The document discusses various fascial plane blocks and the mechanism of action of local anesthetics administered in these blocks. It presents several key points:
1. Fascial plane blocks are a heterogeneous group of techniques that deposit local anesthetic in fascial planes surrounding nerves.
2. The exact mechanism of action of fascial plane blocks is unknown, but local anesthetic may act on nerves within the injected plane, adjacent planes, or at distant sites via systemic absorption.
3. Studies show injectate from fascial plane blocks can spread widely, including to adjacent fascial planes and the thoracic paravertebral space, potentially blocking multiple nerve types over large areas.
Concepts in Fascial Plane Blocks - What Every Anaesthetist Needs to KnowAmit Pawa
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.
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
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
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
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.
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
This document discusses the serratus anterior plane block for pain management following rib fractures. It provides anatomy of what nerves are blocked, including the intercostal, long thoracic, and thoracodorsal nerves. Evidence for how the block provides analgesia is limited but may include direct spread to the periosteum of fractured ribs or splinting of the external intercostal muscle. The document recommends using an e-cath needle to administer 20-40mL of 0.2-1% ropivacaine as a single shot or continuous infusion of 20mL boluses every 4 hours for rib fracture pain management.
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.
Concepts in Fascial Plane Blocks - What Every Anaesthetist Needs to KnowAmit Pawa
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.
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
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
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
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.
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
This document discusses the serratus anterior plane block for pain management following rib fractures. It provides anatomy of what nerves are blocked, including the intercostal, long thoracic, and thoracodorsal nerves. Evidence for how the block provides analgesia is limited but may include direct spread to the periosteum of fractured ribs or splinting of the external intercostal muscle. The document recommends using an e-cath needle to administer 20-40mL of 0.2-1% ropivacaine as a single shot or continuous infusion of 20mL boluses every 4 hours for rib fracture pain management.
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 document discusses the quadratus lumborum (QL) block. It begins by describing the anatomy of the QL muscle and its relation to surrounding fascia. It then outlines four types of QL blocks - lateral, posterior, anterior, and intramuscular - showing their needle positions and expected spread. Studies comparing these blocks found the anterior approach consistently blocked lumbar nerves while the posterior approach showed more reliable thoracic spread. Risks include lumbar plexus involvement and proximity to kidneys. In conclusion, QL blocks may provide superior thoracic coverage to TAP blocks and the anterior approach can block the lumbar plexus, but more research is needed to validate techniques and determine best practices.
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
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
ESRA 2021 Presentation - Optimal Analgesia for Breast Cancer SurgeryAmit Pawa
This document discusses optimal analgesia strategies for breast surgery. It begins by outlining relevant surgical considerations and patient concerns. It then covers breast anatomy and innervation in detail. A variety of regional anesthesia techniques are presented, including paravertebral blocks, pectoral plane blocks, and erector spinae plane blocks. The document emphasizes the importance of a multimodal approach and combining different block techniques for major breast surgeries. Quality of recovery scores are discussed as an outcome measure, with some evidence that paravertebral blocks and combination blocks may improve scores compared to no block or local anesthesia alone.
This document provides information about celiac plexus block (CPB) procedures, including indications, neurolytic agents used, landmarks, insertion technique, complications, success rates, and references. It lists acute or chronic pancreatitis, pancreatic cancer, intra-abdominal metastatic disease, and diagnostic blocks as common indications for CPB. Complications include pneumothorax, nerve injury, and hypotension. Success rates from a referenced study found 89% of patients had adequate or excellent pain relief within the first week and 70-90% continued to have relief at 3 months.
A primer on lower extremity regional anesthesia, including instructions for sciatic, parasacral, lumbar plexus, femoral, saphenous, popliteal, lateral femoral cutaneous, obturator, and ankle blocks
1) Anesthesia has come a long way from the days when surgery was performed without pain relief. Various crude methods were used to relieve pain before the discovery of modern anesthesia in the 1840s.
2) Key milestones in anesthesia history include the first use of ether in 1846, the introduction of injectable cocaine and local anesthesia in 1884, and the development of muscle relaxants and modern inhalational agents.
3) Anesthesia continues to advance with new drugs, monitoring techniques, and the increasing role of technology including automated drug delivery systems and one day possibly robotic anesthesia administration. The future may see further developments in areas like artificial intelligence, personalized medicine, and remote anesthesia delivery via telemedicine.
