Advanced Techniques (pt 2)

Question 1

What are the indications for a Transversus Abdominis Plane (TAP) Block?

Answer 1

Post-op Analgesia only (not anesthesia level block)
-laparotomy
-appendectomy
-laparoscopic surgery
-abdominoplasty
-cesarean delivery
-as an alternative to epidural anesthesia for operations on the abdominal wall

Question 2

What are the risks associated with a TAP Block?

Answer 2

-All common nerve block risks
-Puncture of the bowel
-Puncture of the liver

Question 3

What type of block is a TAP Block?

Answer 3

High volume Plane Block
-Not blocking individual nerves.
-Plane block: using plane to spread LA and find different nerves that go to abdominal wall
-Can place continuous catheters

Question 4

Describe the difference between the 2 Quadrant (Classic) and 4 Quadrant TAP Block

Answer 4

2 Quadrant: (Mid-Axillary)
-30ml total Volume per side
-10ml Exparel
-10ml 0.25% Bupiv
-10ml NS

4 Quadrant: (Mid-Axillary and Subcostal)
-20 ml total volume per block
-5ml Exparel
-5ml 0.25% Bupiv
-10ml NS

Question 5

What is the relevant anatomy for a TAP Block?

Answer 5

-External Oblique
-Internal Oblique
-TAP plane: Must be between IO/TA
-Transversus Abdominis

Triangle of Petit:
-Iliac crest
-Rib cage
-Latissimus Dorsi
-Ext Oblique

Question 6

How do you identify the Mid-Axillary (Classic) approach to a TAP Block?

Answer 6

-T10 – L1 coverage
-For incisions below umbilicus (Belly button to pubis incisions)
-right around umbilicus
-Costal Margin to iliac crest (small area in most people)
-On US: Identify line between IO and TA. TA muscle is pushed down by LA.

Question 7

What coverage is provided by the Subcostal approach to a TAP Block?

Answer 7

Up to T7 coverage (Below Xiphoid) seen.
-For incisions above umbilicus.

Question 8

What are the indications for a Rectus Sheath block?

Answer 8

-Umbilical surgery
-Trocar sites
-Midline incisions
-Rescue for breakthrough
abdominal wall pain
-Very high incisions (sub-xiphoid)
-catches midline incisions well

Question 9

What are the risks associated with a Rectus Sheath block?

Answer 9

-Normal nerve block risks
-Bowel perforation

Question 10

How do you perform a Rectus Sheath block?

Answer 10

-Injecting local within muscle near where nerve distribution occurs will cause sufficient block
-Trying to pierce deep RA fascia can frequently lead to peritoneal puncture
-Transversalis fascia is very thin below RA
-Goal is to drive LA up and underneath the rectus muscle.
-Identify RA muscle and Linea Alba on US.

Question 11

What are the indications and risks for the Ilioinguinal/Iliohypogastric Block?

Answer 11

Used for Inguinal Hernias

Risks:
-Normal nerve block risks
-Peroneal pierced

Question 12

How do you identify the Ilioinguinal/Iliohypogastric Block on US?

Answer 12

Looking for same muscles as TAP blocks, except more medial and inferior to the location where they run.
-Iliac crest (ASIS) - coming off medial and slightly superior to ASIS
-Find muscles more posterior/superior than TAP. EO, IO, and TA muscles
-Separate planes between IO and TA muscles (that’s where ilio nerves run)

Question 13

What are the indications for the Suprascapular Nerve Block?

Answer 13

Provides analgesia to the shoulder without risk of Phrenic Nerve involvement.
-Any shoulder procedure causing posterior pain
-Shoulder procedures in which Interscalene Block is contraindicated (COPD, Lung Ca, etc)
-PACU rescue technique for failed Interscalene Block in which patient complains of posterior shoulder pain (Suprascapular nerve can come off early off of C5 or C4 nerve root and can be missed in interscalene approach. Patient may still complain of pain after interscalene block)

Used in combo with Axillary blocks.

Question 14

How do you identify the Suprascapular Nerve?

