TRUNCAL BLOCKS

1. TRUNCAL BLOCKS BY KARIM YOUSSEF, MD Lecturer of Anesthesia, Intensive Care and Pain Management Ain Shams University

2. INTERCOSTAL NERVE BLOCK

3. Anatomy of the intercostal nerve They are 12 pairs of thoracic anterior primary rami. Intercostal nerves 3–6 (the ‘typical’ intercostal nerves)

4. Anatomy of the intercostal nerve • They enter their intercostal spaces across the anterior aspect of the corresponding superior costotransverse ligament to lie below the intercostal vessels, first between the posterior intercostal membrane and the pleura and then, at the rib angles, between the internal intercostal and the innermost intercostal muscles. • Near the margin of the sternum, each nerve passes in front of the internal thoracic vessels and sternocostalis muscle and pierces the internal intercostal muscle, anterior intercostal membrane and the overlying pectoralis major to become an anterior cutaneous nerve of the thorax.

5. Atypical intercostal nerves • The 1st intercostal nerve (T1) Passes across the front of the neck of the 1st rib, lateral to the superior intercostal artery, to enter into the composition of the brachial plexus. • The 2nd intercostal nerve: its lateral cutaneous branch crosses the axilla to supply the skin of the medial aspect of the upper arm (intercostobracbialnerve). • The 7th to 11th intercostal nerves enter the abdominal wall between the interdigitations of the diaphragm with transversusabdominis. • The 12th thoracic (subcostal) nerve runs along the lower border of the 12th rib below the subcostal vessels, passes behind the lateral arcuate ligament to run in front of quadratuslumborum then passes between transversusabdominis and internal oblique.

6. Indications of intercostal nerve block Any pain from chest wall and upper abdominal wall like: • Cancer pain. • Rib fractures. • Chronic painful inflammation like herpes zoster.

7. Technique

8. Technique of intercostal nerve block Patient is in prone position. By index finger displace the skin over rib in the posterior axillary line . Needle inserted perpendicular to skin until bony contact with the desired rib is made. The needle is walked off the lower edge of rib until bony contact is lost, the needle is advanced 3-5 mm deeper.

9. Complications of Intercostal block • Pneumothorax: Occur relatively in 1% to 2% of patients. • Local anesthetic toxicity: Because of rapid absorption from this site. • Infection.

10. INTAPLEURAL BLOCK

11. Interpleural Block • Unilateral perioperative analgesia : Cholecystectomy, renal or breast op. • Upper extremity ischemic and neuropathic pain, thoracic herpes zoster, pancreatitis, and thoracic cancer pain.

12. Anatomy & technique • Lat. Or semiproneposition. • Ipsilateral arm should hang across the body, retract the scapula anteriorly. • Endpoint for entry into the interpleural space is detection of negative interpleuralpressure. • 5~8thintercostal space, selected rib, 8~10cm lat. to the midline. • Perpendicular to the skin, over rib, and walked cephalad until contact the sup. Edge of rib is lost. • Passive loss of resistance.

13. Dosing • Supine ; intercostal block with less sympathetic block • Head up : Upper abdominal visceral pain • Head down : upper thoracic and cervical spread • Lt. Side : pancreatic, gastric, or splenic pain • Rt. Side : hepatic, gallbladder pain • Therapeutic dose : 20~30ml of 0.25~0.5% bupivacaine over 2~3minutes

14. Complication • Traumatic injury : Pneumothorax (2%), catheter malposition. • Systemic effect from drug : Inflammation of pleural membranes, local anesthetic toxicity(1.3%), Pleural effusion (0.4%). • Etc. : Horner’s syndrome, phrenic n. palsy, bronchopleural fistula formation, injury to the neurovascular bundle.

15. PARAVERTEBRAL NERVE BLOCK (PVNB)

16. Common Indications POSTOPERATIVE ANALGESIA: • Thoracic surgery • Breast surgery • Cholecystectomy • Renal and ureteric surgery • Herniorrhaphy • Appendectomy • Video-assisted thoracoscopic surgery SURGICAL ANESTHESIA: • Breast surgery • Herniorrhaphy • Chest wound exploration • MISCELLANEOUS • Fractured ribs • Therapeutic control of hyperhydrosis • Liver capsule pain after blunt trauma • Acute postherpetic neuralgia

17. Regional Anatomy Wedge shaped area on both sides of vertebra BOUNDARIES: • Anterior/lateral: Parietal pleura • Posterior: Superior costo-transverse ligament • Medial: Postero-lateral aspect of the vertebral body, intervertebral disc and the intervertebral foramen COMMUNICATIONS: • Intercostal space laterally. • Epidural space medially. • Paravertebral space on the other side via the prevertebral and epidural space.

18. Patient position & landmarks Position : Sitting or lateral decubitus, with kyphotic attitude supported by a attendant. Landmarks : • Spinous processes along the midline • Tip of scapula : T10 • Paramedian line 2.5 cms lateral to midline

19. Technique • At thoracic level : Spinous process of upper vertebrae is at level of transverse process of lower spine. Needle Insertion Point: 2.5 cm lateral to the tip of spinous process. Saggital section through the thoracic paravertebral space showing a needle that has been advanced above the transverse process.

