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Original research
Optimal techniques of ultrasound-guided superficial and deep parasternal intercostal plane blocks: a cadaveric study
  1. Artid Samerchua1,
  2. Prangmalee Leurcharusmee1,2,
  3. Kittitorn Supphapipat1,
  4. Kantarakorn Unchiti1,
  5. Panuwat Lapisatepun1,
  6. Naraporn Maikong3,
  7. Perada Kantakam3,
  8. Pagorn Navic3 and
  9. Pasuk Mahakkanukrauh2,3
  1. 1 Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
  2. 2 Excellence in Osteology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
  3. 3 Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
  1. Correspondence to Dr Prangmalee Leurcharusmee, Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; prangmalee.l{at}cmu.ac.th

Abstract

Introduction The optimal techniques of a parasternal intercostal plane (PIP) block to cover the T2–T6 intercostal nerves have not been elucidated. This pilot cadaveric study aims to determine the optimal injection techniques that achieve a consistent dye spread over the second to sixth intercostal spaces after both ultrasound-guided superficial and deep PIP blocks. We also investigated the presence of the transversus thoracis muscle at the first to sixth intercostal spaces and its sonographic identification agreement, as well as the location of the internal thoracic artery in relation to the lateral border of the sternum.

Methods Ultrasound-guided superficial or deep PIP blocks with single, double, or triple injections were applied in 24 hemithoraces (three hemithoraces per technique). A total volume of dye for all techniques was 20 mL. On dissection, dye distribution over the first to sixth intercostal spaces, the presence of the transversus thoracis muscle at each intercostal space and the distance of the internal thoracic artery from the lateral sternal border were recorded.

Results The transversus thoracis muscles were consistently found at the second to sixth intercostal spaces, and the agreement between sonographic identification and the presence of the transversus thoracis muscles was >80% at the second to fifth intercostal spaces. The internal thoracic artery is located medial to the halfway between the sternal border and costochondral junction along the second to sixth intercostal spaces. Dye spread following the superficial PIP block was more localized than the deep PIP block. For both approaches, the more numbers of injections rendered a wider dye distribution. The numbers of stained intercostal spaces after superficial block at the second, fourth, and fifth intercostal spaces, and deep block at the third and fifth intercostal spaces were 5.3±1.2 and 5.7±0.6 levels, respectively.

Conclusion Triple injections at the second, fourth, and fifth intercostal spaces for the superficial approach and double injections at the third and fifth intercostal spaces for the deep approach were optimal techniques of the PIP blocks.

  • nerve block
  • regional anesthesia
  • ultrasonography

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

https://doi.org/10.1136/rapm-2023-104595

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • Presented at ESRA Abstracts, 39th Annual ESRA Congress, 22-25 June 2022 (Lapisatepun P, Samerchua A, Leurcharusmee P, et al B87 A cadaveric study determining optimal techniques for ultrasound-guided parasternal intercostal plane block. Regional Anesthesia & Pain Medicine 2022;47:A127; http://dx.doi.org/10.1136/rapm-2022-ESRA.162).

    • Contributors AS and PLe participated in the conceptualization, methodology, investigation, formal analysis, writing the original draft, reviewing and editing the manuscript, and final manuscript approval. KS, KU, and PLa participated in the conceptualization, investigation, and final manuscript approval. NM, PK, PN, and PM participated in conceptualization, methodology, investigation, reviewing and editing manuscript, and final manuscript approval. PLe is a guarantor responsible for the overall content.

    • 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.

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

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.