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
The document discusses several new and emerging concepts in nerve blocks. It covers new equipment like echogenic needles and catheters, ultrasonography advances like 3D and 4D ultrasound, and pressure monitoring devices. It also discusses learning tools like phantoms and robots. Newer nerve blocks described include the erector spinae block and rhomboid block. Adjuvants to prolong peripheral nerve blocks and new formulations like liposomal bupivacaine and proliposomal ropivacaine are covered.
Neuromonitoring techniques can monitor the brain's function, cerebral blood flow and intracranial pressure, and brain oxygenation and metabolism. Electroencephalography (EEG) measures electrical brain activity and is useful for detecting ischemia. Evoked potentials like somatosensory evoked potentials (SSEPs) monitor sensory pathways from stimulus to cortex. Jugular venous oximetry and near infrared spectroscopy (NIRS) provide noninvasive monitoring of cerebral oxygenation. These techniques guide anesthesia management and detect intraoperative brain injury.
This document provides background information and details on the technique of performing a transversus abdominis plane (TAP) block. It begins with an overview of the TAP block, including its original description and subsequent modifications using ultrasound guidance. Next, it discusses the indications for TAP blocks, including postoperative analgesia for various abdominal surgeries. The anatomy section describes the layers and nerves of the abdominal wall targeted by the block. Finally, the technique section outlines the materials, patient positioning, ultrasound probe placement, needle insertion, and local anesthetic injection steps to perform a TAP block.
This document provides information on brachial plexus nerve blocks. It discusses the various techniques for brachial plexus blocks including interscalene, supraclavicular, infraclavicular, and axillary blocks. The advantages of nerve blocks are outlined as avoidance of general anesthesia, early recovery, and excellent postoperative pain relief. Potential complications include nerve injury, local anesthetic toxicity, hematoma, and diaphragmatic paralysis. Proper patient preparation and use of ultrasound or nerve stimulation techniques can help accurately place the local anesthetic and minimize complications.
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.
There are currently few options to extend the duration of regional analgesia at home beyond the one day expected from most single-injection nerve blocks. Continuous peripheral nerve block (CPNB) with a plain local anesthetic perineural infusion is the most established way to provide days of postoperative pain control and allows titration, but training in insertion techniques and a system to manage ambulatory CPNB patients are necessary. Adjuvants or depot formulations of local anesthetics may offer potential options for limited extension of block duration, but further studies regarding efficacy and safety for regional anesthesia as well as comparative-effectiveness versus CPNB are necessary.
At the conclusion of this activity, learners will be able to: discuss the indications for continuous peripheral nerve blocks; identify obstacles to implementing a continuous peripheral nerve block system; examine various techniques and equipment for continuous peripheral nerve block performance; and discuss the application of ultrasound guidance for perineural catheter insertion.
This document classifies myasthenia gravis into different categories based on the muscles affected and severity of symptoms. Category I involves only ocular muscles with negative tests on other muscles, while Category Ia includes ocular involvement and positive peripheral muscle tests without symptoms. Categories II-IV classify generalized myasthenia gravis as mild, moderate, acute fulminating, or late severe based on impact. Repetitive nerve stimulation and single fiber electromyography are described as electrophysiological tests used in diagnosis.
Interfascial Plane Blocks Offer an Acceptable Alternative to Thoracic Epidura...Edward R. Mariano, MD
This was part of a debate held at #ANES20 (recording available from ASA) between me and Dr. Jeff Gadsden from Duke University School of Medicine. Dr. Gadsden and I clashed on the same topic last year at #ANES19 during which I promoted thoracic epidural analgesia, and Dr. Gadsden made the case for interfascial plane blocks. This year we switched sides! Link to my slides from #ANES19: https://www.slideshare.net/EdwardRMariano/thoracic-epidural-analgesia-is-the-gold-standard-for-major-abdominal-surgery
The objectives of this session were as follows:
1. Discuss multimodal pain management strategies in the context of enhanced recovery programs;
2. Discuss advantages and disadvantages of thoracic epidural analgesia for major abdominal surgery in the context of enhanced recovery programs;
3. Discuss advantages and disadvantages of truncal somatic blocks in the context of enhanced recovery programs; and
4. Discuss developing safe and effective procedure specific pain management strategies for major abdominal surgery.
Newer Truncal Blocks Do they have place in current practice.pptxashokJadon4
Interfascial plane blocks also known as Truncal blocks are US guided regional blocks of thorax and abdomen. They have been used extensively for acute pain management and now their role is further expanding for chronic pain conditions. It has been suggested that they work by neural adhesiolysis, breaking the pain cycle by blocking the pain signals and also by anti-inflammatory action of steroids used with local anesthetic.
