Pneumothorax following serratus anterior plane block
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Serratus anterior plane blockade has been increasingly utilised for analgesia for rib fractures, thoracic surgery and breast surgery. Since the first reported ultrasound‐guided serratus anterior plane block, various approaches have been described. Analgesia is provided by blocking the lateral branches of the intercostal nerves (T2–T6), the long thoracic nerve and the thoracodorsal nerve

A 63‐year‐old woman with a background of hypertension, type 2 diabetes mellitus, ex‐smoker and a body mass index of 39 kg.m−2 was scheduled for a wire‐guided right breast wide local excision with sentinel lymph node biopsy for a grade 2 invasive ductal carcinoma. During the pre‐assessment visit on the day of surgery, she was given paracetamol, ibuprofen, omeprazole and metoclopramide.

She then underwent a wire insertion into the breast lesion in the radiology department before presenting for general anaesthesia. After establishing standard monitoring, intravenous general anaesthesia was induced in the supine position, a size 4 iGel supraglottic airway device was inserted and intermittent positive pressure ventilation commenced. No neuromuscular blockade was administered. After initiation of positive pressure ventilation, the patient started coughing, which resolved with a bolus dose of propofol.

Anaesthesia was maintained with sevoflurane in an oxygen and air mixture. A modified serratus anterior plane block was then performed using a 6–13 MHz linear ultrasound transducer under aseptic conditions with the patient supine. The probe was positioned over the fifth rib in the mid‐axillary line, allowing identification of latissimus dorsi, serratus anterior muscle and underlying ribs in the coronal plane. A 22G, 80 mm Sonoplex needle was used with an in‐plane technique, with the needle directed from caudal to cephalad in the coronal plane to contact the fifth rib. Ten millilitres of bupivacaine 0.25% was injected in the fascial plane deep to the serratus anterior muscle, the needle trajectory was flattened and advanced to extend the hydro‐dissection to the fourth rib and a further 10 ml of bupivacaine 0.25% was injected. No immediate complications were noted.

Intra‐operatively the patient developed a significant episode of oxygen desaturation with elevated peak airway pressures to 37 cmH2O. This temporarily improved by increasing the fractional inspired concentration of oxygen, performing a positive pressure recruitment manoeuvre, applying positive end‐expiratory pressure and increasing the inspiratory to expiratory ratio. The peripheral arterial oxygen saturations increased from 80% to 92% on 60% inspired oxygen concentration. The patient remained haemodynamically stable throughout the surgical procedure, which lasted approximately 90 minutes.

At the end of the procedure the patient was transferred to the bed, sat upright, re‐established on spontaneous respiration and emerged from anaesthesia. The supraglottic airway device was removed, the patient was given 10 l.min−1 oxygen through a facemask and transferred to the post‐anaesthesia care unit.

This case demonstrates that despite purported advantages of local anaesthetic deposition deep to the serratus anterior muscle, there is also the potential for significant patient harm. As the first case of a pneumothorax reported from this approach, it serves as a reminder of a serious complication and the need for vigilance, as such complications can present in a subtle manner.

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