Analgesic efficacy of the serratus anterior plane block in rib fractures pain: A randomized controlled trial

Ultrasound-guided serratus anterior plane block enhances postoperative analgesia and recovery in thoracoscopic surgery

BACKGROUND

The serratus anterior muscle, located in the lateral aspect of the thorax, plays a crucial role in shoulder movement and stability. Thoracoscopic surgery, while minimally invasive, often results in significant postoperative pain, complicating patient recovery and potentially extending hospital stays. Traditional anesthesia methods may not adequately address this pain, leading to increased complications such as agitation due to inadequate pain management.

AIM

To evaluate the application value of ultrasound-guided serratus anterior plane block (SAPB) in patients undergoing thoracoscopic surgery, focusing on its effects on postoperative analgesia and rehabilitation.

METHODS

Eighty patients undergoing thoracoscopic surgery between August 2021 and December 2022 were randomly divided into two groups: An observation group receiving ultrasound-guided SAPB and a control group receiving standard care without SAPB. Both groups underwent general anesthesia and were monitored for blood pressure, heart rate (HR), oxygen saturation, and pulse. The primary outcomes measured included mean arterial pressure (MAP), HR, postoperative visual analogue scale (VAS) scores for pain, supplemental analgesic use, and incidence of agitation.

RESULTS

The observation group showed significantly lower cortisol and glucose concentrations at various time points post-operation compared to the control group, indicating reduced stress responses. Moreover, MAP and HR levels were lower in the observation group during and after surgery. VAS scores were significantly lower in the observation group at 1 h, 4 h, 6 h, and 12 h post-surgery, and the rates of analgesic supplementation and agitation were significantly reduced compared to the control group.

CONCLUSION

Ultrasound-guided SAPB significantly improves postoperative analgesia and reduces agitation in patients undergoing thoracoscopic surgery. This technique stabilizes perioperative vital signs, decreases the need for supplemental analgesics, and minimizes postoperative pain and stress responses, underscoring its high application value in enhancing patient recovery and rehabilitation post-thoracoscopy.

Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management: The SABRE Randomized Clinical Trial

Importance

Rib fractures secondary to blunt thoracic trauma typically result in severe pain that is notoriously difficult to manage. The serratus anterior plane block (SAPB) is a regional anesthesia technique that provides analgesia to most of the hemithorax; however, SAPB has limited evidence for analgesic benefits in rib fractures.

Objective

To determine whether the addition of an SAPB to protocolized care bundles increases the likelihood of early favorable analgesic outcomes and reduces opioid requirements in patients with rib fractures.

Design, Setting, and Participants

This multicenter, open-label, pragmatic randomized clinical trial was conducted at 8 emergency departments across metropolitan and regional New South Wales, Australia, between April 12, 2021, and January 22, 2022. Patients aged 16 years or older with clinically suspected or radiologically proven rib fractures were included in the study. Participants were excluded if they were intubated, transferred for urgent surgical intervention, or had a major concomitant nonthoracic injury. Data were analyzed from September 2022 to July 2023.

Interventions

Patients were randomly assigned (1:1) to receive an SAPB in addition to usual rib fracture management or standard care alone.

Main Outcomes and Measures

The primary outcome was a composite pain score measured 4 hours after enrollment. Patients met the primary outcome if they had a pain score reduction of 2 or more points and an absolute pain score of less than 4 out of 10 points.

Results

A total of 588 patients were screened, of whom 210 patients (median [IQR] age, 71 [55-84] years; 131 [62%] male) were enrolled, with 105 patients randomized to receive an SAPB plus standard care and 105 patients randomized to standard care alone. In the complete-case intention-to-treat primary outcome analysis, the composite pain score outcome was reached in 38 of 92 patients (41%) in the SAPB group and 18 of 92 patients (19.6%) in the control group (relative risk [RR], 0.73; 95% CI, 0.60-0.89; P = .001). There was a clinically significant reduction in overall opioid consumption in the SAPB group compared with the control group (eg, median [IQR] total opioid requirement at 24 hours: 45 [19-118] vs 91 [34-155] milligram morphine equivalents). Rates of pneumonia (6 patients [10%] vs 7 patients [11%]), length of stay (eg, median [IQR] hospital stay, 4.2 [2.2-7.7] vs 5 [3-7.3] days), and 30-day mortality (1 patient [1%] vs 3 patients [4%]) were similar between the SAPB and control groups.

