Truncal blocks.pptx

Abdominal and Thoracic wall nerve blocks

1. SEMINAR ON TRUNCAL BLOCKS Presenter: Dr Dawit G (ACCPM R1) Moderator: Dr. Adane Getachew (Anesthesiologist) Bahirdar University; Collage Of Medicine And Health Sciences November 2022

2. OBJECTIVES Explain Anatomy and sonoanatomy of abdominal wall and chest wall blocks Describe indications, complications and techniques of truncal blocks 2

3. OUTLINES Introduction Abdominal wall blocks Chest wall blocks references 3

4. Introduction Interfascial plane blocks are the current hot topic in regional anaesthesia 4

5. Abdominal wall blocks TAP Rectus sheath Ilioinguinal and Iieohypogastric nerve blocks Quadratum lumborum block 5

6. Abdominal wall anatomy 6

7. Abdominal wall inervation 7

8. Abdominal wall inervation 8

9. TAP block relies on injection of LA in the neurovascular plane between the TA and IO muscles.   targets dermatomes from T8 to L1. The subcostal TAP block is performed at the costal margin to achieve a block as high as T6. 9

10. TAP block part of a multimodal approach to postoperative pain control in prostatectomy, large- and small-bowel surgery, and cesarean section 10

11. TAP block 11

12. TAP block 12

13. TAP BLOCK 13

14. TAP blocks comparison 14

15. TAP block summary 15

16. RECTUS SHEATH BLOCK involves injection of LA between the rectus abdominus muscle and the posterior rectus muscle sheath. This block results in periumbilical anesthesia of the T9 to T11 dermatomes used for percutaneous gastrostomy surgery umbilical hernia and midline ventral hernia repairs 16

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18. RECTUS SHEATH BLOCK 18

19. RECTUS SHEATH BLOCK 19

20. RECTUS SHEATH BLOCK 20

21. ILIOINGUINAL AND ILIOHYPOGASTRIC NERVE BLOCKS blocked together with a targeted injection of LA within the TAP. useful for postoperative analgesia after inguinal hernia repair for children and adults employed for analgesia during inguinal hernia repair, orchiopexy , and hydrocelectomy cannot be used as the only anesthetic for the surgery because the ilioinguinal and iliohypogastric nerves do not cover visceral pain from peritoneal traction and manipulation of the spermatic cord. 21

22. LUMBAR PLEXUS 22

23. 23

24. II AND IH BLOCKS 24

25. II AND IH BLOCKS 25

26. II AND IH BLOCKS 26

27. II AND IH BLOCKS 27

28. II AND IH BLOCKS 28

29. QUADRATUM LUMBORUM BLOCK more consistent method of accomplishing somatic as well as visceral analgesia of the abdomen than the TAP block may provide an extended sensory blockade between T4 and L1. It can be used as an adjuvant technique for analgesia but does not provide adequate blockade to be used for anaesthesia . 29

30. QUADRATUM LUMBORUM BLOCK The QL lies between the anterior muscle layers and the paravertebral space the efficacy is due to extension into the paravertebral space Different approaches to QLB have been described with no large studies to show which is the most effective approach 30

31. QL BLOCK 31

32. QL BLOCK 32

33. SHAMROCK 33

34. SHAMROCK SIGN 34

35. QL BLOCK 35

36. QL BLOCK 36

37. QLB Indications 37

38. QUADRATUM LUMBORUM BLOCK complications are very rare but may include the following . Block Failure Local anaesthetic toxicity Sympatholysis causing hypotension Bowel injury Kidney injury Infection Vascular injury Unwanted femoral nerve block 38

39. CHEST WALL BLOCKS Before the advent of ultrasound-guided regional anaesthesia , chest wall blocks were mainly confined to intercostal nerve blockade , thoracic epidural analgesia and thoracic paravertebral blockade. development of US guided fascial plane blocks, enabled local anaesthetic to be injected into a tissue plane rather than around individual nerves 39

40. CHEST WALL BLOCKS PEC I AND PEC II Seratus plane block (SPB) Thoracic paravertebral block (TPVB) Intercostal block Erector spina block (ESB) 40

41. PEC I AND PEC II BLOCK 41

42. PEC I BLOCK performed by injection of LA in the plane between the pectoralis major and minor muscles blocks the lateral and medial pectoral nerves . Insert the needle in plane  After negative aspiration, inject 10 mL of LA 42

43. PEC I AND PEC II BLOCK 43

44. PEC I BLOCK 44

45. PEC II A lso called the modified Pecs I block A ims to block the pectoral nerves, intercostobrachial nerve, the intercostal nerves 3 through 6, and the long thoracic nerve. The Pecs I block is performed first as above, and A second injection Is given in the plane between the pectoralis minor muscle and the serratus anterior muscle 45

