This talk was given at the 2019 European Society of Regional Anaesthesia Meeting in Bilbao, Spain.
In this Talk, we cover the potential mechanisms behind how fascial plane blocks might work and also discuss why there may be such variation in clinical effect.
This talk was recorded as part of the Norwich Anaesthesia Update on 13th January 2021.
Here Dr Pawa Discusses the role of fascial plane blocks in modern anaesthetic practice along with key concepts ranging from mechanisms of action, evidence of efficacy and whether they are here to stay.
Dr Amit Pawa - concepts in Fascial Plane Blocks Amit Pawa
In this talk given at the Royal College of Anaesthetists Virtual Seminar - Regional Anaesthesia Masterclass - on 24th March 2021, Dr Amit Pawa covers some of the important concepts in the rapidly emerging field of fascial plane blocks - this talk is broadly based on a presentation given at the Norwich Anaesthesia update earlier the same year which was not held live as planned due to COVID19 workforce issues
This presentation was delivered during a webinar held by the association of anaesthetists in association with RA-UK entitled "New Blocks - Friend or Foe?".
This took place on 19th October 2021.
In this short presentation - Dr Pawa covers: a brief overview of the history of Paravertebral blocks; how he got introduced to them; some updates on our understanding on the anatomy; and whether they still have a role in modern anaesthetic practice.
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
Erector spinae plane block is a relatively novel approach to pain management for a variety of surgical procedures. ESP block is a challenging anesthesia and analgesia technique that needs more research.
ESP block - future direction and remaining questionsAmit Pawa
This Talk was delivered by Dr Pawa on 5th June 2021 as part of the ISURA 2021 hybrid conference held in Toronto.
The Future Direction of this block and remaining questions to be answered are covered here
This talk was recorded as part of the Norwich Anaesthesia Update on 13th January 2021.
Here Dr Pawa Discusses the role of fascial plane blocks in modern anaesthetic practice along with key concepts ranging from mechanisms of action, evidence of efficacy and whether they are here to stay.
Dr Amit Pawa - concepts in Fascial Plane Blocks Amit Pawa
In this talk given at the Royal College of Anaesthetists Virtual Seminar - Regional Anaesthesia Masterclass - on 24th March 2021, Dr Amit Pawa covers some of the important concepts in the rapidly emerging field of fascial plane blocks - this talk is broadly based on a presentation given at the Norwich Anaesthesia update earlier the same year which was not held live as planned due to COVID19 workforce issues
This presentation was delivered during a webinar held by the association of anaesthetists in association with RA-UK entitled "New Blocks - Friend or Foe?".
This took place on 19th October 2021.
In this short presentation - Dr Pawa covers: a brief overview of the history of Paravertebral blocks; how he got introduced to them; some updates on our understanding on the anatomy; and whether they still have a role in modern anaesthetic practice.
new technique for pain management ,described by dr forero ,it can replace epidural anesthesia,paravertebral anesthesia and other regional blocks.it can be used for both acute and chronic painful conditions
Erector spinae plane block is a relatively novel approach to pain management for a variety of surgical procedures. ESP block is a challenging anesthesia and analgesia technique that needs more research.
ESP block - future direction and remaining questionsAmit Pawa
This Talk was delivered by Dr Pawa on 5th June 2021 as part of the ISURA 2021 hybrid conference held in Toronto.
The Future Direction of this block and remaining questions to be answered are covered here
Trunk Blocks - Plan A Blocks - Royal College of Anaesthetists & Regional Anae...Amit Pawa
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.
This is a lecture that Dr Amit Pawa gave in Lausanne, Switzerland in October 2018 as part of the 4th Romandie Day of Regional Anaesthesia. In it he covers a variety of techniques applicable to regional anaesthesia for breast surgery- note - versions of this course have been delivered at courses in the UK in the past
The transversus abdominis plane, more commonly referred to as the TAP block,
Places local anesthetic in the lateral abdominal wall in a plane between the internal oblique and the transversus abdominis muscles.
Here, the local anesthetic block can block many of the abdominal nerves as they pass to the abdominal structures.
