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Implantation of the subcutaneous implantable cardioverter–defibrillator with truncal plane blocks

Published:February 15, 2018DOI:https://doi.org/10.1016/j.hrthm.2018.02.014
      Operative anesthetic requirements and perioperative discomfort are barriers to wide adoption of the subcutaneous implantable cardioverter–defibrillator (SICD) system. The SICD implant procedure involves incision and dissection in the richly innervated midaxillary line of the chest wall for placement of the pulse generator and tunneling in subcutaneous tissue for implantation of the defibrillator lead.
      • Brouwer T.F.
      • Miller M.A.
      • Quast A.B.
      • Palaniswamy C.
      • Dukkipati S.R.
      • Reddy V.
      • Wilde A.A.
      • Willner J.M.
      • Knops R.E.
      Implantation of the subcutaneous implantable cardioverter-defibrillator: an evaluation of 4 implantation techniques.
      Intraoperative local anesthetic wound infiltration is routine and provides moderate analgesia, but the effects are short-lasting, and complete coverage of the affected areas is difficult. Consequentially, the procedure is most commonly performed with the patient under general anesthesia or anesthesiologist-delivered deep sedation, and postoperative pain can be substantial.
      • Friedman D.J.
      • Parzynski C.S.
      • Varosy P.D.
      • Prutkin J.M.
      • Patton K.K.
      • Mithani A.
      • Russo A.M.
      • Curtis J.P.
      • Al-Khatib S.M.
      Trends and in-hospital outcomes associated with adoption of the subcutaneous implantable cardioverter defibrillator in the United States.
      Alternatively, truncal blocks are a form of adjunctive regional anesthesia that are becoming an increasingly popular strategy for achieving lasting chest wall analgesia for breast and thoracic surgical procedures.
      • Barbera C.
      • Militio P.
      • Punturieri M.
      • Asti E.
      • Bonavina L.
      Serratus anterior plane block for hybrid transthoracic esophagectomy: a pilot study.
      One type of truncal block is the ultrasound-guided fascial plane block, which relies on local anesthetic diffusion to reach the intended nerves and is considered an easy-to-perform procedure with an excellent analgesic and safety profile.
      • Mayes J.
      • Davison E.
      • Panahi P.
      • Patten D.
      • Eljelani F.
      • Womack J.
      • Varma M.
      An anatomical evaluation of the serratus anterior plane block.
      We recently incorporated 2 truncal blocks into the SICD implant procedure at our institution: the serratus anterior plane (SAP) block and the transversus thoracic muscle plane (TTP) block. The SAP block targets the lateral cutaneous branches of the thoracic intercostal nerves to provide analgesia of the anterolateral thorax (i.e., location of pulse generator), and the TTP block targets the anterior branches of the intercostal nerves to provide analgesia along the sternum (i.e., location of the defibrillator lead) (Figure 1).
      • Ueshima H.
      • Kitamura A.
      Blocking of multiple anterior branches of intercostal nerves (Th2-6) using a transversus thoracic muscle plane block.
      Here we describe the technique and characteristics of patients who underwent SICD implantation with the use of adjunctive truncal blocks.
      Figure thumbnail gr1
      Figure 1Rendering of the anterolateral chest wall, with the target injection site for the serratus anterior plane block (blue star) and the transversus thoracic plane block (purple star).

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