Conclusions and Relevance

This randomized clinical trial found that the addition of an SAPB to standard rib fracture care significantly increased the proportion of patients who experienced a meaningful reduction in their pain score while also reducing in-hospital opioid requirements.

Trial Registration

http://anzctr.org.au Identifier: ACTRN12621000040864.

Serratus anterior plane block improves pain and incentive spirometry volumes in trauma patients with multiple rib fractures: a prospective cohort study

Background

Rib fractures are common injuries associated with considerable morbidity, long-term disability, and mortality. Early, adequate analgesia is important to mitigate complications such as pneumonia and respiratory failure. Regional anesthesia has been proposed for rib fracture pain control due to its superior side effect profile compared with systemic analgesia. Our objective was to evaluate the effect of emergency physician-performed, ultrasound-guided serratus anterior plane block (SAPB) on pain and respiratory function in emergency department patients with multiple acute rib fractures.

Methods

This was a prospective observational cohort study of adult patients at a level 1 trauma center who had two or more acute unilateral rib fractures. Eligible patients received a SAPB if an emergency physician trained in the procedure was available at the time of diagnosis. Primary outcomes were the absolute change in pain scores and percent change in expected incentive spirometry volumes from baseline to 3 hours after rib fracture diagnosis.

Results

38 patients met eligibility criteria, 15 received the SAPB and 23 did not. The SAPB group had a greater decrease in pain scores at 3 hours (-3.7 vs. -0.9; p=0.003) compared with the non-SAPB group. The SAPB group also had an 11% (CI 1.5% to 17%) increase in percent expected spirometry volumes at 3 hours which was significantly better than the non-SAPB group, which had a -3% (CI -9.1% to 2.7%) decrease (p=0.008).

Conclusion

Patients with rib fractures who received SAPB as part of a multimodal pain control strategy had a greater improvement in pain and respiratory function compared with those who did not. Larger trials are indicated to assess the generalizability of these initial findings.

The 2023 WSES guidelines on the management of trauma in elderly and frail patients

BACKGROUND

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.

METHODS

Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.

RESULTS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.

CONCLUSIONS

The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

Comparing the Analgesic Effects Between the Pre- and Post-costal Cartilage Harvest Cohorts Using Ultrasound-Guided Deep Serratus Anterior Plane Block in Children with Microtia Undergoing Auricular Reconstruction: A Randomized Clinical Trial

PURPOSE

Pain following costal cartilage harvest surgery is the most common complaint of auricular reconstruction (AR). Anesthesiologists are continuously searching for an effective postoperative pain control method.

METHODS

This study was conducted from 10 April 2022 to 10 June 2022. Sixty children undergoing AR using costal cartilage were randomly assigned to either a serratus anterior plane block performed before costal cartilage harvest (SAPB-pre-cohort; n = 30) or the SAPB-post-cohort (Post-costal cartilage Harvest Cohort: n = 30). The primary endpoint measures were the Numerical Rating Scale (NRS) scores of the chest and ear pain degrees recorded at 1-, 6-, 12-, 24-, and 48-h after surgery. Intraoperative anesthetic and analgesic dosages, sufentanil consumption and rescue analgesia consumption during the first 24 h post-operation, cough score during extubation, extubation agitation score, length of stay, the extubation time, first ambulatory time, analgesia duration, and opioid-related adverse effects and SAPB-related adverse effects were the secondary endpoints.

RESULTS

The rest and coughing NRS scores were significantly reduced in the SAPB-pre-cohort 6 and 12 h post-operation in comparison with the SAPB-post-cohort (rest 6 h p = 0.002, others p < 0.001). No significant difference in the NRS ear scores existed between the two cohorts (p > 0.05). The use of propofol and remifentanil for general anesthesia during the SAPB-pre-procedure was significantly reduced compared to the SAPB-post-group, with statistical significance (p < 0.001). Sufentanil consumption and rescue analgesia consumption were significantly reduced in the SAPB-pre-cohort (p = 0.001, p = 0.033). The extubation time and first ambulatory time were markedly shorter in the SAPB-pre-cohort (all p < 0.001). Analgesia duration was markedly longer in the SAPB-pre-cohort (p < 0.001). No significant differences were noted in the cough score during extubation, extubation agitation score, length of stay between the two cohorts (all p > 0.05). Opioid-related adverse effects occurred more in the SAPB-post-cohort, while there was no statistical significance (16.7 vs. 36.7%; p = 0.082). There were no blockade-related complications observed in either cohort.

