Alternative regional anesthesia for surgical management of multilevel unilateral rib fractures

ABSTRACT Rib fractures are a frequent occurrence in trauma victims. Patients with a “flail chest” pattern of injury, defined as two fractures per rib in three (or more) consecutive ribs, often struggle with hypoxemic respiratory failure related to inefficient ventilatory mechanics, inability to expectorate, underlying pulmonary contusion and subsequent pneumonia. The operative indications for rib fracture repair have not been established and are considered to be an issue of debate. Over the last ten years, surgical stabilization of rib fractures has emerged as a promising therapy for patients with severe chest wall injuries. When surgical treatment is performed for patients with rib fracture, general anesthesia is the gold standard but, considered the patients clinical condition, we decided to perform the surgery with regional anesthesia and awake patients to avoid risk of ventilator-induced lung injury. Epidural anesthesia, thoracic paravertebral block and erector spinae plane block for analgesia in patients with rib fractures have been reported. In our report, we discussed the use of ultrasound-guided thoracic paravertebral block with administration of local anesthetic posteriorly to superior costo-transverse ligament and erector spinae plane block to perform surgical stabilization of rib fractures.