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Regional Anesthesia > Truncal Blocks > Flashcards

Truncal Blocks Flashcards

1
Q

What is the goal of truncal blocks?

A

Postoperative pain control. Thus, use 1/4 or 1/8% so we can use more volume to ensure greater spread

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2
Q

**What is the indication for a rectus sheath block?

A

Umbilical hernia

T8 - T12

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3
Q

What are your worries w/rectus sheath block?

A

Epigastric arteries

Peritoneum

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4
Q

What is the anatomy with a rectus sheath block?

A
  1. Ventral rami leave vertebral foramen in the neck
  2. Forms brachial plexus
  3. Thoracic region, ventral rami become subcostal nerves and intercostal nerves
  4. As they leave the costal margin they run in a plane of transverse abdominal and posterior fascia
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5
Q

What nerves innervate the abdominal wall

A

T6 - T10/L1

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6
Q

How much LA w/rectus sheath block?

A

10 mL between rectus abdominis and posterior fascia plane

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7
Q

**What are the indications for a TAP block?

A

alternative for low to mid abdominal wall surgery when an epidural and/or intrathecal opioids are contraindicated or refused

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8
Q

TAP block provides somatic anesthesia to….

A

abdominal wall T7 - L1

highly dependent on interfascial spread

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9
Q

T6 - L1

A

full abdomen

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10
Q

T9 - L1

A

more lateral abdomen

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11
Q

TAP Block technique

A
  1. Transducer btw costal margin + iliac crest midaxillary in transverse orientation
  2. Slide transducer medially + laterally until the three muscle layers (external oblique, internal oblique, transverse abdominis) are identified
  3. Needle inserted to penetrate fascia btw internal oblique and transversus abdominis
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12
Q

How much LA per side for TAP block?

A

20 mL

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13
Q

Subcostal TAP block indicated for…

A

any procedures above umbi

somatic, not visceral coverage

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14
Q

Erector Spinae block indicated for:

A

back surgery

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15
Q

Erector Spinae muscles include:

A

spinalis
longisimus
iliocostalis

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16
Q

ESB risks

A

retroperitoneum
kidneys
pleura

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17
Q

What does the ESB target?

A

dorsal rami and potentially ventral rami

18
Q

What type of block is ESB

A 
fascial plane block deep to the spinae muscle group
sensory block (somatic if you hit ventral rami)
19
Q

Technique for ESB

A
  1. Parasaggital plane to determine optimal block level
  2. Volume dependent block
  3. Slide transducer laterally to identify transverse process
  4. Needle cephalad to caudal
  5. Incremental injections of 5 mL for a total of 20 mL
  6. Repeat on opposite side
20
Q

What is the superior border of QL muscle

A

12th rib L1 - L5

21
Q

What is the inferior border of QL muiscle

A

posterior border of ileac crest

22
Q

ESB complications

A 
hematoma
infection
tissue trauma/pneumo
HD instability
LAST
LP block
23
Q

Quadratus Lumborum Block Indications**

A 
large bowel resections, appy, chole
c-sx
total abdominal hysterectomy
prostatectomy
renal tx, nephrectomy
abdominoplasty, iliac crest bone graft
ex-lap
24
Q

What does the QL block target?

A

Iliohypogastric
Ilioinguinal
Subcostal n that cross psoas muscle + transverse fascia
Lateral femoral cutaneous

25
Q

TAP vs QL block

A

TAP - somatic coverageT7 -L1
—>good for lower abdominal wall surgery
QL B- iliohypo, ilioinguinal, subcostal, lat femoral cutaneous

26
Q

QL 3 Technique

A
  1. Patient lateral decubitus w/hips + knees flexed
  2. Curvilinear transducer placed mid-axillary line cephalad to iliac crest
  3. Slide transducer posteriorly, tilt caudad until “shamrock sign” is visualized
  4. LA btw QL and psoas
27
Q

What is the “shamrock sign”

A

L4 transverse process = stem

Erector spinae, QL, Psoas major = trefoil

28
Q

Where does the lower pole of kidney lie

A

anterior to QL muscle and can reach L4 w/deep inspiration

29
Q

PEC I & II indications

A

analgesia following breast surgery

great alternative to paravertebral or thoracic epidural, thus decreases risk of pneumo/spinal

30
Q

What nerves does PECS 1 block

A

medial and lateral pectoral nerves

31
Q

PECS 2

A

extension of PEC I and provides additional blockade of upper intercostal nerves

32
Q

PECS 1 technique

A
  1. supine + abducted arm
  2. cephalad medial and caudad lateral orientation @ caracoid process
  3. costal margines, PM, Pmi, serratus anterior muscles identified
  4. Cephalad to caudad insertion until tip penetrates fascia btw PM and Pmi
33
Q

PECS 2

A

already did pecs I

  1. slide transducer caudad to 2nd rib and angle inferolaterally until Pmi, serratus anterior muscles are identified
  2. further lateral to identify 3 + 4 ribs
  3. LA injected between PmI and serratus anterior
34
Q

if you block ventral rami of cervical vertebrae what do you block

A

phrenic n

35
Q

intercostal vs paravertebral

A

intercostal is one level and paravertebral is the epidural space, thus bilateral

paravertebral targets the paravertebral space (PVS) which contains spinal nerves, branches, symp. trunk

36
Q

paravertebral indications

A

periop analgesia for thoracic, chest wall or breasts

rib fx pain management

37
Q

PVS anatomy

A

wedge-shaped area formed medially by vertebral body
inferiorly by parietal pleura
anteriorly by costotransverse ligament

38
Q

Paravertebral technique

A

patient in lateral decubitus

  1. transverse oreintation at desired level lateral to sp. process
  2. once TP and ribs are identified, slide transducer caudad into the intercostal space
39
Q

Intercostal Nerve Block indications

A

analgesia following breast, thoracic, upper abd sx

pain management of rib fx

40
Q

INB targets …

A

intercostal nerves resulting in ipsilateral anesthesia at specific levels

single dermatome coverage!!

41
Q

INB technique

A

patient sitting, lateral decub, prone

  1. sagittal plane 6 - 8 cm from midline btw ribs
  2. 7 - 12 ribs
  3. in plane, tip btw internal and innermost ic muscles
42
Q

INB pearls

A

hard to perform above t7 d/t scapula

inadequate as a surgical anesthetic

Regional Anesthesia (5 decks)

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