Scientific letter
A new thoracic interfascial plane block as anesthesia for difficult weaning due to ribcage pain in critically ill patients
Nuevo bloqueo del plano interfascial torácico como anestesia para retiradas dificultosas de ventilación mecánica a causa de dolor torácico, en pacientes críticos
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López-Matamala, M. Fajardo, B. Estébanez-Montiel, R. Blancas, P. Alfaro, M. Chana" "autores" => array:6 [ 0 => array:3 [ "nombre" => "B." "apellidos" => "López-Matamala" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Fajardo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "B." "apellidos" => "Estébanez-Montiel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:4 [ "nombre" => "R." "apellidos" => "Blancas" "email" => array:1 [ 0 => "rafael.blancas@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 4 => array:3 [ "nombre" => "P." "apellidos" => "Alfaro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Chana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario del Tajo, Aranjuez, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesia, Hospital Universitario del Tajo, Aranjuez, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nuevo bloqueo del plano interfascial torácico como anestesia para retiradas dificultosas de ventilación mecánica a causa de dolor torácico, en pacientes críticos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1283 "Ancho" => 1584 "Tamanyo" => 97460 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ultrasound of the chest wall showing the planes visualized in the lateral chest. SAM: serratus anterior muscle; ICM: intercostal muscles; R3: third rib; R4: fourth rib; R5: fifth rib; PP: parietal pleura; ETF: enthoracic fascia; FAT: subcutaneous fat; * denotes hydrodissection of the interfascial plane with the anesthetic solution inside this space.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Interfascial plane block of anterior and lateral cutaneous branches of intercostal nerves, known as pecto-intercostal fascial plane block (PIFB) and serratus–intercostal plane block (SIFB), is an anesthetic procedure for ribcage anesthesia not previously reported in the setting of critical care. A similar anesthetic technique has proven adequate pain control during and after abdominal and breast surgery.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Patients with chest trauma and rib fractures or patients with endothoracic drainage tubes (EDTs) often need deep sedoanalgesia, hindering weaning. The use of ultrasound-guided interfascial plane block in critically ill patients opens up several possibilities to improve pain control, decreasing the need of other forms of conventional analgesia.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Description of interfascial plane block</span><p id="par0015" class="elsevierStylePara elsevierViewall">For carrying out PIFB a linear ultrasound (US) probe is placed at 2<span class="elsevierStyleHsp" style=""></span>cm from the sternal body. On the surface plane, the subcutaneous tissue is identified, in the intermediate plane, the pectoralis major muscle, the intercostal muscles and the ribs, and in the deep plane, the pleura and the lungs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A needle is introduced following the lower edge of US probe, directing the tip from the bottom of the sternum and positioning the needle tip between the pectoralis major and the external intercostal muscles.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Twenty milliliters of a solution of 0.25% levobupivacaine plus epinephrine (5<span class="elsevierStyleHsp" style=""></span>mcg/ml) are diluted in 250<span class="elsevierStyleHsp" style=""></span>ml of 0.9% sodium chloride solution. Anesthetic boluses of 5<span class="elsevierStyleHsp" style=""></span>ml are introduced to perform hydrodissection of the interfascial plane. The catheter must be allocated 3–5<span class="elsevierStyleHsp" style=""></span>cm beyond the tip of the needle and is connected to an elastomeric pump, containing the anesthetic solution, at the infusion rate of 5<span class="elsevierStyleHsp" style=""></span>ml/h.</p><p id="par0030" class="elsevierStylePara elsevierViewall">For SIFB, US probe is located on the lateral thoracic longitudinal axis, at the midaxillary line. On the surface plane subcutaneous tissue is identified, in the intermediate plane the anterior serratus muscle, the ribs and the intercostals muscles and in the deep plane the pleura and the lung. The needle is located between the serratus anterior muscle and the external intercostal muscle (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The needle is directed following the lower edge of US probe, from caudal to cranial, to locate it between the serratus anterior and the external intercostal muscles. Hydrodissection of the interfascial plane is made and 3<span class="elsevierStyleHsp" style=""></span>ml of the anesthetic solution is administered for every segment desired to be blocked. The catheter is allocated 3–5<span class="elsevierStyleHsp" style=""></span>cm beyond the tip of the needle and is connected to the elastomeric pump.