The Journal of the Arkansas Medical Society Med Journal Sept 2019 FInal 2 | Page 16

CASE STUDY
Determination of Spread of Injectate After Ultrasound-Guided
Pecto-Intercostal Fascial Plane Block: A Cadaveric Study
Dale Barefoot, MD 2 ; Michael Fiedorek, MD 2 ; Kevin D. Phelan, PhD 3 ;
Gregory Mehaffey, MD 1 ; Mark Stevens, MD 2 ; Charles Napolitano, MD, PhD 2
1
Department of Anesthesiology, College of Medicine, UAMS
2
Department of Anesthesiology, College of Medicine, UAMS
3
Neurobiology and Developmental Sciences, College of Medicine, UAMS
ABSTRACT
O
bjectives: The goal of this
observational study was to
establish the expected spread
of local anesthetic throughout the
pecto-intercostal fascial (PIF) plane
using ultrasound-guided injection of
methylene blue dye. Five lightly embalmed
cadavers were injected bilaterally within the PIF
plane under ultrasound guidance, and the chest
walls were then dissected to determine injectate
spread.
Results: Ultrasound-guided injection of the
PIF plane achieved a spread throughout the
plane entirely.
Conclusion: Ultrasound-guided injection
of the PIF plane reliably involves the anterior
cutaneous branch of the intercostal nerves that
innervate the sternum.
INTRODUCTION
Most pain-management techniques for
anterior-chest-wall pain following chest-wall
trauma, sternotomy, thoracic drainage tube
placement, and mastectomy have involved
the judicious use of opiate medications in the
belief that they are associated with optimal
hemodynamic stability and pain control.
However, large amounts of intravenous opioids
can delay extubation and have multiple side
effects including respiratory depression,
sedation, urinary retention, constipation, and
puritus. 1 The pecto-intercostal fascial plane
block (PIFB) is an innovative, local technique
that presents an alternative method of providing
analgesia for rib-cage and sternal pain. 2
Patients in pain will have prolonged
immobilization,
insufficient
respiratory
function, difficulty coughing and a subsequent
longer period of mechanical ventilation,
longer ICU stays, and longer overall hospital
stays. 2 Inadequate analgesia and uninhibited
perioperative surgical-stress responses also
have the potential to initiate pathophysiologic
changes in all major organ systems leading
to hemodynamic instability, cardiac overload,
increased oxygen consumption, and increased
risk of myocardial ischemia. 3
Different techniques, including blind
parasternal injection and large-volume local
anesthetic infiltration of the sternotomy wound,
have previously been described as a way to
decrease opioid requirements, provide early
postoperative analgesia, and facilitate early
extubation. 4,5 In one study, the use of ultrasound
to guide local anesthetic placement in the PIF
plane was described as a way to assist in the
extubation of critically ill patients who were
difficult to wean from ventilators. 6,7
It is believed that the utilization of the
PIFB to anesthetize the anterior cutaneous
and lateral branches of intercostal nerves will
ultimately reduce opiate consumption and the
complications associated with their use. There
is no anatomical description of local anesthetic
spread for the PIFB in the literature. The goal of
this study is to establish the expected spread of
local anesthetic throughout the PIF plane and the
nerve involvement using an ultrasound-guided
injection of dye into the hemi-chest walls of
lightly embalmed cadavers.
Figure 1: Spread of injectate within the PIFB plane between the pectoralis major
muscle (PMM) and the external intercostal muscle (EIM). The needle is indicated
by arrows.
64 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
VOLUME 116