Answer 14

-Nerve runs with suprascapular Artery
-Top border edge of scapula
-Looking for supraspinous muscle (spSM)
-Suprascapular notch is found in middle of scapula.
-Look for artery
-At notch, nerve is located below transverse scapular ligament. This must be pierced for block to work.
-Pierce ligament and inject LA around nerve

Question 15

What are the indications and risks with an Axillary Nerve block?

Answer 15

Used for Anterior Shoulder pain.

Risks:
-Normal nerve block risks
-No risk of phrenic nerve involvement

Question 16

Where is the Axillary Nerve located?

Answer 16

-Axillary nerve is located in the quadrangular space (Formed by Teres Minor and the medial & lateral heads of the Tricep)
-Feel depression/space at 2 heads of tricep.
-Looking for artery (Circumflex humoral artery).
-Right with artery is axillary nerve.
-Inject LA around nerve.

Question 17

What does the Lateral Pectoral Nerve innervate?

Answer 17

Derived from C5-7
-runs between pectoralis major and minor to supply sensory to pectoralis major m.

Question 18

What does the Medial Pectoral Nerve innervate?

Answer 18

Derived from C8-T1
-runs deep to pectoral minor to supply sensory to pectoralis major and minor muscles.

Question 19

What does the Lateral T2-T6 Spinal Nerves innervate?

Answer 19

Pierces the intercostal muscle/serratus anterior in the mid axillary line to give off anterior and
posterior cutaneous branches.

Question 20

What does the Anterior T2-T6 Spinal Nerves innervate?

Answer 20

Pierces the intercostal muscles and serratus anterior anteriorly to supply the medial breast.

Question 21

What does the Long Thoracic Nerve innervate?

Answer 21

Derived from C5-7
-runs on outer surface of serratus anterior to the axilla where it supplies serratus anterior.

Question 22

What does the Thoracodorsal Nerve innervate?

Answer 22

Derived from C6-8 via the posterior cord
-runs deep to the posterior axillary wall to supply the latissimus dorsi.

Question 23

What are the indications for the PEC1 Block (original)?

Answer 23

Blocking Lat/Med Pectoral nerves.
-Breast tissue expanders
-Reconstruction or Augmentation sub-muscular prosthesis

Doesn’t help with pressure created against chest wall from augmentation.

Question 24

What are the indications for the PEC2 Block (Modified)?

Answer 24

Blocks:
-Med/Lat Pectoral Nerves
-T2-4 spinal nerves
-Long thoracic nerve

Used for:
-More extensive tumor excision
-Node dissections (Axillary node)
-Nipple reconstruction

Question 25

What does the Serratus Plane Block do and what is it used for?

Answer 25

-Blocks thoracodorsal nerve
-Used for Latissimus Dorsi Flap reconstruction

Question 26

How do you perform the PEC 1 Block?

Answer 26

-Place the probe just below the clavicle. First rib underneath clavicle is Rib 2.
-Slide probe down on the chest wall to above the 3rd rib. Find confluence area where you have Pec Major/Minor touching.
-Pop needle through into Pec minor, pull back into confluence
-Inject 10 ccs to separate 2 muscles with LA.
-Plane block. Don’t have to find specific nerves.
-Pectoral artery runs with nerves in this area (be cautious).

Question 27

How do you perform a PEC 2 Block?

Answer 27

-Identify 3rd/4th rib on chest wall with Pec Minor
-Slide prob laterally until Serratus Anterior is noted above ribs 2-5
-Touch rib itself with needle.
-Slowly withdraw back, inject 20 mLjust above Serratus Anterior muscle to get a better spread (Serratus Anterior muscles are paper thin, especially towards anterior portion of ribs)
-Inject larger volume to spread all the way around side of chest to get spinal nerves as they come around (2, 3, 4, maybe SN 5)
-Withdraw to fascia between Pec Major/Minor
-Inject 10 mL LA (perform PEC 1 block on your way back through Pec Minor into Pec Major)

Question 28

Describe the Serratus Plane Block.

Answer 28

-Similar to Pec 2, except sliding probe all the way to Mid-axillary line at 5th rib
-Between Latissimus Dorsi and Serratus Anterior
-larger volume injected (40 mL of LA)
-Gets thoracodorsal nerve (side of chest wall)
-Gets some spinal nerves
-Innervation to Lat Dorsi