These are slides from a Joint Webinar between RA-UK and RCOA held on the 10th November 2020. This was part of a meeting where the Plan A blocks were discussed.

1. Trunk Blocks
Dr Amit Pawa
The Grand Hotel, Brighton
@amit_pawa #PlanABlocks

3. Disclosures
RA-UK President
Honoraria:
GE Healthcare
Sintetica Ltd
Consultation:
B Braun Medical Ltd
@amit_pawaComplete Anatomy App 3D4 Medical

4. Promote competence
in a few HIGH VALUE
“Plan A” Blocks
Increase Patient
access to RA
Anatomical Location Plan A Block
Shoulder Interscalene
Upper limb below Shoulder Axillary
Hip Femoral Nerve
Knee Adductor Canal
Foot & Ankle Popliteal Sciatic
Chest Wall Erector Spinae Plane
Abdominal Midline Rectus Sheath
Endorsed
@amit_pawa

5. Promote competence
in a few HIGH VALUE
“Plan A” Blocks
Increase Patient
access to RA
Endorsed
@amit_pawa

6. RA-UK PlanA Block Posters coming soon!
@ann_barron1
@drstu_wade
@c_johnstone1980
Thanks to:
@amit_pawa

7. Indications, Anatomy, Technique
Rectus Sheath Block
Erector Spinae Plane Block

8. Simple
Safe
Versatile
Rectus Sheath Block
Effective @amit_pawa

9. Indications
Midline Abdominal Surgery
Laparatomy
Para-umbilical Surgery

10. Anterior Rami
T6 - L1
Anatomy: Rectus Abdominis

11. Xiphoid & Costal cartilages
Pubic Symphysis & Pubic Crest
Paired Midline Muscle
Anatomy: Rectus Abdominis

12. Anatomy: Rectus Abdominis

13. Anatomy: Rectus Abdominis
External Oblique
Internal O
blique
Transversus
Abdom
inis
Rectus
Abdominis
Transversalis Fascia
Anterior Rectus Sheath
Posterior Rectus Sheath
Peritoneum

14. Anatomy: Rectus Abdominis
Anterior Rectus Sheath
Posterior Rectus Sheath

15. Anatomy: Rectus Abdominis
Anterior Rectus Sheath
Posterior Rectus Sheath
Caution Epigastric Vessels!

16. Anatomy: Rectus Abdominis
External Oblique
Internal O
blique
Transversus Abdom
inis
Rectus
Abdominis
Transversalis Fascia
Posterior Rectus Sheath
Peritoneum
Lower Midline
Below Arcuate Line…
Anterior Rectus Sheath

17. SonoAnatomy

18. PRS
Rectus Abdominis
TF
“Tram Lines”
Rectus Abdominis
TF
NO “Tram Lines”
Below Arcuate Line

19. Sonoanatomy
Linea Alba
Linea Semilunaris

20. Sonoanatomy

21. Technique
Linear Probe
10-20 mL LA per side
“Danger Zone”!
Needle In-Plane
Above ”Danger Zone"
Patient Supine
@amit_pawa

22. Technique
Linear Probe
10-20 mL LA per side
2 points
Needle In-Plane
Above ”Danger Zone"
Patient Supine
@amit_pawa

23. Technique
Linear Probe
10-20 mL LA per side
4 points
2 points
Needle In-Plane
Above ”Danger Zone"
Patient Supine
@amit_pawa

24. Technique
Linear Probe
10-20 mL LA per side
4 points
2 points
In an ideal world!
Needle In-Plane
Above ”Danger Zone"
Patient Supine
@amit_pawa

25. The Ideal Block & Patient
Credit: Dr Arun Venkataraju

26. The Less Ideal Patient…
@amit_pawa

27. Tips
Colour Doppler
Pre-Op or Post-Op insertion
Rectus Sheath Catheters
Confirm target by starting from TAP…
Assess Spread by long axis scanning…
@amit_pawa

28. Scan from TAP…
@amit_pawa

29. Scan from TAP…
@amit_pawa

30. Long Axis Scanning
Filmed with Dr PJ Bose

31. Rectus Sheath Summary
Simple & Safe
Stay above Arcuate Line
RS Catheters for laparotomy
Single shot block in as rescue
@amit_pawa

32. Indications, Anatomy, Technique
Rectus Sheath Block
Erector Spinae Plane (ESP)
@amit_pawa

33. Erector Spinae Plane (ESP)
Simple
Safe
Versatile
@amit_pawa

34. Indications: Chest Wall Procedures
Breast
Thoracic
Rib Fractures
(Abdo/Spine/Hip)
@amit_pawa
At T4-5
Level

35. @amit_pawa
This Choice
Caused some
Controversy!
Why Not Thoracic Epidural ?
Why Not Serratus Plane Block?
Why Not Thoracic Paravertebral?

36. ESP
Shallow Learning Curve
Teachable
Low Risk
Versatile
Similar principle to Serratus
@amit_pawa

37. Erector Spinae Plane
Trapezius
Rhomboid
TP TPTP
Lung
PVS PVS
PVS
Erector Spinae
Skin of the Back
@amit_pawa

38. Erector Spinae Plane
Trapezius
Rhomboid
TP TPTP
Lung
PVS PVS
PVS
ErectorSpinae
Not “One”
Muscle
Skin of the Back
@amit_pawa

39. Trapezius
Rhomboids
ESM
TPs
ESP Anatomy
@amit_pawa@amit_pawa

40. @amit_pawa@amit_pawa

41. E S P - Mode of Action?..
Dorsal Ramus
Ventral Ramus?
Lateral Cut branch?
T5
@amit_pawa
PV by Proxy?
Serratus by Proxy?

42. Sonoanatomy

43. Adipose
Trapezius
Rhomboid
Erector Spinae
TP TPPVS
Pleura
@amit_pawa

44. @amit_pawa
TP

45. Technique
Ideal dermatomal coverage?@amit_pawa

46. ESP Block Examples

47. ESP Block Videos
@amit_pawa

48. Tips
Use a “Seeker Solution” (don’t waste LA)
Volume Block - (dose of LA)
Successful block has “Black Stripe of LA”
ESP Catheters
@amit_pawa

49. Tips
Use a “Seeker Solution” (don’t waste LA)
Volume Block - (dose of LA)
Successful block has “Black Stripe of LA”
ESP Catheters
Aim for Tip/Corner of TP…
@amit_pawa

50. TP TPTP
Lung
TP
Aiming for
top of TP…
Finding The right plane
I/m
injection
@amit_pawa

51. TP TPTP
Lung
TP
Aiming for
Corner of TP
Finding The right plane
“Stripe” of LA
“Pulsatile” Flow
@amit_pawa

52. Summary
@amit_pawa

53. Summary
New Block - many potential indications
Evidence of Safety & Efficacy coming
Easy to perform
Can be performed Pre/Post Op
Avoids Epidural “issues”
Stepping stone to Paravertebral Block
@amit_pawa

54. Reading List
BJA Ed Article - rectus sheathRAUK - Plan A Blocks
#Blocktober - Rectus ASRA news - ESP#Blocktober - ESP
@amit_pawa

55. @amit_pawa