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  • Thoracic surgery
  • Rib fractures
  • Open cholecystectomy
  • Gastrectomy
  • Mastectomy

  • Nerve runs in a neurovascular bundle just inferiorly to the rib; the nerve is the most inferior structure in this bundle
  • Nerve runs between the internal intercostal and the innermost intercostal muscles
  • Lateral cutaneous branch begins at the midaxillary line; therefore, one should block proximally to this point
  • The block should be done lateral to the beginning of the angle of the rib; the intercostal groove is largest here; therefore, theoretically safer

Figure 150-1. Anatomy of the Intercostal Space

(A) Intercostal nerve, artery, and vein; (B) external intercostal muscle; (C) internal intercostal muscle; (D) innermost intercostal muscle; (E) pleura.

  • Both sensory and motor at the level blocked; only ipsilateral side effected
  • Skin, muscle, and parietal peritoneum, if being used for upper abdominal surgery postoperative analgesia, then additional coverage required for visceral pain
  • Appropriate for thoracic and upper abdominal procedures
  • Bupivacaine or lidocaine with epinephrine provides a block lasting an average of 12 hours

  • Pneumothorax (<1%)
  • Local anesthetic toxicity (this block has a high absorption of local anesthetic; consider the use of epinephrine in the local anesthesia to decrease systemic absorption)
  • Hematoma
  • Spinal or epidural anesthesia

  • Put the patient in a sitting position (lateral and prone are also possible)
  • Palpate and identify the appropriate level of intercostal spaces
  • Identify the angle of the rib, usually about 7 cm from midline. The block can be performed anywhere proximal to the midaxillary line
  • Lift the skin from the intercostal groove up over the rib
  • Insert a 22G, 50-mm needle at a 20° cephalad angle; the needle should come in contact with the rib within about 1 cm (Figure 150-2)
  • Walk the needle off of the rib inferiorly, but keep the 20° cephalad angle of the needle
  • The nerve generally lies less than 3 mm deeper than the depth of the rib; a pop is often felt with a short bevel needle
  • Inject 5 mL of local anesthesia at each level necessary; do not exceed the maximum dose for the chosen local anesthetic

Figure 150-2. Intercostal Block Technique (“Blind” Technique)

Reproduced from Morgan GE, Mikhail MS, Murray MJ.Clinical Anesthesiology. 4th ed. Figure 17-33. Available at: Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

  • Ultrasound imaging can be used to identify the intercostal spaces. Especially helpful in obese patients or patients with challenging anatomy
  • Similar to a landmark-based technique for positioning, a high-frequency linear probe can be placed vertically on the patients back to visualize the rib, intercostal space, and pleura
  • The needle is inserted in an in-plane or out-of-plane technique paying close attention to the depth identified on the ultrasound image. ...

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