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Neuraxial and Truncal Regional Anesthesia

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A step by step lecture explaining thoracic epidural, lumbar epidural, spinal, paravertebral, TAP, and Rectus Sheath blocks. Additional focus on spine anatomy, test dosing.

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Neuraxial and Truncal Regional Anesthesia

  1. 1. BFSA Slide by Brian F S Allen BFSA BFSA Neuraxial and Truncal Regional Anesthesia Brian Allen 07/2014
  2. 2. BFSA Slide by Brian F S Allen BFSA BFSA Scalp* (U,P){2} Interscalene (S,L){2} Transgluteal Sciatic (L,P){4,6} Paravertebral (U,L){4,6} Thoracic Epidural (U,L){4,6} Lumbar Plexus† (L){4,6} TAP (S){4} Superficial Cervical Plexus* (S){2} Axillary* (S,A){2} Infraclavicular (S,A){4} Supraclavicular (S){2} Lumbar Epidural (U,L){4,6} Infragluteal Sciatic (S,L,P){4,6} Ankle* (S){2} Lat Fem Cut* (S){2,4} Popliteal Sciatic (S,U,L){4} Femoral (S){2,4} Obturator* (S){4} Saphenous (S,P){4} HEENT*{2} Wrist* (S){2} Legend: * = Only Single Shot Bold = May Place Catheter Underline = uncommonly done † = Nerve Stimulator always used Positioning ( ): S = Supine U = Sitting Up P = Prone L = Lateral Decubitus or Simms A = Arm Over Head Needle Length { in inches } Common Regional and Neuraxial Blocks Suprascapular* (U){2,4} Spinal (U,L){3.5,6}
  3. 3. BFSA Slide by Brian F S Allen BFSA BFSA Thoracic Epidural Lumbar Epidural Spinal Paravertebral TAP and Rectus Sheath
  4. 4. BFSA Slide by Brian F S Allen BFSA BFSA Spine Anatomy and Site Selection for Neuraxial Anesthesia Brian Allen 06/2015
  5. 5. BFSA Slide by Brian F S Allen BFSA BFSA
  6. 6. BFSA Slide by Brian F S Allen BFSA BFSA Thoracic Spine Cervical Spine Lumbar Spine
  7. 7. BFSA Slide by Brian F S Allen BFSA BFSA
  8. 8. BFSA Slide by Brian F S Allen BFSA BFSA Identifying Vertebral Level Vertebra prominens
  9. 9. BFSA Slide by Brian F S Allen BFSA BFSA Identifying Vertebral Level C7 Most prominent Spinous Process
  10. 10. BFSA Slide by Brian F S Allen BFSA BFSA Identifying Vertebral Level Inferior Angle of the Scapula C7
  11. 11. BFSA Slide by Brian F S Allen BFSA BFSA Identifying Vertebral Level T7 C7
  12. 12. BFSA Slide by Brian F S Allen BFSA BFSA Identifying Vertebral Level T7 C7
  13. 13. BFSA Slide by Brian F S Allen BFSA BFSA Identifying Vertebral Level T7 C7 Counting Vertebrae is more accurate from C7 than T7
  14. 14. BFSA Slide by Brian F S Allen BFSA BFSA Identifying Vertebral Level T7 C7 Your estimate of level is frequently off by 1 level with either method, BUT More likely to be off by 2+ levels if using scapula to determine entry site
  15. 15. BFSA Slide by Brian F S Allen BFSA BFSA Identifying Vertebral Level T7 C7 Iliac Crest
  16. 16. BFSA Slide by Brian F S Allen BFSA BFSA Identifying Vertebral Level T7 C7 Intercristal Line
  17. 17. BFSA Slide by Brian F S Allen BFSA BFSA Identifying Vertebral Level T7 C7 Radiographically L4-5
  18. 18. BFSA Slide by Brian F S Allen BFSA BFSA Identifying Vertebral Level T7 C7 By Palpation L3-4 Especially in Females and High BMI
  19. 19. BFSA Slide by Brian F S Allen BFSA BFSA Identifying Vertebral Level T7 C7 L3-4
  20. 20. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Epidural Insertion Level T7 C7 L3-4 Dermatomes T4 T10 T4 T12 Indication: Rib Fractures Thoracic Surgery Sub-Xiphoid Ex Lap Sub-Umbilical Ex Lap Labor Lower Extremity Ortho or Vascular Surgery Insertion Site T6
  21. 21. BFSA Slide by Brian F S Allen BFSA BFSA T4-T10 (depending on fractures) Anesthetic Coverage RequiredInsertion Site Indication: Rib Fractures Thoracic Surgery Sub-Xiphoid Ex Lap Sub-Umbilical Ex Lap Pelvic Surgery Labor Caesarian Section Lower Extremity Ortho or Vascular Surgery Choosing Epidural Insertion Level T2-T12 (depending on fractures)
  22. 22. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Epidural Insertion Level Insertion Site Anesthetic Coverage RequiredIndication: Rib Fractures Thoracic Surgery Sub-Xiphoid Ex Lap Sub-Umbilical Ex Lap Pelvic Surgery Labor Caesarian Section Lower Extremity Ortho or Vascular Surgery T5-T7 T3-T8
  23. 23. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Epidural Insertion Level Insertion Site Anesthetic Coverage RequiredIndication: Rib Fractures Thoracic Surgery Sub-Xiphoid Ex Lap Sub-Umbilical Ex Lap Pelvic Surgery Labor Caesarian Section Lower Extremity Ortho or Vascular Surgery T7-T9 T4-T12 (depending on surgical extent)
  24. 24. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Epidural Insertion Level Insertion Site Anesthetic Coverage RequiredIndication: Rib Fractures Thoracic Surgery Sub-Xiphoid Ex Lap Sub-Umbilical Ex Lap Pelvic Surgery Labor Caesarian Section Lower Extremity Ortho or Vascular Surgery T6-T12 (surgical) T8-T12 (post-op) T8-T11
