Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Submission | Subscribe | Advertise | Contact | Login 
Users online: 155 Small font size Default font size Increase font size Print this article Email this article Bookmark this page


    Advanced search

    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


 Article Access Statistics
    PDF Downloaded60    
    Comments [Add]    

Recommend this journal


Table of Contents
Year : 2020  |  Volume : 23  |  Issue : 4  |  Page : 540-541
Preventing intubation with the transverse thoracic muscle plane block

Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center, Houston, USA

Click here for correspondence address and email

Date of Submission25-Jan-2019
Date of Acceptance10-Jun-2019
Date of Web Publication19-Oct-2020

How to cite this article:
de Haan JB, Yu D, Hernandez N, Sen S. Preventing intubation with the transverse thoracic muscle plane block. Ann Card Anaesth 2020;23:540-1

How to cite this URL:
de Haan JB, Yu D, Hernandez N, Sen S. Preventing intubation with the transverse thoracic muscle plane block. Ann Card Anaesth [serial online] 2020 [cited 2021 Nov 27];23:540-1. Available from:

To the Editor,

Bilateral transverse thoracic muscle plane (TTMP) block plays an important role in the recovery of poststernotomy patients. The degree of pain that patients experience after sternotomy can be severe, leading to thoracic splinting and poor ventilatory effort, resulting in atelectasis. The ventilation and perfusion mismatch worsen hypoxemia, requiring supplemental oxygen, and mechanically assisted ventilation. This, in turn, may increase intensive care unit length of stay and hospital costs and decreases patient satisfaction scores. We describe a case where bilateral TTMP blocks prevented re-intubation in a patient following an ascending aortic aneurysm repair.

The patient was an obese 69-year-old male with history of severe obstructive sleep apnea, current smoking, and uncontrolled hypertension, underwent elective open surgical repair of an ascending aortic aneurysm through a midline sternotomy incision. The Acute Pain Medicine Service was consulted due to fear by the primary team that administration of opioids would lead to respiratory failure given the patient's history of severe sleep apnea. TTMP blocks were performed bilaterally using the technique as described by Ueshima et al.[1] About 20 mL of 0.25% bupivacaine with 3 mg of preservative-free dexamethasone was injected with cranial and caudal spread of injectate underneath the adjacent ribs from T2 to T6 as described by Thomas et al.[2] Thirty minutes following the TTMP blocks, the patient reported a marked decrease in sternotomy pain, from 10 to 1 out of 10 on visual-analog pain scale. His incentive spirometry volumes improved from 750 to 2,250 mL. Analgesia lasted 24-h postinjection.

The sternum is innervated by the anterior cutaneous branches of intercostal nerves 2–6. The parasternal block,[3] a landmark-guided field block in which >50 mL of local anesthetic infiltrated by the surgeon lateral to the sternum before wire closure anesthetizes the same nerves. The duration of analgesia is limited to only a few hours postoperatively due to the injection of local anesthetic into the wound and not into an avascular plane.[4] In 2016, Ueshima et al. described two cases in which the TTMP provided analgesia to the sternum for median sternotomy.[5] This technique differs from the parasternal block in that the local anesthetic is injected under ultrasound-guidance into an avascular plane between the intercostal muscles and the transverse thoracic muscle. TTMP blocks provide high-quality sternal analgesia both consistently and for an extended period of time, allowing for the severity of acute poststernotomy pain to decrease to a level that is manageable with multimodal analgesia.

The TTMP block, as part of a multimodal pain regimen, helped improve the patient's postoperative pain, oxygenation, and respiratory mechanics, ultimately preventing reintubation due to impending respiratory failure. Incorporating the TTMP block into perioperative pain management following sternotomy for cardiothoracic surgery offers a viable option to facilitate extubation and decrease respiratory complications resulting from uncontrolled pain.

Thank you,

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Ueshima H, Kitamura A. Blocking of multiple anterior branches of intercostal nerves (Th2-6) using a transversus thoracic muscle plane block. Reg Anesth Pain Med 2015;40:388.  Back to cited text no. 1
Thomas KP, Sainudeen S, Jose S, Nadhari MY, Macaire PB. Ultrasound-guided parasternal block allows optimal pain relief and ventilation improvement after a sternal fracture. Pain Ther 2016;5:115-22.  Back to cited text no. 2
McDonald SB, Jacobsohn E, Kopacz DJ, Desphande S, Helman JD, Salinas F, et al. Parasternal block and local anesthetic infiltration with levobupivacaine after cardiac surgery with desflurane: The effect on postoperative pain, pulmonary function, and tracheal extubation times. Anesth Analg 2005;100:25-32.  Back to cited text no. 3
Saeidi M, Aghadavoudi O, Sadeghi MM, Mansouri M. The efficacy of preventive parasternal single injection of bupivacaine on intubation time, blood gas parameters, narcotic requirement, and pain relief after open heart surgery: A randomized clinical trial study. J Res Med Sci 2011;16:477-83.  Back to cited text no. 4
Ueshima H, Hara E, Marui T, Otake H. The ultrasound-guided transversus thoracic muscle plane block is effective for the median sternotomy. J Clin Anesth 2016;29:83.  Back to cited text no. 5

Correspondence Address:
Johanna B de Haan
Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center, 6431 Fannin St, MSB 5.020, Houston, TX, 77030
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.ACA_12_19

Rights and Permissions