Mod IV: Transversus Abdominis Plane (TAP) - Rectus Sheath - Ilioinguinal/Iliohypogastric - Suprascapular - Axillary - Chest Wall bloks

Question 1

_{Transversus Abdominis Plane (TAP) bloks}

—Indications, post-op analgesia for:

Answer 1

Laparotomy

Appendectomy

Laparoscopic surgery

Abdominoplasty

Cesarean delivery

As an alternative to epidural anesthesia for operations on the abdominal wall

Question 2

_{Transversus Abdominis Plane (TAP) bloks}

—Risks:

Answer 2

All common nerve block risks

Puncture of the bowel

Puncture of the liver

Question 3

_{Transversus Abdominis Plane (TAP) bloks}

—High Volume plane block

Answer 3

True

Question 4

_{Transversus Abdominis Plane (TAP) bloks}

—2 quadrant classics:

Answer 4

30ml total Volume per side

10ml Exparel

10ml 0.25% Bupiv

10ml NS

Question 5

_{Transversus Abdominis Plane (TAP) bloks}

—4 quadrant:

Answer 5

20 ml total volume per block

5ml Exparel

5ml 0.25% Bupiv

10ml NS

Question 6

_{Transversus Abdominis Plane (TAP) bloks}

—Continuous catheters.

Answer 6

True

Question 7

_{Transversus Abdominis Plane (TAP)}

Anatomy:

Answer 7

—External Oblique

—Internal Oblique

—TAP plane

^{Must be between IO/TA}

—Transversus Abdiminis

—Triangle of Petit

^{Iliac crest - Rib cage - Latisimus Dorsi - Ext Oblique}

Question 8

_{Transversus Abdominis Plane (TAP)}

Anatomy:

Answer 8

TAP anatomy

Question 9

_{Transversus Abdominis Plane (TAP) bloks}

—Midaxillary (Classic):

Answer 9

T10 – L1 coverage

For incisions below umbilicus

Question 10

_{Transversus Abdominis Plane (TAP) bloks}

—Subcostal:

Answer 10

Up to T7 coverage seen

For incisions above umbilicus

Question 11

_{Transversus Abdominis Plane (TAP) bloks}

—All 4 quadrants can be blocked for incisions above and below umbilicus.

Answer 11

True

Question 12

Transversus Abdominis Plane (TAP)

Answer 12

Transversus Abdominis Plane (TAP)

Question 13

Transversus Abdominis Plane (TAP)

Answer 13

Transversus Abdominis Plane (TAP)

Question 14

_{Rectus Sheath Block}

—Indications:

Answer 14

Umbilical surgery

Trocar sites

Midline incisions

Rescue for breakthrough

Abdominal wall pain

Question 15

_{Rectus Sheath Block}

—Risks:

Answer 15

Normal nerve block risks

Bowel perforation

Question 16

_{Rectus Sheath Block}

—Injecting local within muscle near where nerve distribution occurs will cause sufficient block.

Answer 16

True

Question 17

_{Rectus Sheath Block}

—Trying to pierce deep RA facia can frequently leed to:

Answer 17

Peritoneal puncture

Transversalis facia is very thin below RA

Question 18

Rectus Sheath Block

Answer 18

Rectus Sheath Block

Question 19

_{Ilioinguinal/Iliohypogastric Block}

—Indications:

Answer 19

Inguinal Hernias

Question 20

_{Ilioinguinal/Iliohypogastric Block}

Risks:

Answer 20

Normal nerve block risks

Peroneal pierced

Question 21

_{Ilioinguinal/Iliohypogastric Block}

Can be performed bilaterally

Answer 21

True

Question 22

Ilioinguinal/Iliohypogastric Block

Answer 22

Ilioinguinal/Iliohypogastric Block

Question 23

_{Suprascapular Nerve Block}

—Indications:

Answer 23

Any shoulder procedure causing posterior pain

Shoulder procedures in which Interscalene Block is contraindicated

PACU rescue technique for failed Interscalene Block in which patient complains of posterior shoulder pain

Question 24

_{Suprascapular Nerve Block}

—Nerve runs with:

Answer 24

suprascapular Artery

Question 25

_{Suprascapular Nerve Block}

—At notch nerve is located below which structure that must be pierced for block to work?

