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Pain Exam 3 > Module 9: Part 2 > Flashcards

Module 9: Part 2 Flashcards

18-34

1
Q

Paravertebral Blocks
Positioning
&
Landmarks

A

Seated Position
Vertebral column flexed

Landmarks depend on block:
Thoracic: Count from the prominent C7
Lumbar: iliac crests as reference

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2
Q

Paravertebral Block
Technique
(Marking & Needle Insertion)

A

Marking: Measure 2.5 cm laterally from the midpoint of the superior aspect of each spinous process

Needle:

  • Thoracic Nerves: insert laterally to the spinous process above it
  • Lumbar Nerves: Similar with respect to vertebral landmarks
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3
Q

Which needle to use for Paravertebral Block

A

20G Tuohy

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4
Q

Paravertebral Block:
Landmark based technique

A
  1. Insert 20G Tuohy Perpendicular to skin
  2. Advance to transverse process
  3. Redirection: Withdraw slightly and redirect caudad by 1 cm
  4. Feel pop/LOR when passing costotransverse ligament
  5. inject 5ml LA @ each level

Alternative: use LOR syringe or nerve stimulator

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5
Q

In a paravertebral block, a “pop” or LOR indicates passage thru ________

A

costotransverse ligament

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6
Q

In a paravertebral block, there is risk of _______, due to estimation of transverse process depth

A

Pneumothorax

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7
Q

Paravertebral Block:
Ultrasound-Guided Technique

A
  • Large curvilinear array Transducer
  • Parasagittal Plane: Caudad-to-cephalad
  • Transverse Plane: Lateral-to-medial
  • Structures: ID transverse process, head of the rib, costotransverse ligament, & pleura
  • Visualize needle in-plane passing thru costotransverse ligament
  • Pleura Displacement: Observe for downward displacement upon local anesthetic injection
  • 5-10 mL LA @ each level
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8
Q

Paravertebral Block
Which landmarks are passed thru/identified in both Landmark & U/S technique?

A

transverse process & costotransverse ligament

U/S: also identify head of the rib & pleura

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9
Q

Parasagittal Plane

A

Caudad-to-cephalad direction

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10
Q

Transverse Plane

A

Lateral-to-medial direction

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11
Q

U/S Guided Paravertebral Block:
Observe for ____ displacement of the ____ upon local anesthetic injection

A

downward
pleura

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12
Q

Paravertebral Blocks
Provides effective anesthesia or analgesia for…

A

various thoracic and abdominal procedures

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13
Q

Paravertebral Blocks
Major Complications

A
  • Thoracic: Risk pneumothorax
  • Lumbar: Risk to retroperitoneal structures
  • Systemic Effects: hypoTN & bradycardia d/t sympathectomy
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14
Q

Paravertebral Blocks
Ultrasound vs. Landmark-Based

A

Ultrasound reduces risk and enhances accuracy of needle placement

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15
Q

Long-Acting Anesthetics for Paravertebral blocks have a duration of…

A

up to 24 hours

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16
Q

Erector Spinae Plane Block

A
  • in 2016 for chest wall neuropathic pain
  • possible moA: LA may diffuse to paravertebral space
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17
Q

Erector Spinae Plane Block
-use
-popularity

A
  • Emerging Alternative
  • thoracoabdominal wall Sx & rib fractures
  • Increased use; simple & effective
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18
Q

Erector Spinae Plane Block
vs
Paravertebral Block

A
  • ESP block analgesia< paravertebral block
  • ESP May be preferred for non-experts or if limited resources (simpler)
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19
Q

T/F
Pneumothorax is a potential complication of Erector Spinae Plane Block.

