Serratus anterior plane block home catheter for posterior rib fractures and flail chest

To the Editor,

Figure
figure1

A) Anterior-posterior chest radiograph at the time of serratus anterior plane (SAP) catheter insertion and B) 48 hr later. Right basal atelectasis at the time of SAP catheter insertion can be seen with improvement in right lung volumes 48 hr after ropivacaine infusion via the SAP catheter. The tip of SAP catheter is visible in both images (*)

Traumatic rib fractures carry significant morbidity due to pain and pulmonary compromise.1,2 Epidural analgesia is considered the optimal management yet many trauma patients have contraindications to this technique.3 The serratus anterior plane (SAP) block has fewer contraindications and has been described for rib fracture analgesia.4,5 Herein, we describe a patient with multiple traumatic rib fractures (with a flail segment) managed in hospital and then transitioned home with an ambulatory SAP catheter. Written consent was obtained from the patient for this report.

A previously healthy 39-yr-old male was ejected from a motorcycle and impacted his right upper back. He presented to the emergency department with a respiratory rate of 22 breaths·min−1, peripheral oxygen saturation (SpO2) 95% on room air, heart rate of 107 beats· min−1, and blood pressure 127/78. Lab investigation results were normal. Radiologic investigations showed right antero-lateral and posterior fractures of ribs 3–10 with a flail segment, scapular fracture, thoracic transverse process 6 and 7 fractures, and a right pulmonary contusion with basal atelectasis and small pneumothorax.

Multimodal analgesia was initiated including regular oral acetaminophen and celecoxib, intravenous hydromorphone patient-controlled analgesia, ketamine 5 mg.hr−1 infusion and lidocaine 1.5 mg·kg−1·hr−1 infusion. By post-admission day 1, his numeric rating scale (NRS) for pain worsened to 10/10 with deep inspiration resulting in the inability to cough and mobilize pulmonary secretions. Chest x-ray showed worsening right lower lobe atelectasis (Figure A) and supplemental oxygen was required to maintain SpO2 ≥ 92%. Positioning for an epidural regional technique with a posterior approach was limited by pain and sedation. Therefore, an SAP block was performed.

After informed consent, standard monitors were applied, and the patient was positioned supine with his right arm abducted. Under sterile conditions with ultrasound guidance (LOGIQ S7 Expert; General Electric), a 17G 8-cm Tuohy needle (Arrow StimuCath®, Teleflex, Reading, PA, USA) was inserted anterior-to-posterior below the serratus muscle overlying the fifth rib at the mid-axillary line. This fascial plane between the serratus muscle and rib periosteum or external intercostal muscle contains lateral cutaneous branches of associated intercostal nerves and is the target of the deep SAP block. After hydro-dissection of the plane with 5 mL of normal saline, a 19G catheter was inserted 5 cm beyond the tip of the needle. A total of 30 mL of ropivacaine 0.5% with epinephrine 1:400,000 was incrementally injected. The procedure was well tolerated without complications. A catheter infusion of ropivacaine 0.2% was initiated at 5 mL·hr−1, with an 8 mL patient-controlled bolus with a 30-min lockout.

Within 15 min of the procedure, he was able to inspire deeply and cough with minimal pain. Forty-eight hours later, supplemental oxygen was no longer required and repeat chest x-ray showed reduced atelectasis (Figure B). On post-admission day 5, he was discharged home comfortable with an ambulatory catheter infusion pump (AmbIT® pump, Summit Medical Products, UT, USA) of Ropivacaine 0.2% at 5 mL·hr−1 with a patient-controlled bolus of 5 mL (30-min lockout). Pain scores were rated as 2/10 for the duration of the ambulatory catheter infusion. The patient was highly satisfied with his SAP catheter analgesia in hospital and at home. We treated this catheter similarly to other ambulatory peripheral nerve catheters with daily telephone follow-up and assessment for symptoms of infection, local anesthetic toxicity, or other adverse side effects. With instruction from an acute pain service practitioner, the patient removed the catheter at home on day 7 post-procedure without complications.

The use of an ambulatory SAP nerve-block catheter likely reduced this patient’s expected length of stay by two days. Effective pain management is essential in reducing morbidity and mortality in patients with multiple rib fractures. In contrast to other regional techniques, the SAP block can be approached anteriorly in the supine position and is compressible providing some margin of safety in patients with abnormal coagulation. Furthermore, the SAP block avoids a sympathectomy and catheter placement is distant from the neuraxis making it suitable for home ambulatory infusion. The use of the SAP catheter with a home ambulatory infusion pump is novel and has multiple applications for thoracic wall analgesia.

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This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.

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Correspondence to Peter Rose MD.

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Rose, P., Ramlogan, R., Madden, S. et al. Serratus anterior plane block home catheter for posterior rib fractures and flail chest. Can J Anesth/J Can Anesth 66, 997–998 (2019). https://doi.org/10.1007/s12630-019-01383-y

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