Superficial Parasternal Intercostal Plane Block
Coauthored with Celine Chedid
Indications: Sternotomy, sternal fractures, medial rib fractures, Ravitch pectus repair, medial coverage for breast surgery, medial coverage for placement of a tunneled pacemaker or implantable cardioverter-defibrillator
Special Considerations: Superficial Parasternal Intercostal Plane Block (Superficial PIP, formerly Pecto-Intercostal Fascial Block PIFB) may provide equivalent analgesia to its alternative, the Deep Parasternal Intercostal Plane Block, with a theoretical decreased risk of pneumothorax, pericardial puncture and intravascular injection (internal thoracic artery) as the intermuscular plane is more superficial to these vital structures. However, this block may require multiple injections to adequately open the fascial plane and lift the pectoralis major off of the costal cartilage.
Patient Position: Supine
Technique: In-plane, Parasagittal. *Transverse probe orientation may be utilized to identify vessels with color doppler.*
The superficial PIP plane is the intermuscular fascial plane between the pectoralis major muscle and the intercostal muscle.
Place the probe on the chest in a parasagittal orientation between the third and fourth rib space, lateral to the sternum. Identify the pectoralis major muscle, ribs, intercostal muscle, transversus thoracic muscle and pleura. To identify vascular structures, place the probe in a transverse orientation with color flow doppler to visualize the internal thoracic artery and vein.
Transverse scan between the ribs
After identifying vital anatomical structures, the needle is advanced in-plane to the fascial plane between the pectoralis major and the intercostal muscles. After negative aspiration, hydrodissect with saline to confirm needle placement. Once confirmed, the injection of local anesthetic should lift the pectoralis major off the intercostal muscle and costal cartilage; the needle may need to be advanced further into the plane or newly created space to allow for appropriate spread. If unsuccessful, additional injections above and below the initial injection point may be performed to open the interfascial plane and allow for appropriate spread of local anesthetic.
Coverage: Superficial PIP targets the anterior cutaneous branch of the intercostal nerves, with a dermatomal distribution of T2-T6.
Potential Complications:
· Pneumothorax (if needle directed too deep)
· Pericardial puncture (if needle directed too deep)
· Intravascular injection
· Bleeding or infection at needle insertion site
Patient Positioning, Probe Orientation & Sonoanatomy
The Superficial Parasternal Intercostal Plane Block (Superficial PIP), formerly known as the Pecto-intercostal Fascial Block, is mainly described in literature for post-operative pain management after cardiac surgery, thymectomy, breast surgery, and ICD placement in the adult population. When compared to its alternative the Deep PIP, there is a theoretical decreased risk of pneumothorax, pericardial puncture and intravascular injection (internal mammary artery) as the intermuscular fascial plane for injection is superficial to the intercostal muscle. However, this theory has not been verified in literature to date, and may be masked in the presence of chest tubes.
The great regional debate appears to center around two separate camps—team Superficial PIP versus team Deep PIP. A recent prospective, randomized, pilot comparison of Superficial PIP (PIFB) to Deep PIP (TTMB) by Kaya et al found that both techniques have similar effectiveness in acute post-sternotomy pain control. This study, like most regional evidence, was in adult patients. So how does one choose between the superficial or deep parasternal block, and how do they differ in the pediatric population?
Few studies have described this technique in pediatric patients, and to date there are no studies comparing the two techniques. Chaudary et al described the successful use of parasternal blocks performed by surgeon prior to chest closure (2). Since that initial description, it seems that most of the pediatric studies have focused on the deep parasternal technique, as minimal literature for the superficial technique exists. One abstract showed a decrease in post-operative pain scores in thirty pediatric patients requiring sternotomy for cardiac surgery, and a second case report described the use of superficial PIP in a pediatric patient requiring a subcutaneous ICD placement.
The superficial PIP is an advanced block that provides a potentially safer alternative for anesthetizing the anterior chest. The interfascial plane between the pectoralis major muscle and the intercostal muscle is more superficial to vital structures such as the pleura and pericardium, thus theoretically decreasing the risk of pneumothorax and pericardial puncture. Although as stated in the deep PIP section, reported incidence of pleural or cardiac puncture after deep block was 0-1%.
The internal mammary artery and vein pass through the deep interfacial plane between the intercostal muscle and the transversus thoracic muscle. Thus, there is a theoretical decreased risk of vascular puncture with the superficial PIP, as injection is performed superficial to these vascular structures between the pectoralis major and intercostal muscles.
One big caveat to the superficial PIP block, is that multiple injections may be required for adequate spread of local anesthetic in the interfacial plane, if adequate craniocaudal spread of injectate is not seen during initial injection. In the pediatric population this could be problematic if potential need for additional local anesthetic volume was not accounted for during initial local anesthetic dose calculations.
The superficial PIP block is a relatively safe option for anesthetizing the anterior chest wall that may be preferred for the novice provider, as the costal cartilage and rib can be a safeguard. While the injection is performed more superficial to vital anatomical structures, it may come at the price of multiple injections to provide adequate spread of local anesthetic.
C. Kaya et al. Comparison of Ultrasound-Guided Pecto-intercostal Fascial Block and Transversus Thoracic Muscle Plane Block for Acute Poststernotomy Pain Management After Cardiac Surgery: A Prospective, Randomized, double-Blind Pilot Study. Journal of Cardiothoracic and Vascular Anesthesia 00 (2021) 1-9.
Chaudhary et al. Parasternal Intercostal Block with Ropivacaine for Postoperative Analgesia in Pediatric Patients Undergoing Cardiac Surgery: A Double-Blind, Randomized, Controlled Study. Journal of Cardiothoracic and Vascular Anesthesia, Vol 26, No 3 (June), 2012:pp 439-442.
Ozturk F, Bicer M, Yayik A, et al. Ultrasound guided parasternal subpectoral intercostal plane block for pediatric open heart surgery. Regional Anesthesia & Pain Medicine 2019;44:A91-A92.
Koller MP, Cortez D, Kim TW. Nerve Blocks for Postoperative Pain Management in Children Receiving Subcutaneous Implantable Cardioverter-Defibrillators: A Case Series. A A Pract. 2021 Sep 17;15(9):e01520. doi: 10.1213/XAA.0000000000001520. PMID: 34547010.
Liu V, Mariano ER, Prabhakar C. Pecto-intercostal fascial block for acute poststernotomy pain. A A Pract. 2018;10(12):319–322.
