Overview of Pecto-Intercostal Fascial Plane Block
Chest pain at the front part of the body, after an open heart surgery where a cut is made down the middle of the chest bone (known as a median sternotomy), is a common problem. It can even be very painful for several months after the operation. Because of this, anesthesiologists, who are doctors that specialize in controlling pain during an operation, are looking for ways to reduce the use of opioids, which are strong medicine for pain relief but may have serious side effects. One method they’re using more often is regional anesthesia, which numbs only the specific area of the body where the surgery is done.
However, traditional regional anesthesia is usually not used for open heart surgeries because these procedures require the use of a blood thinning medication called heparin. Some other anesthesia techniques, like one where an anesthetic drug is injected near the spine (paravertebral) or near a group of muscles in the back (erector spinae), can be difficult to perform after surgery since the patient has a tube in their throat helping them breathe and is lying on their back.
This is where a new type of anesthesia called the pecto-intercostal fascial plane (PIFP) block, comes in. It is a procedure where the drug is injected close to the chest bone and between the ribs. It’s becoming a more common method for relieving pain after open heart surgery because it is easier to perform and can be used when the patient is still awake.
Anatomy and Physiology of Pecto-Intercostal Fascial Plane Block
The nerves between our ribs, known as the thoracic intercostal nerves, help us feel sensations on the chest wall. From the outside to the inside, the layers of the chest wall include the skin, a layer of tissue under the skin, a large chest muscle (pectoralis major), several layers of small muscles between the ribs (intercostal muscles), a muscle on the front inside area of the chest (transversus thoracis muscle), and the protective layer around the lungs (pleura).
The innermost layer of the small muscles between the ribs and the transversus thoracis muscle are in a similar area just above the protective layer around the lungs. The chest’s internal mammary artery and one of the intercostal nerves travel through this muscular layer. After supplying the sensory nerves for the side of the chest wall, the rest of the intercostal nerve moves toward the front, sending sensation to the front of the chest.
An anesthetic technique called a PIFP block is designed to numb these nerves. It places the numbing medicine at the layer between the large chest muscle and the outermost layers of the small muscles between the ribs. This technique aims to numb the sensory nerves before they reach the large chest muscle.
One of the benefits of this anesthetic technique over other methods that target individual nerves is that the anesthetic can spread to a larger area on one side of the body. To perform the block safely and effectively, it is usually advised to insert the needle at the midpoint of the surgical incision. The goal is to numb the nerves that supply sensation from the second to the sixth rib. If the anesthetic doesn’t spread to these areas when seen on ultrasound, performing the numbing injections at multiple levels might be considered.
For safety, the ultrasound used during the PIFP block helps ensure that the needle and the internal mammary artery, an important artery used in heart bypass surgery, are separated by layers of muscles in the chest. This helps reduce the risk of damaging the artery.
Why do People Need Pecto-Intercostal Fascial Plane Block
The PIFP block is a type of pain relief method used to reduce pain in the chest and sternum areas. It works by targeting the nerves in these regions. This procedure first became known in 2014 when it was described by Dr. de la Torre and his team as a way to provide added pain relief after breast surgery.
Since then, this method has been increasingly used for different types of chest surgeries, such as median sternotomy and anterior minimally invasive thoracotomy. A median sternotomy is a surgical procedure where the sternum is cut, and the chest is opened. An anterior minimally invasive thoracotomy is a less invasive procedure that involves making small incisions in the side of the chest.
It’s worth mentioning that the PIFP block might be a better choice than a procedure known as a transversus thoracis muscle plane block, especially when a patient’s internal mammary artery needs to be removed. An internal mammary artery is an artery found near the chest wall.
Other reasons for using the PIFP block include providing pain relief for broken sternums and rib fractures near the front of the body. It has also been found beneficial for children undergoing heart surgery, as well as less invasive procedures such as the installation of a subcutaneous implantable cardioverter-defibrillator device, a type of device planted under the skin to regulate heart rhythms.
Plus, there’s a case where PIFP was used to successfully treat a patient suffering from severe lasting pain after coronary artery bypass graft surgery. After a single PIFP block, the patient reported a significant decrease in pain levels, even six months later.
When a Person Should Avoid Pecto-Intercostal Fascial Plane Block
There are certain reasons why a person may not be suitable for the PIFP block, a type of nerve block which is used for pain relief. These include an allergy to the drugs used for numbing (local anesthetics), having an infection or cancer at the spot where the injection would be given, or if the patient does not wish to receive this treatment. No other specific reasons against using the PIFP block have been noted.
