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LETTERS TO EDITOR
Year : 2020  |  Volume : 14  |  Issue : 1  |  Page : 134-135

Serratus anterior plane block: Anatomical landmark-guided technique


1 Department of Anaesthesiology, Sterling Hospital, Rajkot, Gujarat, India
2 Department of Anaesthesiology, AIIMS, Raipur, Chhattisgarh, India
3 Department of Onco-Anaesthesiology, Pain and Palliative Care, National Cancer Institute, Jhajjar, AIIMS, New Delhi, India

Correspondence Address:
Dr. Tuhin Mistry
Department of Anaesthesiology, AIIMS, Raipur - 492 099, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.SJA_540_19

Rights and Permissions
Date of Submission23-Aug-2019
Date of Acceptance23-Aug-2019
Date of Web Publication6-Jan-2020
 


How to cite this article:
Vadera HK, Mistry T, Ratre BK. Serratus anterior plane block: Anatomical landmark-guided technique. Saudi J Anaesth 2020;14:134-5

How to cite this URL:
Vadera HK, Mistry T, Ratre BK. Serratus anterior plane block: Anatomical landmark-guided technique. Saudi J Anaesth [serial online] 2020 [cited 2020 Jul 5];14:134-5. Available from: http://www.saudija.org/text.asp?2020/14/1/134/275119



Sir,

Following the pioneer description of ultrasound guided serratus anterior plane block (SAPB) by Blanco et al.,[1] it has been used effectively to provide analgesia for various indications.[2] It was also described using a peripheral nerve stimulator (PNS) by stimulating long thoracic nerve above the serratus anterior muscle.[3] We describe a novel anatomical landmark-guided technique of SAPB for acute as well as chronic pain management.

In landmark-guided SAPB, our aim is to deposit the local anesthetic (LA) in the fascial plane deep to serratus anterior muscle (SAM) and above the ribs or external intercostal muscle [Figure 1]a. It is performed in lateral decubitus position with the nondependent arm flexed, abducted and raised over head, or in supine position with the ipsilateral arm abducted. The supine position with a folded sheet or a thin pillow placed under the back on the side to be blocked is more comfortable for the patient and allows easy identification of landmarks. The fifth rib is identified and traced till the midaxillary line. This intersecting point is the needle insertion point [Figure 1]b. Deep SAPB blocks the lateral cutaneous branches of intercostal nerves (T2--T6, depending on the level of injection and the volume of LA injected) before their division into anterior and posterior terminal branches.[4] LA injection in this plane is unaffected by surgical dissection, does not diffuse to superficial plane, and thus blockade of long thoracic nerve and thoracodorsal nerve are also avoided.
Figure 1: (a) Schematic diagram of SAPB. (b) Needle insertion point. (c) Back Flow of LA. (d) Ultrasound confirmation. LDM = Latissimus Dorsi Muscle, SAM = Serratus Anterior Muscle, ICM = Intercostal Muscles, LA = Local Anaesthetic, MAL = mid axillary line

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Under aseptic precautions, the needle (22-gauge, 2.5–5 cm short bevelled needle or blunt tipped hypodermic needle) is inserted and advanced perpendicular to the skin in all planes to contact the rib [Figure 1]a. The depth of rib from the skin varies depending upon the build of the individual. After hitting the rib, the needle tip is withdrawn 1--2 mm. At this point, the needle tip lies between the SAM and the rib. After negative aspiration for blood or air, LA is injected in 3–5 ml aliquots. A volume of 20–25 ml of 0.25% (levo) bupivacaine or 0.2% ropivacaine with or without adjuvants can be used for analgesia depending upon the surgery and requirements.


  Case 1 Top


A 42-year-old lady was admitted with a lump in the right breast. She had undergone modified radical mastectomy under general anesthesia and SAPB. This patient demonstrated analgesia involving T2–T6 dermatomes lasting 24 h with a single injection of 25 mL 0.25% bupivacaine with 8 mg dexamethasone and multimodal analgesia.


  Case 2 Top


A 60-year-old lady who had undergone left modified radical mastectomy 2 years back, presented with pain along the site of incision and inner side of left arm. Following landmark-guided SAPB her numeric rating scale score came down to 0 from 7 on a scale of 10. Other analgesics requirement was also decreased.

If the drug is deposited in correct plane, LA will be dripping from needle hub upon disconnection of the syringe [Figure 1]c. Absence of backflow may indicate intramuscular injection. The drug injected in deep serratus plane spreads in both cephalocaudal and anteroposterior directions over several levels depending on the volume of LA administered [Figure 1]d. Although it is simple and easy to perform, a randomized controlled trial is required to validate its efficacy, safety, and reliability compared with PNS or ultrasound-guided techniques.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: A novel ultrasound-guided thoracic wall nerve block. Anaesthesia 2013;68:1107-13.  Back to cited text no. 1
    
2.
Southgate SJ, Herbst MK. Ultrasound guided serratus anterior blocks. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019. Available from: <https://www.ncbi.nlm.nih.gov/books/NBK538476/https://www.ncbi.nlm.nih.gov/books/NBK538476/>. [Last updated on 2019 Mar 19].  Back to cited text no. 2
    
3.
Roy R, Singh SK, Agarwal G, Pradhan C. Peripheral nerve stimulator guided serratus anterior plane block: A novel approach to the chest wall block. J Anaesth Crtical Care Case Rep 2017;3:24-6.  Back to cited text no. 3
    
4.
Biswas A, Castanov V, Li Z, Perlas A, Kruisselbrink R, Agur A, et al. Serratus plane block: A cadaveric study to evaluate optimal injectate spread. Reg Anesth Pain Med 2018;43:854-8.  Back to cited text no. 4
    


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