Regional block: Walking away from central to peripheral nerves and planes for local anaesthetic drug deposition

Garg, Rakesh

doi:10.4103/ija.ija_495_19

Cited by 7 publications

(5 citation statements)

References 20 publications

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“…[ 19 20 ] This can be attributed to the elevated systemic absorption and rapid clearance of the drug from the highly vascular intercostal bed[ 21 22 ] whereas the deposition of the local anaesthetic (LA) drug in a myofascial plane of interest is expected to more selectively block the higher-order ramifications of the branches of the intercostal nerves. [ 8 23 24 25 ] In addition, other analgesics such as non-steroidal anti-inflammatory drugs were avoided in all the study participants, particularly given a cardiac surgical setting where the former can potentially predispose to postoperative bleeding and/or acute-kidney injury. [ 2 ] Moreover, ropivacaine constitutes a safer LA option in cardiac patients considering a lower cardiotoxicity potential.…”

Section: Discussionmentioning

confidence: 99%

A randomised controlled comparison of serratus anterior plane, pectoral nerves and intercostal nerve block for post-thoracotomy analgesia in adult cardiac surgery

et al. 2020

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Background and Aims: Enhanced recovery after cardiac surgery is centred around multimodal analgesia which is becoming increasingly feasible with the advent of safer regional analgesic techniques such as fascial plane blocks. We designed this prospective, single-blind, randomised controlled study to compare the efficacy of serratus anterior plane block (SAPB), pectoral nerves (Pecs) II block, and intercostal nerve block (ICNB) for post-thoracotomy analgesia in cardiac surgery. Methods: 100 adults posted for cardiac surgery through a thoracotomy were randomly allocated to one of the three groups: SAPB, Pecs II or, ICNB wherein the patients received 2.5 mg/kg of 0.5% ropivacaine for ultrasound-guided block after completion of surgery. Postoperatively, intravenous (IV) paracetamol was used for multimodal and fentanyl was employed as rescue analgesia. Visual analogue scale (VAS) was evaluated at 2, 4, 6, 8, 10 and 12 hours post-extubation. Results: The early mean VAS scores at 2, 4 and 6 hours were comparable in the 3 groups. The late mean VAS (8, 10 and 12 hours) was significantly lower in the SAPB and Pecs II group compared with that of the ICNB group ( P value <0.05). The cumulative rescue fentanyl dose was significantly higher in ICNB group compared to SAPB and Pecs II group ( P value <0.001). The SAPB group had the highest time to 1 st rescue analgesic requirement in contrast to the other groups. Conclusion: SAPB and Pecs II blocks are simple single-shot effective alternatives to ICNB with a prolonged analgesic duration following thoracotomy and can potentially enhance pain-free recovery after cardiac surgery.

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Section: Discussionmentioning

confidence: 99%

A randomised controlled comparison of serratus anterior plane, pectoral nerves and intercostal nerve block for post-thoracotomy analgesia in adult cardiac surgery

et al. 2020

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“…We depend on the facial plane anatomy, its structure, and its relation to the surrounding organs and tissues to precisely disseminate the local anesthetic to its desired location. 11 We need to understand the dynamic nature of facial layers and their microanatomy to determine the site of drug spread and predict an outcome thereby increasing the applicability of these blocks in contemporary regional anaesthesia practice. Enthusiasm should not blur our understanding of the basics.…”

Section: Innervation Of the Breastmentioning

confidence: 99%

Rhomboid intercostal subserratus plane block – the Holy Grail of post-operative analgesia in modified radical mastectomy or just another dot in the long list?

Priyanka Bansal,

Nidhi Sultania,

Kunal Bansal

2023

Asian J Med Sci

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Despite the presence of numerous options for breast analgesia, our women continue to suffer the consequences of acute post-operative pain that progresses to chronic pain in up to 55% of the post-mastectomy patients a rapid surge in the use of interfacial blocks for analgesia of chest and abdominal procedures. The importance and efficacy of these blocks are because of the continuity of the interfacial planes across varied anatomical tissues. We report a series of cases of modified radical mastectomy (MRM) in five female patients with the American Society of Anesthesiology Grade II/III in whom rhomboid intercostal subserratus was used for post-operative analgesia proved to be a boon. Two were post-radiation with metastasis to axillary lymph nodes. The other three had invasive ductal carcinoma and were on chemotherapy. Rhomboid intercostal subserratus plain block is a novel block and provides pain management for patients of MRM. The analgesic efficacy may not be superior but the non-inferiority to an epidural is certainly an added advantage with safe efficacious profile fulfilling the enhanced recovery after surgery protocols following minimally invasive surgical techniques.