  25. 25. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Epidural Insertion Level T9-T12 but CSE may be useful Insertion Site Anesthetic Coverage RequiredIndication: Rib Fractures Thoracic Surgery Sub-Xiphoid Ex Lap Sub-Umbilical Ex Lap Pelvic Surgery Labor Caesarian Section Lower Extremity Ortho or Vascular Surgery T6-Sacral (surgical) T8-T12 (post-op)
  26. 26. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Epidural Insertion Level Insertion Site Anesthetic Coverage RequiredIndication: Rib Fractures Thoracic Surgery Sub-Xiphoid Ex Lap Sub-Umbilical Ex Lap Pelvic Surgery Labor Caesarian Section Lower Extremity Ortho or Vascular Surgery L2-L5 T10-Sacral
  27. 27. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Epidural Insertion Level Insertion Site Anesthetic Coverage RequiredIndication: Rib Fractures Thoracic Surgery Sub-Xiphoid Ex Lap Sub-Umbilical Ex Lap Pelvic Surgery Labor Caesarian Section Lower Extremity Ortho or Vascular Surgery T4-Sacral L2-L5
  28. 28. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Epidural Insertion Level L2-L5 Insertion Site Anesthetic Coverage RequiredIndication: Rib Fractures Thoracic Surgery Sub-Xiphoid Ex Lap Sub-Umbilical Ex Lap Pelvic Surgery Labor Caesarian Section Lower Extremity Ortho or Vascular Surgery T12-S3
  29. 29. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Epidural Insertion Level T4-T10 T5-T7 T7-T9 T8-T11 L2-L5 T9-T12 L2-L5 Insertion Site T2-T12 Anesthetic Coverage Required T4-T12 T3-T8 Indication: Rib Fractures Thoracic Surgery Sub-Xiphoid Ex Lap Sub-Umbilical Ex Lap Pelvic Surgery Labor Caesarian Section Lower Extremity Ortho or Vascular Surgery T8-T12 (post-op) T6-T12 (surgical) T6-Sacral (surgical) T10-Sacral T4-Sacral T8-T12 (post-op) L2-L5 T12-S3
  30. 30. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Epidural Insertion Level High Thoracic Epidurals: Block Cardiac Accelerator Fibers Hypotension Likely Very Low Thoracic or Lumbar Epidurals: Block Lumbar Roots Leg Weakness, Urinary Retention Likely
  31. 31. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Spinal Insertion Level All Spinal Placements L2-S1 Preferably L3 or below Insertion Site Anesthetic Coverage RequiredIndication: Rib Fractures not used Thoracic Surgery not used Sub-Xiphoid Ex Lap rare Sub-Umbilical Ex Lap Pelvic Surgery Labor Caesarian Section Lower Extremity Ortho or Vascular Surgery T6-Sacral T6-Sacral T10-Sacral T4-Sacral T12-Sacral T4-Sacral
  32. 32. BFSA Slide by Brian F S Allen BFSA BFSA Spinous Process Lamina Transverse Process
  33. 33. BFSA Slide by Brian F S Allen BFSA BFSA 3 Ligaments Deep Superficial
  34. 34. BFSA Slide by Brian F S Allen BFSA BFSA 3 Ligaments Deep Superficial Interspinous Ligamentum Flavum
  35. 35. BFSA Slide by Brian F S Allen BFSA BFSA Deep Superficial Dural Sac
  36. 36. BFSA Slide by Brian F S Allen BFSA BFSA Dural Sac Deep Superficial Ligamentum Flavum
  37. 37. BFSA Slide by Brian F S Allen BFSA BFSA Dural Sac Deep Superficial Epidural Space
  38. 38. BFSA Slide by Brian F S Allen BFSA BFSA Angle of Spinous Processes
  39. 39. BFSA Slide by Brian F S Allen BFSA BFSA Angle of Successful Midline Needle Pass
  40. 40. BFSA Slide by Brian F S Allen BFSA BFSA Deep Superficial
  41. 41. BFSA Slide by Brian F S Allen BFSA BFSA Deep Superficial Comes in from the side, bypasses some ligament
  42. 42. BFSA Slide by Brian F S Allen BFSA BFSA • Lumbar Epidurals generally done midline • Thoracic epidurals generally done paramedian • Spinals generally done midline Practical Guide to Neuraxial Placement
  43. 43. BFSA Slide by Brian F S Allen BFSA BFSA • General tips: – Positioning is crucial – Use time wisely – Communicate with the patient • Use lay terms • Avoid troubling words/phrases – Blood = “Heme” – Bone = “Os” – “Oops” & Uh-oh” are 4 letter words – Provide appropriate sedation – Work in one plane at a time – Technical skills improve faster than sterile technique – Protect yourself! • Needle tips pointing down on the tray • No sharps on patient bed Practical Guide to Epidural Placement
  44. 44. BFSA Slide by Brian F S Allen BFSA BFSA • Time saving performance sequence: – Arrive & Communicate with patient – Position patient & Palpate landmarks – Time Out & Prep skin • Chlorhexidine X 2 for CPS • Povidone Iodine (in the kit) for OB – Allow prep to dry then apply drape – Draw & Give skin local (25g needle) – Finally, set up remaining kit – Place epidural – Put sharps in small tray as you go Practical Guide to Epidural Placement
  45. 45. BFSA Slide by Brian F S Allen BFSA BFSA Skin Localization Skin Come in parallel to the back in all planes Lumbar Epidural Thoracic Epidural
  46. 46. BFSA Slide by Brian F S Allen BFSA BFSA Skin Localization Skin Inject JUST under the skin, raising a broad, flat weal Lumbar Epidural Thoracic Epidural
  47. 47. BFSA Slide by Brian F S Allen BFSA BFSA Skin Localization Skin If the injection is too deep, weal will be more raised, distorting landmark palpation Lumbar Epidural Thoracic Epidural