CONCLUSION

The analgesic effect of the SAPB-pre-cohort was better than the SAPB-post-cohort suggesting both efficacy and feasibility of preemptive analgesia.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Analgesia for rib fractures: a narrative review

PURPOSE

Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach.

SOURCE

Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts.

PRINCIPAL FINDINGS

Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities.

CONCLUSION

Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).

Efficacy and safety of ultrasound-guided erector spinae plane block compared to sham procedure in adult patients with rib fractures presenting to the emergency department: A randomized controlled trial

OBJECTIVES

The primary objective was to compare the analgesic efficacy of ultrasound-guided erector spinae plane block (ESPB) with a sham procedure in adult patients presenting with rib fractures to the emergency department (ED).

METHODS

A randomized controlled trial was conducted at an academic ED over a 17-month period. Forty-six adults with confirmed rib fractures and numeric rating score (NRS) greater than 4 were randomized to one of two treatment arms: ultrasound-guided ESPB group or placebo (sham procedure). Intravenous opioids were prescribed as rescue analgesia when self-reported pain scores were ≥4. The primary outcome measure, pain intensity reduction, was derived using the 11-point NRS at six time points over 12 h. Secondary outcome measures included the amount of rescue analgesia, in morphine equivalents, and the occurrence of adverse events. Two-way repeated-measures ANOVA was used to compare the trend in NRSs across the two arms. The association between the complications and intervention was explored using the Fisher's exact test.

RESULTS

Forty-six patients (23 in each arm) completed the study. There was no difference between treatment groups with respect to age, sex, vital signs, preenrollment analgesia, or baseline pain intensity. In comparing pain intensity during the study period, NRS scores at 30, 60, and 120 min were significantly lower in the ESPB group (p < 0.001) during rest and deep inspiration. Moreover, patients in the ESPB group received lesser rescue analgesia than those in the sham group (10 mg, IQR 2.5 vs. 20 mg, IQR 5 mg; p ≤ 0.01). There was no difference in adverse events between groups.

CONCLUSIONS

Ultrasound-guided ESPB resulted in significantly reduced pain intensity over the study period and reduced amount of rescue analgesia and had no discernible difference in adverse events when compared with a sham.

Pain management for hospitalized patients with rib fractures: A systematic review of randomized clinical trials

STUDY OBJECTIVE

Rib fractures (RF) are common injuries. Multiple analgesia strategies are available for treatment of pain associated with RF. However, the optimal multimodal technique for pain management is not known. The primary aim of this review was to evaluate the status of evidence derived from randomized clinical trials (RCTs) on the effectiveness of pain management modalities for rib fracture pain. Other patient-centered outcomes were secondary objectives.

METHODS

Searches were conducted in MEDLINE, Embase, Scopus, and Cochrane Library. The screening process involved two phases, two researchers independently screened the title and abstract and subsequently screened full text. RCT data were extracted independently by two research team members. Consensus was achieved by comparison and discussion when needed. Risk of bias assessment was performed using the Cochrane Risk of Bias 2 tool.

RESULTS

A total of 1344 citations were identified. Title and abstract screening excluded 1128 citations, and full text review excluded 177 articles. A total of 32 RCTs were included in the full review. Multiple analgesia techniques and medications were identified and their effect on pain score and need for rescue opioid analgesia. None of the included studies were judged to have a high risk of bias, while only 10 studies were assessed as having a low risk of bias.

CONCLUSIONS

This systematic review found that studies are of low quality with diverse methodologies and outcomes. A reduction in pain scores was found for epidural analgesia when compared with other modalities. However, the low quality of the evidence necessitates cautious interpretation of this finding. PROSPERO registration: CRD42022376298 (Nov, 16, 2022).

Regional anesthesia and POCUS in the intensive care unit

This chapter focuses on resident recruitment and recent US National Resident Matching Program changes and the impact in the evaluation and ranking of applicants within the specialty of anesthesiology. Recruitment challenges are examined as well as program strategies and potential future directions. Also discussed are DEI initiatives within the recruitment process.

