Rib Fracture Serratus

Letters to the Editor
Serratus Anterior Plane Block for Multiple Rib

Fractures
To
the
Editor
A 63-year-old man, admitted to a tertiary care hospital, with a history of motor vehicle accident 2 days
before was referred to a pain clinic within the hospital
with severe chest pain on the left side. He was morbidly obese, with a body mass index of 44, a positive history of hypertension, uncontrolled diabetes mellitus,
and obstructive sleep apnea. The patient had difficulty
breathing due to pain and was unable to lie supine or
prone or take deep breaths. He reported his static and
dynamic pain scores on the Visual Analog Scale as 60
and 100 respectively. A posteroanterior x-ray revealed
fractures of the 4th-7th ribs with no evidence of pneumothorax or hemothorax. The patient had already
received intravenous (IV) diclofenac (75 mg every 12
hours), oral acetaminophen (1 g every 6 hours) and IV
tramadol (100 mg every 8 hours). These analgesics did
not provide any relief in dynamic pain. We therefore
decided to perform a serratus anterior plane (SAP)
block under ultrasound guidance, followed by catheter insertion for continuous infusion of local anesthetic
which was done following informed consent.
The patient was placed in a sitting position with
his left arm resting on a side table (Fig 1). An intravenous line was secured and all standard monitoring
was applied. The procedure was performed with a 5-2
MHz curvilinear ultrasound probe (Sonosite M Turbo,
Bothell, WA) under strict aseptic conditions. The serratus anterior muscle was localized over the 5th rib in a
posterior axillary line in the vertical axis (Fig. 2A). Then
the probe was aligned along the rib along the long
axis of the rib. The needle entry point was anesthetized with 1% lidocaine. An 18 G Touhy needle was
introduced under real time ultrasound using an in-line
needle technique from a posterior to an anterocaudal direction. The needle tip was placed on the surface
of the rib under the serratus anterior muscle between
the posterior and mid-axillary line (Figure 2B). Hydro
dissection was done with 3 mL saline to confirm the
position of the needle tip. Thereafter, 20 mL of 0.125%
bupivacaine was injected under ultrasound guidance.
A 20 G epidural catheter was advanced through the
epidural needle to a depth of 4 cm beyond the needle
tip and tunneled subcutaneously to prevent dislodgement. The patient reported a significant decrease in
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Fig. 1. Position of the patient and placement of the needle by

inline needling technique.
pain 15 minutes after the procedure. Continuous infusion of 0.0625% bupivacaine with 1 g/mL of fentanyl
using an elastomeric pump was started at 7mL/h after
4 hours. Infusion was increased to 12 mL/h the next day
since the patient had pain in his left lower chest after
the effect of the bolus dosage decreased. Thereafter
the patients static and dynamic VAS pain scores were
reduced to 00 and 10-20 respectively and he was able to
ambulate and undergo respiratory physiotherapy without pain. Other analgesics were stopped except acetimenophen. The catheter was removed on the sixth day
and the patient was discharged 24 hours later with no
complications. He was advised to continue oral nonsteroidal anti-inflammatory drugs (NSAIDs) for one week.
Multiple rib fractures (MRF) continue to be a challenging problem as the associated pain leads to a compromise in respiration, especially in obese patients;
accompanying obstructive sleep apnea further complicates the management. Proper analgesia is required for
early ambulation, physiotherapy, and to prevent development of respiratory failure (1,2). There are several
regional analgesic methods used in treating MRF (3-6).
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Pain Physician: July/August 2014; 17:E549-E557
Fig. 2. Ultrasound images; A) - short axis view of ribs (probe placed vertically); B) - long axis view of 5th rib with needle in
serratus anterior plane. SA: Serratus anterior muscle, Arrows: needle in plane.
Ultrasound-guided SAP block has recently been described as a regional anesthetic technique to provide
analgesia for breast and thoracic wall surgeries (7). SAP
block provides analgesia to a hemithorax by blocking
the lateral branches of the intercostal nerves (7). SAP
block has also been reported to provide analgesia and
to facilitate weaning from mechanical ventilation in
critical care patients with MRF (8). SAP block is technically simple and can be safely performed as a bedside
procedure.
Our patient was morbidly obese and had obstructive sleep apnea. He developed MRF (4th to 7th ribs)
following a traffic accident and presented to us with
severe pain and difficulty in breathing. He had already
received NSAIDs and tramadol with no relief in pain.
Opioids were not tried because of a fear of respiratory
depression due to associated obstructive sleep apnea
(9). A single thoracic epidural steroid injection was recently described in the literature for managing pain
in multiple rib fractures (10). Due to the patients associated morbid obesity, which made placing the thoracic epidural technically difficult, and his uncontrolled
blood sugar, we decided to perform the SAP block. On
account of the short duration of action of a single shot
bupivaciane block (4-8 hours) and the fact that the patient was hospitalized for control of his blood sugar,
we opted for a continuous infusion of local anesthetic
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opioid combination. We started with an infusion rate