  48. 48. BFSA Slide by Brian F S Allen BFSA BFSA Skin Localization Skin After skin weal, advance needle, injecting somewhat AS YOU GO Note any increase in injection pressure, c/w ligament Lumbar Epidural Thoracic Epidural
  49. 49. BFSA Slide by Brian F S Allen BFSA BFSA Skin Localization Skin If Os (bone) contacted, infiltrate well Lumbar Epidural Thoracic Epidural
  50. 50. BFSA Slide by Brian F S Allen BFSA BFSA Skin Localization Skin If landmarks are clear, only administer local in midline, dorsal-ventral plane If landmarks unclear, use local needle as finder for Os or ligament Lumbar Epidural
  51. 51. BFSA Slide by Brian F S Allen BFSA BFSA Skin Localization Skin Do not go too deep in low BMI patients Lumbar Epidural
  52. 52. BFSA Slide by Brian F S Allen BFSA BFSA Skin Localization Skin For Paramedian approach, walk medial along lamina, injecting as you go
  53. 53. BFSA Slide by Brian F S Allen BFSA BFSA Skin Localization Skin For Paramedian approach, walk medial along lamina, injecting as you go
  54. 54. BFSA Slide by Brian F S Allen BFSA BFSA Skin Localization Skin Do not go too deep in low BMI patients
  55. 55. BFSA Slide by Brian F S Allen BFSA BFSA Skin Localization Skin Save enough medication in syringe for localization of an additional skin site Lumbar Epidural
  56. 56. BFSA Slide by Brian F S Allen BFSA BFSA Thoracic Epidural Lumbar Epidural Spinal Paravertebral TAP and Rectus Sheath
  57. 57. BFSA Slide by Brian F S Allen BFSA BFSA Palpate: Vertebra Prominens Practical Guide to Thoracic Epidural Placement Skin
  58. 58. BFSA Slide by Brian F S Allen BFSA BFSA Count: From C7 down to desired level T1 T2 T3 T4 T5 T6 T7 Practical Guide to Thoracic Epidural Placement Skin
  59. 59. BFSA Slide by Brian F S Allen BFSA BFSA Confirm Midline by Palpation T6 Practical Guide to Thoracic Epidural Placement Skin
  60. 60. BFSA Slide by Brian F S Allen BFSA BFSA Judge 1 cm lateral & 0.5 cm caudal to tip of Spinous Process 1 cm 0.5 cm 1 cm 1 cm 0.5 cm Practical Guide to Thoracic Epidural Placement Skin
  61. 61. BFSA Slide by Brian F S Allen BFSA BFSA Mark: Needle Insertion Skin Practical Guide to Thoracic Epidural Placement Skin
  62. 62. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Thoracic Epidural Placement Insert needle in dorsal to ventral plane, perpendicular to skin in all planes Skin Plane 1: Dorsal to Ventral
  63. 63. BFSA Slide by Brian F S Allen BFSA BFSA Advance needle to lamina Mark needle depth Practical Guide to Thoracic Epidural Placement Skin Lamina Depth Plane 1: Dorsal to Ventral
  64. 64. BFSA Slide by Brian F S Allen BFSA BFSA Withdraw needle, angle 5-10 degrees medial, advance to bone Plane 2: Lateral to Medial Stop if no bone found before lamina depth + 0.5 cm Skin Practical Guide to Thoracic Epidural Placement
  65. 65. BFSA Slide by Brian F S Allen BFSA BFSA Repeat needle withdrawal, medial angulation and advancement Skin Repeat process until bone found at shallower depth Practical Guide to Thoracic Epidural Placement Plane 2: Lateral to Medial
  66. 66. BFSA Slide by Brian F S Allen BFSA BFSA When shallower depth to bone found, stop medial angulations. Skin Practical Guide to Thoracic Epidural Placement Plane 2: Lateral to Medial
  67. 67. BFSA Slide by Brian F S Allen BFSA BFSA Return to angle where bone found deepest Mark deepest depth in lateral to medial plane Skin Practical Guide to Thoracic Epidural Placement Plane 2: Lateral to Medial
  68. 68. BFSA Slide by Brian F S Allen BFSA BFSA Withdraw needle, angle 5-10 degrees cephalad, advance to bone Plane 3: Caudal to Cranial Stop if no bone found before previous bone depth + 0.5 cm Skin Practical Guide to Thoracic Epidural Placement
  69. 69. BFSA Slide by Brian F S Allen BFSA BFSA Repeat needle withdrawal, cephalad angulation and advancement Repeat until bone “walked off” and/or engaged in ligament Skin Practical Guide to Thoracic Epidural Placement Plane 3: Caudal to Cranial
  70. 70. BFSA Slide by Brian F S Allen BFSA BFSA Repeat needle withdrawal, cephalad angulation and advancement Repeat until bone “walked off” and/or engaged in ligament Skin Practical Guide to Thoracic Epidural Placement Plane 3: Caudal to Cranial
  71. 71. BFSA Slide by Brian F S Allen BFSA BFSA When engaged in ligament, remove stylet, connect LOR syringe With LOR syringe, check for LOR initially and every 2mm advancement Skin Practical Guide to Thoracic Epidural Placement Plane 3: Caudal to Cranial
  72. 72. BFSA Slide by Brian F S Allen BFSA BFSA Disconnect syringe, pass catheter Skin Practical Guide to Thoracic Epidural Placement Plane 3: Caudal to Cranial When LOR noted, stop advancement, inject LOR fluid (or air)
  73. 73. BFSA Slide by Brian F S Allen BFSA BFSA Thoracic Epidural Lumbar Epidural Spinal Paravertebral TAP and Rectus Sheath
  74. 74. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Lumbar Epidural Placement Palpate: Iliac Crests Skin
