Serratus plane block: a novel ultrasound-guided thoracic wall nerve block

Abstract

SummaryWe present a novel ultrasound-guided regional anaesthetic technique that may achieve complete paraesthesia of the hemithorax. This technique may be a viable alternative to current regional anaesthetic techniques such as thoracic paravertebral and central neuraxial blockade, which can be technically more challenging and have a higher potential side-effect profile. We performed the serratus block at two different levels in the midaxillary line on four female volunteers. We recorded the degree of paraesthesia obtained and performed fat-suppression magnetic resonance imaging and three-dimensional reconstructions of the spread of local anaesthetic in the serratus plane. All volunteers reported an effective block that provided long-lasting paraesthesia (750-840 min). There were no side-effects noted in this initial descriptive study. While these are preliminary findings, and must be confirmed in a clinical trial, they highlight the potential for the serratus plane block to provide analgesia following surgery on the thoracic wall. We suggest that this novel approach appears to be safe, effective, and easy to perform, and is associated with a low risk of sideeffects. Surgery on the chest wall is relatively common and can be associated with considerable postoperative discomfort and pain. Breast cancer has continued to be the most common cancer afflicting women, accounting for 31% of all new cancer cases in the female population [1,2]. Every year, thousands of patients undergo surgery in the region of the breast and axilla. These procedures cause significant acute pain and may progress to chronic pain states in 25-60% of cases [3]. Blockade of the lateral cutaneous branches of the thoracic intercostal nerves (T2-T12) will provide analgesia to the anterolateral chest wall in this patient population [4]. Patients undergoing other surgical procedures involving the chest wall, including anterior thoracotomy, may also benefit from thoracic nerve blockade to reduce postoperative pain.Following on from our previous work on the Pecs I and II blocks [5][6][7], we performed a detailed ultrasound examination of the relevant anatomy of the thoracic cage. This revealed two potential spaces, superficial and deep underneath the serratus anterior muscle, between the muscle and the intercostal nerves

Intercostal/paraspinal nerve block for thoracic surgery

“…Recently, Anaesthesia has carried a number of descriptions of chest wall nerve blocks, derived from serratus plane block [1][2][3][4].…”

“…Catheter position within this space and continuous infusion of 8 ml.h À1 ropivacaine 0.2% can be used to provide analgesia for two or three days postoperatively. Single operator techniques have been highlighted in this journal in the past [2,3], such as the 'Jedi Hand Grip' where both the regional block needle and syringe are held in one hand and the ultrasound probe is held in the other. This method is supposed to have the advantage of providing tactile feedback about injection pressure, whilst allowing the operator the opportunity to concentrate on events displayed on the ultrasound screen.…”

Ultrasound guided Pectoral nerves block (PEC) I, II and Serratus Anterior Plane (SAP) block as primary anaesthetic for Video- Assisted Thoracoscopic Surgery (VATS)

“…4 Regional anaesthesia will result in better pain control(both intra and post operatively), better control of stress response and lesser respiratory complications as compared to administration of systemic opioids under general anaesthesia. This will reduce the risk of pulmonary complications and perioperative morbidity significantly.…”

A reply

“…His main problem was insulating his instruments from contact with the surrounding tissues. To emphasise the safety of his method, he mentioned a death under chloroform in Epsom in 1858, the dentist being one of his own students, a Mr Keeling [3]. He also wrote a letter to The Times on the safety of his method [4].…”