Perioperative Pain Management for Chest Wall Procedures

Fascial plane blocks involve injecting local anesthetic between myofascial tissue layers to target multiple nerves or nerve branches. Initially, these blocks were primarily utilized in breast surgery. Recently, they have demonstrated efficacy in both thoracic and cardiac surgery, thus are now being accepted into perioperative analgesic plans. Effective fascial plane blocks for surgeries involving the chest wall include the Pectoralis I and II (PECS I and II), Serratus Anterior Plane (SAP), Erector Spinae Plane (ESP), Transversus Thoracis Plane (TTP), Pectointercostal Fascial Plane (PIF), Retrolaminar Block (RLB), Midpoint Transverse Process to Pleura (MTP), Rhomboid Intercostal Block (RIB), and Rhomboid Intercostal Sub-Serratus (RISS) blocks. Of note, in order to help standardize nomenclature in regional anesthesia, several of these blocks have undergone name changes during the ASRA-ESRA Delphi consensus in 2021 (El-Boghdadly et al. in Reg Anesth Pain Med 46:571–580, 2021 [1]). PECS I blocks are now referred to as Interpectoral Plane blocks and PECS II blocks are now referred to as Pectoserratus Plane blocks. PIF and TTP blocks are now referred to as Superficial and Deep Parasternal Intercostal Plane blocks, respectively. The RIP and RISS blocks have since been lumped together as the RIP block while the MTP block has been renamed as one of the Intertransverse Process blocks. The old nomenclature will mostly be referred to in this chapter, as most of the research articles mentioned took place prior to the nomenclature change. These blocks have been shown to reduce postoperative pain scores, intraoperative and postoperative opioid requirements, need for rescue analgesia, and postoperative nausea and vomiting. In some situations, these blocks have not only been shown to improve postoperative lung function and decrease time to extubation, but also improve patient satisfaction. Due to their utility as a component of multimodal analgesia, fascial plane blocks have the potential to be included in enhanced recovery pathways for surgeries involving the chest wall.