Thoracic Epidural Analgesia is the Gold Standard for Major Abdominal SurgeryEdward R. Mariano, MD
At Anesthesiology 2019, the annual meeting of the American Society of Anesthesiologists (#ANES19), I debated Dr. Jeff Gadsden from Duke on the topic of whether or not thoracic epidural analgesia is the gold standard for major abdominal surgery. Dr. Vijay Gottumukkala organized and moderated the debate and assigned sides: pro (me) and con (Jeff).
PCA is neither “ one size fits all “ or a “ set and forget “ therapy
An Anesthesiologist style ……….
no fixed dose of drug fits all patient
make patient analgesia and take care
Diaphragm sparing nerve blocks for shoulder surgery부휘 홍
- Diaphragm sparing nerve blocks aim to provide analgesia for shoulder surgery while avoiding hemidiaphragmatic paralysis.
- Several techniques were evaluated including supraclavicular, interscalene, suprascapular, superior trunk, and costoclavicular blocks.
- The superior trunk block had the lowest rate of hemidiaphragmatic paralysis compared to the interscalene block. The costoclavicular block also had a lower rate than the supraclavicular block.
- Low volumes, extrafascial injections, and targeting specific branches may further reduce hemidiaphragmatic paralysis risk for various nerve blocks. Future techniques aim to develop a reliable diaphragm
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
This study investigated the effects of N-acetylcysteine (NAC) on asprosin and meteorin-like protein (METRNL) levels in a rat model of lower extremity ischemia-reperfusion injury. Rats were divided into five groups: a control group, sham surgery group, NAC treatment group, ischemia-reperfusion injury group, and ischemia-reperfusion injury plus NAC treatment group. Serum and tissue levels of asprosin and METRNL were measured after 120 minutes of reperfusion. The results showed that asprosin and METRNL levels were lower in the ischemia-reperfusion injury group compared to controls, but higher in the ischemia-reperfusion injury plus NAC treatment group compared
This document discusses the quadratus lumborum (QL) block. It begins by describing the anatomy of the QL muscle and its relation to surrounding fascia. It then outlines four types of QL blocks - lateral, posterior, anterior, and intramuscular - showing their needle positions and expected spread. Studies comparing these blocks found the anterior approach consistently blocked lumbar nerves while the posterior approach showed more reliable thoracic spread. Risks include lumbar plexus involvement and proximity to kidneys. In conclusion, QL blocks may provide superior thoracic coverage to TAP blocks and the anterior approach can block the lumbar plexus, but more research is needed to validate techniques and determine best practices.
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
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
ESRA 2021 Presentation - Optimal Analgesia for Breast Cancer SurgeryAmit Pawa
This document discusses optimal analgesia strategies for breast surgery. It begins by outlining relevant surgical considerations and patient concerns. It then covers breast anatomy and innervation in detail. A variety of regional anesthesia techniques are presented, including paravertebral blocks, pectoral plane blocks, and erector spinae plane blocks. The document emphasizes the importance of a multimodal approach and combining different block techniques for major breast surgeries. Quality of recovery scores are discussed as an outcome measure, with some evidence that paravertebral blocks and combination blocks may improve scores compared to no block or local anesthesia alone.
This document provides information about celiac plexus block (CPB) procedures, including indications, neurolytic agents used, landmarks, insertion technique, complications, success rates, and references. It lists acute or chronic pancreatitis, pancreatic cancer, intra-abdominal metastatic disease, and diagnostic blocks as common indications for CPB. Complications include pneumothorax, nerve injury, and hypotension. Success rates from a referenced study found 89% of patients had adequate or excellent pain relief within the first week and 70-90% continued to have relief at 3 months.
A primer on lower extremity regional anesthesia, including instructions for sciatic, parasacral, lumbar plexus, femoral, saphenous, popliteal, lateral femoral cutaneous, obturator, and ankle blocks
1) Anesthesia has come a long way from the days when surgery was performed without pain relief. Various crude methods were used to relieve pain before the discovery of modern anesthesia in the 1840s.
