Continuous Interpleural Block

Ovid: Peripheral Nerve Blocks: A Color Atlas

Editors: Chelly, Jacques E.
Title: Peripheral Nerve Blocks: A Color Atlas, 3rd Edition
> Table of Contents > Section III – Continuous Nerve Blocks > 30 – Continuous Interpleural Block

Continuous Interpleural Block
Bruce Ben-David
Patient Position:
Lateral decubitus with the arm dangling anteriorly and cephalad so as
to rotate the scapula forward and expose the posterolateral chest wall.
Postoperative analgesia following mastectomy, nephrectomy, and
cholecystectomy. Analgesia for rib fractures, pancreatitis, neuralgia,
and invasive tumor of the chest wall, flank, and retroperitoneum.
Needle Size and Catheter: 18-gauge epidural needle and 20- or 21-gauge catheter.
Volume and Infusion Rate: Initial bolus of 20 to 30 mL 1% lidocaine followed by continuous infusion of 6 to 8 mL/hour 1% lidocaine.
Anatomic Landmarks: The seventh or eighth intercostal space, the scapula, and the posterior axillary line (Fig. 30-1A).
Approach and Technique:
The site of needle insertion is at the seventh or eighth intercostal
space at the level of the tip of the scapula and the cephalad border of
the rib in a vertical direction perpendicular to the chest wall. Once
inserted to a depth of 1 cm into the intercostal muscles, a syringe
(with its plunger removed) is attached to the needle. The open syringe
barrel is filled with saline. The needle is then slowly advanced while
observing for both a “clicking” sensation and a downward movement (the
“falling column”) of the saline as it is drawn into the chest by the
negative pleural pressure. The syringe is removed (Fig. 30-1B)
and the epidural catheter threaded 6 to 10 cm into the interpleural
space. The Tuohy needle is removed, and the catheter is secured with 12
mm × 100 mm Steri-Strip (3M, St. Paul, MN) and covered with a
transparent dressing (Fig. 30-1C).
  • An alternative site is 8 to 10 cm lateral from the posterior midline.
  • Interpleural blockade routinely causes
    pneumothorax due to the entrance of air through the needle. This is
    typically of small degree (<10%) and asymptomatic. The risk of lung
    injury is reduced by the use of proper technique and by avoiding


    in patients with pulmonary bullae or those likely to have pleural
    adhesions. Proper technique includes (a) the use of a visual end point
    such as the “falling column” technique as opposed to a
    “loss-of-resistance” technique, and (b) placement during spontaneous
    ventilation as opposed to controlled ventilation or apnea.

    Figure 30-1. A: Anatomic landmarks. B: The syringe is removed and the epidural catheter threaded 6 to 10 cm into the interpleural space. C: The Tuohy needle is removed, and the catheter is secured and covered with a transparent dressing.
  • As a result of drug sequestration, uneven
    distribution, and drug loss through chest tubes, interpleural block has
    not proven particularly useful after thoracotomy. However, satisfactory
    blockade can, at times, be achieved in the presence of a chest tube
    (e.g., rib fractures) by clamping the chest tube for 30 minutes
    following intermittent bolus of local anesthetic.
  • Placement at too low an intercostal space can lead to intraperitoneal placement of the needle and catheter.
  • The catheter should thread freely without
    resistance, which may indicate improper placement, lung penetration, or
    the presence of pleural adhesions.
  • Epinephrine should be added to any bolus to reduce peak systemic levels of local anesthetic.
  • Patient positioning will determine where
    the local anesthetic pools are, where it traverses the parietal pleura,
    and which nerves are affected. Lateral position (blocked side up) will
    promote blockade of the sympathetic chain while a supine or lateral
    position (blocked side down) will promote blockade of the intercostal
    nerves. A


    position will promote upper thoracic and cervical sympathetic blockade
    (producing Horner syndrome) and even, at times, blockade of inferior
    roots of the ipsilateral brachial plexus.

  • Interpleural block is most useful when
    combined with multimodal analgesic therapies which may include
    nonsteroidal antiinflammatory drugs (NSAIDs) or a COX-2 inhibitor
    (celecoxib), NMDA blockade, alpha-2 agonists, A-2 delta calcium channel
    blockade (pregabalin), and opiates.
  • To minimize risk of systemic toxicity
    from the rapid reabsorption of local anesthetic solution in the
    interpleural space, lidocaine may be the preferred local anesthetic for
    infusion. While this author has typically used a 1% solution, a lower
    concentration may prove adequate.
  • Interpleural block will not usually
    provide the degree of neural blockade seen with thoracic paravertebral
    block (TPVB), but its simplicity is especially useful in certain
    patients, for example, the ventilated ICU patient with multiple rib
    fractures who is receiving low molecular weight heparin anticoagulation.
Suggested Readings
Ben-David B, Lee E. The falling column: a new technique for interpleural catheter placement. Anesth Analg 1990;71:212.
CE, Kirz LI, VadeBoncouer TR, et al. Continuous infusion of
interpleural bupivacaine maintains effective analgesia after
cholecystectomy. Anesth Analg 1991;72:516–521.
DP, Lema MJ, de Leon-Casasola OA, et al. Interpleural analgesia for the
treatment of severe cancer pain in terminally ill patients. J Pain Symptom Management 1993;8:505–510.
Reiestad F, Strømskag KE. Interpleural catheter in the management of postoperative pain: a preliminary report. Reg Anesth 1986;11:89–91.
Strømskag KE, Minor B, Steen PA. Side effects and complications related to interpleural analgesia: an update. Acta Anaesthesiol Scand 1990;34:473–477.
Kleef JW, Logeman EA, Burm AG, et al. Continuous interpleural infusion
of bupivacaine for postoperative analgesia after surgery with flank
incisions: a double-blind comparison of 0.25% and 0.5% solutions. Anesth Analg 1992;75:268–274.

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