ASA) monitoring and
supplemental oxygen, the operator locates the coracoid process on US in
the paramedian sagittal plane.
• The transducer is rotated slightly to allow an in-plane needle trajectory
from the proximal and medial side toward the lateral side (ie, the caudal
border of the transducer is moved laterally, while the proximal border
remains unchanged).
• This rotation helps image the pectoral branch of the thoracoacromial
artery.
• The proper fascial plane is confirmed by hydrodissection to open the
space between the pectoralis muscles.
Pecs II Block
• The first injection is similar to Pecs I with the transducer at the
midclavicular level and angled infero-laterally, whereas the
second is made at the anterior axillary line at the level of the
fourth rib.
• The depth is usually 1–3 cm for the first injection and 3–6 cm for
the second injection.
• The transducer is then moved laterally until the pectoralis minor
and serratus anterior are identified. With further lateral
transducer movement, the third and fourth rib can then be
identified.
• The local anesthetic is injected at two points
SAP Block
• The first method requires counting the ribs from the
clavicle while moving the transducer laterally and distally
until the fourth and fifth ribs are identified. The transducer
is orientated in the coronal plane and then tilted posteriorly
until the latissimus dorsi (a superficial thick muscle) is
identified. The serratus muscle, a thick, hypoechoic muscle
deep to the latissimus dorsi is imaged over the ribs.
• An alternative method is to place the transducer across the
axilla, where the latissimus dorsi will appear more
prominent. The location of the thoracodorsal artery is easier
to identify this way.
Summary - Interfascial Plane Block

Pecs and serratus plane nerve blocks are newer US-

guided nerve blocks for analgesia after breast and lateral
thoracic wall surgery. The key sonographic landmarks
are the pectoralis major, pectoralis minor, and serratus
anterior muscles and the pectoral branch of the
acromiothoracic artery.
Terimakasih