  75. 75. BFSA Slide by Brian F S Allen BFSA BFSA Count: From L3-L4 to desired level Practical Guide to Lumbar Epidural Placement Choose: the best Interspace Skin
  76. 76. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Lumbar Epidural Placement 0.5 cm 0.5 cm 0.5 cm 0.5 cm Judge a slight distance ~ 0.5 cm caudal to tip of Spinous Process Skin
  77. 77. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Lumbar Epidural Placement Mark: Needle Insertion Skin
  78. 78. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Lumbar Epidural Placement Insert needle in dorsal to ventral plane, perpendicular to skin in all planes Skin
  79. 79. BFSA Slide by Brian F S Allen BFSA BFSA • Before you advance needle, come up with 3 numbers in your mind: – #1: Expected depth to epidural space (ED) – #2: Shortest possible depth to epidural space (SD) – #3: Longest reasonable depth to epidural space (LD) Practical Guide to Lumbar Epidural Placement
  80. 80. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Lumbar Epidural Placement Advance needle until engaged in ligament Stop if engaged in ligament or you reach shortest possible epidural depth (SD) Skin
  81. 81. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Lumbar Epidural Placement When engaged in ligament or at SD, remove stylet, connect LOR syringe With LOR syringe, check for LOR initially and every 2mm advancement Skin
  82. 82. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Lumbar Epidural Placement When engaged in ligament or at SD, remove stylet, connect LOR syringe With LOR syringe, check for LOR initially and every 2mm advancement Skin
  83. 83. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Lumbar Epidural Placement Skin When engaged in ligament or at SD, remove stylet, connect LOR syringe With LOR syringe, check for LOR initially and every 2mm advancement
  84. 84. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Lumbar Epidural Placement Skin Disconnect syringe, pass catheter When LOR noted, stop advancement, inject LOR fluid (or air)
  85. 85. BFSA Slide by Brian F S Allen BFSA BFSA If Bone encountered Mark Depth Withdraw, Redirect Cephalad, Pass Needle Deeper Bone encountered Pass Successful Same DepthMore Shallow Location: Walking up Inferior Spinous Process Location: On Lamina Reassess Landmarks Location: Walking down Superior Spinous Process Practical Guide to Lumbar Epidural Placement
  86. 86. BFSA Slide by Brian F S Allen BFSA BFSA • Test dose – to rule out IV or IT – 2 to 3 mL 1.5% Lidocaine with 1:200,000 Epinephrine • Lidocaine 45 mg • Epinephrine 15 mcg • Each component has different effect depending on catheter location • 4 main possibilities – Intrathecal – Intravascular – Epidural – Intramuscular or within other tissue – Rarely subdural Practical Guide to Any Epidural Placement
  87. 87. BFSA Slide by Brian F S Allen BFSA BFSA Test dose effect based on catheter location Epinephrine Effect Intravascular Intrathecal Epidural Intramuscular • Heart Rate Elevation HR rises 20 sec after dose HR up 20 BPM Lasts 20 sec HR drops 20 BPM HR tracing like square wave May be non-diagnostic in: • Labor if contraction occurs • Patients on Beta Blockers • Heart transplant • No Acute Effect • No Acute Effect • No Effect H R Time “Rule” of 20s
  88. 88. BFSA Slide by Brian F S Allen BFSA BFSA Test dose effect based on catheter location Lidocaine Effect Intravascular Intrathecal Epidural Intramuscular • Effect within 20 sec • Tinnitus • Roaring in ears • Perioral numbness • No effect No sensory or motor changes found • Effect within 3-8 min • If LEC: leg motor block • If TEC: broad chest numbness, possible leg or arm weakness or numbness Thoracic Intrathecal Lumbar Intrathecal • Effect within 5-10 min • Band of numbness • 2-4 dermatomes • Depends on vertebral level catheter placed Thoracic Epidural Lumbar Epidural
  89. 89. BFSA Slide by Brian F S Allen BFSA BFSA Epidural Catheter Testing • All epidural catheters should be evaluated after placement • 3 mL test dose should take effect rapidly – 5-10 minutes to development of discernable level – Small bilateral sensory level to ice or pinprick – Approximately 2 dermatomes wide • No patient should go to surgery without block eval – Takes little time – Presence of a level confirms correct placement – Absence of level reveals need for troubleshooting/replacement – Testing preop limits need for epidural function confirmation postop – Unilateral blocks can be addressed immediately • Failure to evaluate block = poor patient care
  90. 90. BFSA Slide by Brian F S Allen BFSA BFSA Thoracic Epidural Lumbar Epidural Spinal Paravertebral TAP and Rectus Sheath
  91. 91. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Spinal Placement Similar to Lumbar Epidural Locate best lumbar interspace Skin Lower interspaces preferable. Spinal cord ends at L1-L2 in adults Can be lower in high proportion