Analgesic Techniques for Rib Fractures-A Comprehensive Review Article

PURPOSE OF REVIEW

Rib fractures are a common traumatic injury that has been traditionally treated with systemic opioids and non-opioid analgesics. Due to the adverse effects of opioid analgesics, regional anesthesia techniques have become an increasingly promising alternative. This review article aims to explore the efficacy, safety, and constraints of medical management and regional anesthesia techniques in alleviating pain related to rib fractures.

RECENT FINDINGS

Recently, opioid analgesia, thoracic epidural analgesia (TEA), and paravertebral block (PVB) have been favored options in the pain management of rib fractures. TEA has positive analgesic effects, and many studies vouch for its efficacy; however, it is contraindicated for many patients. PVB is a viable alternative to those with contraindications to TEA and exhibits promising outcomes compared to other regional anesthesia techniques; however, a failure rate of up to 10% and adverse complications challenge its administration in trauma settings. Serratus anterior plane blocks (SAPB) and erector spinae blocks (ESPB) serve as practical alternatives to TEA or PVB with lower incidences of adverse effects while exhibiting similar levels of analgesia. ESPB can be performed by trained emergency physicians, making it a feasible procedure to perform that is low-risk and efficient in pain management. Compared to the other techniques, intercostal nerve block (ICNB) had less analgesic impact and required concurrent intravenous medication to achieve comparable outcomes to the other blocks. The regional anesthesia techniques showed great success in improving pain scores and expediting recovery in many patients. However, choosing the optimal technique may not be so clear and will depend on the patient's case and the team's preferences. The peripheral nerve blocks have impressive potential in the future and may very well surpass neuraxial techniques; however, further research is needed to prove their efficacy and weaknesses.

Serratus anterior fascia plane block for pain control in patients with multiple rib fractures

[Purpose] Respiratory physiotherapy plays an important role in the management of acute respiratory disturbance; however, chest pain often impedes patients from performing respiratory physiotherapy. In this study, we investigated whether pain due to multiple rib fractures can be managed with intermittent serratus anterior fascia plane (SAP) block. [Participants and Methods] We performed intermittent SAP blocks in three consecutive patients with pain due to multiple rib fractures based on the level of pain. The level of pain and differences in expiratory/inspiratory chest expansion were evaluated before and after performing the SAP block. [Results] All three patients reported an improvement in the severity of pain and increase in the thoracic range of motion after receiving the SAP block. No adverse events associated with intermittent SAP blocks were observed in any of the patients. [Conclusion] We report the cases of three patients who completed respiratory physiotherapy after receiving intermittent SAP blocks for the management of pain due to multiple rib fractures. SAP blocks are associated with a low risk of complications as the ribs are not punctured while performing SAP blocks.

Exploring a Cadaver-Based Model for Teaching Emergency Medicine Residents Ultrasound-Guided Serratus Anterior Plane Blocks

Background Ultrasound-guided regional anesthesia (USGRA) is increasingly being incorporated into ED clinical practice to provide pain control for a variety of traumatic injuries. The serratus anterior plane block (SAPB) has been shown to be effective at reducing intravenous opioid use and improving pulmonary function for patients with rib fractures, but there is limited prior research about how to safely teach this procedure to emergency medicine (EM) residents. Our goal was to examine the effect of a cadaver-based education model on EM residents' confidence in performing USGRA and provide a review of commonly encountered errors. Methods EM residents participated in a half-day cadaver-based education session that included a variety of less-commonly performed procedures including SAPB and fascia iliaca compartment block (FICB) USGRA. Residents received a didactic lecture and hands-on simulation practice during the month prior to the session. During the session, residents performed a SAPB and FICB on the cadaver patient using the same nerve block kit and ultrasound machine they would use for a living patient, with 1:1 supervision by an emergency ultrasound fellowship-trained physician who provided real-time feedback during the procedure. Representative ultrasound video clips were saved and reviewed. Surveys that were completed by residents after the session were analyzed. Results There were 23 residents who participated, and most had not performed any FICB (74%) or SAPB (87%) previously. The percentage of residents comfortable with general USGRA increased from 8.7% to 91.3% (p<0.001). Comfort with FICB increased from 9.1% to 77.3% (p<0.001), and comfort with SAPB increased from 9.1% to 77.3% (p<0.001). Instructors identified and corrected several common errors, such as overly aggressive needle insertion, instillation of air, and instillation of anesthetic into muscle rather than the fascial plane. Conclusion We found that a cadaver-based education model for teaching EM residents the SAPB and the FICB was associated with significant increases in resident confidence in performing the procedure and facilitated identification and correction of common procedural errors that may otherwise have gone undetected.