2) Key milestones in anesthesia history include the first use of ether in 1846, the introduction of injectable cocaine and local anesthesia in 1884, and the development of muscle relaxants and modern inhalational agents.
3) Anesthesia continues to advance with new drugs, monitoring techniques, and the increasing role of technology including automated drug delivery systems and one day possibly robotic anesthesia administration. The future may see further developments in areas like artificial intelligence, personalized medicine, and remote anesthesia delivery via telemedicine.
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
The document discusses several new and emerging concepts in nerve blocks. It covers new equipment like echogenic needles and catheters, ultrasonography advances like 3D and 4D ultrasound, and pressure monitoring devices. It also discusses learning tools like phantoms and robots. Newer nerve blocks described include the erector spinae block and rhomboid block. Adjuvants to prolong peripheral nerve blocks and new formulations like liposomal bupivacaine and proliposomal ropivacaine are covered.
Neuromonitoring techniques can monitor the brain's function, cerebral blood flow and intracranial pressure, and brain oxygenation and metabolism. Electroencephalography (EEG) measures electrical brain activity and is useful for detecting ischemia. Evoked potentials like somatosensory evoked potentials (SSEPs) monitor sensory pathways from stimulus to cortex. Jugular venous oximetry and near infrared spectroscopy (NIRS) provide noninvasive monitoring of cerebral oxygenation. These techniques guide anesthesia management and detect intraoperative brain injury.
This document provides background information and details on the technique of performing a transversus abdominis plane (TAP) block. It begins with an overview of the TAP block, including its original description and subsequent modifications using ultrasound guidance. Next, it discusses the indications for TAP blocks, including postoperative analgesia for various abdominal surgeries. The anatomy section describes the layers and nerves of the abdominal wall targeted by the block. Finally, the technique section outlines the materials, patient positioning, ultrasound probe placement, needle insertion, and local anesthetic injection steps to perform a TAP block.
This document provides information on brachial plexus nerve blocks. It discusses the various techniques for brachial plexus blocks including interscalene, supraclavicular, infraclavicular, and axillary blocks. The advantages of nerve blocks are outlined as avoidance of general anesthesia, early recovery, and excellent postoperative pain relief. Potential complications include nerve injury, local anesthetic toxicity, hematoma, and diaphragmatic paralysis. Proper patient preparation and use of ultrasound or nerve stimulation techniques can help accurately place the local anesthetic and minimize complications.
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.
There are currently few options to extend the duration of regional analgesia at home beyond the one day expected from most single-injection nerve blocks. Continuous peripheral nerve block (CPNB) with a plain local anesthetic perineural infusion is the most established way to provide days of postoperative pain control and allows titration, but training in insertion techniques and a system to manage ambulatory CPNB patients are necessary. Adjuvants or depot formulations of local anesthetics may offer potential options for limited extension of block duration, but further studies regarding efficacy and safety for regional anesthesia as well as comparative-effectiveness versus CPNB are necessary.
At the conclusion of this activity, learners will be able to: discuss the indications for continuous peripheral nerve blocks; identify obstacles to implementing a continuous peripheral nerve block system; examine various techniques and equipment for continuous peripheral nerve block performance; and discuss the application of ultrasound guidance for perineural catheter insertion.
This document classifies myasthenia gravis into different categories based on the muscles affected and severity of symptoms. Category I involves only ocular muscles with negative tests on other muscles, while Category Ia includes ocular involvement and positive peripheral muscle tests without symptoms. Categories II-IV classify generalized myasthenia gravis as mild, moderate, acute fulminating, or late severe based on impact. Repetitive nerve stimulation and single fiber electromyography are described as electrophysiological tests used in diagnosis.
Interfascial Plane Blocks Offer an Acceptable Alternative to Thoracic Epidura...Edward R. Mariano, MD
This was part of a debate held at #ANES20 (recording available from ASA) between me and Dr. Jeff Gadsden from Duke University School of Medicine. Dr. Gadsden and I clashed on the same topic last year at #ANES19 during which I promoted thoracic epidural analgesia, and Dr. Gadsden made the case for interfascial plane blocks. This year we switched sides! Link to my slides from #ANES19: https://www.slideshare.net/EdwardRMariano/thoracic-epidural-analgesia-is-the-gold-standard-for-major-abdominal-surgery
The objectives of this session were as follows:
1. Discuss multimodal pain management strategies in the context of enhanced recovery programs;
2. Discuss advantages and disadvantages of thoracic epidural analgesia for major abdominal surgery in the context of enhanced recovery programs;