Answer 25

Transverse scapular ligament

Question 26

Suprascapular Nerve Block

Answer 26

Suprascapular Nerve Block

Question 27

_{Axillary Nerve Block}

—Indications:

Answer 27

Anterior shoulder pain

Question 28

_{Axillary Nerve Block}

—Risks:

Answer 28

Normal nerve block risks

No risk of phrenic nerve involvement

Question 29

_{Axillary Nerve Block}

Nerve located in quadrangular space formed by:

Answer 29

—Teres minor and medial and lateral heads of tricept

Question 30

Axillary Nerve Block

Answer 30

Axillary Nerve Block

Question 31

Axillary Nerve Block

Answer 31

Axillary Nerve Block

Question 32

Axillary Nerve Block

Answer 32

Axillary Nerve Block

Question 33

_{Chest Wall Blocks - PEC1 and PEC2}

Neural innervation of Anterior Chest

Answer 33

—Pectoral Nerves

—T2-T6 Spinal Nerves

—Long Thoracic and Thoracodorsal Nerve

Question 34

_{Neural innervation of Anterior Chest}

—Pectoral Nerves:

Answer 34

—Lateral pectoral nerve

C5-7, runs between pectoralis major and minor to supply sensory to pectorals major

—Medial pectoral nerve

C8-T1, runs deep to pectoral minor to supply sensory to pectoralis major and minor

Question 35

_{Neural innervation of Anterior Chest}

—T2-T6 Spinal Nerves:

Answer 35

—Lateral

Pierces the intercostal muscle/serratus anterior in the mid axillary line to give off anterior and

—Posterior cutaneous branches

—Anterior

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

Question 36

_{Neural innervation of Anterior Chest}

—Long Thoracic and Thoracodorsal Nerve:

Answer 36

Long Thoracic Nerve

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

—Thoracodorsal Nerve

C6-8 via the posterior cord, runs deep to the posterior axillary wall to supply the latissimus dorsi

Question 37

_{Chest Wall Blocks - PEC1 and PEC2}

Indications for Chest wall blocks - —PEC1 (original):

Answer 37

Blocking Lat/Med Pectoral nerves

Breast tissue expanders

Reconstruction or Augmentation sub-muscular prosteses

Question 38

_{Chest Wall Blocks - PEC1 and PEC2}

Indications for Chest wall blocks - —PEC2 (modified):

Answer 38

Blocks:

^{Med/Lat Pectoral Nerves}

^{T2-4 spinal nerves}

^{Long thoracic nerve}

More extensive tumor excision

Node dicections

Nipple reconstruction

Question 39

_{Chest Wall Blocks - PEC1 and PEC2}

Indications for Chest wall blocks - —Serratus Plane Block:

Answer 39

Blocks thoracodorsal nerve

Latissimus Dorsi Flap reconstruction

Question 40

_{Chest Wall Blocks}

PEC1 Block:

Answer 40

—Probe placed on chest wall above 3rd rib

—Visualize pec major and Minor

—10ml of LA infiltrated between major/minor

Question 41

_{Chest Wall Blocks}

PEC2 Block:

Answer 41

—Probe placed on chest wall

—4th rib, Pec minor identified

—Slide probe lateral until seratus anterior noted above ribs 2-5

—Needle touching 4th rib

—Inject 20ml of LA

—Withdraw to fascia b/t Pec major/minor

—Inject 10ml of LA

Question 42

Serratus Plane Block:

Answer 42

—MidAxillary line at the 5th rib

—b/t Latissimus Dorsi and Serratus Anterior

—40ml of LA

Question 43

References:

Answer 43

—www.cambridgeorthopaedics.com/

—www.blockjocks.com/

—www.ncbi.nlm.nih.gov/pubmed/

—www.nysora.com/

—www.neuraxiom.com/

—www.usra.ca

—www.ultrasoundblock.com