BLOCKS OF CHEST WALL IN ANESTHESIA 1.pptx

Different types of block for chest wall

1. BLOCKS OF CHEST WALL MODERATOR:DR SANGAMESH PRESENTER:DR RANI

2. INDEX Anatomy Chest wall blocks division Discription of each block

3. ANATOMY OF CHEST WALL Skin Superficial fascia Cutaneous nerves,fat and superficial vessels Breast Deep fascia Muscles( superficial,intermediate and deep) Nerve supply of chest wall

4. MUSCLES OF CHEST WALL SUPERFICIAL:Subclavius,Pectoralis major and minor,Latismus dorsi,Seratus anterior INTERMEDIATE:External ,inner and innermost intercostal muscle DEEP:Transverse thoracic(ANTERIOR), Subcostalis ( Poaterior )

5. PACTORALIS MAJOR ORIGIN:Medial half of the clavicle,the sternum,upper six costal cartilage INSERTION:Lateral lip of bicipital groove of the humerus NERVE SUPPLY:Medial (C8-T1)and lateral (C5-C7)pectoral nerves ACTION:Adduction,internal rotation of arm in the shoulder joint

6. PACTORALIS MINOR ORIGIN:3 rd ,4 th ,5 th rib near their cartilage INSERTION:Anterior border of the coracoid process of the scapula NERVE SUPPLY:Medial pectoral nerve(C8-T1) ACTION:Stabilises scapula against chest wall ,Elevates ribs during inspiration

7. LATISSIMUS DORSI ORIGIN:Spinous process T7-L5,thoracolumbar fascia,iliac crest,inferior 3 ribs,Inferior angle of scapula INSERTION:Intertubercualar groove of the humerus NERVE SUPPLY:Thoracodorsal nerve(C6-C8) ACTION:Adduct,medially rotate and extend arm on gleinohemeroid joint

8. SERRATOUS ANTERIOR ORIGIN:External surface of ribs 1-9 INSERTION:Medial margin of scapula NERVE SUPPLY:Long thoracic nerve(C5-C7) ACTION:Protracts and stabilizes scapula

9. INTERCOSTAL MUSCLES SUPPIED BY VENTRAL RAMI OF T1-T12 NERVES EXTERNAL INTERNAL INNERMOST ORIGIN Inferior border of 1 to 11 ribs Costal groove of 2-12 ribs Inferoposterior border of each rib INSERTION Superior border of 2-12 ribs Superior aspect of 1-11 ribs Superoposterior border of the rib ACTION Lift rib and rib cage and increases AP dimension Depress rib during forced expiration Expiratory muscles

10. NERVE SUPPLY OF CHEST WALL Lateral pectoral nerve(C5-C7): Supplies pectoralis major Medial pectoral nerve(C5-C7): Supplies pectoralis major and minor Long thoracic nerve (C5-C7):Supplies serratus anterior Thoraco dorsal nerve:Supplies latissimus dorsi Intercostal nerves:Gives muscular branches to intercostal muscle and cutaneous branches to chest wall

11. INTERCOSTAL NERVE Thoracic spinal nerves from T1 to T11 all have anterior rami corresponding with intercostal nerves. 1 to 6 intercostal nerve supply parietal pleura,skin,serratus posterior and intercostal muscles The next five supply parietal peritoneum,skin , and different abdominal muscles

12. INTERCOSTAL NERVE

13. Lateral cutaneous branch of intercostal nerve Lateral cutaneous branches of T2 to T11 pierce the internal and external intercostal muscles obliquely before diving to anterior and posterior branches Innervates lateral wall of chest T7-T11 also innervate the skin over the abdominal muscles

14. Anterior cutaneous branch of intercostal nerve Anterior cutaneous branches of T2 to T6 pierces the external intercostal and pectoralis major to enter superficial fascia near the lateral border of sternum to supply the skin of the anterior part of the chest near midline and slightly beyond T7 to T12 supplies the skin of the anterior abdominal wall

15. Dermatomal distribution of intercostal nerve

16. INTERCOSTAL SPACE It is the space between to adjucent ribs Bordered by the ribs,above and below Superficially by deep fascia of the thorax Internally by fascia and pleura There are 12ribs and 11 spaces Contains muscles,nerves and vessels