3. Discuss advantages and disadvantages of truncal somatic blocks in the context of enhanced recovery programs; and
4. Discuss developing safe and effective procedure specific pain management strategies for major abdominal surgery.
Newer Truncal Blocks Do they have place in current practice.pptxashokJadon4
Interfascial plane blocks also known as Truncal blocks are US guided regional blocks of thorax and abdomen. They have been used extensively for acute pain management and now their role is further expanding for chronic pain conditions. It has been suggested that they work by neural adhesiolysis, breaking the pain cycle by blocking the pain signals and also by anti-inflammatory action of steroids used with local anesthetic.
Thoracic Epidural Analgesia is the Gold Standard for Major Abdominal SurgeryEdward R. Mariano, MD
At Anesthesiology 2019, the annual meeting of the American Society of Anesthesiologists (#ANES19), I debated Dr. Jeff Gadsden from Duke on the topic of whether or not thoracic epidural analgesia is the gold standard for major abdominal surgery. Dr. Vijay Gottumukkala organized and moderated the debate and assigned sides: pro (me) and con (Jeff).
PCA is neither “ one size fits all “ or a “ set and forget “ therapy
An Anesthesiologist style ……….
no fixed dose of drug fits all patient
make patient analgesia and take care
Diaphragm sparing nerve blocks for shoulder surgery부휘 홍
- Diaphragm sparing nerve blocks aim to provide analgesia for shoulder surgery while avoiding hemidiaphragmatic paralysis.
- Several techniques were evaluated including supraclavicular, interscalene, suprascapular, superior trunk, and costoclavicular blocks.
- The superior trunk block had the lowest rate of hemidiaphragmatic paralysis compared to the interscalene block. The costoclavicular block also had a lower rate than the supraclavicular block.
- Low volumes, extrafascial injections, and targeting specific branches may further reduce hemidiaphragmatic paralysis risk for various nerve blocks. Future techniques aim to develop a reliable diaphragm
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
This study investigated the effects of N-acetylcysteine (NAC) on asprosin and meteorin-like protein (METRNL) levels in a rat model of lower extremity ischemia-reperfusion injury. Rats were divided into five groups: a control group, sham surgery group, NAC treatment group, ischemia-reperfusion injury group, and ischemia-reperfusion injury plus NAC treatment group. Serum and tissue levels of asprosin and METRNL were measured after 120 minutes of reperfusion. The results showed that asprosin and METRNL levels were lower in the ischemia-reperfusion injury group compared to controls, but higher in the ischemia-reperfusion injury plus NAC treatment group compared
The document summarizes a study that investigated whether adding hyaluronidase to ropivacaine reduces the time to achieve complete sensory block after axillary brachial plexus block. Patients were randomly assigned to receive ropivacaine with or without hyaluronidase. The study found that the group receiving ropivacaine with hyaluronidase had a significantly shorter mean time to achieve complete sensory block, sensory block onset time, and time to reach surgical anesthesia compared to the control group receiving ropivacaine alone. Addition of hyaluronidase to ropivacaine resulted in faster blockade times for axillary brachial plexus blocks.
This document provides information about spinal anesthesia including:
- Definitions and the advantages of spinal anesthesia such as reduced risk of respiratory complications.
- Indications for spinal anesthesia including lower body and pelvic surgeries.
- Relevant anatomy including dermatomes, vertebrae, and spinal cord landmarks.
- How to perform a spinal anesthetic including patient positioning, identifying the injection site, and inserting the spinal needle.
- Factors that influence the level and duration of the spinal block such as drug choice, dosage, and patient characteristics.
- Potential complications of spinal anesthesia.
This document discusses the transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) approaches to laparoscopic inguinal hernia repair. It provides details on the relevant anatomy and differences between TAPP and TEP. The author describes their experience transitioning to the "eTEP" or "extended TEP" technique, which provides an enlarged surgical field through an extended view of the preperitoneal space. Their initial experience with 36 patients found eTEP to be satisfactory with no major complications and excellent functional results. The author believes eTEP has potential to become the gold standard approach due to its ease of use, reproducibility, and ability to manage large or complex hernias
This document provides information on the transversus abdominis plane (TAP) block, including its uses, techniques, effectiveness, and safety. The TAP block involves injection of local anesthetic in the plane between the internal oblique and transversus abdominis muscles to provide analgesia for abdominal surgeries when epidural is not possible. Ultrasound guidance improves accuracy. Studies show TAP blocks reduce postoperative opioid use and pain, with no serious complications reported. Further research is still needed to define optimal procedures and outcomes.