A

True

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20
Q

Anatomy of ESP Block

ESP: Erector Spinae Plane

A
  • Muscle Group: Iliocostalis, longissimus, and spinalis
  • Function: Straighten and rotate the axial skeleton

Location:

  • High Thoracic: Deep to trapezius and rhomboid muscles
  • Low Thoracic: Deep to latissimus dorsi muscle
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21
Q

Erector Spinae
high vs low
thoracic region

A
  • High Thoracic Region: Deep to trapezius and rhomboid muscles
  • Low Thoracic Region: Deep to latissimus dorsi muscle
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22
Q

Erector Spinae Block
Deposit local anesthetic in the….

A

plane deep to the erector spinae muscles, between the muscle and transverse process

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23
Q

Erector Spinae Block
Ultrasound Procedure

A
  1. linear or large curvilinear probe
  2. placed parasagittally on the back
  3. Identify trapezius, rhomboid, and erector spinae muscles above the transverse processes
  4. Insert needle caudad or cephalad to the probe, directed towards the transverse process
  5. In-plane technique
  6. 30–50 mL LA covers multiple dermatomes
  7. Ensure visualization of spread deep to the erector spinae over several spinal levels
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24
Q

Inject how many mL for ESP Block

A

30-50

25
Q

Pecs I/II Block is an alternative to

A

Paravertebral Block

Used for chest wall surgery

26
Q

Pecs I/II Block is used for…

A

chest wall surgery

27
Q

Pecs I Block
&
Pecs II Block

A

I:

  • First Described
  • Medial & lateral pectoral nerves
  • Inject into plane between pectoralis major & minor

II:

  • Modified Technique; covers more nerves
  • Intercostobrachial nerve, 3rd-6th intercostals, & long thoracic nerves
  • Inject between pectoralis minor & serratus anterior muscles
28
Q

T/F
For a Pecs I block, inject the LA between the pectoralis minor and serratus anterior muscles.

A

False
Pecs II

Pecs I: inject into plane between the pectoralis major and minor muscles

29
Q

Pecs I Block
Muscles Involved

A

Pectoralis Major
Pectoralis Minor
Serratus Anterior

30
Q

Pecs I vs II
Injection site

A
  • Pecs I: Plane between the pectoralis major and minor at the level of the third rib
  • Pecs II: Additional injection between the pectoralis minor and serratus anterior
31
Q

Pecs I Injection Technique

A
  1. High-frequency linear transducer at mid-clavicular line with oblique orientation to the parasagittal plane
  2. Identify pectoralis major, pectoralis minor, & axillary vessels
  3. Needle: Lateral to the transducer, advanced in-plane to target the interfascial plane
  4. Inject 10-15 mL in the plane between pectoralis major and minor
32
Q

Pecs II Block Procedure

A
  1. After Pecs I injection, advance needle through the pectoralis minor
  2. Inject between the pectoralis minor & serratus anterior muscles
  3. Additional 10-15 mL LA
  4. Ensure spread between the pectoralis minor & serratus anterior
33
Q

Pecs II Block
Benefits

A

broader coverage of chest wall and upper abdominal wall nerves

34
Q

Which block is a modification of Pectoralis Nerve Block & targets a different anatomical plane?

A

Serratus Anterior Plane Block

35
Q

Serratus Anterior Plane Block
Purpose

A

Anesthetize the hemithorax via lateral cutaneous branches of the intercostal nerves

36
Q

Serratus Anterior Plane Block
Superficial Alternative

A

Similar to ESP and Pecs blocks

37
Q

Further studies are needed for the comparison of Serratus Anterior Plane Blocks to…(2)

A

paravertebral & other chest wall blocks

38
Q

Serratus Anterior Plane Block
Injection Plane

“SAP” Block

A

Between the serratus anterior and latissimus dorsi muscles

39
Q

T/F
The optimal position for SAP Block is Prone Position with the contralateral shoulder adducted, arm resting behind the head.