Extra care should be taken with individuals who have certain health conditions which may increase the risk of problems arising from the local anesthetics being absorbed into the body. This might occur if a person has a liver disease, certain metabolic conditions, or is very young or very old. This is important as the liver is responsible for breaking down the type of anesthetics used.
Due to the close proximity of the injection to the lung membrane (pleura), a lung collapse (pneumothorax) could potentially occur as a serious complication. This may be more of a concern in people who already have lung problems or who had a part of their lung removed in the past. But in cases of open-heart surgery, where tubes are often placed in the chest area beforehand, these could help avoid this potential issue.
Equipment used for Pecto-Intercostal Fascial Plane Block
The procedure known as the PIFP block uses ultrasound guidance to reduce the risk of complications. Here’s a simplified list of what your doctor needs to carry out this process:
- An ultrasound machine with a device that emits high frequency sounds
- A sterile covering for the ultrasound and gel to improve the image quality
- Sterile gloves to prevent infection
- Chlorhexidine 2% or another cleanser to sterilize the skin
- Two syringes filled with an anesthetic, which could be mixed with other substances to manage your pain. Usually, this anesthetic is called bupivacaine, and it is given up to a limit of 2.5mg per kilogram of your bodyweight.
- A specialized needled designed to deliver the anesthetic accurately to the nerve, usually between 50 to 100 mm long with a connecting extension tube.
Helping to monitor your wellbeing throughout the procedure will be devices used by anesthesiologists:
- A pulse oximeter which measures the oxygen level in your blood
- A noninvasive blood pressure monitor to keep track of your blood pressure
- An electrocardiogram to check your heart’s electrical activity
Note that devices to monitor your body temperature and the amount of carbon dioxide you exhale are not needed if you are awake during this procedure.
Who is needed to perform Pecto-Intercostal Fascial Plane Block?
The PIFP block, a type of anesthesia often used to numb a specific region of the body, should be done by a healthcare professional who regularly performs procedures using ultrasound guidance and understands the related body structure well.
Another healthcare provider should also be there to perform what’s known as a “safety timeout” or a similar protocol established by the institution. During this time, they double-check that they’re doing the right procedure for the right patient, on the right part of the body (usually on both sides). They also review any allergies the patient may have. This second provider is also involved in the procedure. They handle the syringe with the numbing drug, taking out a small amount and injecting it as instructed by the health professional carrying out the block procedure.
Finally, a medical provider needs to closely watch the patient after the procedure. They look for any signs of a condition called LAST, which can occur if too much of the local anesthetic is absorbed into the bloodstream. If necessary, they will give medications to counter this and call for additional help.
Preparing for Pecto-Intercostal Fascial Plane Block
Before any procedure, it’s important to talk about your medical history with your healthcare provider. They will want to know details like any allergies you might have, whether or not you’ve had anesthesia before, if there are any problems with your breathing, or if there are any issues with your blood clotting properly. This discussion helps to ensure your safety during the procedure.
Remember, it’s essential to understand everything about the procedure completely; this includes the potential risks, the potential benefits, and any alternative options. You should keep asking questions until you feel completely informed about the procedure. Then, you can make an educated decision about whether or not to proceed with the procedure.
Before and during the procedure, medical staff will monitor key parts of your physiology like your heart rate, the level of oxygen in your blood, and your blood pressure. This is all done to keep track of your wellbeing during the procedure. They will also set up an intravenous line (or IV), which is a small tube inserted into your vein. This can be used to give medicine, such as medicine to calm your nerves if the procedure is done while you’re awake.
Before the procedure actually begins, the team will carry out a safety check. This is to confirm that they have the right patient and the correct procedure planned. They’ll also double-check any known allergies you have. It’s also important to note that there will be medical staff present not only during your procedure but afterward as well, to continue monitoring for any signs of complications. This attentive monitoring is another way healthcare providers work to ensure your safety and wellbeing during medical procedures.
How is Pecto-Intercostal Fascial Plane Block performed
The patient is first laid down flat for the procedure, then their skin is thoroughly cleaned and covered safely to maintain cleanliness. A device that uses sound waves to create images, known as an ultrasound transducer, is placed on the chest, a bit to the side of the breastbone, positioned from head to toe. We identify the third and fourth ribs, which appear to cast a shadows in the ultrasound image.