46. SERRATUS PLANE BLOCK a simple, effective and safe thoracic fascial plane block designed to anesthetize the thoracic intercostal nerves in order to provide analgesia for the lateral chest wall. Intercostal nerves from T2 to T9 are usually blocked . The SP block is a more posterior and lateral modification of the Pecs II block 46

47. SERRATUS PLANE BLOCK Place a linear probe in a sagittal plane under the mid-clavicle . Move the probe inferolaterally , counting ribs until the fifth rib is identified in the midaxillary line. After negative aspiration, inject 20 mL of LA in 5-mL increments, aspirating between injections 47

48. SERRATUS PLANE BLOCK 48

49. SERRATUS PLANE BLOCK 49

50. SERRATUS PLANE BLOCK 50

51. SERRATUS PLANE BLOCK Indications include breast surgery chronic pain after mastectomy, rib fractures thoracoscopy and thoracotomy . 51

52. Thoracic paravertebral block anesthetizes spinal nerves as they emerge from intervertebral foramina. TPVB results in somatic and sympathetic nerve block, 52

53. PVB Compared with epidural blockade, TPVB offers the possibility of unilateral block and is associated with a lower incidence of hypotension , urinary retention, respiratory problems, and postoperative nausea and vomiting (PONV) 53

54. Paramedian sagittal PVB 54

55. Transverse intercostal PVB 55

56. PVB , ANATOMIC APPROACH 56 At a depth of 2 to 4 cm, contact should be made with the transverse process; withdraw the needle slightly and redirect cranially or caudally to walk off the transverse process. The needle should be inserted 1 cm past the transverse process ;. After negative aspiration, inject 5 mL of LA.

57. PVB , ANATOMIC APPROACH 57

58. PVB , ANATOMIC APPROACH 58

59. 59

60. TPVB 60

61. TPVB Complications of the Paravertebral Blockade vessel puncture hematoma epidural spread (via the intervertebral foramina ) intrathecal spread (via dural cuff), and pneumothorax 61

62. INTERCOSTAL BLOCKS The intercostal space is contiguous with paravertebral space. Indications are very similar to traditional paravertebral nerve block . This block is easy to perform, though multiple blocks are often required. 62

63. INTERCOSTAL BLOCKS useful when the placement of traditional paravertebral blockade is contraindicated if the patient is anticoagulated , thrombocytopenic , or coagulopathic or if there is a question of transverse process fracture and unstable spine 63

64. ICB, Anatomic approach   Palpate the rib 6 to 8 cm from the midline. Insert a needle at the inferior border of the rib, oriented approximately 20 degrees cephalad , and advance 0.5 cm underneath the rib. After negative aspiration, inject 3 to 5 mL of local anesthetic (LA) . 64

65. ICB, Anatomic approach 65

66. ICB, US GUIDED Place the ultrasound transducer 4 cm from the spinous process in a sagittal plane After negative aspiration, inject 3 to 5 mL of LA; as the drug is injected, the pleura can be seen moving away. 66

67. INTERCOSTAL BLOCKS 67

68. Erector spinae block An easy-to-perform regional anaesthesia technique An alternative analgesic option to thoracic epidural analgesia and paravertebral blocks, Has a good safety profile with very few reported complications. 68

69. Erector spinae block uses ultrasound to deposit LA deep to the 3 columns of ES muscles ( iliocostalis , longissimus , spinalis ). run the length of the spine from the base of the skull to the medial crest of the sacrum . Overlying the ES complex are 2 further layers of muscle: the trapezius and rhomboid major. 69

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71. Erector spinae block 71

72. Erector spinae block 72

73. Erector spinae block Thoracic surgery Breast surgery Cardiac surgery Abdominal surgeries Lower limb surgery 73

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75. R eferences The New York School Of Regional Anesthesia HADZIC’S TEXTBOOK OF REGIONAL ANESTHESIA AND ACUTE PAIN MANAGEMENT SECOND EDITION ; 2017 Ultrasound for Interventional Pain Management; 2020 Atlas of sonoanatomy for regional anesthesia and pain medicine; 2018 Essentials of Regional Anesthesia; 2012 Ultrasound Guidance in Regional Anaesthesia ; Principles and Practical Implementation; SECOND EDITION ; 2010 WFSA Anesthesia tutorial of the week, QLB; 2020 Uptodate 2018 www.nysora.com/truncalblocks 75

76. Thank you! 76