Combined Serratus Intercostal Fascial Block (SIFB) and Rectus Sheath Block (RSB) for Chest Wall Fracture

Purpose: Rib fractures are common in patients presenting chest trauma and are associated with significant morbidity and mortality. Traditional pain management options for rib fractures include thoracic epidural and/or paravertebral blocks. However, novel regional anesthesia techniques have been demonstrated to improve pain scores and aid patient recovery. We describe the application of a combined Serratus-Intercostal Fascial (SIFB) and Rectus Sheath (RS) nerve blocks to provide analgesia for a patient with lower anterior and lateral rib fractures. Clinical Features: To perform the combined block, an 18-gauge Tuohy needle was inserted deep to the rectus sheath muscle above the transversus muscle with obvious spread of local anesthetic superficial to the posterior rectus sheath where 10mls of 0.375% bupivacaine was injected. The needle continued laterally under the external oblique until it was positioned deep to the left serratus anterior muscle where an additional 15ml was injected. In both blocks, CPNB catheters were inserted beyond the end of the Tuohy needles. On postoperative day 2, the patient reported no pain in his anterior chest and abdomen with improved inspiratory capacity and was able to ambulate. After postoperative day 7 the patient no longer required his oral scheduled opioids and continued to report no chest pain. Conclusion: A combined SIFB and RS block using a single-incision was effective in providing analgesia while being less invasive and providing more control over potential infection sites. The technique also allows for lower dosage of anesthetics which can be relevant in other clinical settings.