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Chapter 11b - Regional Anesthesia: Chest and Abdominal Plane Blocks

Published online by Cambridge University Press:  24 May 2023

Alan David Kaye
Louisiana State University School of Medicine
Richard D. Urman
Brigham and Women’s Hospital, Boston
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The intercostal nerves are the continuations of the ventral ramus of the thoracic spinal nerves. To perform an effective ICB, the block should be performed proximal to the mid-axillary line, where the lateral cutaneous branch takes off. ICBs can be performed using landmarks, a nerve stimulator, or under ultrasound guidance. Evidence supports the effectiveness of ICBs for chest tube placement, rib fractures, and procedures of the breast and chest wall. Limitations of ICBs include the need to perform blocks at multiple levels (each level of fractured rib) and their association with a shorter duration of action, compared to other chest wall fascial plane blocks such as pectoralis (PECS) II block and serratus anterior plane block (SAP). This is mainly related to a high rate of absorption of local anesthetic within the intercostal space. These considerations make ICBs a less favorable option, as with each injection, there is a potential risk of complications, such as neurovascular injury and pneumothorax. The risk of local anesthetic systemic toxicity (LAST) may also be increased with multiple intercostal injections related to the highly vascularized bundle located underneath each rib, resulting in a high rate of absorption.

Publisher: Cambridge University Press
Print publication year: 2023

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Further Reading

Baldinelli, F, Capozzoli, G, Pedrazzoli, R, Feil, B, Pipitone, M, Zaraca, F. Are thoracic wall blocks efficient after video-assisted thoracoscopy surgery-lobectomy pain? A comparison between serratus anterior plane block and intercostal nerve block. J Cardiothorac Vasc Anesth. 2021;35(8):2297–302.Google Scholar
Carney, J, Finnerty, O, Rauf, J, Bergin, D, Laffey, JG, Mc Donnell, JG. Studies on the spread of local anesthetic solution in transversus abdominis plane blocks. Anesthesia. 2011;66(11):1023–30.CrossRefGoogle ScholarPubMed
Forero, M, Adhikary, SD, Lopez, H, Tsui, C, Chin, KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621–7.Google Scholar
Karmakar, MK. Thoracic paravertebral block. Anesthesiology. 2001;95(3):771.Google Scholar
Kaushal, B, Chauhan, S, Saini, K, et al. Comparison of the efficacy of ultrasound-guided serratus anterior plane block, pectoral nerves II block, and intercostal nerve block for the management of postoperative thoracotomy pain after pediatric cardiac surgery. J Cardiothorac Vasc Anesth. 2019;33(2):418–25.CrossRefGoogle ScholarPubMed
Kaye, AD, Urman, RD, Vadivelu, N. Essentials of Regional Anesthesia, 2nd ed. Cham: Springer;2018.Google Scholar
Kim, S, Bae, CM, Do, YW, Moon, S, Baek, SI, Lee, DH. Serratus anterior plane block and intercostal nerve block after thoracoscopic surgery. Thorac Cardiovasc Surg. 2021;69(6):564–9.Google Scholar
Kot, P, Rodriguez, P, Granell, M, et al. The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019;72(3):209–20.Google Scholar
Wang, W, Song, W, Yang, C, et al. Ultrasound-guided pectoral nerve block I and serratus-intercostal plane block alleviate postoperative pain in patients undergoing modified radical mastectomy. Pain Physician. 2019;22(4):E315–23.Google Scholar
Yang, H, Dong, Q, Liang, L, et al. The comparison of ultrasound-guided thoracic paravertebral blockade and internal intercostal nerve block for non-intubated video-assisted thoracic surgery. J Thorac Dis. 2019;11(8):3476–81.Google Scholar

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