of 7 mL/h (8) and subsequently increased to 12 mL/h
the next day because of inadequate blockade (Baxter
2C9961 multi-rate infuser LV 5,7,12 with flow rate of
5, 7, 12 mL/h). A low concentration of local anesthetic
(0.0625% bupivacaine) for continuous infusion was
used to minimize the chances of local anesthetic toxicity and motor blockade, if any. The patient reported
significant pain relief after 15 minutes of the SAP block
and started mobilizing. His breathing significantly improved and he could subsequently undergo chest physiotherapy without pain.
Ultrasound-guided serratus anterior plane block is
a simple and effective technique for providing pain relief in unilateral MRF, especially in obese patients who
have obstructive sleep apnea.
Dr. Nishad Poolayullathil Kunhabdulla
Senior Resident
Department of Anesthesiology
Sanjay Gandhi Postgraduate
Institute of Medical Sciences
Lucknow, India
Email:[email protected]
Dr.Anil Agarwal
Professor
Letters to the Editor

Lucknow, India
Lucknow, India
Dr.Rakhi Gupta
Senior Resident
Lucknow, India
Dr Atul Gaur
Consultant Anaesthetist
University Hospitals of Leicester
NHS Trust
Leicester, UK
Email : [email protected]
Dr.Amita Agarwal, Ex-Dental Surgeon

Lucknow, India
Dr.Sujeet Kumar Singh Gautam

Assistant Professor
References:
1.
Karmakar MK, Critchley LA, Ho AM, Gin

T, Lee TM, Yim AP. Continuous thoracic
paravertebral infusion of bupivacaine for
pain management in patients with multiple fractured ribs. Chest. 2003; 123: 42431.
2. Easter A. Management of patients with
multiple rib fractures. Am J Crit Care.
2001; 10: 320-7.
3. Ho AM, Karmakar MK, Critchley LA.
Acute pain management of patients with
multiple fractured ribs: a focus on regional techniques. Curr Opin Crit Care.
2011; 17: 323-7
4. Murata H, Salviz EA, Chen S, Vandepitte
C, Hadzic A. Case report: ultrasoundguided continuous thoracic paraverte-
5.
6.
7.
bral block for outpatient acute pain management of multilevel unilateral rib fractures. Anesth Analg. 2013; 116: 255-7.
Short K, Scheeres D, Mlakar J, Dean R.
Evaluation of intrapleural analgesia in
the management of blunt traumatic
chest wall pain: a clinical trial. Am Surg.
1996; 62:488-93.
Mohta M, Verma P, Saxena AK, Sethi AK,
Tyagi A, Girotra G. Prospective, randomized comparison of continuous thoracic
epidural and thoracic paravertebral infusion in patients with unilateral multiple fracture ribs--a pilot study. J Trauma.
2009; 66: 1096-101
Blanco R, Parras T, McDonnell JG, PratsGalino A. Serratus plane block: a novel
ultrasound-guided thoracic wall nerve

block.Anaesthesia.2013, 68, 11071113
8. Lopez-Matamala B, Fajardo M, Estebanez-Montiel B, Blancas R, Alfaro P,
Chana M. A new thoracic interfascial
plane block as anesthesia for difficult
weaning due to ribcage pain in critically
ill patients. Med Intensiva.2013.
9. Etches RC. Respiratory depression associated with patient controlled analgesia: a review of eight cases. Can J Anaesth.1994; 41:12532.
10. Rauchwerger JJ, Candido KD, Deer
TR,Frogel JK, Iadevaio R, Kirschen NB.
Thoracic epidural steroid injection for rib
fracture pain. Pain Pract.2013;13:416-21.
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Letters to the Editor

Serratus Anterior Plane Block for Multiple Rib

Fig. 1. Position of the patient and placement of the needle by

Pain Physician: July/August 2014; 17:E549-E557

opioid combination. We started with an infusion rate

Letters to the Editor

Institute of Medical Sciences

Dr.Amita Agarwal, Ex-Dental Surgeon

Dr.Sujeet Kumar Singh Gautam

Karmakar MK, Critchley LA, Ho AM, Gin

ultrasound-guided thoracic wall nerve

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