Rhomboid Intercostal and Subserratus Plane Block: A Cadaveric and Clinical Evaluation

Background and Objectives Fascial plane blocks are rapidly emerging to provide safe, feasible alternatives to epidural analgesia for thoracic and abdominal pain. We define a new option for chest wall and upper abdominal analgesia, termed the rhomboid intercostal and subserratus plane (RISS) block. The RISS tissue plane extends deep to the erector spinae muscle medially and deep to the serratus anterior muscle laterally. We describe a 2-part proof-of-concept study to validate the RISS block, including a cadaveric study to evaluate injectate spread and a retrospective case series to assess dermatomal coverage and analgesic efficacy. Methods For the cadaveric portion of the study, bilateral ultrasound-guided RISS blocks were performed on 6 fresh cadavers with 30 mL of 0.5% methylcellulose with india ink. For the retrospective case series, we present 15 patients who underwent RISS block or RISS catheter insertion for heterogeneous indications including abdominal surgery, rib fractures, chest tube–associated pain, or postoperative incisional chest wall pain. Results In the cadaveric specimens, we identified staining of the lateral branches of the intercostal nerves from T3 to T9 reaching the posterior primary rami deep to the erector spinae muscle medially. In the clinical case series, dermatomal coverage was observed in the anterior hemithorax with visual analog pain scores less than 5 in patients who underwent both single-shot and continuous catheter infusions. Conclusions Our preliminary cadaveric and clinical data suggest that RISS block anesthetizes the lateral cutaneous branches of the thoracic intercostal nerves and can be used in multiple clinical settings for chest wall and upper abdominal analgesia. Accepted for publication March 10, 2018. Address correspondence to: Hesham Elsharkawy, MD, MBA, MSc, Department of General Anesthesia and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Ave, Mail Code E31, Cleveland, OH 44195 (e-mail: elsharh@ccf.org). H.E. has received unrestricted educational funding from PAJUNK (Norcross, GA) and consultant fees from Pacira Pharmaceuticals, Inc. Those companies had no input into any aspect of the present project design or manuscript preparation. The authors declare no conflict of interest. All images are created and used with permission of Cleveland Clinic Center for Medical Art and Photography. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.rapm.org). Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Noninvasive measures in atopic dermatitis

Purpose of review To summarize the current knowledge on the morphology, functionality and biochemical composition of the skin in allergic reactions. We address novel noninvasive techniques that promise to disclose intimate mechanisms of skin allergy in vivo. Epidermal barrier is not just a static wrap of the organism but rather a dynamic field for immunological, biophysical and biochemical processes and serves as a bio-sensor for exogenous danger signals. Recent findings Classical biophysical methods are amended by novel in-vivo techniques, such as Raman spectroscopy, analysing the skin microcomposition and develop epidermal profiles. Visualization techniques, such as reflectance spectroscopy and optical coherence tomography (OCT) are employed in studying the micro-morphological changes in the skin of allergic patients. Summary The noninvasive assessment of skin functions, micro-morphology and biochemical as well as immunological pathways will help to better understand skin allergies. They will allow to detect subtypes, for example in atopic dermatitis and to develop specific treatment modalities.

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Globalization and anaphylaxis

Purpose of review To understand the impact of globalization in the management of anaphylaxis and identify potential strategies to improve patients' care and prevention. Recent findings Developments in the field of anaphylaxis have been consistently following these globalization trends offering possibilities of collaborations of the allergy community and integrated international initiatives to reach quality care of allergic patients worldwide. Summary Globalization is the process of interaction and integration between people, companies, and governments worldwide. Developments in the field of anaphylaxis have been following these globalization trends offering possibilities of collaborations and integrated international initiatives to reach quality care of allergic patients worldwide. Complex disorders, such as anaphylaxis, have called for complex integrative strategies, leading to a new acceptance of outside traditions. Allergy is encouraging us to accept holistic and integrative medical practices as viable options. With the dissolution of multinational boundaries and the universal free access to information, the notion of holistic and global-based care is emerging as the new reality of the medicine. We strongly believe that the integrated action plan to the management and prevention of anaphylaxis, just possible through the globalization, is a key health, political and economical move that advocates for the best practice of allergology.

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Cosmetics and ocular allergy

Purpose of review The purpose of this review was to explore recent developments in the study of ocular cosmetics, as they pertain to adverse reactions that can be attributed to them. Recent findings Immunologically mediated adverse reactions to cosmetics are most commonly the result of sensitization to preservatives, fragrances and dyes used in these products. Metals such as nickel, cobalt, chromium and lead are used in products such as eye shadows and eye liners as well as toy makeup sets in amounts greater than the recommended amount of 1 ppm. Cosmetics make up the majority of fragrance-induced contact dermatitis. Recently, a free smartphone app was developed by American Contact Dermatitis Society that holds promise in better enabling patients to utilize their patch test data while shopping for cosmetics. Summary Both immediate and delayed hypersensitivity reactions linked to cosmetics are often the result of sensitization to preservatives, fragrances and additives in the products themselves. Despite significant advances in our understanding of these reactions, further research will be necessary to elucidate the mechanisms behind these reactions and bring this knowledge to the bedside as to improve patient care with potential cosmetic-based related allergic disorders.

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Phenotypes, endotypes and biomarkers in anaphylaxis: current insights

Purpose of review The aim of the review is to describe the different clinical pictures of anaphylaxis (phenotypes), in relation to the underlying mechanisms and potential biomarkers, to describe anaphylaxis endotypes. This may aid in achieving a better understanding, management and outcomes of such severe reactions. Recent findings Different anaphylaxis phenotypes have been outlined, ranging from the classical type-I-like to those suggestive of cytokine-storm-like or complement-mediated reactions. Underlying mechanisms differ and biomarkers of cells and systems involved are being identified (tryptase, IL-6, bradykinin etc.) Summary Identifying specific phenotypes/endotypes will allow the application of precision medicine in patients with anaphylaxis, providing insights to the most appropriate approach in each case.

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Novel systemic drugs in treatment of atopic dermatitis: results from phase II and phase III studies published in 2017/2018

Purpose of review The present review will give an update of recently published clinical studies on novel systemic treatment approaches in atopic dermatitis. Recent findings Until 2017 immunosuppressive drugs such as cyclosporine had to be used in atopic dermatitis when the disease could not sufficiently be treated with topical drugs. Several new substances specifically targeting inflammation in atopic dermatitis are currently studied. In 2017, dupilumab was approved in the United States and in Europe for first-line biologic treatment of moderate to severe atopic dermatitis in adults. The antibody blocks a subunit of the interleukin (IL)-4 and IL-13 receptor, thus inhibiting effects of two key cytokines in type 2 polarized inflammation. In addition to the studies on dupilumab recent clinical investigations on the effects on anti-IL-13 (lebrikizumab, tralokinumab), anti-IL-31 receptor (nemolizumab), anti-IL-22 (fezakinumab), and on small molecules targeting the histamine-4-receptor (ZPL389) and the Janus kinase inhibitor baricitinib have been published as full papers in the last 2 years. Summary A couple of promising novel therapeutical targets have recently been investigated and published in clinical trials on atopic dermatitis.

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