Update on regional anesthesia for breast surgery - Michael Herrick - SSAI2017scanFOAM
A talk by Michael Herrick at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
These slides have been selected from an "ask the expert" session that Dr Amit Pawa gave at the Dublin Convention Centre on 13th September 2018 for the ESRA (European Society of Regional Anaesthesia) 2018 annual meeting. These slides are shared to anyone with the link - please only practice techniques described if you are suitably trained to do so. Many thanks
Trunk Blocks - Plan A Blocks - Royal College of Anaesthetists & Regional Anae...Amit Pawa
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.
This is a lecture that Dr Amit Pawa gave in Lausanne, Switzerland in October 2018 as part of the 4th Romandie Day of Regional Anaesthesia. In it he covers a variety of techniques applicable to regional anaesthesia for breast surgery- note - versions of this course have been delivered at courses in the UK in the past
The transversus abdominis plane, more commonly referred to as the TAP block,
Places local anesthetic in the lateral abdominal wall in a plane between the internal oblique and the transversus abdominis muscles.
Here, the local anesthetic block can block many of the abdominal nerves as they pass to the abdominal structures.
Update on regional anesthesia for breast surgery - Michael Herrick - SSAI2017scanFOAM
A talk by Michael Herrick at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
These slides have been selected from an "ask the expert" session that Dr Amit Pawa gave at the Dublin Convention Centre on 13th September 2018 for the ESRA (European Society of Regional Anaesthesia) 2018 annual meeting. These slides are shared to anyone with the link - please only practice techniques described if you are suitably trained to do so. Many thanks
Tips and tricks to site and maintain nerve cathetersAmit Pawa
This lecture was given on Friday 13th September 2019 at the annual congress of the European Society of Regional Anaesthesia in Bilbao and Spain. The talk was also contributed to by the Twitter Community. Strategies and techniques to site, secure and maintain perineural nerve catheters is discussed
Cervical Hybrid Arthroplasty by Pablo Pazmino MDPablo Pazmino
This video explains Cervical Arthroplasty in combination with a fusion. When people have more than one cervical disc which has degenerated or which has sustained a traumatic rupture they may need a procedure to address both levels. These herniations may begin to affect the surrounding nerves and/or spinal cord. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Cervical Herniations/ Radiculopathy at multiple levels feel free to look us up online www.beverlyspine.com or call toll free 1-8SPINECAL-1
Fundamentals of Regional Anaesthesia & Plan A BlocksAmit Pawa
This Talk Was delivered by Dr Pawa at the South London Regional Anaesthesia workshop programme Monday 6th December at Guy's Hospital. It features material covered previously, but with updates and QR code links to references
Regional Anaesthesia for the Obese PatientAmit Pawa
This talk was delivered virtually by Dr Amit Pawa on 2nd December 2021 as part of a joint webinar between the Society for Obesity and Bariatric Anaesthesia (SOBAUK) and the European Society for Perioperative Care of Obese Patients (ESPCOP).
He covers the advantages and range of Regional Anaesthetic Techniques to consider when placing regional anaesthesia in patients living with obesity
ESRA 2021 Presentation - Optimal Analgesia for Breast Cancer SurgeryAmit Pawa
This talk was delivered virtually at the 2021 ESRA Congress.
In this Presentation, Dr Pawa uses the new approved Block Nomenclature and helps navigate a journey through optimal analgesia for patients having breast cancer surgery
This Talk was given by Dr Amit Pawa during the #RAUK21 Spinal & Paraspinal Symposium on 5th May 2021. The Case presented is as follows:
Case:
You are asked to review a 69 yo woman who has fallen down a flight of stairs and has sustained multiple rib fractures 4-10 with flail segment on right and 5-7 ribs on left. She also has fractures of her right clavicle, scapula and thoracic spine injuries. She is anticoagulated for a recent DVT.
Learning outcomes:
1. Do all rib fractures score a regional technique?
2. What is your block of choice here? When to perform ESP vs SPB pattern of injury.
3. Any concerns regarding anticoagulation here?
4. Is it worth attempting to block for other commonly injured bones?
The Recorded talk will be available for those registered to view on the conference website for 1 year after the event
his lecture was given as part of the Doctors Updates Online webinar 2020 which was due to be held in Da Balaia but due to COVID-19 was turned into an online meeting. Dr Pawa covers Regional Anaesthesia Use during the COVID-19 Pandemic and Potential Strategies to utilise it during the recovery phase
Regional Anaesthesia in a Nationalised Healthcare SystemAmit Pawa
Dr Pawa was invited to the American Society of Regional Anaesthesia and Pain Medicine in Las Vegas in April 2019. He was asked to discuss the delivery of Regional Anesthesia in the NHS
Pro-Con Debate - Are we making RA too complicated? Con SideAmit Pawa
At The Regional Anaesthesia UK (RA-UK) annual Scientific Meeting In Belfast in May 2019 - Dr Pawa Had a fun and lively debate with Dr Lloyd Turbitt on this very relevant subject - you can find his side of the argument here!
