1. Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics,Ph D(physiology) Mahatma Gandhi medical college and research institute, puducherry, India

2. Indications Analgesia after upper abdominal and thoracic surgery. Rib fracture PHN Anaesthesia Minor chest wall procedures ICD insertion Any patient is ok but obesity ??

3. Drugs Supplement to assist motor block 0.5 % bupi or 2 % lignocaine Sensory block 0.25 % bupi or 0.25 % Ropi Addition of epinephrine

4. Anatomy intercostal nerves are the ventral rami of T1 to T11 T12 is subcostal nerve Ilio inguinal T1 – prefixed T2 and T3 – intercostobrachial

5. Branches and course 2 - sympathetic Dorsal Lateral – midaxillary line Anterior cutaneous At the rib's posterior angle, the area most commonly used during intercostal nerve block, the nerve lies between the internal intercostal muscles and the intercostalis intimus muscle. Throughout the intercostal nerve's course, it traverses the intercostal spaces inferior to the intercostal artery and vein of the same space.

6. Branches

7. Course

8. Technique Position and mild sedation prone position- pillow under the abdomen Reduce lumbar lordosis, increase posterior intercostal space. Arms hang down, to rotate the scapula

9. marking pen to outline the anatomy for most regional blocks. The midline should be marked from T1 to L5, then two paramedian lines should be drawn at the posterior angle of the ribs. These lines should angle medially in the upper thoracic region so that they parallel the medial edge of the scapula

10. Technique

11. Skin puncture with retraction of skin Hit the rib Gauge depth Take the needle back subcutaneous Leave the retraction Go back again – 2 -3 mm behind the previous depth Walk off 3 to 5 mL of local anesthetic solution is injected

12. Lateral approach mid-axillary line while the patient is in a supine position Cryo probe as an open technique for post op analgesia

13. USG picture of intercostal nerve

14. Complications vascularity of the intercostal space, blood levels of local anesthetic are higher for multiple-level intercostal block. peak blood levels may be delayed for 15 to 20 minutes, patients should be closely monitored after the completion of a block for at least that interval. Hemorrhage Pneumothorax ( 0.1 % ) More imaginary

15. Thank you all