  92. 92. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Spinal Placement Skin Place needle introducer in dorsal to ventral plane, perpendicular to skin in all planes
  93. 93. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Spinal Placement Skin Advance needle until engaged in ligament
  94. 94. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Spinal Placement Skin Place spinal needle thru introducer, paying attention to feel during needle advancement
  95. 95. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Spinal Placement Skin When subtle “pop” felt, remove stylet, check for CSF flow If CSF flow, Connect syringe, aspirate, inject spinal med
  96. 96. BFSA Slide by Brian F S Allen BFSA BFSA If Bone encountered Mark Depth Withdraw, Redirect Cephalad, Pass Needle Deeper Bone encountered Pass Successful Same DepthMore Shallow Location: Walking up Inferior Spinous Process Location: On Lamina Reassess Landmarks Location: Walking down Superior Spinous Process Practical Guide to Spinal Placement
  97. 97. BFSA Slide by Brian F S Allen BFSA BFSA Thoracic Epidural Lumbar Epidural Spinal Paravertebral TAP and Rectus Sheath
  98. 98. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement Pleura Catheter Sympathetic Ganglion Touhy Needle Spinous Process Transverse Process Rib Lamina Dorsal Root Ventral Root Gray and White Rami Communicantes Vertebral Body Ventral Ramus Dorsal Ramus
  99. 99. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement • Paravertebral space – Triangular space lateral to neural foramen – Medial Boundary: Vertebra – Posterior Boundary: Costotransverse ligament – Anterior and Lateral Boundary: Pleura – Holds emerging spinal roots – Communicates vertically
  100. 100. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement • Paravertebral space – Triangular space lateral to neural foramen – Medial Boundary: Vertebra – Posterior Boundary: Costotransverse ligament – Anterior and Lateral Boundary: Pleura – Holds emerging spinal roots – Communicates vertically
  101. 101. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement • Paravertebral space – Triangular space lateral to neural foramen – Medial Boundary: Vertebra – Posterior Boundary: Costotransverse ligament – Anterior and Lateral Boundary: Pleura – Holds emerging spinal roots – Communicates vertically
  102. 102. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement • Paravertebral space – Triangular space lateral to neural foramen – Medial Boundary: Vertebra – Posterior Boundary: Costotransverse ligament – Anterior and Lateral Boundary: Pleura – Holds emerging spinal roots – Communicates vertically
  103. 103. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement • Paravertebral space – Triangular space lateral to neural foramen – Medial Boundary: Vertebra – Posterior Boundary: Costotransverse ligament – Anterior and Lateral Boundary: Pleura – Holds emerging spinal roots – Communicates vertically
  104. 104. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement Image: Chelly 2012
  105. 105. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement Image: Chelly 2012 • Paravertebral space – Medial Boundary: Vertebra – Posterior Boundary: Costotransverse ligament – Lateral Boundary: Pleura – Communicates vertically
  106. 106. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement Image: Chelly 2012 • Paravertebral space – Medial Boundary: Vertebra – Posterior Boundary: Costotransverse ligament – Lateral Boundary: Pleura – Communicates vertically
  107. 107. BFSA Slide by Brian F S Allen BFSA BFSA Epidural Unilateral Uncommon No No No Very Rare Features Laterality Hypotension Pruritis PONV Urinary Retention Spinal Injury Risk Bilateral Common Common Common Common Rare Comparing Paravertebral and Epidural Characteristics Paravertebral Chart: Chelly 2012
  108. 108. BFSA Slide by Brian F S Allen BFSA BFSA Palpate: Vertebra Prominens Practical Guide to Paravertebral Placement Skin
  109. 109. BFSA Slide by Brian F S Allen BFSA BFSA Count: From C7 down to desired level T1 T2 T3 T4 T5 T6 T7 Practical Guide to Paravertebral Placement Skin
  110. 110. BFSA Slide by Brian F S Allen BFSA BFSA Confirm Midline by Palpation T4 Practical Guide to Paravertebral Placement Skin
  111. 111. BFSA Slide by Brian F S Allen BFSA BFSA Measure 2.5 cm lateral to tip of Spinous Process 2.5 cm 2.5 cm 2.5 cm Practical Guide to Paravertebral Placement Skin
  112. 112. BFSA Slide by Brian F S Allen BFSA BFSA Mark: Needle Insertion Practical Guide to Paravertebral Placement Skin
  113. 113. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement Skin Plane 1: Dorsal to Ventral Insert needle in dorsal to ventral plane, perpendicular to skin in all planes
  114. 114. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement Skin Plane 1: Dorsal to Ventral Advance needle to transverse process Mark needle depth