How I perform my Paravertebral Blocks for breast surgeryAmit Pawa
In October 2019 Dr Pawa Was invited to the Romandie Day of Regional Anaesthesia in Lausanne, Switzerland by Dr Eric Albrecht. He was asked to share some of his tips on siting Paravertebral blocks for Breast Surgery
Local anaesthetic prescription for continuous nerve blocksAmit Pawa
In October 2019 Dr Pawa was invited by Dr Eric Albrecht to Lecture at the Romandie Day of Regional Anaesthesia in Lausanne, Switzerland. He was given the task of summarising the options and evidence for post-operative prescriptions of Local Anaesthetic for continuous nerve catheters.
In November 2019 Dr Pawa was invited to lecture and teach at the World Famous Cleveland Clinic for the 6th Annual Cadaveric Regional Anaesthesia Course & POCUS Workshop. This Lecture was on Anatomy and Ultrasound of the upper limb and featured mostly videos - PDFs of the slides are available here and credit must go to 3D4Medical app Essential Anatomy 5 that Dr Pawa used to create the video animations
Peripheral Nerve Catheters - an introductionAmit Pawa
In November 2019 Dr Pawa Delivered a Lecture to the South Thames Acute Pain Group, in Cobham, Just outside London, on Peripheral Nerve Catheters. This was meant to serve as an introduction to the subject and to outline some of the challenges and difficulties he had instituting these at his own trust.
These are an edited selection of slides from A lecture given by Dr Amit Pawa on Regional Anaesthesia and Sedation techniques for Awake Breast Surgery. The Lecture was delivered at the Association of Anaesthetists Trainee Conference #TraineeConf19 in Telford, UK on 3rd July 2019
This is a lecture that Dr Amit Pawa gave in Lausanne, Switzerland in October 2018 as part of the 4th Romandie Day of Regional Anaesthesia. In it he covers some tips and tricks as part of an introduction to Ultrasound guided regional anaesthesia - note - versions of this course have been delivered at courses in the UK in the past
PAWA Vs NEWMAN - GA vs RA for Hip FractureAmit Pawa
Here are my slides from my pro-con debate with Prof Neuman
at ASRAWorld18 in NYC. - It was a lighthearted debate in the setting of a court case with General Anaesthesia being "put on trial" - I was the defense attorney
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
20. Soft collagen-containing
loose & dense fibrous connective tissue
Permeates whole body
Skin
Superficial fascia
Deep Fascia
(multilayer)
Muscle & related fasciaSuperficial adipose tissue
Deep adipose tissue
Loose connective tissue
What is Fascia?
@amit_pawa
21. Deep Fascia
Multiple layers
Extends through whole body
Target for Fascial plane blocks
Forms sheaths for nerves/vessels/organs
Independent of muscle below
@amit_pawa
26. Parietal pleura
Ventral ramus
Dorsal ramus
ESM
Lateral cutaneous branch of intercostal nerve
Anterior cutaneous branch of intercostal nerve
Transversus thoracis muscle
Pec. major
Pec. minor
Inn IMInt IMExt IM
Serratus anterior muscle
Latissimus dorsi muscle
Lateral and medial pectoral nerves
PEC I
PEC II
SAP Blocks
Pecto-Intercostal Fascial Block
RLBESP TPVBMTP
Pectoral branch of thoracoacromial artery
SIFB
Rhomboid
Rhomboid
Intercostal Block
Subserratus
Plane Block
RISS
Dr Ann Barron
@Ann_Barron1
PIFB: Pecto-Intercostal Fascial Block
SIFB: Serratus intercostal Fascial block
SAP: Serratus Anterior Plane
RISS: Rhomboid Intercostal & SubSerratus Plane Block
MTP: Mid-Point Transverse Process to Pleura
ESP: Erector Spinae
TPVB: Thoracic ParaVertebral Block
RLB: RetroLaminar Block
@amit_pawa
27. Parietal pleura
Lateral cutaneous branch of intercostal nerve
Anterior cutaneous branch of intercostal nerve
Transversus thoracis muscle
Pec. major
Pec. minor
Latissimus dorsi muscle
Lateral and medial pectoral nerves
PEC I
PEC II
SAP Blocks
Pecto-Intercostal Fascial Block
Pectoral branch of thoracoacromial artery
SIFB
33. 3. Biomechanical properties
Pumping mechanism due to muscle tendons?