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 1</span><p id="par0035" class="elsevierStylePara elsevierViewall">A 31-year-old man was admitted to the intensive care unit (ICU) due to severe community-acquired pneumonia and acute respiratory distress syndrome. Orotracheal intubation and prolonged mechanical ventilation were needed. Bilateral pneumothorax complicated respiratory progress. EDTs were placed on the left (lateral and anterior) and on the right (upper) chest.</p><p id="par0040" class="elsevierStylePara elsevierViewall">When the weaning was thought to be suitable, three days after EDTs placement, sedoanalgesia with a morphine chloride infusion (0.42<span class="elsevierStyleHsp" style=""></span>mcg/kg/min) and propofol (55.56<span class="elsevierStyleHsp" style=""></span>mcg/kg/min) were needed because of severe ribcage pain when sedation windows were planned in multiple attempts of weaning. Sedative drugs hindered an adequate level of consciousness and collaboration for weaning.</p><p id="par0045" class="elsevierStylePara elsevierViewall">PIFB was thought to be the best option for ribcage pain management. Five hours after the start of PIFB, intravenous sedative drugs were withdrawn and the patient could be extubated 1<span class="elsevierStyleHsp" style=""></span>h later. The following days, the patient remained painless, not requiring any other analgesic. On the seventh day, PIFB catheters were removed. No germs grew in the cultures of catheters.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case 2</span><p id="par0050" class="elsevierStylePara elsevierViewall">A 61-year-old man was admitted to the ICU after thoracic trauma. The patient showed fractures from the third to the eleventh ribs on the right thorax, fractures from the third to the twelfth ribs on the left thorax, fractures of the left L1–L4 transverse apophysis, fracture of the sacrum and fracture of the right iliac blade.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The patient required endotracheal intubation and mechanical ventilation due to respiratory failure, and surgery for pelvic external fixation. Sedoanalgesia with mizadolam (7.5<span class="elsevierStyleHsp" style=""></span>mcg/kg/min) and morphine chloride (0.5<span class="elsevierStyleHsp" style=""></span>mcg/kg/min of) was started.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Four days later, in anticipation of an expected difficult weaning, SIFB was performed on both hemithorax with an infusion of levobupivacain 0.0625% at a 10<span class="elsevierStyleHsp" style=""></span>ml/h rhythm. The concentration of levobupivacain infusion was intentionally reduced, with an increased infusion rhythm (larger volume infused) to achieve a wider spread of the anesthetic, due to patient obesity (body mass index, 34.6). After 5<span class="elsevierStyleHsp" style=""></span>h of levobupivacain infusion, midazolam and morphine chloride were withdrawn. Metamizol (2<span class="elsevierStyleHsp" style=""></span>g/6<span class="elsevierStyleHsp" style=""></span>h, IV) and paracetamol (1<span class="elsevierStyleHsp" style=""></span>g/6<span class="elsevierStyleHsp" style=""></span>h) were prescribed due to painful fractures outside the chest. Dipotassium clorazepate (20<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h, IV) and clonidine (300<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h, through the nasogastric tube) were initiated to prevent deprivation syndrome. Ninety hours after intravenous midazolam and morphine chloride were withdrawn, the patient was awake and collaborative. He showed no ribcage pain and he was extubated successfully in the first attempt. The patient denied ribcage pain after extubation, even with mobilizations.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Catheters were kept in place for ten days and its cultures were sterile.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Comments</span><p id="par0070" class="elsevierStylePara elsevierViewall">PIFB and SIFB have not been described previously as anesthesia for critically ill patients.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In Case 1, PIFB was clearly effective for ribcage pain control, preventing prolonged weaning and avoiding the use of other analgesic drugs. In Case 2, anti-inflammatory drugs were added for pain due to pelvis and vertebral fractures. Anyway, the use of non-steroidal anti-inflammatory agents appeared to be insufficient for the control of pain after multiple and bilateral rib fractures. The patient could not be extubated before sedative drugs had no effects on consciousness; ribcage pain was not an obstacle for weaning after PIFB was initiated.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The patients we report were pain free even with cough and mobilization after PIFB and SIFB. Elastomeric pumps were changed every 48<span class="elsevierStyleHsp" style=""></span>h. No significant increase in the nursing staff workload, compared to administration of intravenous analgesics, was needed.