  115. 115. BFSA Slide by Brian F S Allen BFSA BFSA T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 Practical Guide to Paravertebral Placement Skin Above T7 Walk off Caudal or Cranial to TP T7 or below Walk off Caudal to TP For this example, we will adjust caudal
  116. 116. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement Skin Plane 2: Cranial to Caudal Withdraw needle, angle 5-10 degrees caudal, advance If bone contacted remove needle and repeat caudal angulation
  117. 117. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement Skin Plane 2: Cranial to CaudalRepeat needle withdrawal, caudad angulation and advancement Maintain needle in strict AP plane
  118. 118. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement Skin Plane 2: Cranial to Caudal When bone walked off, advance cautiously Advance NO MORE than 1 cm to 1.25 cm past transverse process
  119. 119. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement Skin Subtle LOR can be felt, but is nonspecific Feels different from epidural LOR When 1 to 1.25 cm past TP, remove stylet, connect LOR syringe
  120. 120. BFSA Slide by Brian F S Allen BFSA BFSA Practical Guide to Paravertebral Placement Skin Catheter can be difficult to thread Dilate paravertebral space then pass catheter
  121. 121. BFSA Slide by Brian F S Allen BFSA BFSA • Test dosing with epinephrine-containing solution recommended • Ultrasound can be used – Preprocedure OR Intraprocedure – Intraprocedure can challenging for catheters • Single Injection Paravertebrals – May block multiple levels – Unilateral or Bilateral – LOR technique not used – Closed system limits pneumothorax risk Practical Guide to Paravertebral Placement
  122. 122. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Paravertebral Insertion Level T1-T5 Insertion Site Indication: Breast Surgery Esophagectomy Thoracic Surgery Liver Resection Abdominal Surgery Pelvic Surgery
  123. 123. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Paravertebral Insertion Level T2-T3 Bilateral Insertion Site Indication: Breast Surgery Esophagectomy Thoracic Surgery Liver Resection Abdominal Surgery Pelvic Surgery
  124. 124. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Paravertebral Insertion Level T4-T5 Insertion Site Indication: Breast Surgery Esophagectomy Thoracic Surgery Liver Resection Abdominal Surgery Pelvic Surgery
  125. 125. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Paravertebral Insertion Level T6-T7 Bilateral Insertion Site Indication: Breast Surgery Esophagectomy Thoracic Surgery Liver Resection Abdominal Surgery Pelvic Surgery
  126. 126. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Paravertebral Insertion Level T8-T9 Bilateral Insertion Site Indication: Breast Surgery Esophagectomy Thoracic Surgery Liver Resection Abdominal Surgery Pelvic Surgery
  127. 127. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Paravertebral Insertion Level T10-L1 Bilateral Insertion Site Indication: Breast Surgery Esophagectomy Thoracic Surgery Liver Resection Abdominal Surgery Pelvic Surgery
  128. 128. BFSA Slide by Brian F S Allen BFSA BFSA Choosing Paravertebral Insertion Level T2-T6 T4-T5 T2-T3 T6-T7 T8-T9 T10-L1 Insertion Site Indication: Breast Surgery Esophagectomy Thoracic Surgery Liver Resection Abdominal Surgery Pelvic Surgery
  129. 129. BFSA Slide by Brian F S Allen BFSA BFSA T1 T2 T3 T4 T5 T6 Practical Guide to Paravertebral Placement Skin 2.5 cm For Single Injection PVBs: Mark All Needle Insertion Sites Usually every level or every other level Limit volume and concentration injected to prevent toxicity 2.5 cm
  130. 130. BFSA Slide by Brian F S Allen BFSA BFSA Thoracic Epidural Lumbar Epidural Spinal Paravertebral TAP and Rectus Sheath
  131. 131. BFSA Slide by Brian F S Allen BFSA BFSA Trunk Blocks Brian Allen
  132. 132. BFSA Slide by Brian F S Allen BFSA BFSA • TAP Block = Transversus Abdominus Plane Block – Injection into fascial plane between 2 muscle layers • Internal Oblique • Transversus Abdominus • Rectus Sheath Block – Injection into fascial plane deep to Rectus Abdominus muscle • Between Rectus and Peritoneum Practical Guide to Trunk Block Placement Postero-Lateral Antero-Medial Deep Superficial
  133. 133. BFSA Slide by Brian F S Allen BFSA BFSA • Numbs body wall, muscles, fascia • No effect on visceral pain • Performed under Ultrasound – Landmark based blocks inaccurate Practical Guide to Trunk Block Placement Postero-Lateral Antero-Medial Deep Superficial
  134. 134. BFSA Slide by Brian F S Allen BFSA BFSA • Muscles of Abdominal Wall – External Oblique – Internal Oblique – Transversus Abdominus – Rectus Abdominus • Landmarks – Costal Margin – Iliac Crest Practical Guide to Trunk Block Placement Postero-Lateral Antero-Medial Deep Superficial
  135. 135. BFSA Slide by Brian F S Allen BFSA BFSA Costal Margin Iliac Crest Practical Guide to Trunk Block Placement • Muscles of Abdominal Wall – External Oblique – Internal Oblique – Transversus Abdominus – Rectus Abdominus • Landmarks – Costal Margin – Iliac Crest Postero-Lateral Antero-Medial Deep Superficial
