Ultrasound guided truncal blocks Flashcards
All of the truncal blocks are considered to be
pain management blocks- not used as primary anesthetic
volume blocks (never use more than 0.25%)
target planes & not specific nerves
List the abdominal block types:
rectus sheath
transversus abdominis plane
quadratus lumborum
Indications for a rectus sheath block include
useful technique for umbilical surgery (especially in the pediatric population)
-allows for safe placement of LA in close proximity to the epigastric arteries and peritoneum
The technique for the rectus sheath block is
patient supine
high-frequency transducer is placed lateral to the umbilicus in transverse orientation
needle is inserted using an in-plane technique
up to 10 mL of local anesthetic injected bilaterally between the rectus abdominis muscle and the posterior fascial plane
Pearls for the rectus sheath block include
the potential for complication due to puncture of the peritoneum as it is just below the posterior fascia
injections along the lateral wall have been shown to be more efficacious
Indications for the TAP block include
an alternative for low to mid abdominal wall surgery when an epidural and/or intrathecal opioids are contraindicated or refused
Block success of the TAP block depends on
the correct identification of the transversus abdominis plane
The TAP block provides
somatic anesthesia to the abdominal wall from T7-L1, however is highly dependent on interfascial spread
The key to the TAP block is to
understand muscle planes; people either inject too deep or too superficial
The technique for the TAP block is
patient is supine
high-frequency transducer placed between the costal margin & iliac crest midaxillary line to transverse orientation
transducer slid medially and laterally until the three muscle layers (external oblique, internal oblique, and transversus abdominus) are identified
needle inserted using in-plane technique until tip penetrates fascia between the internal oblique and transversus abdominis
up to 20 mL of dilute LA per side
List the three muscle layers that should be seen in the TAP block:
external oblique, internal oblique, transversus abdominus
The erector spinae is a group of three muscles that
provides support to the spinal column
-spinalis, longissimus, iliocostalis
The erector spinae block primarily targets the
dorsal rami and potentially the ventral rami
The erector spinae block benefits include
easy to identify with US
not technically difficult
reduced incidence of complications
The erector spinae block is a
fascial plane block deep to the spinae muscle group- sensory block, minimal hemodynamic effects
Describe the technique for the erector spinae block.
use parasagittal plane to determine optimal block level
-volume dependent block- four dermatomal level of distribution (two above and below injection site)
once the desired level is achieved slide the transducer laterally to identify the transverse process
needle insertion is cephalad to caudal
-following negative aspiration, incremental injections of 5 mL for a total of 20 mL
repeat on the opposite side
most likely will require curvilinear array transducer
Pearls for the erector spinae block include:
unilateral block- will require bilateral block for most surgical procedures
volume dependent block- as a sensory block, low concentration allows for increased volume
Complications of the erector spinae block include:
hematoma infection at the needle insertion site tissue trauma pneumothorax hemodynamic instability LAST lumbar plexus block block failure
Indications for the quadratus lumborum block include
large bowel resections, appendectomy, cholecystectomy
c-section, total abdominal hysterectomy
prostatectomy, renal transplant surgery, nephrectomy, abdominoplasty, iliac crest bone graft, exploratory laparotomy
The quadratus lumborum block targets the
iliohypogastric, ilioinguinal, and subcostal nerves that cross the psoas muscle and transversalis fascia
Describe the technique for the quadratus lumborum block:
patient lateral decubitus position with hips and knees flexed
curvilinear transducer placed mid-axillary line cephalad to iliac crest
transducer slid posteriorly, and tilted caudad until “shamrock” sign is visualized
Describe what makes up the “shamrock sign”
L4 transverse process stem, the erector spinae, QL, and psoas major represent the trefoil
Pearls for the quadratus lumborum block include:
the lower pole of the kidney lies anterior to the QL muscle and can reach L4 with deep inspiration
Describe the indications for PECS I & II blocks
analgesia following breast surgery
Pectoralis nerve 1 block are designed to
anesthetize the medial and lateral pectoral nerves
Pectoralis nerve 2 block is
an extension of the Pecs I block and provides additional blockade of the upper intercostal nerves
The Pecs I & II block are an alternative to
paravertebral block or thoracic epidural
reduces risk of pneumothorax & spinal
Describe the Pecs I technique
patient supine with arm abducted
high frequency transducer placed in a cephalad medial & caudad lateral orientation at the level of the coracoid process
identify costal margins, pectoris major, pectoris minor, and serratus muscle
needle inserted in-plane, cephalad to caudad until the tip penetrates the fascia between the PM & Pmi
Describe the muscles located for the pecs I technique
costal margins, pectoris major, pectoris minor and serratus muscles
Describe the Pecs II technique
transducer slid caudad to the level of the 2nd rib and angled inferolaterally until the pec minor and serratus anterior muscles are identified
further lateral movement will identify the 3rd and 4th rib
local anesthetic is injected in two areas:
between the pec major and pec minor
between the pec minor and the serratus anterior muscles
Describe the thoracic blocks
intercostal
paravertebral
The indications for the paravertebral block include
perioperative analgesia for thoracic, chest wall, or breast surgery
pain management of rib fractures
The paravertebral block targets the
paravertebral space (PVS) which contains spinal nerves and their branches as well as the sympathetic trunk
Describe the anatomy of the paravertebral block
the PVS is a wedge-shaped area formed medially by the vertebral body, inferiorly by the parietal pleura and anteriorly by the costotransverse ligament
Describe the transverse in-plane technique.
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
Describe the pearls for the paravertebral block.
downward displacement of the pleural, indicates correct spread of local anesthetic
bilateral epidural anesthesia is possible
constant visualization of the needle tip is essential
Describe the indications for the intercostal nerve block.
analgesia following breast, thoracic, and upper abdominal surgery
pain management of rib fractures
The intercostal nerve block targets the
intercostal nerves resulting in ipsilateral anesthesia at specific levels (only blocks one level at a time)
Describe the technique for the intercostal nerve block.
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
identify the 7th and 12th ribs to estimate position of relative ribs
needle inserted in-plane until the tip is observed between the internal and innermost intercostal muscles
The pearls for the intercostal block include
difficult to perform above T7 because of the scapula
excellent for analgesia but inadequate as a surgical anesthetic