Pecs block, serratus plane block with literature review when and how부휘 홍
The document summarizes different regional anesthesia techniques for chest wall analgesia. It discusses the Pecs block, Serratus plane block, and their variations. It provides details on the anatomical landmarks, local anesthetic volumes and concentrations used, as well as the nerves targeted. The document also reviews literature on the effectiveness of these blocks for various procedures like breast surgery and rib fractures.
Bloqueo abdominal guiado por usg en niñosmireya juarez
Ultrasound guided Transverses Abdominal Plane Block versus Ilioinguinal/iliohypogastric Nerve Blocks for Postoperative Analgesia in Children Undergoing Lower Abdominal Surgery. Sixty children scheduled for lower abdominal surgery were randomized to receive either a TAP block or ilioinguinal/iliohypogastric nerve block. Pain scores were recorded and rescue analgesia was provided when needed. The average time to first rescue analgesia was longer in the TAP block group compared to the nerve block group. TAP block provided longer lasting postoperative pain relief than ilioinguinal/iliohypogastric nerve blockade.
LECTURE5-Regional Anaesthesia Techniques Dr MASOUN (1).pptIhsan Ghannam
Regional anesthesia lecture objectives were to understand risks and benefits of regional anesthesia, contraindications, and cardiovascular changes from different spinal levels of blockade. The lecture defined regional anesthesia and covered spinal and epidural anatomy, needle types, complications, and differences between techniques. It also discussed peripheral nerve blocks, the role of ultrasound, local anesthetics including pharmacology, doses, and toxicity.
LECTURE5-Regional Anaesthesia Techniques Dr MASOUN.pptZikrillahYazid1
Regional anesthesia lecture objectives were to understand risks and benefits of epidural/spinal anesthesia, contraindications, preventing hypotension, appropriate procedures, cardiovascular changes, and differences between spinal and epidural anesthesia. The lecture defined regional anesthesia and covered anatomy, needle types, preparation, indications, complications, epidural and spinal techniques, peripheral blocks, ultrasound guidance, local anesthetics pharmacology and toxicity.
This a power point presentation (Iecture slides) on regional anaesthesia techniques. It explains in detail the regional anaesthesia techniques involved, the indications as well as the contraindications.
This document discusses the anesthetic challenges of performing thyroidectomy for a patient with a large retrosternal goiter. It outlines the preoperative evaluation and planning required, including airway assessment, optimization of thyroid function, and involvement of a multidisciplinary team. Specific challenges addressed are potential for difficult intubation, intraoperative blood loss and cardiovascular compromise, postoperative tracheomalacia, and recurrent laryngeal nerve injury. Careful preparation and perioperative management are needed for a successful outcome in these high-risk cases.
The document discusses paravertebral cervical sympathetic block, including:
- Its history dating back to 1905-1910 with further developments in the 1920s and 1930s.
- Applied anatomy of the sympathetic chain and ganglia in the cervical region, including the stellate ganglion.
- Indications for stellate ganglion block such as CRPS, ischemic diseases, and hyperhidrosis.
- Techniques for the block including the anterior paratracheal approach using local anesthetic.
- Potential side effects include Horner's syndrome and diffusion of the local anesthetic to nearby nerves.
The document discusses brachial plexus block techniques and reviews relevant anatomy, history, approaches, and complications. It provides an overview of the brachial plexus anatomy and different block techniques like interscalene, supraclavicular, infraclavicular, and axillary blocks. Complications discussed include nerve injuries from mechanical trauma, ischemia, or chemical toxicity from local anesthetics. Proper technique and drug administration are important to minimize risks.
This document provides an overview of ultrasound-guided peripheral nerve blocks. It lists the benefits of ultrasound guidance such as visualizing surrounding structures and avoiding injury. It discusses machine controls and optimizing ultrasound imaging. The objectives are to list benefits of ultrasound guidance, discuss machine controls, and identify images of peripheral nerves. It then covers techniques for various upper and lower extremity nerve blocks and provides ultrasound images of relevant anatomy.
