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Pectointercostal Fascial Block Catheters for Thoracic Injuries

A Case Series

Burns, Landon T., MD*; Beasley, Drew A., MD; Stevens, Mark A., MD; Crabtree, Donald E., DO; Mehaffey, Gregory R., MD

doi: 10.1213/XAA.0000000000000821
Case Reports

Providing analgesia for patients with anterior rib and sternum fracture has been addressed from various types of modalities. Regional anesthesia via epidurals or peripheral nerve blocks, opiates, and other forms of multimodal pain regimens have been used. However, in the polytraumatic injury patient, positioning for an epidural may be problematic, and a predominantly opiate-based treatment plan may compromise respiratory status. In this case series, we describe the pectointercostal fascial block as another tool to treat patients with anterior rib and sternal fracture with polytraumatic injuries. All 3 of the block’s successes were evident by improvement in the respiratory status of each patient.

From the *Emory University, Atlanta, Georgia

Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas.

Accepted for publication May 8, 2018.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Landon T. Burns, MD, Emory University, 1364 Clifton Rd, Atlanta, GA 30322. Address e-mail to Ltburns@emory.edu.

Pectointercostal fascial blocks (PIFBs) have been used for adjunct analgesia after surgery involving the anterior chest and sternum.1 There have also been reports of PIFB used in patients with traumatic fracture of the sternum and anterior ribs after blunt force trauma,2–5 and patients who are at high risk for respiratory failure due to concomitant narcotic analgesic regimens and limitations to pulmonary function due to rib and sternal pain. In this case series, we describe PIFB catheter placement in 3 trauma patients with sternal and/or anterior rib fractures for analgesia.

Anesthesiologists have long used the thoracic epidural as a means of providing postoperative analgesia to patients with thoracic injury due to thoracotomy, rib fracture, and sternotomy. In addition, paravertebral blocks have been used to deposit local anesthetic into the paravertebral space, as with isolating thoracic spinal nerves for pain control in rib fractures and incisional pain of the thorax.2 As the use of ultrasound guidance has become established in regional anesthesia, new regional modalities have been developed to manage many of the surgical and trauma-related injuries previously covered with a thoracic epidural or paravertebral block. For example, for anterior thoracic incisions extending into the axilla, such as with mastectomy surgery, the pectoral nerve II block has been used to inject local anesthetic between the pectoralis minor and serratus anterior muscles at the level of the third and fourth rib for T2-T6 dermatomal blockade and intercostobrachial nerve coverage.3 The PIFB is another interfascial plane block in the anesthesiologist’s regional repertoire that can be used to cover anterior chest wall pain by depositing local anesthetic between the fascial planes of the pectoralis major and intercostal muscles, where the anterior and lateral cutaneous nerves traverse.2–5

We used the PIFB technique in 3 separate trauma patients to provide analgesia for traumatic fracture of the anterior ribs and/or sternum. These patients sustained polytrauma injuries as a result of separate motor vehicle accidents, and due to their injuries, positioning these patients for a thoracic epidural or paravertebral block would have been quite difficult. Thus, we propose that the PIFB could improve pain control to patients with such injuries and in a manner that provides minimal discomfort to the patient. Written consent was obtained from all 3 patients before preparing the case report.

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CASE SERIES

Case I

A 54-year-old (1.8 m, 156.8 kg, body mass index 47.4) African American man presented to the emergency department at our level 1 trauma center as a transfer from an outside hospital. He had been involved in a motor vehicle crash and suffered several traumatic injuries including a fracture/displaced sternomanubrial junction, mildly displaced fractures of the right sixth, seventh, and eighth ribs, a left femur fracture, and intraabdominal solid organ injuries. The surgical intensive care unit (ICU) team consulted the Acute Pain Service (APS) for expertise in managing thoracic wall pain and to improve his pulmonary function. Due to the nature and location of the sternal and rib fractures, the decision was made to place bilateral PIFB catheters (Figure).

Figure

Figure

The patient provided consent for bilateral PIFB catheters, and the site was marked and prepared in the usual sterile fashion. A time-out was performed, and a linear high-frequency ultrasound probe was placed in a cranial-caudal orientation approximately 2 cm lateral to the left lateral edge of the sternum over the fourth and fifth rib. A 25-gauge (G) needle was then used to anesthetize the skin below the caudal side of the ultrasound probe with 1% lidocaine. A Halyard (Alpharetta, GA) 16-G echogenic ON-Q, QUIKBLOCK over-the-needle catheter set (#QB15016SG) was then flushed with normal saline and inserted through the anesthetized skin caudal to cephalad orientation relative to the ultrasound probe. Under ultrasound visualization, the needle was advanced superiorly over the fifth rib, through the pectoralis major muscle, to reach the pectointercostal fascial plane between the fourth rib and the pectoralis major. The plane was then hydrodissected using normal saline, and the needle was removed from the catheter, leaving the 16-G catheter in the pectointercostal fascial plane. The catheter was then flushed with 10 mL of 0.50% bupivacaine in incremental doses after negative aspiration. The same procedure was then performed on the right side of the anterior chest. The catheters were secured in place with Dermabond (Ethicon; Bridgewater, NJ), Steri-Strips, and large Tegaderm dressings (3M; Maplewood, MN), attached to a Halyard 600-mL dual-catheter On-Q ball (#CB6007) that was filled with 0.125% plain bupivacaine, and each catheter infusion was set to infuse at 7 mL/h. The procedure was performed without any complications, and the patient reported no difficulties tolerating the procedure without intravenous sedation.