  136. 136. BFSA Slide by Brian F S Allen BFSA BFSA Costal Margin Iliac Crest • Muscles of Abdominal Wall – External Oblique – Internal Oblique – Transversus Abdominus (TA) – Rectus Abdominus • Landmarks – Costal Margin – Iliac Crest TA Practical Guide to Trunk Block Placement Postero-Lateral Antero-Medial Deep Superficial
  137. 137. BFSA Slide by Brian F S Allen BFSA BFSA Costal Margin Iliac Crest • Muscles of Abdominal Wall – External Oblique – Internal Oblique (IO) – Transversus Abdominus (TA) – Rectus Abdominus • Landmarks – Costal Margin – Iliac Crest IO TA Practical Guide to Trunk Block Placement Postero-Lateral Antero-Medial Deep Superficial IO TA
  138. 138. BFSA Slide by Brian F S Allen BFSA BFSA Costal Margin Iliac Crest • Muscles of Abdominal Wall – External Oblique (EO) – Internal Oblique (IO) – Transversus Abdominus (TA) – Rectus Abdominus • Landmarks – Costal Margin – Iliac Crest EO IO TA Practical Guide to Trunk Block Placement Postero-Lateral Antero-Medial Deep Superficial IO TA EO
  139. 139. BFSA Slide by Brian F S Allen BFSA BFSA Costal Margin Iliac Crest • Muscles of Abdominal Wall – External Oblique (EO) – Internal Oblique (IO) – Transversus Abdominus (TA) – Rectus Abdominus (RA) • Landmarks – Costal Margin – Iliac Crest EO IO TA RA Practical Guide to Trunk Block Placement Postero-Lateral Antero-Medial Deep Superficial IO TA EO RA
  140. 140. BFSA Slide by Brian F S Allen BFSA BFSA Costal Margin Iliac Crest • Muscles of Abdominal Wall – External Oblique (EO) – Internal Oblique (IO) – Transversus Abdominus (TA) – Rectus Abdominus (RA) • Landmarks – Costal Margin – Iliac Crest EO IO TA RA Practical Guide to Trunk Block Placement Postero-Lateral Antero-Medial Deep Superficial IO TA EO RA
  141. 141. BFSA Slide by Brian F S Allen BFSA BFSA TAP Blocks
  142. 142. BFSA Slide by Brian F S Allen BFSA BFSA Ultrasound Guidance for TAP Block Placement Ultrasound Probe Place probe lateral and posterior on body wall Postero-Lateral Antero-Medial Deep Superficial Antero-Medial Deep Superficial
  143. 143. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep Superficial IO TA EO RA Find Peritoneum Postero-Lateral Antero-Medial Deep Superficial It is the deepest bright line. Its contents peristalse Ultrasound Guidance for TAP Block Placement Intraperitoneal
  144. 144. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep Superficial IO TA EO RA Count muscular layers from deepest to superficial Postero-Lateral Antero-Medial Deep Superficial Transversus Abdominus below Internal Oblique below External Oblique Ultrasound Guidance for TAP Block Placement Intraperitoneal TA
  145. 145. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep Superficial IO TA EO RA Postero-Lateral Antero-Medial Deep Superficial Ultrasound Guidance for TAP Block Placement Intraperitoneal TA Count muscular layers from deepest to superficial IO Transversus Abdominus below Internal Oblique below External Oblique
  146. 146. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep Superficial IO TA EO RA Postero-Lateral Antero-Medial Deep Superficial Ultrasound Guidance for TAP Block Placement Intraperitoneal TA IO Count muscular layers from deepest to superficial EO Transversus Abdominus below Internal Oblique below External Oblique
  147. 147. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep Superficial IO TA EO RA Deep Superficial Ultrasound Guidance for TAP Block Placement Intraperitoneal TA IO Above External Oblique is skin, SQ tissue, fascia Superficial tissue often easy to confuse with muscle EO Skin, SQ, Fascia Muscle
  148. 148. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep IO TA EO RA Postero-Lateral Antero-Medial Deep Superficial Ultrasound Guidance for TAP Block Placement TA IO Target is plane between Internal Oblique and Transversus Abdominus EO Mark: Needle Insertion Antero-Medial to Probe
  149. 149. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep IO TA EO RA Postero-Lateral Antero-Medial Deep Superficial Ultrasound Guidance for TAP Block Placement TA IO In Plane with ultrasound probe EO Advance needle steeply from Antero- Medial to Postero- Lateral
  150. 150. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep IO TA EO RA Postero-Lateral Antero-Medial Deep Superficial Ultrasound Guidance for TAP Block Placement TA IO Look for ideal hypoechoic spead of injectate between IO & TA EO Use 4” Stimuplex needle and stand on Ipsilateral side as the block
  151. 151. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep RA Antero-Medial Postero-Lateral Deep Superficial Ultrasound Guidance for TAP Block Placement TA IO Repeat on Contralateral side EO Inject on EACH side: 20-30 mL local anesthetic +/- Dexamethasone