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
This document provides an overview of ultrasound-guided peripheral nerve blocks. It lists the benefits of ultrasound guidance such as visualizing surrounding structures and avoiding injury. It discusses machine controls and how to optimize ultrasound imaging. The objectives are to list benefits of ultrasound guidance, discuss machine controls, and identify images of peripheral nerves. It then covers techniques for various upper and lower extremity nerve blocks and provides ultrasound images of relevant anatomy.
This product discuss Hirschsprung’s disease in pediatrics included [pathology, presentation, diagnostic tools, surgical procedures complications and management. Also discuss the recent concepts of management of post operative complications.
This document discusses various approaches for skull base surgery, including combined approaches. It provides examples of combining the anterior skull base approach with lateral skull base approaches like the neurosurgical or trans-temporal approaches. Another combined approach discussed is the frontotemporal orbitozygomatic (FTOZ) approach combined with transpetrous approaches to provide control of the middle and posterior cranial fossae. Neurosurgeons may also combine the FTOZ approach with the Kawase approach for control of the middle and posterior fossae. Videos and links are provided as examples of these combined approaches.
The document discusses craniospinal irradiation (CSI), which delivers radiation to the entire cranial-spinal axis to treat intracranial tumors. It was pioneered in the 1950s and is commonly used to treat tumors that may spread through the cerebrospinal fluid such as medulloblastoma. The document outlines the techniques, challenges, indications, and evolving approaches for CSI such as reduced dose protocols and hyperfractionated regimens. It discusses topics like patient positioning, target volumes, critical structures, field arrangements, and the use of newer technologies like virtual simulation.
Similar to Fascial Plane Blocks - Norwich Anaesthesia Update 2021 pdf (20)
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
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
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
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
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Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
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The Children are very vulnerable to get affected with respiratory disease.
In our country, the respiratory Disease conditions are consider as major cause for mortality and Morbidity in Child.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
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Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Discover the benefits of homeopathic medicine for irregular periods with our guide on 5 common remedies. Learn how these natural treatments can help regulate menstrual cycles and improve overall menstrual health.
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Nutritional deficiency Disorder are problems in india.
It is very important to learn about Indian child's nutritional parameters as well the Disease related to alteration in their Nutrition.
35. 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
36. Deep Fascia
Multiple layers, Fibrous
Extends through whole body
Target for Fascial plane blocks
Forms sheaths for nerves/vessels/organs
@amit_pawa
37. Deep Fascia Subtypes
Epimysial Aponeurotic
Thin Thick
Specific to 1 muscle May cover several muscles
Adherent to muscle Easily separated
PECS/TAP/Serratus Rectus Sheath/Adductor Canal
38. Deep Fascia Subtypes
Epimysial Aponeurotic
Thin Thick
Specific to 1 muscle May cover several muscles
Adherent to muscle Easily separated
PECS/TAP/Serratus Rectus Sheath/Adductor Canal
39. Lines of Fusion
Distinct fusion points
e.g. Linea Alba/Semilunaris
Creates a “compartment”
(Pathological LOF due to surgery/Adhesions)
Limit Spread - Good (rectus) & Bad!
@amit_pawa
40. Fascial Interconnectivity
Connections between fascia
Many Planes are continuous
Communicate without clear boundaries
Thoracolumbar Fascia
Endothoracic FasciaGluteal Fascia
May help Mechanism of Action
@amit_pawa
41. Not All fascias are the same
Number of layers
Pectoral region - 1
The Limbs - 2 or 3
Middle Thoracolumbar 2 or 3
Function & Mobility More mobile may
increase LA spread
Surrounding structures
Lungs/liver/spleen
IPPV vs SV
@amit_pawa
43. Mechanism of Action?
LA action on:
Nerves in the injected Plane
Nerves in adjacent Planes/tissue
Nerves in distant Planes/tissue
(Systemic Absorption)
Mechanisms of Action Of Fascial Plane Blocks - Jinn KJ, Lirk P, Hollmann M, Schwarz S - Ahead of Print RAPM 2021
