The blockage of anterior branches of the intercostal nerves is a selective superficial block, with a very low incidence of complications and effective in different surgeries involving the chest wall and for rib fractures.
Thoracic spinal nerves from T1 to T11 all have anterior rami corresponding with intercostal nerves. The space located between the parietal pleura and the posterior intercostal membrane is the location where every single intercostal nerve arises from their appropriate space. In the subcostal groove of every rib, the nerve lays beneath the intercostal vessels, and they are associated with the somatic nervous system. Collateral, lateral cutaneous, rami communicantes, anterior cutaneous, muscular, pleural, and peritoneal sensory are considered the diverse branches given by the intercostal nerves.
Exclusive characteristics of the first intercostal nerve are that it is the smallest nerve of all of them, it is incorporated into the brachial plexus through a unique branch, and there is no anterior cutaneous branch. The second intercostal nerve has the sole distinctive feature that it is connected to the medial cutaneous nerve in both arms by the intercostobrachial nerve. That is responsible for the innervation of the skin surrounding the armpit, the upper medial side of the arm, and the second intercostal space as well.
Considering the pattern of innervation, the 1 to 6 intercostal nerves usually supply parietal pleura, skin, serratus posterior, levatores costarum, and intercostal muscles. The next five intercostal nerves supply innervation to several structures such as parietal peritoneum, skin, and different abdominal muscles (internal/external oblique, rectus abdominis, and transversus muscles).
A special peculiarity that differentiates the intercostal nerves from the other spinal nerves is that they do not constitute a plexus and trace an autonomous course.
There are several absolute and relative contraindications for intercostal nerve blockade.
The following block supplies are necessary for intercostal nerve blocks:
A board-certified anesthesiologist skilled in providing competent and safe ultrasound-guided regional anesthesia should be necessary to perform this peripheral nerve block, with a registered nurse or an anesthesiology resident to assist the procedure.
The equipment necessary to perform this regional blockade in a safe and standard monitored environment usually includes labeled premedication drugs, resuscitation supplies easily identifiable, and all the equipment to perform the block readily available ideally in an induction room. It is crucial a well-trained assistant present handle medications, help with the position of the patient, and during the injection of the local anesthetics. This figure should be properly familiar with CPR and resuscitation protocols if it becomes necessary in the block area.
Different monitors are available to decrease the risk of complications related to regional anesthesia, such as intraneural injection or needle-nerve damage. One of them may be an expendable in-line pressure-monitoring mechanism for controlling the pressure while injecting the local anesthetic in the site of the regional block, and it can be documented. Documentation of every stage of this procedure is essential in every institution performing currently regional anesthesia for ensuring an effective and safe practice.
Intercostal nerve blocks without US guidance are performed following the next steps:
It is considered that a dose of the local anesthetic agent of 0.1 to 0.15 ml/kg per intercostal space (maximum dose 2 to 3 ml per space) can be administered after making sure that the tip of the needle is in the proper tissue plane. Common medications used for this blockade are ropivacaine 0.2%, levobupivacaine 0.25%, or bupivacaine 0.25%.
This single specific block commonly provides around 8 to 12 hours of analgesia with fewer complications compared with other different blocks or epidural injections, and even a shorter learning curve. Besides that, it is demonstrated up to 72 hours of pain relief when liposomal bupivacaine suspension is administered intraoperatively as part of this intercostal block. With the consideration of not to exceed the maximum dose of 266 mg and combined with multimodal analgesia, it would require fewer doses of opioids given to the patient.
Clinicians performing intercostal nerve block need to be well trained in recognizing the thoracic anatomy using the ultrasound and be familiar with anatomic variations as well. Besides that, to provide a safe technique, all the necessary equipment should be readily available, and good communication with the assistant during the procedure is crucial. Complications like hemopneumothorax, intravascular damage, or severe toxicity anesthetics-related should be minimized, and early recognition and urgent management by the providers of the regional block is mandatory. Multiple randomized trials found that a well organized interprofessional team of health workers from different specialties decreases the risk of severe adverse events while performing successful regional anesthesia. [Level 1]
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