  152. 152. BFSA Slide by Brian F S Allen BFSA BFSA Before injection After properly placed injection Ultrasound Guidance for TAP Block Placement
  153. 153. BFSA Slide by Brian F S Allen BFSA BFSA • Counting muscles – If you can find peritoneum, count up from TA – If unclear, verify by counting down EO to IO to TA – SQ tissues can be mistaken for muscle • If target, TA, & IO still unclear: – Place probe over RA, scan lateral until muscle layers apparent Practical Guide to TAP Block Placement IO TA EO RA
  154. 154. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep IO TA EO RA Postero-Lateral Antero-Medial Deep Superficial TA IO EO Distribution of Analgesia for TAP Block Distribution may be influenced by insertion site
  155. 155. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep IO TA EO RA Postero-Lateral Antero-Medial Deep Superficial TA IO EO Distribution of Analgesia for TAP Block Distribution may be influenced by insertion site
  156. 156. BFSA Slide by Brian F S Allen BFSA BFSA Rectus Sheath Blocks
  157. 157. BFSA Slide by Brian F S Allen BFSA BFSA Ultrasound Guidance for Rectus Sheath Block Placement Ultrasound Probe (placement depends on desired block distribution) Place probe in midline at desired location on abdomen Superficial Deep Superficial Antero-Medial Deep Superficial Midline
  158. 158. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep Superficial IO TA EO RA Deep Superficial Ultrasound Guidance for Rectus Sheath Block Placement Superficial Deep Midline Intraperitoneal Find Peritoneum It is the deepest bright line. Its contents peristalse
  159. 159. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep Superficial IO TA EO RA Deep Superficial Ultrasound Guidance for Rectus Sheath Block Placement Superficial Deep Midline Intraperitoneal Find Peritoneum It is the deepest bright line. Its contents peristalse Pre-peritoneal Fat
  160. 160. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep Superficial IO TA EO RA Deep Superficial Ultrasound Guidance for Rectus Sheath Block Placement Superficial Deep Midline Intraperitoneal Find paired Rectus Muscles RA RA
  161. 161. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep Superficial IO TA EO RA Superficial Ultrasound Guidance for Rectus Sheath Block Placement Superficial Deep Midline Intraperitoneal Slide the probe to one side
  162. 162. BFSA Slide by Brian F S Allen BFSA BFSA Antero-Medial Deep Superficial IO TA EO RA Superficial Ultrasound Guidance for Rectus Sheath Block Placement Superficial Deep Intraperitoneal RA Slide the probe to one side
  163. 163. BFSA Slide by Brian F S Allen BFSA BFSA Superficial Deep Intraperitoneal RA Antero-Medial Deep Superficial IO TA EO RA Above Rectus Abdominus is skin, SQ tissue, fascia Superficial tissue can be confused with muscle Skin, SQ, Fascia Muscle Ultrasound Guidance for Rectus Sheath Block Placement
  164. 164. BFSA Slide by Brian F S Allen BFSA BFSA Deep IO TA EO RA Deep Superficial Mark: Needle Insertion Ultrasound Guidance for Rectus Sheath Block Placement Superficial Deep RA Can be Medial or Lateral to the probe
  165. 165. BFSA Slide by Brian F S Allen BFSA BFSA Deep IO TA EO RA Deep Superficial Ultrasound Guidance for Rectus Sheath Block Placement Superficial Deep RA If high subcostal or subxiphoid injection desired, probe can be rotated Many different injection sites can be chosen
  166. 166. BFSA Slide by Brian F S Allen BFSA BFSA Superficial Deep RA Deep IO TA EO RA Target is plane between Rectus Abdominus and Peritoneum Ultrasound Guidance for Rectus Sheath Block Placement
  167. 167. BFSA Slide by Brian F S Allen BFSA BFSA Deep RA Deep IO TA EO RA Ultrasound Guidance for Rectus Sheath Block Placement In Plane with ultrasound probe Advance needle from Medial to Lateral (Lateral to Medial is OK too)
  168. 168. BFSA Slide by Brian F S Allen BFSA BFSA Deep RA Deep IO TA EO RA Ultrasound Guidance for Rectus Sheath Block Placement Look for ideal hypoechoic spead of injectate between RA & Peritoneum Use 4” Stimuplex needle
  169. 169. BFSA Slide by Brian F S Allen BFSA BFSA Deep RA Deep IO TA EO RA Ultrasound Guidance for Rectus Sheath Block Placement Slide the probe to opposite side SuperficialMidline
  170. 170. BFSA Slide by Brian F S Allen BFSA BFSA Deep RA Deep Ultrasound Guidance for Rectus Sheath Block Placement Use the same skin insertion site Superficial Block the contralateral side
  171. 171. BFSA Slide by Brian F S Allen BFSA BFSA Deep RA Deep Ultrasound Guidance for Rectus Sheath Block Placement Superficial Inject on EACH side: 10-15 mL local anesthetic +/- Dexamethasone Block the contralateral side
  172. 172. BFSA Slide by Brian F S Allen BFSA BFSA Deep RA Deep IO TA EO RA Distribution of Analgesia for Rectus Sheath Block
  173. 173. BFSA Slide by Brian F S Allen BFSA BFSA Deep RA Deep IO TA EO RA Distribution of Analgesia for Rectus Sheath Block

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