Used to provide analgesia for acute and chronic pain conditions affecting the thorax including the following:
Significant rib fractures causing hypoventilation, splinting respirations, or atelectasis
Chest wall/upper abdominal surgery: Thoracotomy, thoracostomy, gastrostomy tube placement
Neuralgia: Posttraumatic, postherpetic (acute herpes simplex virus [HSV] infection), metastatic neoplasm of vertebral body
Inadvertant creation of bilateral pneumothorax puts the patient at unnecessarily high health risk
Routine rib fracture that is tolerating oral analgesia
Lack of surgical expertise
Serious hemostasis disorders, such as platelets <50,000 or international normalized ratio (INR) >1.0
Procedure can cause local pain. Local anesthesia will be given.
Needle puncture can cause local bleeding, which is usually minimal. More significant bleeding can occur if the intercostal artery is punctured but care will be taken to avoid the artery.
The needle could puncture the lung and cause a collapsed lung (pneumothorax). The risk is <1.5% and we have definitive treatment to reinflate the lung if the situation arises.
Potential for introducing infection exists; however, this is extremely rare. Sterile technique will be utilized.
The following landmarks are useful to determine the position of the desired rib:
7th rib is the lowest rib covered by the angle of the scapula
12th rib is the last rib palpable (FIGURE 78.1)
The intercostal nerves (ICNs) course in the subcostal groove parallel to the ribs. Within the subcostal groove, the ICNs lie inferior to the intercostal arteries (vein, artery, nerve).
Most ICN blocks are performed between the posterior and midaxillary line at a point proximal to the origin of the lateral cutaneous nerve. In adults, this correlates with 6 to 8 cm from the spinous process at the angle of the rib.
Standard 25-gauge needle and 22-gauge 1.5-inch short-bevel needle
Sterile draping and sterile gloves
Povidone–iodine solution or chlorhexidine