Chest wall muscle atrophy as a contributory factor for forced vital capacity decline in systemic sclerosis-associated interstitial lung disease.

OBJECTIVE: To investigate the potential contribution of accessory respiratory muscle atrophy to the decline of forced vital capacity (FVC) in patients with SSc-associated interstitial lung disease (ILD). METHODS: This single-centre, retrospective study enrolled 36 patients with SSc-ILD who underwent serial pulmonary function tests and chest high-resolution CT (HRCT) simultaneously at an interval of 1-3 years. The total extent of ILD and chest wall muscle area at the level of the ninth thoracic vertebra on CT images were evaluated by two independent evaluators blinded to the patient information. Changes in the FVC, ILD extent, and chest wall muscle area between the two measurements were assessed in terms of their correlations. Multiple regression analysis was conducted to identify the independent contributors to FVC decline. RESULTS: Interval changes in FVC and total ILD extent were variable among patients, whereas chest wall muscle area decreased significantly with time (P=0.0008). The FVC change was negatively correlated with the change in ILD extent (r=-0.48, P=0.003) and was positively correlated with the change in the chest wall muscle area (r = 0.53, P=0.001). Multivariate analysis revealed that changes in total ILD extent and chest wall muscle area were independent contributors to FVC decline. CONCLUSION: In patients with SSc-ILD, FVC decline is attributable not only to the progression of ILD but also to the atrophy of accessory respiratory muscles. Our findings call attention to the interpretation of FVC changes in patients with SSc-ILD.

PECS, serratus plane, erector spinae, and paravertebral blocks: A comprehensive review.

Thoracic planar blocks represent a novel and rapidly expanding facet of regional anesthesia. These recently described techniques represent the potential for excellent analgesia, enhanced technical safety profiles, and reduced physiological side effects versus traditional techniques in thoracic anesthesia. Regional techniques, particularly those described in this review, have potential implications for mitigation of surgical pathophysiological neurohumoral changes. In the present investigation, we describe the history, common indications, technique, and limitations of pectoral nerves (PECS), serratus plane, erector spinae plane, and thoracic paravertebral plane blocks. In summary, these techniques provide excellent analgesia and merit consideration in thoracic surgery.

Thoracic wall blocks: From paravertebral to retrolaminar to serratus to erector spinae and back again - A review of evidence.

A multitude of thoracic wall blocks have been described, including parasternal-intercostal plane, Pecs I and II, serratus anterior plane, paraspinal-intercostal plane, erector spinae plane blocks, and retrolaminar blocks. They are almost all fascial plane blocks, relying on passive spread of local anesthetic to target nerves within the plane or in adjacent tissue compartments. They have emerged as attractive alternatives to thoracic paravertebral and epidural blocks because of their relative simplicity and safety. Although research into these techniques is still at an early stage, the available evidence indicates that they are effective in reducing opioid requirements and improving the pain experience in a wide range of clinical settings. They are best employed as part of multimodal analgesia with other systemic analgesics, rather than as sole anesthetic techniques. Catheters may be beneficial in situations where moderate-to-severe pain is expected for >12 h, although the optimal dosing regimen requires further investigation.

Ultrasound-guided serratus plane block enhances pain relief and quality of recovery after breast cancer surgery: A randomised controlled trial.

BACKGROUND: Multimodal analgesia can improve postoperative pain and possibly accelerate functional recovery after surgery. Serratus plane block (SPB) is a novel, ultrasound-guided regional anaesthetic technique for complete analgesia of the anterolateral chest wall. But, the effect of SPB on the quality of recovery after breast cancer surgery has not been established. OBJECTIVE: To test the hypothesis that pre-operative SPB would enhance the quality of recovery following breast cancer surgery. DESIGN: A randomised, double-blind, parallel-group, placebo-controlled trial. SETTING: Single university teaching hospital, from March 2016 to June 2017. PATIENTS: Seventy-two women scheduled for breast cancer surgery. INTERVENTION: Participants were randomised in a 1 : 1 ratio to receive SPB with 25 ml of ropivacaine 0.5% or physiological saline. MAIN OUTCOME MEASURES: The primary endpoint was the 40-item Quality of Recovery questionnaire score 24 hours postoperatively hours. Secondary endpoints were postoperative pain intensity, cumulative opioid consumption, postoperative nausea and vomiting, dizziness, post anaesthesia care unit discharge time and patient satisfaction. RESULTS: The global median [IQR] 40-item Quality of Recovery questionnaire score at 24 postoperative hours was significantly higher in the SPB group (158 [153.8 to 159.3]) than the control group (141 [139 to 145.3]) with a median difference of 15 (95% confidence interval: 13 to 17, P < 0.001). Compared with the control group, postoperative pain scores at rest were significantly lower up to 24 h in the SPB group. Pre-operative SPB reduced postoperative cumulative opioid consumption, the incidence of postoperative nausea and vomiting and the post anaesthesia care unit discharge time. In addition, patient satisfaction scores were higher in the SPB group. CONCLUSION: Pre-operative administration of SPB with ropivacaine improved the quality of recovery, postoperative analgesia and patient satisfaction following breast cancer surgery. TRIAL REGISTRATION: ClinicalTrials.gov (identifier: NCT02691195).