Contractile elements within fascia?
-> Variable/extensive dermatomal spread?
Effect of:
Depth of Anaesthesia & Muscle Relaxation?
@amit_pawa
34. Nerve elements may lie within the fascia
A & C Fibres
Wide Dynamic Range neurons
Mechanoreceptors
Do these influence Fascial plane blocks?
4. Local Fascial Innervation
@amit_pawa
35. Not All fascias are the same
Number of layers
Pectoral region - 1
The Limbs - 2 or 3
Middle Thoracolumbar 3
Function & Mobility More mobile may
increase LA spread
Surrounding structures
Lungs/liver/spleen
IPPV vs SV
@amit_pawa
38. Even when you get in the correct
plane - does the LA stay there?
Yang H, Kim SH Injectate spread in interfascial plane block: a microscopic finding
Regional Anesthesia & Pain Medicine Published Online First: 05 July 2019.
doi: 10.1136/rapm-2019-100693
@amit_pawa
39. Even when you get in the correct
plane - does the LA stay there?
Yang H, Kim SH Injectate spread in interfascial plane block: a microscopic finding
Regional Anesthesia & Pain Medicine Published Online First: 05 July 2019.
doi: 10.1136/rapm-2019-100693
“The Fascial plane is not a closed space”
"Injectate spread into the internal oblique &
transversus abdominus muscle via the Perimysium”
Could this affect the amount of LA
available to act?
@amit_pawa
41. What can we say so far?
Not all fascial plane blocks are equal
Not all fascial plane blocks work (the same way!)
Fascial plane blocks have variable efficacy
Identifying the correct plane is not always easy
(“Seeker” solution)
@amit_pawa
43. (a)
(b)
Anaesthesia, 2011, 66, pages 1023–1030
..............................................................................................
rsal extension with an anterior subcostal
ock. (b) Bilateral mid-axillary ultra-
(b)
Figure 8 (a) Bilateral ultrasound via the posterior approac
showing extension along the quadratus lumborum muscle
ORIGINAL ARTICLE
Studies on the spread of local anaesthetic solution in
transversus abdominis plane blocks*
J. Carney,1
O. Finnerty,1
J. Rauf,1
D. Bergin,4
J. G. Laffey2
and J. G. Mc Donnell3
1 Registrar, 2 Professor, 3 Senior Clinical Lecturer, Department of Anaesthesia and Intensive Care Medicine,
4 Senior Clinical Lecturer, Department of Radiology, Galway University Hospitals, Galway, Ireland
Summary
The extent of analgesia provided by transversus abdominis plane blocks depends upon the site of
injection and pattern of spread within the plane. There are currently a number of ultrasound-
guided approaches in use, including an anterior oblique-subcostal approach, a mid-axillary
approach and a more recently proposed posterior approach. We wished to determine whether the
site of injection of local anaesthetic into the transversus abdominis plane affects the spread of the
local anaesthetic within that plane, by studying the spread of a local anaesthetic and contrast
solution in four groups of volunteers. The first group underwent the classical landmark-based
transversus abdominis plane block whereby two different volumes of injectate were studied:
0.3 ml.kg)1
vs 0.6 ml.kg)1
. The second group underwent transversus abdominis plane block using
the anterior subcostal approach. The third group underwent transversus abdominis plane block
using the mid-axillary approach. The fourth group underwent transversus abdominis plane block
using the posterior approach, in which local anaesthetic was deposited close to the antero-lateral
border of the quadratus lumborum. All volunteers subsequently underwent magnetic resonance
imaging at 1, 2 and 4 h following each block to determine the spread of local anaesthetic over time.
The studies demonstrated that the anterior subcostal and mid-axillary ultrasound approaches res-
ulted in a predominantly anterior spread of the contrast solution within the transversus abdominis
plane and relatively little posterior spread. There was no spread to the paravertebral space with the
anterior subcostal approach. The mid-axillary transversus abdominis plane block gave faint contrast
ORIGINAL ARTIC
Studies on the sp
transversus abdom
1 1
Anaesthesia, 2011, 66, pages 1023–1030
..............................................................