Comprehensive Review of Current Pain Management in Rib Fractures With Practical Guidelines for Clinicians

Rib fractures are present in 15% of all traumas and 60% of patients with chest traumas. Rib fractures are not life-threatening in isolation, but they can be quite painful which leads to splinting and compromise of respiratory function. Splinting limits the ability of a patient to take a deep breath, which leads to atelectasis, atelectasis to poor secretion removal, and poor secretion removal leads to pneumonia. Pneumonia is the common pathway to respiratory failure in patients with rib fractures. It is noted that in the elderly, each rib fracture increases developing pneumonia by 27% and the risk of dying by 19%. From a public health perspective, rib fractures have long-term implications with only 59% of patients returning to work at 6 months. In this review we will examine the state of art as it currently exists with regard to the management of pain associated with rib fractures. Included in this overview will be a brief review of the anatomy of the thorax and some important physiologic concepts, the latest trends in pharmacologic and noninvasive means of managing rib pain, a special section on epidural anesthesia, some other alternative invasive methods of pain control, and a review of the recent literature on rib plating. Finally, a practical, easy to follow guideline, to manage the patient with pain from rib fractures will be presented.

Management of thoracic trauma

Managing major thoracic trauma begins with identifying and anticipating injuries associated with the mechanism of injury. The key aims are to reduce early mortality and the impact of associated complications to expedite recovery and restore the patient to their pre-injury state. While imaging is imperative to identify the extent of thoracic trauma, some pathology may require immediate treatment. The majority can be managed with adequate pleural drainage, but respiratory failure and poor gas exchange may require either non-invasive or invasive ventilation. Ventilation strategies to protect from complications such as barotrauma, volutrauma and ventilator-induced lung injury are important to consider. The management of pain is vital in reducing respiratory complications. A multimodal strategy using local, regional and systemic analgesia may mitigate respiratory side effects of opioid use. With optimal pain management, physiotherapy can be fully utilised to reduce respiratory complications and enhance early recovery. Thoracic surgeons should be consulted early for consideration of surgical management of specific injuries. With a greater understanding of the mechanisms of injury and the appropriate use of available resources, favourable outcomes can be reached in this cohort of patients. Overall, a multidisciplinary and holistic approach results in the best patient outcomes.

Successful weaning from mechanical ventilation after Serratus Anterior Plane block in a chest trauma patient

OBJECTIVES

Chest trauma is associated with severe pain, which can hamper normal breathing. Serratus Anterior Plane block (SAPB) is a novel technique, which provides analgesia for chest wall surgery. We describe an interesting clinical case about the use of SAPB to improve pain and pulmonary function in a patient with severe chest trauma.

CASE PRESENTATION

We report the pain management and the clinical evolution of a patient in ICU, with a severe chest trauma, after performing the SAPB. Following the SAPB, the patient had a reduction in pain intensity and an improvement in both respiratory mechanics and blood gas analysis allowing a weaning from mechanical ventilator.

CONCLUSIONS

Pain control greatly affects mortality and morbidity in patients with chest trauma. SAPB seems to be safer and equally effective in pain control compared to epidural analgesia in patients with chest trauma.

The Anesthetic Effect of Ultrasound-Guided Serratus Anterior Plane Block in Arthroscopic Shoulder Surgery and Its Effect on Postoperative Analgesia

Objective

To investigate the anesthetic effect of anterior serratus muscle plane block under ultrasound guidance in arthroscopic shoulder surgery and its effect on postoperative analgesia.

Methods

A total of 94 patients who received arthroscopic shoulder surgery in our hospital were selected as the research subjects, and they were divided into a control group and a study group according to the random number table method. The control group underwent brachial plexus block under ultrasound guidance, and the study group underwent anterior serratus plane block under ultrasound guidance. The visual analogue score (VAS) of pain at each time point, intraoperative anesthetic dosage, the use of postoperative analgesic, pain mediators and oxidative stress factors before and after surgery, and the occurrence of adverse reactions were compared between the two groups after surgery.

