Anesthesiology, Article

Erector spinae block versus serratus anterior block in chest wall trauma, which is better?

Journal logoUnlabelled imageErector spinae block versus serratus ant”>patient need a block?”>American Journal of Emergency Medicine 38 (2020) 2221-2223

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Erector spinae block versus serratus anterior block in chest wall trauma, which is better?:

A response and decision making guide

Dear Editor,

We thank A.Houghton for his input on this important topic [1]. The aim of our exploratory study was to confirm the efficacy and safety of the erector spinae plane block (ESP) and serratus anterior block (SAB) in an effort to guide future research [2]. We agree that currently there is very little evidence to support the efficacy of one regional anesthesia technique over another for the management of rib fractures. In re- sponse to the risks associated with the ESP and SAB, both can result in damage to deeper structures [1,3]. A.Houghton refers to a case of a pneumothorax following the performance of an SAB as a potential indicator of a disparity in safety profiles, favoring the use of an ESP [1]. However, there has also been a prior report of pneumothorax fol- lowing an ESP [3]. Therefore, the decision-making process is not eas- ily determined by efficacy and safety data alone. Additionally, there are many other regional anesthesia options aside from the ESP and SAB. For this reason, we would propose the following as a guide to decision making surrounding the implementation of regional anes- thesia for rib fractures.

Does the patient need a block?

A variety of factors affect the decision of whether a patient will ben- efit from a regional block. This has previously been discussed at length in the literature [4,5]. Common indications include those unable to cough or perform deep inspiration, pain refractory to intravenous anal- gesia and patients at high risk of complications (e.g Patients over the age of 65 with multiple rib fractures).

What are the options?

Once the decision has been made to perform a regional or neuraxial block, the physician then needs to decide which block is most appropri- ate for the individual patient. Current literature is largely based around six techniques; thoracic epidural (TE), paravertebral block (PVB), erec- tor spinae plane block (ESP), serratus anterior block (SAB), rhomboid intercostal block (RIB) and the intercostal block (ICB) [4-7]. Deciding which block to place at times can seem complex. Factors to be consid- ered include the location of fractures, number of fractures, absolute and relative contraindications, as well as, physician comfort with vari- ous types of neuraxial and regional blocks. Fig. 1 may serve as a guide to deciding which block may be most appropriate for each patient on a case by case basis. These decisions can also be considered from the ad- vantages and disadvantages outlined in Table 1.

Image of Fig. 1

Fig. 1. Decision making algorhythm for choosing a regional anesthesia technique to manage rib fracture related pain. Thoracic Epidural (TE), Paravertebral Block (PVB), Erector Spinae Plane block (ESP), Serratus Anterior Block (SAB), Rhomboid Intercostal Block (RIB), Intercostal Block (ICB).

https://doi.org/10.1016/j.ajem.2020.08.004 0735-6757/(C) 2020

Table 1

advantages and disadvantages of thoracic epidural and other regional analgesic techniques for the management of rib fractures [4-7].

Thoracic epidural

Paravertebral block

Erector spinae block

Serratus anterior block

Intercostal block

Rhomboid intercostal block

Bilateral

Yes

No

No

No

No

No

Number of fracture levels covered by

Up to 12b

4-6 at any level

6-9 at any level

Ribs 2-9

1-3 at any level

Ribs 2-9

catheter

Location of rib fractures

Anterior, lateral or

Anterior, lateral or

Anterior, lateral or

Anterolateral

Anterior, lateral or

Anterior, lateral or

posterior

posterior

posterior

posterior

posterior

Hypotension

Common

Occasional

Rare

Rare

Rare

Rare

Pneumothorax risk

Rare

Higha

Rare

Rare

Highest

Rare

Ultrasound-guided

No

Operators choice

Yes

Yes

Operators choice

Yes

LAST risk

Lowest

Low

Low

Low

Highest

Low

Catheter Insertion Skill requirement

Advanced

Advanced

Relatively easy

Relatively

Relatively easy

Relatively easy

easy

a Relative to other blocks.

b Limited by sympatholytic effects.

Table 2

Suggested local anesthetic doses for isolated rib fractures with various regional techniques. Adjust for physiological status and body weight [4-7].

Thoracic epidural

Paravertebral block

Erector spinae block

Serratus anterior block

Intercostal block

Rhomboid intercostal block

Long acting amidea

7.5-12 mL of 0.25%

20-25 mL

of 0.2-0.5%

20-40 mL of 0.2-0.5%

20-40 mL of 0.2-0.5%

5 mL

of 0.2-0.5%

15-20 mL of 0.5%

a includes ropivicaine, bupivicaine and levobupivicaine.