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Possible PIFB and SIFB indications in ICU may include chest trauma (sternum and/or ribs fractures), thoracic and heart surgery, EDT maintenance, etc.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Description of interfascial plane block" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 2" ] ] ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Comments" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1171 "Ancho" => 1584 "Tamanyo" => 93330 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ultrasound of the chest wall showing the structures visualized in the anterior chest. PMM: pectoralis major muscle; ICM: intercostal muscles; R4: fourth rib; R5: fifth rib; * denotes hydrodissection of the interfascial plane with the anesthetic solution inside this space. The arrow points the position of the needle crossing from the subcutaneous tissue up to the interfascial plane.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1283 "Ancho" => 1584 "Tamanyo" => 97460 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ultrasound of the chest wall showing the planes visualized in the lateral chest. SAM: serratus anterior muscle; ICM: intercostal muscles; R3: third rib; R4: fourth rib; R5: fifth rib; PP: parietal pleura; ETF: enthoracic fascia; FAT: subcutaneous fat; * denotes hydrodissection of the interfascial plane with the anesthetic solution inside this space.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasound description of the Pecs II (modified Pecs I): a novel approach into breast surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. Blanco" 1 => "M. Fajardo" 2 => "T. Parras" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2012.07.003" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2012" "volumen" => "59" "paginaInicial" => "470" "paginaFinal" => "475" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22939099" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The transversus abdominis plane block: a valuable option for postoperative analgesia? A topical review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P.L. Petersen" 1 => "O. Mathiesen" 2 => "H. Torup" 3 => "J.B. Dahl" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1399-6576.2010.02215.x" "Revista" => array:6 [ "tituloSerie" => "Acta Anaesthesiol Scand" "fecha" => "2010" "volumen" => "54" "paginaInicial" => "529" "paginaFinal" => "535" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20175754" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transversus Abdominis Plane (TAP) Block" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "K. Mukhtar" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "JNYSORA" "fecha" => "2009" "volumen" => "12" "paginaInicial" => "28" "paginaFinal" => "33" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Application of the transversus abdominis plane block in the intensive care unit" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Niraj" 1 => "A. Kelkar" 2 => "A.J. Fox" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anaesth Intensive Care" "fecha" => "2009" "volumen" => "37" "paginaInicial" => "650" "paginaFinal" => "652" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19681428" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transversus abdominis plane block for laparoscopic surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "K. Mukhtar" 1 => "S. Singh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aen338" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2009" "volumen" => "102" "paginaInicial" => "143" "paginaFinal" => "144" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19059927" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000003800000007/v1_201410030040/S2173572714000599/v1_201410030040/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/21735727/0000003800000007/v1_201410030040/S2173572714000599/v1_201410030040/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572714000599?idApp=WMIE" ]
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| 2019 August | 95 | 43 | 138 |
| 2019 July | 92 | 30 | 122 |
| 2019 June | 79 | 35 | 114 |
| 2019 May | 97 | 40 | 137 |
| 2019 April | 91 | 33 | 124 |
| 2019 March | 77 | 37 | 114 |
| 2019 February | 58 | 39 | 97 |
| 2019 January | 80 | 26 | 106 |
| 2018 December | 106 | 50 | 156 |
| 2018 November | 117 | 57 | 174 |
| 2018 October | 62 | 19 | 81 |
| 2018 September | 50 | 22 | 72 |
| 2018 August | 39 | 18 | 57 |
| 2018 July | 34 | 18 | 52 |
| 2018 June | 34 | 10 | 44 |
| 2018 May | 24 | 5 | 29 |
| 2018 April | 46 | 9 | 55 |
| 2018 March | 50 | 7 | 57 |
| 2018 February | 23 | 11 | 34 |
| 2018 January | 22 | 14 | 36 |
| 2017 December | 16 | 14 | 30 |
| 2017 November | 22 | 25 | 47 |
| 2017 October | 26 | 15 | 41 |
| 2017 September | 18 | 14 | 32 |
| 2017 August | 10 | 10 | 20 |
| 2017 July | 17 | 13 | 30 |
| 2017 June | 35 | 27 | 62 |
| 2017 May | 30 | 25 | 55 |
| 2017 April | 27 | 25 | 52 |
| 2017 March | 6 | 22 | 28 |
| 2017 February | 19 | 41 | 60 |
| 2017 January | 9 | 14 | 23 |
| 2016 December | 28 | 19 | 47 |
| 2016 November | 30 | 40 | 70 |
| 2016 October | 44 | 54 | 98 |
| 2016 September | 55 | 88 | 143 |
| 2016 August | 47 | 27 | 74 |
| 2016 July | 24 | 20 | 44 |
Show all
