II. Indications
- Common indications
- Tube Thoracostomy (Chest Tube placement)
- Other indications
- Consider regional Nerve Blocks or Conscious Sedation instead
III. Contraindications
- Pleural adhesions
- Infection overlying injection site
- Anesthetic allergy
IV. Medications
-
Anesthetic
- Bupivacaine 0.5% (example dose 0.3 ml/kg)
- Ropivacaine 0.75% (example dose 15 ml in an adult)
- Topical Antiseptic (e.g. Chlorhexidine, Povidone Iodine)
- Delivery device
- Chest Tube (if already placed and tube can be clamped)
- Syringe with spinal needle
-
Ultrasound
- Consider for needle placement (if Chest Tube not yet placed)
V. Technique
-
Chest Tube instillation
- Instill Anesthetic and clamp tube for 20-30 minutes
- Intrapleural injection
- Ultrasound guidance as available
- Prepare skin with antiseptic solution (e.g. Chlorhexidine, Povidone Iodine)
- Superficial Anesthetic injection of skin
- Advance needle over top of rib into the intrapleural space
- Inject Anesthetic into intrapleural space
- Intrapleural catheter
- Anesthesiology or Intervention Radiology performed procedure
VI. Adverse Effects
-
General adverse effects
- LAST Reaction (including Ventricular Fibrillation, esp. with Bupivacaine)
- Nerve injury
- Vascular injury or Hemorrhage (esp. at subcostal vessels)
- Pneumothorax (including Tension Pneumothorax)
- Infection
- Intrapleural catheter associated complications
- Horner Syndrome
- Epidural spread of Anesthetic
VII. Resources
- Intrapleural Analgesia (StatPearls)
VIII. References
- Warrington (2025) Crit Dec Emerg Med 39(7): 20-1