Results

At 6, 12, 48, and 72 h after surgery, there was no obvious difference in the VAS score between the two groups (P > 0.05); 24 h after surgery, the VAS score of the study group was significantly lower than that of the control group (P < 0.05). The intraoperative dosage of propofol and remifentanil in the study group was significantly lower than that in the control group (P < 0.05). The number of effective compressions of analgesic pump and the total amount of sufentanil in the study group were significantly lower than those in the control group within 48 hours after operation, and the time of first compressions of analgesic pump was significantly longer than that in the control group (P < 0.05). Before surgery, there were no significant differences in CGRP, NPY, and MDA levels and SOD enzyme activity between the two groups (P > 0.05). After surgery, the levels of pain mediators CGRP and NPY in the study group were lower than those in the control group (P < 0.05). The level of MDA was lower than that of the control group, and SOD enzyme activity was higher than that of the control group (P < 0.05). There was no significant difference in the incidence of adverse reactions between the two groups (P > 0.05).

Conclusion

Ultrasound-guided anterior serratus plane block for arthroscopic shoulder surgery has a good anesthesia effect and long action time. It can significantly reduce the dosage of opioids, enhance the postoperative analgesic effect, effectively inhibit postoperative pain and oxidative stress reaction, and has good safety.

Chest Wall Nerve Blocks for Cardiothoracic, Breast Surgery, and Rib-Related Pain

PURPOSE OF REVIEW

Perioperative analgesia in patients undergoing chest wall procedures such as cardiothoracic and breast surgeries or analgesia for rib fracture trauma can be challenging due to several factors: the procedures are more invasive, the chest wall innervation is complex, and the patient population may have multiple comorbidities increasing their susceptibility to the well-defined pain and opioid-related side effects. These procedures also carry a higher risk of persistent pain after surgery and chronic opioid use making the analgesia goals even more important.

RECENT FINDINGS

With advances in ultrasonography and clinical research, regional anesthesia techniques have been improving and newer ones with more applications have emerged over the last decade. Currently in cardiothoracic procedures, para-neuraxial and chest wall blocks have been utilized with success to supplement or substitute systemic analgesia, traditionally relying on opioids or thoracic epidural analgesia. In breast surgeries, paravertebral blocks, serratus anterior plane blocks, and pectoral nerve blocks have been shown to be effective in providing pain control, while minimizing opioid use and related side effects. Rib fracture regional analgesia options have also expanded and continue to improve.  Advances in regional anesthesia have tremendously improved multimodal analgesia and contributed to enhanced recovery after surgery protocols. This review provides the latest summary on the use and efficacy of chest wall blocks in cardiothoracic and breast surgery, as well as rib fracture-related pain and persistent postsurgical pain.

Efficacy of Ultrasound-Guided Serratus Anterior Plane Block for Managing Pain Due to Multiple Rib Fractures: A Scoping Review

Ultrasound (US) guided serratus anterior plane block (SAPB) is a fascial plane block that has been utilized for managing pain after thoracotomy, mastectomy, and fractured ribs. We conducted this qualitative review to investigate the analgesic efficacy of US-guided SAPB in patients who sustained multiple rib fractures (MRFs).

We registered our review proposal in a prospective register of systematic reviews, PROSPERO, with identifier CRD42020177145. This review adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for the identification, screening, and inclusion of relevant articles. Two authors independently searched Pubmed, Embase, the Cochrane Library, Google Scholar, and Web of Science to identify available randomized controlled trials (RCT), case reports, case series reports where SAPB was used for managing pain due to MRFs.

Out of the 66 articles identified by the search strategy, 23 articles were assessed for eligibility, and 16 articles were included in the qualitative review. Due to significant heterogenicity, the presence of only one RCT, the presence of case report or series, availability of only retrospective studies for review, a quantitative analysis using statistical tests were not done. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment was not done as there was only one RCT in the review which had limitations like allocation concealment and blinding.

US-guided SAPB is a safe and effective fascial plane block for managing pain in patients who sustain MRFs. Further research in the form of well-designed and adequately powered RCTs is needed to confirm its use in patients with MRFs.

The erector spinae plane block for acute pain management in emergency department patients with rib fractures

OBJECTIVE

Rib fractures represent a significant cause of morbidity and mortality in trauma patients. The erector spinae plane block has come to the forefront as a potential safe and effective option for analgesia in painful conditions of the thorax over multiple dermatomal levels. Given the high morbidity associated with rib fractures, the inadequacy of opioid analgesia and the strong safety profile of the erector spinae plane block, this pilot study sought to address whether this block can be used to safely and effectively provide analgesia in emergency department (ED) patients with acute rib fractures.

