Background and Aims When integrated in a multimodal, opioid-sparing strategy, regional analgesic techniques present clear advantages specially in critically ill patients^1,2. Prevalence of coagulopathy, hypocoagulation and/or anti-aggregation and multi-organ dysfunction in the Intensive Care Unit (ICU) represent additional difficulties to regional techniques^2,3. Ultrasound-guided peripheral techniques are promising alternatives, namely the Serratus Anterior Plane Block (SAPB) for chest wall analgesia^2,4,5. We present a case of a critically ill patient in whom SAPB was essential for ventilation weaning after thoracic trauma.

Methods Male, 59 YO,ASAIII, diabetes mellitus, peripheral arterial disease, heavy alcohol and smoking habits. Admitted to the emergency room with right femorotibial bypass thrombosis for supracondylar amputation due to critical ischaemia. Immediate postoperative ICU admission evolved with multiorgan dysfunction. A lumbar epidural catheter was placed on day 1 for better pain control. Started dual anti-platelet therapy and prophylactic hypocoagulation. On day 2 patient suffered a cardiac arrest, returning to spontaneous circulation after 30 minutes of advance life support; subsequent bilateral anterior rib fracture with thorax vollet and unilateral pneumothorax. Weaning from ventilation became extremely difficult due to chest pain. US-guided SAPB was performed bilaterally with ropivacaine infusion and rescue bolus, associated with lumbar epidural and multimodal analgesia.

Results Better pain control allowing extubation to non-invasive ventilation 8 days later.

Conclusions Analgesia optimization is crucial to critical ill patients enhancing recovery, promoting early mobilization and chest physiotherapy^2,3. Continuous bilateral SAPB is an excellent alternative to neuroaxial approach in thorax trauma, and should be considered early in these patients as part of a multimodal opioid sparing analgesia planification^3,4,5.