@amit_pawa
44. What Nerves might the LA act on?
Cutaneous
Lat. cut. intercostal branches
(Serratus Plane)
Non-Cutaneous - usually silent Nociceptors
Muscle/Ligaments/Joint capsules/Bone/others in fascia
Upregulated in inflammation /injury
Motor Nerves
Some fibres still sensory/nociceptive
Blockade relieves spasm
@amit_pawa
45. @amit_pawa
Nerves in the injected Plane
Hydrodissection via Hydraulic Pressure
“Transmission Belts” & “Decompression planes”
Eg Rectus Sheath, TAP, PECS
46. Plane 1.Plane 2.
Nerves in Adjacent Planes/Tissue
Bulk Flow
E.g. PECS, ESP, MTP
@amit_pawa
Diffusion
concentration gradient
47. @amit_pawa
Nerves at Distant
Sites via
Systemic Absorption
pleura
mus
mus
ESM
ostal nerve
or cutaneous branch of intercostal nerve
Transversus thoracis muscle
ectoral nerves
RLBESP TPVBMTP
acromial artery
Rhomboid
d
Block
53. Nerve elements may lie within the fascia
A & C Fibres - Responsible for nociception?
Wide Dynamic Range neurons
Mechanoreceptors
Do these influence Fascial plane blocks?
4. Local Fascial Innervation
@amit_pawa
54. (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
55. 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
58. 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
@amit_pawa
59. 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
63. 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
65. Fascial Plane Blocks can be
Unpredictable
Inconsistent Effect
Inconsistent Efficacy
Inconsistent Evidence
Dense Neural Blockade is Rare
@amit_pawa
66. LA Spread Affected by…
Thickness of fascia
Thick fascia - easy to identify, limited diffusion,
“contains LA”, but spread limited
Thin fascia - harder to identify, better diffusion,
LA “spills out” so spread variable
@amit_pawa
68. Is this good enough?
@amit_pawa
Less Ideal Blocks
69. 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
70. 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
71. 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
72. Receptors within Fascia
Somatic Nerves (Sensory/Motor) - variable path
Sympathetic
Nerves to the Fascia - “Fasciatome”
Could action on last two subtypes
explain successful block without
dermatomal loss of sensation?
73. Does Inconsistent Dermatomal
sensory loss = Failed Block?
Analgesia & Opioid Reduction still evident
Differential block - (C >A-delta fibres)?
If pt derives benefit, does it matter?
PROM & Minimum Clinically Important Difference
(MCID) in QoR
Mechanisms of Action Of Fascial Plane Blocks - Jinn KJ, Lirk P, Hollmann M, Schwarz S - Ahead of Print RAPM 2021
@amit_pawa
74. Does Inconsistent Dermatomal
sensory loss = Failed Block?
Anatomical Cutaneous innervation is complex
Overlapping innervation across midline
Interindividual variation
Pharmacokinetic variability & concentration of LA at target
Accuracy of deposition & Variability of spread
Non-cutaneous contributions to nociception
Mechanisms of Action Of Fascial Plane Blocks - Jinn KJ, Lirk P, Hollmann M, Schwarz S - Ahead of Print RAPM 2021
@amit_pawa
75. How Can We Improve Efficacy?
Deposit LA closer to target- (e.g. Rectus > Lat TAP)
Inject at more than 1 site?
Increase Concentration of LA ?
Increase Mass of LA deposited ?
Use Epinephrine?
Catheters - Intermittent Boluses
Mechanisms of Action Of Fascial Plane Blocks - Jinn KJ, Lirk P, Hollmann M, Schwarz S - Ahead of Print RAPM 2021
@amit_pawa
80. 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
84. PECS/Serratus/ESP -significant benefit in breast/thoracics
Similar to Th PVB (PECS)
Their role in trauma & cardiac surgery is holds great potential
@amit_pawa
89. Increasing Access to RA
Much of USGRA - daunting to uninitiated
Idea of Fascial Plane Blocks is Simple
Superficial Planes - eg Rectus/PECS/TAP
Similar technique - Split the plane
Focus on “Plan A blocks” - Build from there
@amit_pawa
90. 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
95. Conclusions
@amit_pawa
1. Fascial Plane Blocks are Heterogenous
2. Unknown Mechanism of Action
3. Unpredictable efficacy
4. May have a role where No Epi/PVB
5. Increasing RA Delivery
96. Why We Need Fascial Plane Blocks In Our Toolkit
We need Alternatives when we can’t Perform classic
blocks, or when they fail
@amit_pawa
Regional Anaesthesia is part of MMA
We need to increase RA delivery so more patients
benefit
Some fascial plane blocks are simple to teach &
perform