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“…The patients had enhanced recovery and quality of life scores (QoR-40), especially in terms of pain and emotional status. 6 RISS has proved its non-inferiority as compared to ESP, paravertebral, PEC, and SAP which are closer to neuroaxis, at non-compressible sites and difficult to execute in obese patients (Figure 3). 7,8 Thus RISS is excellent as a part of MMA for postoperative pain management in MRM patients, who remain comfortable for up to 14 h and have an NRS score <3 was seen in all of our five patients.…”

Section: Sirmentioning

confidence: 99%

“…We depend on the facial plane anatomy, its structure, and its relation to the surrounding organs and tissues to precisely disseminate the local anesthetic to its desired location. 3,6 In this blind sheep race, enthusiasm should not blur our understanding of the basics. We should remember Triple A, improve health, enhance patient outcomes, and decrease the costs.…”

Section: Sirmentioning

confidence: 99%

Rhomboid intercostal sub serratus plane block – Same bird with different horizons

Priyanka Bansal,

Nidhi Sultania,

Kunal Bansal

2023

Asian J Med Sci

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Sir,We did a case series in five patients undergoing modified radical mastectomy who were given RISS for post-operative analgesia. We noticed that the intraoperative fentanyl consumption as well as the post-operative analgesic consumption was significantly less. The overall quality of life and satisfaction score for routine daily activities like wearing clothes was better in our patients. The importance and efficacy of these blocks are because of the continuity of the interfacial planes across varied anatomical tissues. These planes have various cutaneous as well as sympathetic branches and hence drug given spreads to cover a large dermatomal area. RISS has been proposed to cover lateral cutaneous branches of T2 to T11 that extend medially to cover dorsal rami deep to the errector spinae muscle plane (ESP). The site of injectate is at T5-T6. The dermatomal coverage is 4 cm lateral to the midline anteriorly, posteriorly 4 cm medial to the posterior axillary line, cranially up to serrated posterior superior caudally up to serratus posterior inferior. The advantages of RISS block are that the injection is far from the surgical site and hence the drug does not interfere with the surgical field or cautery if given preoperatively. After induction technically, it is more feasible than serratus plane block or pectoral blocks. Logistically prior catheterization is possible that does not interfere with the sterility of the surgical field. Despite the above advantages, the axillary coverage is inconsistent as it does not cover the intercostobrachial nerve (LCB of second ICN T2). The midline, thoracodorsal nerve, and long thoracic nerve are not covered. Complete analgesia is not provided for latissimus dorsi flap, segmental resection surgeries, lymph node dissections, or radical mastectomies. Dr. Tulgar, first-ever reported of the use of RIB in a patient of MRM and highlighted the superiority of peri-peri-paravertebral blocks apart from previously used ESP and paravertebral blocks for a similar condition. Altiparimak conducted an RCT on 30 MRM patients with axillary lymph node dissection. The patients had enhanced recovery and quality of life scores (QoR-40), especially in terms of pain and emotional status. RISS has proved its non-inferiority as compared to ESP, paravertebral, PEC, and SAP which are closer to neuroaxis, at non-compressible sites and difficult to execute in obese patients. Thus RISS is excellent as a part of MMA for post-operative pain management in MRM patients, who remain comfortable for up to 14 h and have an NRS score <3 was seen in all of our five patients. The dynamic nature of pain was apparent at 14 h in three of the patients who had extensive axillary lymph node dissection. Is the journey of regional anesthesia just the replacement of “pops and clicks” with see it and block it? The renaissance in the era of blocks is visualizing an invention of a new block almost every month. We depend on the facial plane anatomy, its structure, and its relation to the surrounding organs and tissues to precisely disseminate the local anesthetic to its desired location. In this blind sheep race, enthusiasm should not blur our understanding of the basics. We should remember Triple A, improve health, enhance patient outcomes, and decrease the costs. We open the doors for larger studies with more patients, comparing different blocks with RIB/RISS blocks before generalizing the results. CONCLUSIONRhomboid intercostal subserratus plane block is an excellent option for intra and post-operative pain management as a part of multimodal analgesia in MRM patients.

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Regional block: Walking away from central to peripheral nerves and planes for local anaesthetic drug deposition

Cited by 7 publications

References 20 publications

A randomised controlled comparison of serratus anterior plane, pectoral nerves and intercostal nerve block for post-thoracotomy analgesia in adult cardiac surgery

A randomised controlled comparison of serratus anterior plane, pectoral nerves and intercostal nerve block for post-thoracotomy analgesia in adult cardiac surgery

Rhomboid intercostal subserratus plane block – the Holy Grail of post-operative analgesia in modified radical mastectomy or just another dot in the long list?

Rhomboid intercostal sub serratus plane block – Same bird with different horizons

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