Truncal Nerve Blocks Flashcards
target of truncal blocks
- fascial planes and NOT individual nerves
- looking for fascial planes between muscles
rectus sheath block
- indications - useful for umbilical surgery (esp in peds)
- least common bc usually surgeon will just inject local
- US allows safe placement of LA in close proximity to the epigastric arteries in and peritoneum
rectus sheath block technique
- patient supine
- high frequency linear array transducer placed lateral to the umbilicus in transverse orientation
- needle is inserted using an in-plane technique
- up to 10 mL of LA injected bilaterally between rectus abdominus muscle and the posterior fascial plane
rectus sheath block pearls
- peritoneum is just below the posterior fascia
- injections along the lateral wall have been shown to be more efficacious
TAP block
- indications = alternative for low to mid abdominal wall surgery when an epidural and/or intrathecal opioids are contraindicated or refused
- block success depends on correct identification of transversus abdominus plane
- provides somatic anesthesia to the abomdinal wall from T7-L1 however is highly dependent on interfascial spread
TAP block technique
- patient supine
- high frequency transducer placed between costal margin and iliac crest midaxillary line in transverse orientation
- transducer slid medially and laterally until the three muscle layers (external oblique, internal oblique, and transversus abdominis) are identified
- needle inserted using in plane technique until tip penetrates fascia between internal oblique and transversus abdominis
- up to 20 mL of dilute LA per side
TAP Block pearls
- reports of LAST events following TAP blocks
- theory that because it is in such a tight fascial plane that it is absorbed faster
erector spinae block (ESB)
- fasical plane block deep to the spinae muscle group
- sensory block
- minimal hemodynamic effects
- primarily targets dorsal rami and potentially ventral rami (depends on appraoch)
- easy to identify with ultrasound
- reduced incidence of complications
how do you cover the ventral rami with an ESB?
if you inject by the lateral aspect of the transverse process
ESB anatomy
- erector spinae is a group of three muscles (epaxial muscles) that provide support to the spinal column
- spinalis
- longisimus
- iliocostalis
ESB technique
- use parasagittal plane to determine optimal block level
- volume dependent
- four dermatomal level of distribution (two above and below the injection site
- once the desired level is achieved, slide transducer laterally to identify the transverse process
- needle cephalad to caudal
- following negative aspiration, incremental injections of 5mL for a total of 20 mL
- repeat on opposite side
ESB pearls
- unilateral block - will require bilateral block for most surgical procedures
- volume dependent block - as a sensory block, low concentration allows for increased volume
ESB complications
- hematoma
- infection at needle insertion site
- tissue trauma
- pneumo
- hemodynamic instability
- LAST
- lumbar plexus block
- block failure
quadratus lumborum indications
- large bowel resections, appy, chole
- C-section, total abdominal hysterectomy
- prostatectomy, renal transplant, nephrectomy, abdominoplasty
- iliac crest bone graft
- ex lap
quadratus lumborum block
- targets iliohypogastric, ilioinguinal, and subcostal nerves that cross the psoas muscle and transversalis fascia
- lateral wall and some hip coverage
what are the attachments of the quadratus lumborum muscle?
superior = T12 inferior = iliac crest medial = transverse processes
quadratus lumborum block technique
- most technically difficult
- patient lateral decubitus position with hips and knees flexed
- curvilinear transducer placed midaxillary line cephalad to iliac crest
- transducer slid posteriorly and tilted caudad until “shamrock sign” is visualized
components of shamrock sign
- stem = L4 transverse process
- leaves = erector spinae, quadratus lumborum, and psoas major
QL3
shamrock sign
QL1
- find the TAP block
- slide until transverse abdominis and internal oblique join together
- go to thoraco-lumbar fascial plane
QLB pearls
-the lower pole of the kidney lies anterior to the QL muscle and can reach L4 with deep inspiration
PECs block indications
- analgesia following breast surgery
- biospy
- MAJOR breast reconstruction
- alternative to paravertebral block or thoracic epidural (reduces risk of pneumo and spinal)
PECs I block
designed to anesthetized the medial and lateral pectoral nerves
PECs II block
extension of PECs I and provides additional blockade of the upper intercostal nerves
PECs I technique
- patient supine with arm abducted
- high frequency transducer placed in cephalad medial and caudal lateral orientation at the level of the coracoid process
- costal margins, pectoris major (PM), pectoris minor (Pmi), and serratus muscles are identified
- needle inserted in plane, cephalad to caudad, until the tip penetrates the fascia between the PM and Pmi
PECs II technique
- transducer slid caudad to the level of the 2nd rib and angled inferolaterally until the Pmi and serratus anterior muscles identified
- further lateral movement will identify the 3rd and 4th rib
- LA injected in two areas –> between the PM and Pmi AND between the Pmi and serratus anterior muscles
paravertebral indications
- preioperative analgesia for thoracic, chest wall or breast surgery
- pain management of rib fractures
paravertebral block
targets the paravertebral space (PVS) which contains spinal nerves and their branches as well as the sympathetic trunk
paravertebral anatomy
-wedge shaped area formed medially by the vertebral body, inferiorly by the parietal pleura, and anteriorly by the costotransverse ligament
paravertebral technique
- transverse, in-plane
- patient in lateral decubitus position
- high frequency transducer placed in transverse orientation at the desired level just lateral to the spinous process
- once the hyperechoic transverse process (TP) and ribs are identified, slide the transducer slightly caudad into the intercostal space
paravertebral pearls
- downward displacement of pleura indicates correct spread of LA
- bilateral epidural anesthesia is possible
- constant visualization of needle tip is ESSENTIAL
intercostal nerve block indications
- analgesia following breast, thoracic, and upper abdominal surgery
- pain management of rib fractures
intercostal nerve block
targets intercostal nerves resulting in ipsilateral anesthesia of specific levels; single dermatome level block
intercostal nerve block technique
- patient in sitting, lateral decubitus or prone position with arms hanging freely
- high-frequency transducer placed in a sagittal plane over the costae approximately 6-8 cm from midline
- ID the 7th and 12th ribs to estimate the position of relative ribs
- needle inserted in plane until the tip is observed between the internal and innermost intercostal muscles
intercostal nerve block pearls
- difficult to perform above T7 due to the scapula
- excellent for analgesia, but inadequate surgical anesthesia