Then we focus on recognizing several layers beneath the skin: the fatty layer under the skin, the chest muscle (pectoralis major), the muscles between the ribs (intercostal muscles), and the thin layer covering the lungs (pleura). In some people, we might not be able to see a certain muscle (transversus thoracis muscle), especially if the ultrasound device is too far from the breastbone.
A needle that can be seen on the ultrasound is inserted. It’s placed just above and to the surface of the third rib to avoid accidentally going through the delicate pleura. The needle is carefully directed to the space between the third and fourth ribs, more specifically to the layer between the chest muscle and intercostal muscles. After making sure that there is no blood coming out when we pull back the needle (to make sure we are not in a blood vessel), we inject a small amount of sterile water to check that the needle is placed correctly and if the water is spreading to the right layer. Once we’re sure everything is okay, we inject 10 to 15 milliliters of the pain blocker slowly, checking before each injection that blood isn’t being drawn into the needle which would indicate we’re in a blood vessel. Once one side is done, we then repeat this entire procedure on the other side of the chest.
Possible Complications of Pecto-Intercostal Fascial Plane Block
The PIFP block is a type of regional anesthetic block used in medical procedures. It comes with certain potential risks, like all anesthetic blocks. These risks can include excessive bleeding or a blood-filled swelling known as a hematoma at the site where the needle was inserted, infection, damage to nearby nerves and blood vessels, an injection into a blood vessel, and a condition called ‘local anesthetic systemic toxicity’ (LAST) where too much anesthetic gets into your blood system.
Because the PIFP block is a relatively new procedure, there aren’t many reports about complications that are exclusive to it. However, one notable risk is pneumothorax, a medical condition where air collects in the space around the lungs. Fortunately, with the help of real-time ultrasound guidance during the procedure, this complication is very unlikely to happen. Even if a pneumothorax did occur, its effects would be less severe during open heart surgery – another medical procedure where chest tubes are routinely used.
Another factor to consider is that if the internal mammary artery (a major blood vessel in your chest) gets damaged during the procedure, it can have serious consequences, especially for patients who need this artery for another part of their surgery. That being said, given that the PIFP block doesn’t go as deep into the body as TTMP block another type of regional anesthetic block, the process is likely safer in terms of this specific potential risk.
What Else Should I Know About Pecto-Intercostal Fascial Plane Block?
If you’ve had sternotomy surgery – that’s when a surgeon makes an incision in your chest to access your heart – you might experience long-lasting pain after the procedure. This happens to as many as half of patients, and in about 5% of patients, this pain can be incredibly severe. Previously, doctors relied heavily on prescribing large amounts of opioids to manage this pain. However, this approach had some drawbacks like delaying patients’ recovery, causing breathing issues, problems with bowel movements, extending their hospital stays, making them continue using opioids after leaving the hospital, and potentially developing opioid dependency or sensitivity to pain.
There are alternatives to opioids. They aren’t without controversy. For example, thoracic epidural analgesia and paravertebral nerve blocks, which are types of pain medication administered into the spine, have a risk of causing neuraxial hematoma – a serious condition where blood clots form around the spine. The bilateral erector spinae plane blocks, another alternative, can give good pain relief but it is not easy to do after the operation because the patient is lying on their back.
Fascial plane chest wall blocks, a new trend in managing pain, are becoming increasingly popular. One of them is parasternal block (PSB). It brings substantial relief to sternotomy pain by targeting specific nerves indeed. It had been confirmed to reduce both pain and the use of opioids in patients going through cardiac surgery. There are two common types of PSBs – TTMP and PIFP. And both could be done under ultrasound guidance.
Bringing your attention to the PIFP block, firstly used for relief after breast surgeries, it has several notable advantages. It covers a broad area, minimizes the chance of injury to the layers surrounding the lungs (pleura) or blood vessels, and lessens absorption compared to intercostal nerve blockade. Recent studies of the PIFP block have shown promising results – less need for opioids, decreased hospital stays, lesser pain scores, and fewer episodes of post-operative nausea or vomiting.
However, there’s a key difference between the PIFP and TTMP block. The PIFP block inserts a local anesthetic between two muscles in the chest, whereas the TTMP block does so between two other muscles. The PIFP block location is less close to the heart and lungs, theoretically reducing the chances of developing complications like hematoma (swelling filled with blood) and pneumothorax (collapsed lung). Moreover, it also bypasses the region of a significant blood vessel (the Internal Mammary Artery), making the procedure safer.
On another note, PIFP block sometimes might require injections at different levels, as the pain-relieving medicine might not spread across the entire intended area. So, if this method is chosen to manage your pain, your doctor might need to make multiple injections.
