| Control Group |
Serratus anterior plane block for continuous analgesia in rib fractures |
We will inject a bolus of 0.3 mL/kg (1.5 mg/kg) bupivacaine 0.5%. Then we will insert a catheter 2-3 cm into the space, tunnel, and secure in place. Correct catheter placement will be confirmed by demonstrating further bupivacaine spread under ultrasound visualization. Bupivacaine 0.25% will be infused (weight dependant) at 0.1 mL/kg/h via an elastomeric pump. |
it will be kept running for up to 7 days if no signs of infection and we will ensure not to exceed maximum dose.
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The patient will be in the supine position with abducted arm. A high frequency linear ultrasound probe set between 6 and 13 MHz will be used. The probe will be placed in the sagittal plane and identify the fifth rib in the mid-axillary line. Latissimus dorsi and serratus anterior muscles will be easily identifiable overlying the fifth rib. The planes will be found between a depth of 1-2 cm from the skin, with the thoracodorsal artery passing in the superficial plane to serratus anterior.
After sterilization and local anaesthetic infiltration, an 18 Gauge Tuohy catheter needle will be used. The needle will be inserted in plane superficial to the serratus anterior muscle. Bupivacaine will be injected and good spread between latissimus dorsi and the serratus muscle will be confirmed. We will ensure not to exceed the maximum local dose of bupivacaine.
We will inject a bolus of 0.3 mL/kg (1.5 mg/kg) bupivacaine 0.5%. Then we will insert a catheter 2-3 cm into the space, tunnel, and secure in place. Correct catheter placement will be confirmed by demonstrating further bupivacaine spread under ultrasound visualization. Bupivacaine 0.25% will be infused (weight dependant) at 0.1 mL/kg/h via an elastomeric pump and it will be kept running for up to 7 days if no signs of infection and we will ensure not to exceed maximum dose.
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25 |
Active-Treatment of Control Group |
| Experimental Group |
Rhomboid intercostal and subserratus block for continuous analgesia in rib fractures |
A bolus of 0.15 mL/kg bupivacaine 0.5% will be injected in the fascial plane between the rhomboid major muscle and the intercostal muscles and 0.15 mL/kg bupivacaine 0.5% will be injected in the tissue plane between the serratus anterior and external intercostal muscle, hydrodissecting the tissue plane between the serratus anterior muscle and the attachments of the serratus to the rib then bupivacaine 0.25% will be infused (weight dependant) at 0.1 mL/kg/h via an elastomeric pump. |
It will be kept running for up to 7 days if no signs of infection and we will ensure not to exceed maximum dose.
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The patient will be placed in the sitting position with abducted and internally rotated arm to move the inferior angle of the scapula laterally. A linear ultrasound transducer (6-13 MHz) will be placed in the sagittal plane medial to the medial border of the scapula with the orientation marker directed cranially. The transducer will be then rotated so the cranial end will be directed slightly medially and the caudal end laterally to produce an oblique sagittal view (paramedian sagittal oblique) approximately 1 to 2 cm medial to the medial scapular border.
The following structures will be identified from superficial to deep: trapezius muscle, rhomboid major muscle, intercostal muscles between ribs, pleura, and lung. The tissue plane between the rhomboid major and intercostal muscles will be identified. An18 Gauge Tuohy needle will be advanced in plane from a supero-medial to infero-lateral direction, through the trapezius and rhomboid major muscles.
0.15 mL/kg bupivacaine 0.5% will be injected in the fascial plane between the rhomboid major muscle and the intercostal muscles. The skin entry point for the first injection will be at the T5-T6 level just medial to the scapula. Two landmarks verified identification of the T5-T6 level:
1. Counting down from the C7 spinous process
2. Identifying the medial part of the spine of the scapula at the T3 level.
Next, to identify the subserratus plane, the transducer will be moved caudally and laterally, distal to the inferior angle of the scapula behind the posterior axillary line. Tissue layers will be identified from superficial to deep: latissimus dorsi, serratus anterior, intercostal muscles between ribs, pleura, and lung. The needle will be inserted at the same skin entry site as that will be used for the rhomboid intercostal injection but will be directed caudally and laterally beyond the inferior angle of the scapula.
If the needle tip won’t reach beyond the inferior edge of the scapula (eg, obese and tall habitus), a new skin entry point medial to the lower angle of the scapula and posterior axillary line will be used. 0.15 mL/kg bupivacaine 0.5% will be injected in the tissue plane between the serratus anterior and external intercostal muscle, hydrodissecting the tissue plane between the serratus anterior muscle and the attachments of the serratus to the rib. We will ensure not to exceed the maximum bupivacaine dose.
Then we will insert a catheter 2–3 cm into the space, tunnel, and secure in place. Correct catheter placement will be confirmed by demonstrating further bupivacaine spread under ultrasound visualization. Bupivacaine 0.25% will be infused (weight dependant) at 0.1 mL/kg/h via an elastomeric pump, and will be kept running for up to 7 days if no signs of infection and we will ensure not to exceed maximum dose.
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25 |
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