Detailed Vascular Anatomy and Flap Harvest Technique of the Serratus Anterior/Rib Composite Flap.

BACKGROUND: The hemodynamics of blood flowing from the anterior serratus to the ribs has yet to be analyzed in detail in serratus anterior/rib composite flaps. The authors focused on new blood circulation, whereby the slip arteries branched from the serratus anterior branch, off the thoracodorsal artery and the intercostal arteries, directly through the interconnecting vessels (axial route). The authors analyzed in detail the hemodynamics of serratus anterior/rib composite flaps and developed a new method for flap elevation. METHODS: The axial route was identified and analyzed by performing macroscopic autopsies of formalin perfusion-fixed cadavers involving three-dimensional computed tomographic angiography and vascular corrosion casting. Flap elevation was performed with new blood circulation, which included the axial route, and blood flow was evaluated using indocyanine green fluorescence angiography. RESULTS: The interconnecting vessels penetrated the intercostal muscles at a mean distance of 4.5 cm from the anterior margin of the attachment sites of the serratus anterior muscle to the ribs and at a mean distance of 7.4 cm from the costochondral junction. The interconnecting vessels had a mean diameter of 0.5 mm. Vascular corrosion casting helped identify multiple capillaries that were distributed from the intercostal arteries to the periosteum of the ribs. In addition, intraoperative indocyanine green fluorescence angiography confirmed blood flow from the slip arteries to the intercostal arteries. CONCLUSION: Good blood flow in harvested graft tissue can be achieved by including the axial route with the periosteal blood circulation at the rib attachment sites of the serratus anterior in a serratus anterior/rib composite flap.

Serratus Plane Block: A Cadaveric Study to Evaluate Optimal Injectate Spread.

BACKGROUND AND OBJECTIVES: Although serratus plane block reportedly provides satisfactory analgesia for breast and thoracic surgeries, the optimal technique for consistent success has not been studied. The goal of this anatomical study was to evaluate the impact of volume, level, and site of injection on the extent of injectate spread that can influence anesthetic coverage. METHODS: Ultrasound-guided dye injection and subsequent dissection were performed in 39 cadaveric hemithoraces. Methylene blue was injected according to 1 of 4 injection protocols as follows: one 20-mL bolus, either superficial or deep to the serratus anterior muscle (SAM), at the fifth rib level (groups SUP-20 and DEEP-20, respectively), or two 20-mL boluses, either superior or deep to the SAM, one at the third rib and one at the fifth rib level (group SUP-40 and group DEEP-40, respectively). Following injection, dissection and 3-dimensional digitization were performed to map the area of dye spread. RESULTS: We found that the extent of dye spread was mostly influenced by the volume of injection rather than the plane of injection (superficial vs deep to SAM). Increasing the volume from 20 to 40 mL doubled the area of injectate spread and promoted dye spread preferentially to the anterior chest wall, with some impact on cephalad-to-caudad spread and no impact on posterior spread. Dye was found most consistently in the axilla when a separate injection was performed at the third rib level. CONCLUSIONS: Our data showed that a high-volume double-injection technique provides extensive and consistent dye spread in the anterior chest wall and axilla, regardless of the plane of injection relative to the SAM. This technique likely provides more reliable analgesic coverage for breast procedures especially those that involve the axilla, pending confirmation in future clinical studies.

Too Deep or Not Too Deep?: A Propensity-Matched Comparison of the Analgesic Effects of a Superficial Versus Deep Serratus Fascial Plane Block for Ambulatory Breast Cancer Surgery.

