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LETTERS TO EDITOR
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 188-190
 

Ultrasound-guided intermediate cervical plexus block added to thoracic epidural for pain management in multiple ribs and clavicle fracture


Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India

Date of Submission19-Feb-2021
Date of Acceptance04-Apr-2021
Date of Web Publication29-Sep-2021

Correspondence Address:
Dr. Ankur Sharma
Associate Professor, Department of Anaesthesiology and Critical care, AIIMS, Jodhpur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_26_21

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How to cite this article:
Ramalingam H, Sharma A, Goyal S, Kothari N. Ultrasound-guided intermediate cervical plexus block added to thoracic epidural for pain management in multiple ribs and clavicle fracture. Indian Anaesth Forum 2021;22:188-90

How to cite this URL:
Ramalingam H, Sharma A, Goyal S, Kothari N. Ultrasound-guided intermediate cervical plexus block added to thoracic epidural for pain management in multiple ribs and clavicle fracture. Indian Anaesth Forum [serial online] 2021 [cited 2021 Dec 7];22:188-90. Available from: http://www.theiaforum.org/text.asp?2021/22/2/188/326973




Sir,

Cervical plexus block is widely used for intraoperative anaesthesia or analgesia during ear and neck surgeries.[1] It has been used as the sole anesthetic technique for clavicle fracture fixation surgery, as well as in conjunction with an interscalene block.[2] We present a case in which ultrasound (USG)-guided intermediate cervical plexus block (ICBP) was used to supplement a thoracic epidural to relieve pain of a patient with multiple ribs fractures and a comminuted clavicle fracture.

A 37-year-old male patient was brought to the emergency room (ER) in an altered state of consciousness with an alleged history of a road traffic accident. On arrival, he was hemodynamically unstable. He was intubated and put on mechanical ventilation in the ER and intravenous crystalloids were used for resuscitation. The extended focused assessment with sonography for trauma showed hydropneumothorax on the right side with fluid in the right upper quadrant of the abdomen. Computed tomography (CT) head and neck were normal, while CT thorax showed right pneumothorax, comminuted displaced fracture at the right clavicle, ribs fracture involving first to the eighth ribs excluding 5, 6. Once he was stabilized, GCS improved, and hemodynamic stability attained, a thoracic epidural was inserted at T6–T7 level under sedation, and 0.2% ropivacaine was infused at 7 ml/h for pain management. Subsequently, he was extubated and regained full consciousness. However, the cough was inadequate due to severe pain in the right upper thorax and near the right shoulder with a visual analog scale (VAS) of 8. The pain persisted even after intravenous analgesics, and he was dissatisfied with pain relief from the thoracic epidural infusion. Mobilization was not possible due to pain from the clavicle fracture and soft-tissue injury in the surrounding area, despite chest physiotherapy and incentive spirometry. USG-guided ICPB was given using 0.25% ropivacaine 5 ml with 4 mg dexamethasone. After 15 min, there was substantial pain relief, and the VAS was reduced to 2. He was entirely satisfied with the pain relief, and effective coughing was also possible. Active chest exercise and incentive spirometry were encouraged, and the patient was transferred to the ward.

Thoracic epidural covers analgesia for rib injuries from T1 to T10. However, thoracic epidural infusion does not alleviate pain caused by clavicle fractures or extensive soft-tissue injury in the clavicle region. Pain sensation from the clavicle is carried through the ventral ramus of C3, C4. The branches from C1-C4 exit through the posterior border sternocleidomastoid (SCM) muscle's midsection and enter into subcutaneous space. The superficial cervical plexus block is executed in the subcutaneous plane, but ICPB is implemented more proximally, deep to SCM muscle.[3] Local anesthetics are deposited deep to the posterior part of the SCM muscle but above the prevertebral fascia in ICPB [Figure 1]. The right site of drug deposition displaces prevertebral fascia downward. This block's complication rate is very low compared to the deep cervical plexus and rarely reported.[4]
Figure 1: Ultrasound image of the lateral aspect of the neck near the posterior border of SCM muscle: The red arrow indicates prevertebral fascia, and the yellow shaded area is the site of drug deposition. SCM: Sternocleidomastoid, SM: Scalenus medius, SA: Scalenus anterior, IJV: Internal jugular vein, CA: carotid artery

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We conclude that for a patient with multiple rib fractures and a clavicle fracture, USG-guided ICPB can be used in conjunction with thoracic central blocks to provide adequate pain relief. The importance of ICPB in the critical care setting is emphasized in this article.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kim JS, Ko JS, Bang S, Kim H, Lee SY. Cervical plexus block. Korean J Anesthesiol 2018;71:274-88.  Back to cited text no. 1
    
2.
Baran O, Kır B, Ateş İ, Şahin A, Üztürk A. Combined supraclavicular and superficial cervical plexus block for clavicle surgery. Korean J Anesthesiol 2020;73:67-70.  Back to cited text no. 2
    
3.
Roy R, Patnaik S, Padhy R, Sarawgi G. Superficial and Intermediate Cervical Plexus Block for Neck Dissection in Patients with High Risk of General Anaesthesia. J Anesth Crit Care. 2015;3:00093.  Back to cited text no. 3
    
4.
Pandit JJ, Satya-Krishna R, Gration P. Superficial or deep cervical plexus block for carotid endarterectomy: a systematic review of complications. Br J Anaesth 2007;99:159-69.  Back to cited text no. 4
    


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