Single shot block versus catheter based infusion?

Once the decision to perform a particular block has been made, there is then the question of whether to perform a single shot or site a cathe- ter. Generally, the pain resulting from rib fractures is shown to peak around day five post injury [8]. Some studies report high pain scores at two weeks post injury [9]. Given the somewhat predictable pattern of pain scores post injury, we advocate for patients who have demon- strated a clear need for a block, to have a catheter sited. Instances where a single shot block may be of benefit include patients where the indication is less clear or when an appropriately skilled clinician isn’t available for catheter placement.

What local anesthetic to load with?

Ideally the single shot or loading dose will utilize a safe dose of a high concentration, long acting amide local Anesthetic agent to provide a high quality, high density block. Similar to the comparison between an- algesic efficacy of the individual blocks, there is very little evidence com- paring difference loading doses. Current recommendations are summarized in Table 2. These local anesthetic doses need to be adjusted based on patient body weight, comorbidities such as chronic liver dis- ease, as well as, the requirement for local anesthetic to perform regional anesthesia for other injuries. Following the initial bolus, either a pro- grammed Intermittent bolus or continuous local anesthetic regimen should be started. The programing of this infusion should be done in consultation with an acute pain service as there is very little data on safe efficacious infusions to suit all patients.

In conclusion, there is currently not enough evidence to choose one block over another on efficacy and safety data alone. Until this evidence is available the decision should be guided by factors such as fracture lo- cation, number of fractures and contraindications.

Funding

None.

Declaration of Competing Interest

None to declare for any of the authors.

References

  1. Houghton A. ESB vs SAB in chest wall trauma, which is better? Am J Emerg Med. 2020;0(0):1 In press.
  2. Riley B, Malla U, Snels N, Mitchell A, Abi-Fares C, Basson W, et al. Erector spinae and serratus anterior blocks for the management of rib fractures: a retrospective explor- atory matched study. Am J Emerg Med. 2020;38(8):1689-91.
  3. Tsui BC, Fonseca A, Munshey F, McFadyen G, Caruso TJ. The erector spinae plane (ESP) block: a pooled review of 242 cases. J Clin Anesth. 2019;53:29-34.
  4. May L, Hillermann C, Patil S. Rib fracture management. Bja Educ. 2016;16(1):26-32.
  5. Thiruvenkatarajan V, Eng HC, Adhikary SD. An update on Regional analgesia for rib fractures. Curr Opin Anesthesiol. 2018;31(5):601-7.
  6. El-Boghdadly K, Wiles MD. Regional anaesthesia for rib fractures: too many choices, too little evidence. Anaesthesia. 2019 Mar 11;74(5):564-8.
  7. Elsharkawy H, Maniker R, Bolash R, Kalasbail P, Drake RL, Elkassabany N. Rhomboid intercostal and subserratus plane block: a cadaveric and clinical evaluation. Reg Anesth Pain Med. 2018;43(7):745-51.
  8. Kerr-Valentic MA, Arthur M, Mullins RJ, Pearson TE, Mayberry JC. Rib fracture pain and disability: can we do better? J Trauma Acute Care Surg. 2003;54(6):1058-64.
  9. Karangelis D, Tagarakis G, Karkos C, Pantelaki I, Desimonas N, Papadopoulos D, et al. Rib fractures and Pain peak 2 weeks down the line: myth or a fact? Am J Emerg Med. 2011;29(2):229.

    L. White Department of Anaesthesia and Perioperative Medicine, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia

    Corresponding author.

    E-mail address: [email protected]

    B. Riley

    Department of Intensive Care Medicine, Sunshine Coast Hospital and

    Health Service, Birtinya, QLD, Australia

    U. Malla Department of Anaesthesia and Perioperative Medicine, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia

    N. Snels Department of Anaesthesia and Perioperative Medicine, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia

    A. Mitchell Department of Anaesthesia and Perioperative Medicine, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia

    C. Abi-Fares Department of Anaesthesia and Perioperative Medicine, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia

    W. Basson Department of Anaesthesia and Perioperative Medicine, Sunshine Coast Hospital and Health Service, Birtinya, QLD, Australia

    C. Anstey

    Department of Intensive Care Medicine, Sunshine Coast Hospital and

    Health Service, Birtinya, QLD, Australia

    11 August 2020

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