METHODS

A total of nine patients underwent the procedure successfully. Patients were found to have a significant reduction in their pain score pre- and post-block. The reduction in mean pre- and post-block pain scores was 9.89 vs 3.56 which was statistically significant (p < 0.0001).

CONCLUSION

In a pilot sampling of emergency department patients with acute fractures who failed traditional analgesic therapy, the erector spinae plane block performed by emergency physicians provided safe and effective pain control. Further research is needed to fully establish the clinical benefit and safety of this procedure.

A randomized clinical trial of single dose liposomal bupivacaine versus indwelling analgesic catheter in patients undergoing surgical stabilization of rib fractures

INTRODUCTION

Locoregional analgesia (LRA) remains underused in patients with chest wall injuries. Surgical stabilization of rib fractures (SSRF) offers an opportunity to deliver surgeon-directed LRA under direct visualization at the site of surgical intervention. We hypothesized that a single-dose liposomal bupivacaine (LB) intercostal nerve block provides comparable analgesia to an indwelling, peripheral nerve plane analgesic catheter with continuous bupivacaine infusion (IC), each placed during SSRF.

METHODS

Noninferiority, single-center, randomized clinical trial (2017-2020) was performed. Patients were randomized to receive either IC or LB during SSRF. The IC was tunneled into the surgical field (subscapular space), and LB involved thoracoscopic intercostal blocks of ribs 3 to 8. The primary outcome was the Sequential Clinical Assessment of Respiratory Function score, measured daily for 5 days postoperatively. Secondary outcomes included daily narcotic equivalents and failure of primary LRA, defined as requiring a second LRA modality.

RESULTS

Thirty-four patients were enrolled: 16 IC and 18 LB. Age, Injury Severity Score, RibScore, Blunt Pulmonary Contusion Score, and use of nonnarcotic analgesics was similar between groups. Duration of IC was 4.5 days. There were three failures in the IC group versus one in the LB group (p = 0.23). There was no significant difference in Sequential Clinical Assessment of Respiratory Function score between the IC and LB groups. On postoperative days 2 to 4, narcotic requirements were less than half in the LB, as compared with the IC group; however, this difference was not statistically significant. Average wholesale price was US $605 for IC and US $434 for LB.

CONCLUSION

In this noninferiority trial, LB provided at least comparable and potentially superior LRA as compared with IC among patients undergoing SSRF.

LEVEL OF EVIDENCE

Therapeutic, level II.

The effect of erector spinae block versus serratus plane block on pain scores and diaphragmatic excursion in multiple rib fractures. A prospective randomized trial

OBJECTIVES

We aimed to investigate whether ultrasound guided erector spinae plane block and serratus anterior plane block would provide effective and safe analgesia in patients with fracture ribs, and to detect their effects on diaphragmatic excursion in such cases.

DESIGN

Prospective double-blind randomized study.

SETTINGS

Tanta University Hospitals.

SUBJECT

Fifty adult patients ASA I, II with fracture ribs.

METHODS

Patients were randomized to receive either ultrasound guided erector spinae block (Group I) or serratus plane block (Group II) with injection of 19 ml bupivacaine 0.25% plus 1 ml dexamethasone (4 mg). Pain scores, 24 hour total analgesic requirements, diaphragmatic excursion and incidence of adverse events were recorded.

RESULTS

At rest and dynamic pain scores were significantly lower in Group I as compared to Group II from 2 hour up to 24 hour post block [median differences (95% CI): -1(-0.9999;0.0002), -1(-0.9999;0.0002), -1(-0.9998;0.0003), -1(-1.000;-0.000) and -1(-2.0000;-1.0000), -1(-0.9998;-0.0001), -1(-1.0001;-1.0002), -1(-2.000;0.000) respectively], with a significant reduction in 24h opioid consumption in Group I in comparison to Group II (P= 0.004*). Diaphragmatic excursion showed a significant improvement in Group I when compared to Group II at 2, 6, 12, and 24 hour after the block (p = 0.024*, 0.038*, 0.027*, 0.042* correspondingly). No adverse events were noted.

CONCLUSIONS

Both erector spinae block and serratus plane block provided safe and effective pain relief in traumatic rib fractures. Though the erector spinae group displayed significantly reduced pain scores, decreased analgesic needs and improved diaphragmatic excursion as compared to serratus group, nevertheless, this was of no clinical significance.