Before placement of the PIFB catheters, the patient reported a Visual Analog Scale (VAS) score of 10 when asked about his chest wall pain, and his maximum incentive spirometer level was 400 mL. One hour after the catheter placement procedure, he reported a VAS score of 0 regarding chest wall pain, and on the day after the catheters were placed, he reached 1500 mL on the incentive spirometer. The patient was then followed by the APS team for the next 4 days, and the pain of the patient was monitored via the VAS and narcotic consumption. The patient did not require intubation or mechanical ventilation, other than for the brief intraoperative period required for fixation of his femur fracture.

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Case II

A 76-year-old Caucasian man was admitted to our level 1 trauma center as a transfer from an outside hospital after being involved in a motor vehicle crash. He suffered the following injuries: sternal fracture, mediastinal hematoma, right 2–7 anterolateral rib fractures, left 1–5 anterolateral rib fractures, and T4 and T7 compression fractures. On arrival, the patient had a peripheral oxygen saturation in the low 90s to upper 80s and was hypercapneic with an arterial blood gas test showing a PCO2 of 89. He was subsequently intubated in the emergency department, and sedation was maintained with fentanyl and dexmedetomidine. The surgical ICU team consulted the APS to provide expertise in managing thoracic wall pain and improving pulmonary function. Bilateral PIFB catheters were chosen due to the nature and location of the fractures.

The patient’s family gave consent for bilateral PIFB catheters, and the site was marked and prepared in the usual sterile fashion. As in the manner of case I, a time-out was performed and followed by bilateral catheter placement. After catheter placement, a solution of 0.125% plain bupivacaine was infused through each catheter at a rate of 7 mL/h.

Before PIFB catheter placement, the patient was maintained on the ventilator using a synchronized intermittent mandatory ventilation setting with a tidal volume of 500 mL, rate of 20, pressure support of 10, and fraction of inspired oxygen at 50%. After the catheters were placed, the patient was able to tolerate continuous positive airway pressure with an exhaled tidal volume of 548 mL with continuous pressure setting of 14 cm H2O, on fraction of inspired oxygen at 50%. Pain scores were not recorded in the medical chart, but on our evaluation, the patient was able to communicate with us by providing a thumbs-up, a thumbs-down, and shaking of his head indicating “yes” and “no.” He reported that his pain was much improved from the day before, and it was a 3 of 10 on the VAS.

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Case III

The third case in our series was a 36-year-old Caucasian man transferred to our facility after being involved in a motor vehicle collision with an 18-wheel tractor trailer. Computed tomography scan revealed left 2–5 displaced rib fractures with left upper lobe lung laceration, right 2–5 buckled ribs, grade III splenic laceration with surrounding hematoma, pancreas head hematoma, right-hip dislocation with a femoral-head chip fracture, right-posterior acetabular fracture, left-superior and left-inferior pubic rami fractures, and left-anterior and left-posterior acetabular fractures. This patient also had a history of Crohn disease with a subsequent ostomy and was told by his primary care provider that he could not take non-steroidal anti-inflammataory drugs. The APS was consulted on hospital day 1 for the management of his rib fracture–associated pain.

PIFB catheters were placed bilaterally between the fourth and fifth ribs in the same manner as the previous 2 cases with the same infusion setting of 0.125% plain bupivacaine at 7 mL/h. Before the placement of the PIFB catheters, he was limited to a maximum of 250 mL on his incentive spirometry due to associated chest wall pain, and he also could not tolerate a cough during this time. Within 24 hours of placement of the PIFB catheters, he was able to achieve 500 mL on incentive spirometry without difficulty, and was also able to cough with tolerable discomfort. He was taken to the operating room for a procedure and returned to the ICU intubated, but he was extubated within 24 hours. After extubation on catheter day 3, the patient was able to achieve 1500 mL on his incentive spirometry.