US- Guided Posterior TAP spreads to PVS
@amit_pawa
44. SCIENTIFIC ARTICLE
Axillary local anesthetic spread after the thoracic
interfacial ultrasound block --- a cadaveric and
radiological evaluation
Patricia Alfaro de la Torrea
, Jerry Wayne Jones Jr.b
, Servando López Álvarezc
,
Paula Diéguez Garciac
, Francisco Javier Garcia de Migueld
, Eva Maria Monzon Rubioe
,
Federico Carol Boerisf
, Monir Kabiri Sacramentog
, Osmany Duanyh
,
Mario Fajardo Pérezi,∗
, Borja de la Quintana Gordonj
a
Tajo University Hospital, Madrid, Spain
b
University of Tennessee Health Science Center/Regional One Health, College of Medicine, Department of Anesthesiology, TN,
USA
c
Hospital Complexo Hospitalario de A Coru˜na, Coru˜na, Spain
d
Hospital General de Segovia, Departamento de Anestesia, Segovia, Spain
e
Tajo University Hospital, Departamento de Anestesia, Madrid, Spain
f
Hospital Universitario Parc Tauli Sabadell, Sabadell, Spain
g
Hospital Universitario de Guadalajara, Guadalajara, Spain
h
Primary Care and Chronic Pain Management Attending, Department of Veterans Affairs, Muskogee, OK, USA
i
Hospital Universitario de Móstoles, Madrid, Spain
j
Hospital Universitario de Móstoles, Departamento de Anestesia, Madrid, Spain
Received 23 February 2015; accepted 14 April 2015
Available online 22 June 2016
KEYWORDS
Anesthesia,
conduction;
Axilla;
Intercostal muscles;
Brachial plexus block;
Intercostal nerves;
Lymph node excision;
Ultrasonography
Abstract
Background: Oral opioid analgesics have been used for management of peri- and postoperative
analgesia in patients undergoing axillary dissection. The axillary region is a difficult zone to block
and does not have a specific regional anesthesia technique published that offers its adequate
blockade.
Methods: After institutional review board approval, anatomic and radiological studies were
conducted to determine the deposition and spread of methylene blue and local anesthetic
injected respectively into the axilla via the thoracic inter-fascial plane. Magnetic Resonance
Imaging studies were then conducted in 15 of 34 patients scheduled for unilateral breast surgery
that entailed any of the following: axillary clearance, sentinel node biopsy, axillary node biopsy,
or supernumerary breasts, to ascertain the deposition and time course of spread of solution
within the thoracic interfascial plane in vivo.
Rev Bras Anestesiol. 2017;67(6):555---564
REVISTA
BRASILE
ANESTE
SCIENTIFIC ARTICLE
Axillary local anesthetic
cal anesthetic spread after the thoracic interfacial 559
to identify, in the surface plane, the pectoralis muscles,
the toracho-achromial artery and the cephalic vein that lie
between them. In the deep plane, the SAM is identified,
resting on the ribs. The needle is then introduced in-plane
from medial to lateral, and its tip is placed between the
SAM and the External Intercostal muscle at level of sec-
ond rib. Twenty mL of Levobupivacaine 0.25% + Epinephrine
1:200,000 were injected under direct ultrasound visualiza-
tion in real time, fragmenting the total volume, aspirating
every 3 mL to reduce the risk of intravascular injection
and minimizing the patient discomfort on hydrodissection
(Fig. 2A).
Study 1: determination of injectate spread during
SIFB using MRI
The aim of this study was to determine the axillary spread
of the injectate within the SIFB anterior approach. Our
image study consisted of a MRI done immediately after
LA injection. Our radiologist used MRI sequences to show
T2---weighed, fat-suppressed images, making axial and coro-
nal thoracic sections from the supraclavicular regions to the
inframammary crease. The same radiologist, proficient in
thoracic MRI, analyzed the images and issued a report of
the spread of the LA injectate in the interfascial thoracic
“PECS" spreads to
Intercostobrachial
Medial Brachiocutaneous
Lateral Cutaneous Branches T1-3
@amit_pawa
47. ESP Mechanism?
PVB spread by Proxy?
jected dyes into the back muscles after retrolaminar (RL, right) and ESP block (ESP, left).
columbar fascia covering the erector spinae muscle was revealed. (b) The muscle fibre
The spread pattern of the dyes in the vertebral laminae was seen after removal of all bac
ocostalis; Lo, longissimus thoracis).