A

False
Prone Position: Ipsilateral shoulder abducted, arm resting behind the head

40
Q

SAP block
Ultrasound Procedure

A

Probe Placement:
1. Sagittal orientation on the chest
2. Count ribs: Down to 4th or 5th
3. Final Position: Move probe laterally to the midaxillary line, achieving a nearly coronal orientation
4. Muscle Identification5
5. Superficial Muscle: Latissimus dorsi
6. Deep Muscle: Serratus anterior
7. Ribs: Maintain visualization of ribs in cross-section
8. Insert needle on the superomedial side of the probe
9. Inferolaterally toward the plane between latissimus dorsi and serratus anterior
10. LA 20-30 mL
11. ensure effective spread: Hydrodissection of the plane

Target depth should be no more than 1 to 3 cm

41
Q

Target depth for SAP block is…..
This is done to…..

A
  • no more than 1 to 3 cm
  • prevent pleural injury
42
Q

SAP Block
How to avoid Complications

A

Careful to avoid deep insertion to prevent pleural injury

no more than 1 to 3 cm deep

43
Q

Transversus Abdominis Plane (TAP) Block
Uses

A
  • Surgical Anesthesia: minor, superficial procedures of lower abdominal wall
  • Postop Analgesia: surgery below umbilicus
  • Inguinal Hernia Surgery: May require additional IV or local for peritoneal traction
44
Q

T/F
A TAP block can act as the sole anesthetic for Inguinal Hernia Surgery.

A

False
May require additional intravenous or local anesthesia for peritoneal traction

45
Q

TAP Block
Potential Complications

A
  • Peritoneal Violation: Risk of bowel perforation
  • Ultrasound Guidance: Essential to minimize complications
46
Q

T/F
A potential complication of a TAP block includes bowel perforation. Ultrasound guidance is essential to minimize risk.

A

True

47
Q

TAP Block
Anatomical Targets/Nerves Blocked

A
  • Subcostal Nerve
  • Ilioinguinal Nerve
  • Iliohypogastric Nerve
  • Anesthesia Area: Ipsilateral lower abdomen below the umbilicus
48
Q

T/F
A TAP block provides anesthesia to the contralateral lower abdomen above the umbilicus.

A

False
Ipsilateral lower abdomen below the umbilicus

49
Q

TAP Block
needle placement & positioning

A
  • Target Plane: Between the internal oblique and transversus abdominis muscles
  • Ideal Position: Lateral decubitus
  • Alternative: Supine if lateral decubitus is not feasible
50
Q

Which nerves are blocked from a TAP block?

A
  • Subcostal Nerve
  • Ilioinguinal Nerve
  • Iliohypogastric Nerve
51
Q

TAP Block
Ultrasound Procedure

A
  1. Transducer Parallel to the inguinal ligament
  2. Muscle Layers Identified: External oblique, internal oblique, and transversus abdominis
  3. Needle: In-plane, lateral to the transducer
  4. Tactile Feedback: Noting fascial planes and the hyperechoic effacement
  5. 30 mL LA
  6. Visualization: Ensure an elliptical separation between the fascial layers
52
Q

What should be visualized on TAP block to verify correct spread?

A

elliptical separation between the fascial layers

53
Q

How much ml LA for TAP block?

A

30

54
Q

TAP Block
Muscle Layers Identified

A

External oblique
internal oblique
transversus abdominis

55
Q

TAP Block
Insert the needle in-plane, _____ to the transducer.

A

lateral

56
Q

In which block do we insert needle on the superomedial side of the probe?

A

Serratus Anterior Plane (SAP) Block

57
Q

Hydrodissection of the plane to ensure effective spread should be visualized with which block?

A

Serratus Anterior Plane (SAP) Block

58
Q

SAP Block
muscles identified

A
  • Superficial Muscle: Latissimus dorsi
  • Deep Muscle: Serratus anterior
  • Ribs: Maintain visualization of ribs in cross-section
59
Q

TAP Block Tactile Feedback:
Noting fascial planes and the (hypo/hyper)echoic effacement.

A

hyperechoic

Pain Exam 3 (16 decks)

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