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Intrapleural Anesthesia

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Intrapleural Anesthesia, Intrapleural Analgesia

  • See Also
  1. Tube Thoracostomy
  2. Regional Anesthesia
  3. Thoracentesis
  • Indications
  1. Common indications
    1. Tube Thoracostomy (Chest Tube placement)
  2. Other indications
    1. Rib Fractures
    2. Flail Chest
  3. Consider regional Nerve Blocks or Conscious Sedation instead
    1. Erector Spinae Plane Block
    2. Serratus Anterior Nerve Block
  • Contraindications
  1. Pleural adhesions
  2. Infection overlying injection site
  3. Anesthetic allergy
  • Medications
  1. Anesthetic
    1. Bupivacaine 0.5% (example dose 0.3 ml/kg)
    2. Ropivacaine 0.75% (example dose 15 ml in an adult)
      1. Chen (2021) J Pain Res 14:785-91 +PMID: 33776475 [PubMed]
  2. Topical Antiseptic (e.g. Chlorhexidine, Povidone Iodine)
  3. Delivery device
    1. Chest Tube (if already placed and tube can be clamped)
    2. Syringe with spinal needle
  4. Ultrasound
    1. Consider for needle placement (if Chest Tube not yet placed)
  • Technique
  1. Chest Tube instillation
    1. Instill Anesthetic and clamp tube for 20-30 minutes
  2. Intrapleural injection
    1. Ultrasound guidance as available
    2. Prepare skin with antiseptic solution (e.g. Chlorhexidine, Povidone Iodine)
    3. Superficial Anesthetic injection of skin
    4. Advance needle over top of rib into the intrapleural space
    5. Inject Anesthetic into intrapleural space
  3. Intrapleural catheter
    1. Anesthesiology or Intervention Radiology performed procedure
  • Adverse Effects
  1. General adverse effects
    1. LAST Reaction (including Ventricular Fibrillation, esp. with Bupivacaine)
      1. Jagadeesan (2007) Ann Plast Surg 59(4):445-6 +PMID: 17901739 [PubMed]
    2. Nerve injury
    3. Vascular injury or Hemorrhage (esp. at subcostal vessels)
    4. Pneumothorax (including Tension Pneumothorax)
    5. Infection
  2. Intrapleural catheter associated complications
    1. Horner Syndrome
    2. Epidural spread of Anesthetic
  • Resources
  1. Intrapleural Analgesia (StatPearls)
    1. https://www.ncbi.nlm.nih.gov/books/NBK526020/
  • References
  1. Warrington (2025) Crit Dec Emerg Med 39(7): 20-1