Authors: 

Kirolos M. Georges MD, Tewfeek Abu-Shami MD, Qian C. Chen MD

Introduction

• Serratus anterior blocks (SABs) are well-known ultrasound-guided procedures to provide analgesia to the hemithorax.

• SABs are frequently used in the setting of rib fractures, thoracic surgery, or breast surgery.

• They have well-documented benefits, including:

• Reduction of opioid use.

• Decreased risk of pulmonary complications.

• Promotion of faster recoveries [2-3].

• We present a novel and challenging case where SABs were used to facilitate extubation in a patient who experienced intractable pain due to multiple rib fractures from CPR after a cardiac arrest in fully anticoagulated patient on ECMO.

Materials and Methods

• This is a case report with information collected from patient chart review.

• The case report contains no identifiable patient information.

• As per NYU Langone policy, the case report is exempt from IRB review requirements.

Case Report

• A 64-year-old male presented after a cardiac arrest with bystander CPR and emergently underwent catheterization with PCI.

• Patient had rapid normalization of cardiac function but hospital course was complicated by ARDS and the patient was placed on ECMO.

• Extubation was challenging as the patient’s vital capacity was limited by pain secondary to multiple bilateral rib fractures from chest compressions done during CPR.

• Pain service was consulted for bilateral SABs to provide analgesia and facilitate extubation.

• Thoracic epidural or paravertebral blocks were not considered because the patient was thrombocytopenic, fully anticoagulated with Heparin for ECMO, and on Cangrelor for recent coronary stents.

Case Report (continued)

• The procedure carried significant risks due to the recent coronary stent placement and the patient being on ECMO.

• Holding anticoagulation and antiplatelet therapy risked STEMI or ECMO catheter thrombosis, whereas proceeding with SABs without stopping these medications posed a high bleeding risk

• After careful risk-benefit assessment with the primary team, the decision was made to proceed with SABs without holding anticoagulation.

• The patient received effective analgesia and was safely extubated the same day.

• He was eventually weaned off ECMO and later discharged.

Discussion

• This case presents a unique indication for the use of SABs to facilitate extubation in a patient with several rib fractures.

• It posed an interesting challenge in determining whether to continue or hold anticoagulation in the setting of ECMO and cardiac stents.

• This case highlights the broad range of indications for nerve block techniques.

• It illustrates that pain procedures can be safely performed in high-risk patients through appropriate risk assessment, where it is determined that the benefits outweigh the risks.

References

1. Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013 Nov;68(11):1107-13. doi: 10.1111/anae.12344. Epub 2013 Aug 7. PMID: 23923989.

2. Xie C, Ran G, Chen D, Lu Y. A narrative review of ultrasound-guided serratus anterior plane block. Ann Palliat Med. 2021 Jan;10(1):700-706. doi: 10.21037/apm-20-1542. Epub 2020 Dec 31. PMID: 33440981.

3. Southgate SJ, River GF, Herbst MK. Ultrasound-Guided Serratus Anterior Blocks. 2024 Feb 12. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 30860711.