(b)
(c)
Anaesthesia 2018, 73, 1244–1250
Original Article
Comparison of injectate spread and nerve involvement
between retrolaminar and erector spinae plane blocks in
the thoracic region: a cadaveric study
H.-M. Yang,1
Y. J. Choi,2
H.-J. Kwon,3
J. O,3
T. H. Cho3
and S. H. Kim4
1 Assistant Professor, 2 Instructor, 3 Research Assistant, Department of Anatomy, 4 Associate Professor, Department of
Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine,
Seoul, Korea
Summary
Although different injection locations for retrolaminar and erector spinae plane blocks have been described,
the two procedures have a similar anatomical basis. In this cadaveric study we compared anatomical spread of
dye in the thoracic region following these two procedures. Following randomisation, 10 retrolaminar blocks
and 10 erector spinae plane blocks were performed on the left or right sides of 10 unembalmed cadavers. For
each block, 20 ml of dye solution was injected at the T5 level. The back regions were dissected and the
involvement of the thoracic spinal nerve was also investigated. Twenty blocks were successfully completed. A
consistent vertical spread, with deep staining between the posterior surface of the vertebral laminae and the
overlaying transversospinalis muscle was observed in all retrolaminar blocks. Moreover, most retrolaminar
blocks were predominantly associated with fascial spreading in the intrinsic back muscles. With an erector
spinae plane block, dye spread in a more lateral pattern than with retrolaminar block, and fascial spreading in
the back muscles was also observed. The number of stained thoracic spinal nerves was greater with erector
spinae plane blocks than with retrolaminar blocks; median 2.0 and 3.5, respectively. Regardless of technique,
the main route of dye spread was through the superior costotransverse ligament to the ipsilateral paravertebral
space. Although erector spinae plane blocks were associated with a slightly larger number of stained thoracic
spinal nerves than retrolaminar blocks, both techniques were consistently associated with posterior spread of
Anaesthesia 2018 doi:10.1111/anae.14408
Original Article
Comparison of injectate spread and ner
between retrolaminar and erector spina
the thoracic region: a cadaveric study
H.-M. Yang,1
Y. J. Choi,2
H.-J. Kwon,3
J. O,3
T. H. Cho3
and S. H
Anaesthesia 2018, 73, 1244–1250
“the amount of dye within the paravertebral space following both
retrolaminar and ESP injections seemed to be too small to allow for upward
or downward flow.”
@amit_pawa
50. Spread to Th PV Space in 4 out of 11 cadavers
(T2 injection)
Unpredictable Spread
Anesthesia & Analgesia. Publish Ahead of Print():, MAY 15, 2019 DOI: 10.1213/ANE.0000000000004187
ESP Mechanism?
@amit_pawa
51. ESP/MICB vs ThPVB
PV Spread in BOTH
MICB > ESP
2019 - Pub ahead of print
@amit_pawa
53. What can we say so far?
There is limited evidence of “By-Proxy” spread
Variation exists in Cadaver studies too!
Cadaver results may not relate to “Real Life”
(Mechanical Ventilation/Movement)
@amit_pawa
59. What do these say?
QL/ESP fascial plane blocks:
1. Reduce Pain Scores
2.Reduce Opioid Requirements
When compared to SYSTEMIC analgesia alone
@amit_pawa
63. Fascial Plane Blocks
Many unanswered questions
Unknown mechansims of action
Cadaveric studies do not reflect “real life”
Clinical studies demonstrate benefit - variable efficacy
Need more evidence
More Likely to be performed by the less experienced
@amit_pawa
64. Fascial Plane Blocks
Many unanswered questions
Unknown mechansims of action
Cadaveric studies do not reflect “real life”
Clinical studies demonstrate benefit - variable efficacy
Need more evidence
More Likely to be performed by the less experienced
Because, compared to TEA/PVB…
@amit_pawa
65. Fascial Plane Blocks
May be EASIER to site
May be SAFER to site - and may work “By Proxy”
May be QUICKER to site
SHOULD be combined with Multimodal Analgesics
Are HERE TO STAY!
@amit_pawa