The patient reported a 10 of 10, with impending respiratory failure, VAS pain score before PIFB catheter insertion, as recorded in the APS notes. At 24 hours after catheter placement, the patient reported a VAS pain score of 6 of 10. He did have some pain issues on the second day, possibly due to his other injuries; however, his On-Q ball was also empty. The On-Q ball was discontinued, and he received scheduled boluses, given by the APS team of 20 mL of 0.125% bupivacaine on each side every 12 hours. This significantly reduced his pain to a VAS pain score of 4 of 10. The PIFB catheters were removed after 96 hours, and the patient did not require any further mechanical ventilation.

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DISCUSSION

The PIFB nerve block was first described in 2014 by de la Torre et al6 as a technique for providing analgesia to the anterior chest wall. Traditional regional analgesia options for sternal and rib fractures have been thoracic epidural or paravertebral catheter infusion. These techniques would have been challenging to use with the described patients due to their body habitus and multiple other injuries and thus an inability to properly position themselves for neuraxial analgesia. The ultrasound-guided PIFB catheter technique simplified the sternal and rib fracture pain management in these patients by providing a technically simple approach away from the neuraxis that could be performed with the patients in the supine position. A key benefit of the PIFB catheter technique is the ability to avoid a neuraxial technique in patients receiving venous thromboembolism prophylaxis, which averts the potentially catastrophic complication of an epidural hematoma.

Perhaps the greatest benefit seen in our patient series is the overall improvement in respiratory function. All 3 patients had some decreased level of function in their respiratory abilities secondary to sternal and/or rib fracture pain. After the PIFB catheters were placed, there was documentation of both decreased pain in the affected area and an increase in respiratory function, as determined by incentive spirometry maximum values or by a decrease in ventilator support. Given that decreases in incentive spirometry values and inability to cough and clear secretions could increase atelectasis and contribute to potential for other negative sequelae, such as pneumonia,7 the PIFB catheter for sternal/rib trauma could potentially improve patient outcomes.

One limitation to the data in this case series is that pain scores decreased in relation to chest wall pain, as stated by the patients on the VAS scale on direct interview by the APS team; however, in nursing notes, pain scores were seldom differentiated between sternal/rib pain and pain from the site of other injuries. Also, these patients were polytrauma victims; therefore, data related to narcotic consumption before and after PIFB catheter placement are not entirely relevant to the level of analgesia provided to the thoracic wall. It is also worth noting that the use of reusable digital infusion pumps would likely be a more cost-effective way to infuse the local anesthetic solution into the PIFB catheters in the inpatient setting in which these cases occurred, as opposed to the disposable elastomeric pumps that are traditionally used for outpatient continuous nerve block infusions.

No patients in our case series experienced complications from PIFB blocks. Our catheters did not stay in for >4 days, yet López-Matamala et al4 reported leaving PIFB catheters in place for 10 days for analgesic purposes.4 Acknowledging the potential risk of infection, they cultured the catheters after removal, and they returned negative for microbial growth. The PIFB, while relatively new, could have a wide array of clinical applications that are safer, easier to perform, and display a relatively lower risk from prolonged indwelling time than neuraxial techniques.

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DISCLOSURES

Name: Landon T. Burns, MD.

Contribution: This author helped with each procedure and helped write the case series.

Name: Drew A. Beasley, MD

Contribution: This author helped perform each procedure and helped write the case series.

Name: Mark A. Stevens, MD.

Contribution: This author helped with each procedure and helped review the case series.

Name: Donald E. Crabtree, DO

Contribution: This author helped with each procedure and helped review the case series.

Name: Gregory R. Mehaffey, MD.

Contribution: This author helped with each procedure and helped review the case series.

This manuscript was handled by: Mark C. Phillips, MD.

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REFERENCES

1. Versyck B, van Geffen GJ, Van Houwe P. Prospective double blind randomized placebo-controlled clinical trial of the pectoral nerves (Pecs) block type II. J Clin Anesth. 2017;40:46–50.
2. Jadon A. Pain management in multiple fractured ribs: role of regional anesthesia. Am J Anesth Clin Res. 2017;3:21–26.
3. Del Buono R, Costa F, Agrò FE. Parasternal, pecto-intercostal, Pecs, and transverse thoracic muscle plane blocks: a rose by any other name would smell as sweet. Reg Anesth Pain Med. 2016;41:791–792.
4. López-Matamala B, Fajardo M, Estébanez-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. 2014;38:463–465.
5. Raza I, Narayanan M, Venkataraju A, Ciocarlan A. Bilateral subpectoral interfascial plane catheters for analgesia for sternal fractures: a case report. Reg Anesth Pain Med. 2016;41:607–609.
6. de la Torre PA, García PD, Alvarez SL, Miguel FJ, Pérez MF. A novel ultrasound-guided block: a promising alternative for breast analgesia. Aesthet Surg J. 2014;34:198–200.
7. Ekpe EE, Eyo C. Effect of analgesia on the changes in respiratory parameters in blunt chest injury with multiple rib fractures. Ann Afr Med. 2017;16:120–126.
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