BACKGROUND AND OBJECTIVES: Serratus fascial plane block can reduce pain following breast surgery, but the question of whether to inject the local anesthetic superficial or deep to the serratus muscle has not been answered. This cohort study compares the analgesic benefits of superficial versus deep serratus plane blocks in ambulatory breast cancer surgery patients at Women's College Hospital between February 2014 and December 2016. We tested the joint hypothesis that deep serratus block is noninferior to superficial serratus block for postoperative in-hospital (pre-discharge) opioid consumption and pain severity. METHODS: One hundred sixty-six patients were propensity matched among 2 groups (83/group): superficial and deep serratus blocks. The cohort was used to evaluate the effect of blocks on postoperative oral morphine equivalent consumption and area under the curve for rest pain scores. We considered deep serratus block to be noninferior to superficial serratus block if it were noninferior for both outcomes, within 15 mg morphine and 4 cm·h units margins. Other outcomes included intraoperative fentanyl requirements, time to first analgesic request, recovery room stay, and incidence of postoperative nausea and vomiting. RESULTS: Deep serratus block was associated with postoperative morphine consumption and pain scores area under the curve that were noninferior to those of the superficial serratus block. Intraoperative fentanyl requirements, time to first analgesic request, recovery room stay, and postoperative nausea and vomiting were not different between blocks. CONCLUSIONS: The postoperative in-hospital analgesia associated with deep serratus block is as effective (within an acceptable margin) as superficial serratus block following ambulatory breast cancer surgery. These new findings are important to inform both current clinical practices and future prospective studies.

Use of Serratus Plane Block for Repair of Coarctation of Aorta: A Report of 3 Cases.

OBJECTIVES: The practice of regional anesthesia techniques (thoracic, epidural, paravertebral) in pediatric cardiac surgery enhances perioperative outcomes such as improved perioperative analgesia, decreased stress response, early extubation, and shortened hospital stay. However, these blocks can be technically challenging and can be associated with unacceptable failure rate and complications in infants. For these reasons, regional anesthesia is sometimes avoided in pediatric cardiac surgery. We describe the simple and effective serratus plane block for thoracotomy analgesia in 2 neonates and a child. CASE REPORT: We present 3 pediatric patients, each of whom was having coarctation repair and received an ultrasound-guided serratus plane block for thoracotomy analgesia. The patients were 3 days, 14 days, and 4 years old, weighing from 1.9 to 16 kg. The serratus plane block was performed prior to surgical incision. The block was technically simple compared with thoracic epidural or paravertebral block. All patients were extubated immediately after completion of surgery. Apart from the induction dose of fentanyl (2 µg/kg), no further opioids were required intraoperatively. Postoperative opioid requirements as well as duration of intensive care and hospital stay were lower than recent averages (for the same demographic and procedure) in our hospital. CONCLUSIONS: We propose that the serratus plane block is a simple procedure that provides good perioperative analgesia for infant thoracotomy, potentially facilitating early extubation and a shorter hospital stay.

Intermuscular technique for implantation of the subcutaneous implantable cardioverter defibrillator: long-term performance and complications.

AIMS: The subcutaneous cardioverter defibrillator was designed to overcome electrode complications of transvenous defibrillation systems. While largely achieved, pocket complications have increased. Subcutaneous implantation of the pulse generator leaves it prone to erosion, extrusion, discomfort, and poor cosmesis. METHODS AND RESULTS: We use a demonstration electrode and pulse generator with fluoroscopy, prior to prepping and draping, to maximize the left ventricular mass between them. We adapted a submuscular abdominal ICD technique to implant the S-ICD intermuscularly between the anterior surface of serratus anterior and the posterior surface of latissimus dorsi. Surgery in our patients beyond the subcutaneous tissue was bloodless, as muscle layers were carefully separated but not incised, which also protected the long thoracic nerve. Two layers of muscle protect the pulse generator. We have implanted 82 consecutive patients with this technique, taking ∼65 min. All patients were converted with 65 J standard polarity shock during induced arrhythmia conversion testing, with six (7.3%) patients requiring a repositioning of the pulse generator prior to successful conversion. Seven spontaneous episodes of ventricular fibrillation were detected in three (3.6%) patients, all successfully converted back to sinus rhythm. Long-term patient outcomes have been good with low complication rates over the mean ± standard deviation 3.6 ± 1.2 years. CONCLUSION: Our intermuscular technique and implant methodology is successful for placement of the subcutaneous defibrillator pulse generator. Our technique leads to an excellent cosmetic result and high levels of patient satisfaction. Rates of first shock conversion during defibrillation testing, inappropriate shocks, and complications during follow-up compare favourably with previous published case series. There were no left arm movement limitations post-operatively.

Ultrasound-Guided Serratus Anterior Plane Block in Breast Reconstruction Surgery.

Pecs block and its variations have been used for various breast surgeries. We describe 2 cases of mastectomy and breast reconstruction by latissimus dorsi (LD) flap where regional analgesia was provided by a combination of ultrasound-guided Pecs-I block and serratus anterior plane block, a recently described technique in which local anesthetic is deposited in the plane between the LD and serratus anterior muscle. This resulted in excellent intraoperative and postoperative analgesia and a minimum of systemic analgesics. The described technique is safe to administer and provides good analgesia for breast reconstruction surgery by LD flap.