Truncal Blocks Flashcards
What is the goal of truncal blocks?
Postoperative pain control. Thus, use 1/4 or 1/8% so we can use more volume to ensure greater spread
**What is the indication for a rectus sheath block?
Umbilical hernia
T8 - T12
What are your worries w/rectus sheath block?
Epigastric arteries
Peritoneum
What is the anatomy with a rectus sheath block?
- Ventral rami leave vertebral foramen in the neck
- Forms brachial plexus
- Thoracic region, ventral rami become subcostal nerves and intercostal nerves
- As they leave the costal margin they run in a plane of transverse abdominal and posterior fascia
What nerves innervate the abdominal wall
T6 - T10/L1
How much LA w/rectus sheath block?
10 mL between rectus abdominis and posterior fascia plane
**What are the indications for a TAP block?
alternative for low to mid abdominal wall surgery when an epidural and/or intrathecal opioids are contraindicated or refused
TAP block provides somatic anesthesia to….
abdominal wall T7 - L1
highly dependent on interfascial spread
T6 - L1
full abdomen
T9 - L1
more lateral abdomen
TAP Block technique
- Transducer btw costal margin + iliac crest midaxillary in transverse orientation
- Slide transducer medially + laterally until the three muscle layers (external oblique, internal oblique, transverse abdominis) are identified
- Needle inserted to penetrate fascia btw internal oblique and transversus abdominis
How much LA per side for TAP block?
20 mL
Subcostal TAP block indicated for…
any procedures above umbi
somatic, not visceral coverage
Erector Spinae block indicated for:
back surgery
Erector Spinae muscles include:
spinalis
longisimus
iliocostalis
ESB risks
retroperitoneum
kidneys
pleura
What does the ESB target?
dorsal rami and potentially ventral rami
What type of block is ESB
fascial plane block deep to the spinae muscle group sensory block (somatic if you hit ventral rami)
Technique for ESB
- Parasaggital plane to determine optimal block level
- Volume dependent block
- Slide transducer laterally to identify transverse process
- Needle cephalad to caudal
- Incremental injections of 5 mL for a total of 20 mL
- Repeat on opposite side
What is the superior border of QL muscle
12th rib L1 - L5
What is the inferior border of QL muiscle
posterior border of ileac crest
ESB complications
hematoma infection tissue trauma/pneumo HD instability LAST LP block
Quadratus Lumborum Block Indications**
large bowel resections, appy, chole c-sx total abdominal hysterectomy prostatectomy renal tx, nephrectomy abdominoplasty, iliac crest bone graft ex-lap
What does the QL block target?
Iliohypogastric
Ilioinguinal
Subcostal n that cross psoas muscle + transverse fascia
Lateral femoral cutaneous
TAP vs QL block
TAP - somatic coverageT7 -L1
—>good for lower abdominal wall surgery
QL B- iliohypo, ilioinguinal, subcostal, lat femoral cutaneous
QL 3 Technique
- Patient lateral decubitus w/hips + knees flexed
- Curvilinear transducer placed mid-axillary line cephalad to iliac crest
- Slide transducer posteriorly, tilt caudad until “shamrock sign” is visualized
- LA btw QL and psoas
What is the “shamrock sign”
L4 transverse process = stem
Erector spinae, QL, Psoas major = trefoil
Where does the lower pole of kidney lie
anterior to QL muscle and can reach L4 w/deep inspiration
PEC I & II indications
analgesia following breast surgery
great alternative to paravertebral or thoracic epidural, thus decreases risk of pneumo/spinal
What nerves does PECS 1 block
medial and lateral pectoral nerves
PECS 2
extension of PEC I and provides additional blockade of upper intercostal nerves
PECS 1 technique
- supine + abducted arm
- cephalad medial and caudad lateral orientation @ caracoid process
- costal margines, PM, Pmi, serratus anterior muscles identified
- Cephalad to caudad insertion until tip penetrates fascia btw PM and Pmi
PECS 2
already did pecs I
- slide transducer caudad to 2nd rib and angle inferolaterally until Pmi, serratus anterior muscles are identified
- further lateral to identify 3 + 4 ribs
- LA injected between PmI and serratus anterior
if you block ventral rami of cervical vertebrae what do you block
phrenic n
intercostal vs paravertebral
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
paravertebral indications
periop analgesia for thoracic, chest wall or breasts
rib fx pain management
PVS anatomy
wedge-shaped area formed medially by vertebral body
inferiorly by parietal pleura
anteriorly by costotransverse ligament
Paravertebral technique
patient in lateral decubitus
- transverse oreintation at desired level lateral to sp. process
- once TP and ribs are identified, slide transducer caudad into the intercostal space
Intercostal Nerve Block indications
analgesia following breast, thoracic, upper abd sx
pain management of rib fx
INB targets …
intercostal nerves resulting in ipsilateral anesthesia at specific levels
single dermatome coverage!!
INB technique
patient sitting, lateral decub, prone
- sagittal plane 6 - 8 cm from midline btw ribs
- 7 - 12 ribs
- in plane, tip btw internal and innermost ic muscles
INB pearls
hard to perform above t7 d/t scapula
inadequate as a surgical anesthetic