17. CHEST WALL BLOCKS ARE DIVIDED INTO ANTEROMEDIAL :PIP(Parasternal intercostal plane block),TIP(Transverse thoracis plane block) ANTEROLATERAL:Pectoralis nerve block(PEC1,PEC2) Seratous anterior plane block(SAPB) Intercostal block

18. ANTEROMEDIAL CHEST BLOCKS PIP(Parasternal intercostal plane block) TTP(Transverse thoracis plane block)

19. NERVE BLOCKED Anterior branches of the intercostal nerves

20. LANDMARK 3 rd rib parasternally about 2-3cm Position of the transducer:3 rd rib parasternally Direction: caudal to cranial drug: 0.25% bupivacaine or 0.2% ropivacaine

21. PIP (Parasternal intercostal plane block) Plane is between pectoralis major and intercostal muscles

22. TTP (Transverse thoracis plane block) Plane is between intercostal muscles and transverse thoracis muscle

23. Important vessel :Internal thoracic artery

24. INDICATIONS Analgesia : mid clavicular line to sternum Sternotomy Sternal fractures Thoracic surgery Breast surgeries with other blocks Minor procedures like subcutaneous implantable cardioverter defibrillator(S-ICD)placement Chronic pain:Costochondral pain(costochondritis and slipped rib syndrome)

25. CONTRAINDICATIONS Patient refusal Allergy to local anesthetics Infection at the site Bleeding disorders

26. COMPLICATIONS Pnemothorax Injury to Internal thoracic artery Infection Local anesthetic toxicity

27. ANTEROLATERAL BLOCK Pectoralis nerve block(PEC):PEC1 and PEC2 Seratous anterior nerve block

28. Pectoralis nerve block(PEC) PEC1 PEC2(modified PEC1 Block) Nerves blocked Medial(C8-T1) and Lateral(C5-C7) pectoral nerve Medial and Lateral pectoral nerve Long thoracic nerve T2-T6 Lateral cutaneous branches of Intercoastal nerve Site of injection Between Pectoralis major and minor Between Pectoralis major and minor(PEC1) and Between Pectoralis minor and Serratous anterior muscle Landmark Midclavicular line 2 nd rib Lateral 3-4 th rib along anterior axillary line Depth 1-3cm 3-4cm Drug 0.25% bupivacaine or 0.2% ropivacaine 0.25% bupivacaine or 0.2% ropivacaine Volume 10ml 20ml

29. LANDMARK PEC1:Midclavicular line 2 nd rib PEC2:Lateral 3-4 th rib along anterior axillary line

30. PEC1 Place the probe inferior to the clavicle at the midclavicular line 2 nd rib angled inferolaterally Identify the pectoralis muscle with the axillary artery and vein and thoracoacromial artery advance the needle in plane from medial to lateral in an oblique manner until the tip lies between pactoralis major and minor and insert the drug

31. PEC2 Perform sonography as fpr PECS1,but also identify the potential space between the lateral extent of pectoralis minor and serratous anterior at the level 3 rd and 4 th rib along anterior axillary line. First perform a PEC1 inection between pectoralis major and minor,then inject between pectoralis minor and serratous anterior

32. Important vessel:Thoracoacromial artery

33. NERVE STIMULATOR TECHNIQUE Position:Supine with ipsilateral arm slightly adbducted Landmark:A line joining from the angle of louis(2 nd rib) to anterior axillary line,at this point needle is inserted Block is done with a 50mm insulated nerve stimulator The stimulator is initially set at 1 to 1.5milliampere current for 0.1miliseconds and 1hz frequency The needle is slowly advanced till the pectoralis contracts The needle is kept this depth and current is gradually reduced to 0.3 to 0.5 milliampere Persistance of contractions confirms the needle placement at the target site Local anesthetic is then injected in increments with frequent negative aspirations

34. INDICATIONS OF PEC1 Breast surgeries(to insert expanders) Pacemaker insetion Adjuvant to paravertebral block following mastectomy

35. INDICATIONS OF PEC2 Wide local excision of breast Sentinal lympnode biopsy Axillary clearance Submascular breast prosthesis Pacemaker and implantable cardiac defibrillator

36. CONTRAINDICATIONS Patient refusal Allergy to local anesthetics Infection at the site Bleeding disorders

37. COMPLICATIONS Pnemothorax Injury to vessels Infection Local anesthetic toxicity

38. SERRATUS ANTERIOR PLANE BLOCK 2 planes are described based on serratus anterior muscle Superficial SAP Block Deep SAP Block

