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Comparison of serratus anterior plane block with epidural and paravertebral block in critically ill trauma patients with multiple rib fractures
  1. Paul I Bhalla1,
  2. Stuart Solomon1,
  3. Ray Zhang1,
  4. Cordelie E Witt2,3,
  5. Arman Dagal1,
  6. Aaron M Joffe1
  1. 1Department of Anesthesiology and Pain Medicine, Harborview Medical Center, Seattle, Washington, USA
  2. 2Department of Surgery, University of Washington, Seattle, Washington, USA
  3. 3Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
  1. Correspondence to Dr Paul I Bhalla; pbhalla{at}


Background Pain from rib fractures is associated with significant pulmonary morbidity. Epidural and paravertebral blocks (EPVBs) have been recommended as part of a multimodal approach to rib fracture pain, but their utility is often challenging in the trauma intensive care unit (ICU). The serratus anterior plane block (SAPB) has potential as an alternative approach for chest wall analgesia.

Methods This retrospective study compared critically injured adults sustaining multiple rib fractures who had SAPB (n=14) to EPVB (n=25). Patients were matched by age, body mass index, American Society of Anesthesiology Physical Status, whether the patient required intubation, number of rib fractures and injury severity score. Outcome measures included hospital length of stay, ICU length of stay, preblock and post block rapid shallow breathing index (RSBI) in intubated patients, pain scores and morphine equivalent doses administered 24-hour preblock and post-block in non-intubated patients, and mortality.

Results There were no demographic differences between the two groups after matching. Nearly all of the patients who received either SAPB or EPVB demonstrated a reduction in RSBI or pain scores. The preblock RSBI was higher in the serratus anterior plane block group, but there was no difference between any of the other outcome measures.

Discussion This retrospective study of our institutional data suggests no difference in efficacy between the serratus anterior plane block and neuraxial block for traumatic rib fracture pain in critically ill patients, but the sample size was too small to show statistical equivalence. Serratus anterior plane block is technically easier to perform with fewer theoretical contraindications compared with traditional neuraxial block. Further study with prospective comparative trials is warranted.

Level of evidence Retrospective matched cohort; Level IV.

  • acute pain
  • analgesics
  • opioid
  • nerve block
  • rib fractures

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  • Presented at This paper was presented at American Society of Anesthesiologists Annual Meeting 2018.

  • Contributors PB helped write the introduction, discussion and abstract, guided the data collection and helped with editing and formatting. SS collected and organized data, created the figure, drafted the overall manuscript and contributed to edits. He also submitted the project to the University of Washington IRB Committee for determination of consent requirement waiver and HIPAA waiver, which was approved. RZ helped with data collection and case matching, drafting of the methods and results section, and overall editing. AJ had the initial idea for the case matching, advised on the data collection and case matching and contributed to major edits of the manuscript. CEW provided trauma registry data, helped with data matching and helped edit the document. AD helped write and edit the document and provided expertise on the interpretation and writing of the results.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study obtained ethics approval from University of Washington, Seattle, WA Institutional Review Board (IRB) STUDY00003775. Informed consent was not required as this was a retrospective study based on chart reviews.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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