Truncal Blocks Flashcards
Abdominal Blocks
Rectus sheath
Transversus abdominis plane
Quadratus lumborum
Rectus Sheath Block
Indications
Umbilical surgery (especially pediatric population) LA placement close to epigastric arteries & peritoneum Injections along lateral wall more efficacious
Rectus Sheath Block
Technique
Supine
High-frequency transducer
Place lateral to umbilicus in transverse orientation
Needle inserted in-plane
Inject up to 10mL LA bilaterally b/w rectus abdominis muscle & posterior fascial plane
TAP Block
Indications
Transversus abdominis plane
Alternative low to mid abdominal wall surgery when epidural and/or intrathecal opioids are contraindicated or refused
Block success depends on correctly identifying transversus abdominis plane
Provides somatic anesthesia to abdominal wall from T7-L1 (highly dependent on interfascial spread)
TAP Block
Technique
Supine
High-frequency transducer
Place b/w costal margin & iliac crest midaxillary line in transverse orientation
Slide transducer medially & laterally until identify 3 muscle layers (external oblique, internal oblique, & transversus abdominis)
Insert in-plane until needle penetrates fascia b/w internal oblique & transversus abdominis
Up to 20mL dilute LA per side
Erector Spinae Block
Fascial plane block deep to spinae muscle group
Sensory block w/ minimal hemodynamic effects
1° target dorsal rami
Somatic coverage when ventral rami blocked
Erector Spinae Anatomy
3 muscles provide support to the spinal column
- Spinalis
- Longissimus
- Iliocostalis
Erector Spinae
Technique
Parasagittal plane to determine optimal block level
Volume dependent block
Slide transducer laterally to identify transverse process
Insert needle cephalad to caudal
LA 20mL injection
Repeat on opposite side
Erector Spinae
Complications
Hematoma Infection at insertion site Tissue trauma Pneumothroax Hemodynamic instability LAST Lumbar plexus block Block failure
Quadratus Lumborum
Indications
Large bowel resection, appendectomy, cholecystectomy
C/S or total abdominal hysterectomy
Prostatectomy, renal transplant, nephrectomy, abdominoplasty, iliac crest bone graft
Exploratory laparotomy
Targets iliohypogastric, ilioinguinal, & subcostal nerves that cross psoas muscle & transversalis fascia
Quadratus Lumborum
Technique
Lateral decubitus position w/ hips & knees flexed
Curvilinear transducer
Place mid-axillary line cephalad to iliac crest
Slide transducer posteriorly & tilt caudad until “shamrock sign” visualized
L4 transverse process = stem
Trefoil - erector spinae, quadratus lumborum, & psoas major
PECs I & II Blocks
Indications
Analgesia follow breast surgery
Difficult to place prior to surgery
Place block under general
Alternatives to paravertebral block or thoracic epidural
Reduces pneumothorax & spinal risk
Pectoralis Nerve I
Anesthetize medial & lateral pectoral nerves
PECs II
PECs I extension
Provides additional blockade to upper intercostal nerves
PECs I
Technique
Supine w/ arm abducted
High-frequency transducer
Place in cephalad medial & caudad lateral orientation at coracoid process level
Identify costal margins, pectoris major, pectoris minor, & serratus muscles
Insert needle in-plane
Cephalad to caudad
Need tip penetrates fascia b/w pec major & minor
PECs II
Technique
ADDITION to PECs I
Slide transducer caudad to 2nd rib level & angle inferolaterally until pec minor & serratus anterior muscles are identified
Move further lateral to identify 3rd & 4th ribs
Inject LA b/w pec major & minor AND b/w pec minor & serratus anterior muscles
Thoracic Blocks
Intercostal
Paravertebral
Intercostal Block
Indications
Analgesia following breast, thoracic, & upper abdominal surgery
Rib fractures pain management
Targets intercostal nerves resulting in ipsilateral anesthesia at specific levels
Inadequate as surgical anesthetic
Difficult to perform above T7 bc scapula
Intercostal Technique
Sitting, lateral decubitus, or prone position w/ arms hanging freely
High-frequency transducer
Place in sagittal plane over costae approximately 6-8cm from midline
Identify 7th & 12th ribs to estimate relative ribs position
Needle insertion in-plane
Observe tip b/w internal & innermost intercostal muscles
Paravertebral Block
Indications
Periop analgesia thoracic, chest wall, or breast surgery
Rib fractures pain management
Targets paravertebral space
Paravertebral Space Anatomy
Wedge-shaped area contains spinal nerves & branches as well as sympathetic trunk
Medial = vertebral body Inferior = parietal pleural Anterior = costotransverse ligament
Paravertebral Technique
Lateral decubitus position
High-frequency transducer
Place in transverse orientation at desired level lateral to spinous process
Identify hyperechoic transverse process & ribs
Slide transducer caudad into intercostal space
Observe proximal & distal spread
Pleura pushed down = successful block