39. TWO PLANES OF SERRATUS ANTERIOR BLOCK SUPERFICIAL:Above the serattus anterior muscle(latissimus dorsi and serattus anterior) DEEP:Below the serattus anterior muscle( serattus anterior and external intercostal muscle at the T6-T9 level ) also known as subserratus block

40. NERVE BLOCKED: Intercostobrachialis nerve Lateral cutaneous branches of the intercostal nerve(T3-T9) Long thoracic nerve Thoracodorsal nerve These nerve are located in a compartment between the serratus anterior and latissimus dorsi,between the posterior and midaxillary line

41. SERRATOUS ANTERIOR PLANE BLOCK LANDMARK:5 TH rib,serattus anterior muscle and latissimus muscle

42. SERRATOUS ANTERIOR PLANE BLOCK Place the probe inferior to the clavicle at the midclavicular line 2 nd rib angled inferolaterally Then move the probe inferiorly and posteriorly with increasing coronal orientatiom until 5 th rib is reached in mid axillary line and insert the needle between 4 th and 5 th rib caudal to cranial and deposite the drug Locate thoracodorsal artery between lattismus dorsi and serratus anterior to avoid intravascular injection Drug:0.25%bupivacaine or 0.2%ropivacaine ,20ml(0.4ml per g)

43. Important vessel Thoracodorsal artery between lattismus dorsi and serratus anterior

44. NERVE STIMULATOR TECHNIQUE Position:supine with the arm brought forward In the midaxillary line, at the space between 4 th and 5 th rib the needle is inserted and connected to nerve stimulator The needle is slowly advanced till the serratus anterior contracts Local anesthetic is then injected in increments with frequent negative aspirations

45. INDICATIONS Breast surgery Chronic pain after mastectomies Rib fracture Thoracoscopy and thoracotomy Chest tube associated pain

46. CONTRAINDICATIONS Patient refusal Allergy to local anesthetics Infection at the site Bleeding disorders

47. COMPLICATIONS Pnemothorax Injury to vessels Infection Local anesthetic toxicity

48. INTERCOSTAL NERVE BLOCK LANDMARK Midthoracic vertebral line Angle of the ribs Internal intercostal muscle

49. INTERCOSTAL NERVE BLOCK Position: sitting,lateral or prone Count the ribs from the 12 th rib or from the 7 th rib(inferior tip of scapula) The inferior edges of the ribs to be blocked are marked just lateral to lateral border of the paraspinous muscle group(usually 6-8cm from the midline in the lower ribs and 4-7cm from the midline in the upper ribs),corresponding to the angle of ribs(here the costal groove is at its broadest and deepest and lateral branch of the ICN is not yet branched) The drug is injected between internal and innermost intercostal muscle The ideal angle of entry into the subcostal groove is about 20degree cephalad 3-5ml drug for each ICN

50. NERVE BLOCKED Lateral cutaneous branch of lntercostal nerve

51. The drug is injected between internal and innermost intercostal muscle

52. NEEDLE ANGLE The ideal angle of entry into the subcostal groove is about 20degree cephalad

53. INTERCOSTAL NERVE BLOCK Epidual analgesia may be better suited alternative to bilateral intercostal nerve block because of the risk of bilateral pneumothorax Intercostal nerve block above T7 may be difficult because of the scapulae, an alternative to this is paravertebral or epidural block

54. INDICATIONS Incisional pain from thoracic surgery Analgesia for thoracostomy Herpes zoster or post herpetic neuralgia Rib fractures Breast surgery Upper abdominal surger Analgesia for chest tubes Differentiating between visceral and somatic pain(diagnostic block)

55. CONTRAINDICATIONS Patient refusal Allergy to local anesthetics Infection at the site Bleeding disorders

56. COMPLICATIONS Pnemothorax Injury to vessel Infection Local anesthetic toxicity Difficulty in breathing from blocking the innervation to the abdominal wall muscles(because 7 th to 11 th intercostal nerve supply abdominal wall muscles)

57. REFERRENCES Hazdics textbook of regional anaesthesia Atlas of regional anaesthesia Nishank P Nooli , Jordan E,Goldhmmer,Regina E.Linganna FASCIAL PLANE BLOKS AS REGIONAL ANALGESIA TECHNIQUES FOR CARDIAC SURGERIES

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