20. Technique Procedure consists of 3 maneuvers • Contacting transverse processes of individual vertebrae (depth 2-4 cms). • Withdrawing needle to skin level and reinserting it 10 deg caudal or cranial. • Inserting needle 1 cm deeper than level of transverse processes. • Called “Walking Off” (Cranially/Caudally)

21. Technique

22. Technique (Continuous Thoracic paravertebral block) • The same method can be modified and a catheter can be placed in the paravertebral space for giving more prolonged postoperative analgesia. • A Touhy’s needle is used for the procedure and a catheter is inserted 5 cms beyond the tip of the needle. • Catheter is ideally inserted 1-2 segmental levels below the thoracotomy incision.

23. Commonly used drugs

24. Local Anesthetic: 3-4 ml/ level for multiple level block, 15-20 ml for single level, and infusion @ 0.1 ml/kg/h. Appropriate drugs: bupivacaine 0.25-0.5%, ropivacaine 0.25-0.5%, or lidocaine 1%; with epinephrine (2.5 μg/ml). Mechanism and Spread of Anesthesia: 15 ml bupivacaine 0.5% in TPVs produces unilateral somatic block over 5 (range: 1-9) dermatomes, and sympathetic block over 8 (range 6-10) dermatomes. Possible areas of spread: • May remain localized • May spread to contiguous levels above and below • Intercostal space laterally • Epidural space, mostly unilateral and insignificant, in up to 70% • Single 15-20 ml injection as effective as multiple 3-4 ml/site. • Increasing volume may predispose to bilateral anesthesia • If a wide block (≥ 5 dermatomes) is desired, preferable to do multiple injections, or 2 injections several dermatomes apart

25. ABSOLUTE Infection at the site of needle insertion. Empyema. Allergy to local anesthetic drugs, and Tumor occupying the TPVS. RELATIVE Coagulopathy Kyphoscoliosis (chest deformity may predispose to pleural or thecal puncture) Patient with previous thoracotomy: TPVB may be obliterated by scar tissue and adhesion of lung to chest wall Contraindications

26. Complications and ways to avoid them

27. TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK

28. The anterior abdominal wall (skin, muscles, parietal peritoneum) is innervated by the anterior rami T7 to T12 and L1. Terminal branches of them course through the lateral abdominal wall within a plane between the internal oblique and transversusabdominis muscles. Injection of local anesthetic within the TAP produce unilateral analgesia to the skin, muscles, and parietal peritoneum. Anatomy of transversusabdominis plane (TAP)

29. Indications of TAP block For supplementary anesthesia or analgesia for lower abdominal surgery like: • Inguinal hernia. • Cesarean section.

30. Technique of transversusabdominis block • Needle is inserted at triangle of Petitbounded by the latissimusdorsi muscle posteriorly, the external oblique muscle anteriorly and the iliac crest inferiorly. • A needle is inserted perpendicular to enter TAP plane after two pops. • The first pop: penetration of the external oblique fascia. • The second pop: penetration of internal oblique muscle.

31. Patient is placed in a supine position and the abdomen is exposed between the costal margin and the iliac crest. Identify the three muscular layers of the abdominal wall: the external oblique (most superficial), the internal oblique and transversusabdominis muscles. Among the three muscles, the internal oblique muscle is the most prominent layer. Ulrasound guided technique for TAP block

32. Needle is inserted in-plane with the transducer, in an antero-posterior direction. Choosing an insertion point some distance away from the transducer improves needle shaft and tip visualization. Deposit local anesthetic deep to the fascial layer that separates the internal oblique and transversusabdominis muscles. Ultrasound guided TAP block (cont)

33. INGUINAL BLOCK

34. Anatomy • Innervation of the inguinal region lumbar plexus nerves: • Ilioinguinal, Iliohypogastric nerves (L1). • Genitofemoral nerve (L1,L2). • These nerves coarse anteriorly near an important landmark for the block , the anterior superior iliac spine. • The ilioinguinal nerve lies between the transversusabdominis muscle and the internal oblique muscle initially and then penetrates the internal oblique muscle some distance medial to the anterior superior iliac spine. • The iliohypogastric nerve lies between the internal and external oblique muscles near the anterior superior iliac spine. • The genitofemoral nerve follows a different coarse, and it is this nerve that must often be supplemented intraoperatively. • All these nerves continue anteriorly in a medial orientation and become superficial as they terminate in the skin and muscles of the inguinal region.

35. Course of the ilioinguinal, iliohypogastric, and genitofemoral nerves.

36. Technique of inguinal block • The anterior superior iliac spine (ASIS) should be marked while the patient is supine. Another mark should be made approx. 3 cm. medial and inferior to the ASIS. • A skin wheal is created, and a 8-cm, 22-gauge needle is inserted in a cephalolateral direction to contact the inner surface of ilium. 10 mm of local anesthetic is injected as the needle is slowly withdrawn through the layers of the abdominal wall. • The needle should then reinserted at a steeper angle to ensure penetration of the three muscle layers. • From the previously placed skin wheal, the injection is extended toward the umbilicus, creating a subcutaneous field block.

37. CELIAC PLEXUS BLOCK

38. Anatomy for celiac plexus block • Celiac plexus is situated retroperitoneally in paravertebralareolar tissue at anterolateral edge of the first lumbar vertebra on both sides. • It lies posterior to the stomach and pancreas, anterior to the crura of diaphragm and the aorta. • The numbar of ganglia varies from 1 to 5 on both sides. • It receives afferent fibers of both sympathetic and parasympathetic from viscera. • The celiac plexus provides innervation to most of the gut from the lower esophagus to the level of the splenic flexure of the colon.

39. Indications of celiac plexus block Cancer from upper abdomen: cancer stomach or pancreas. Chronic non malignant pain from upper abdomen

40. Triangle is made between 3 points: spine between T 12 & L 1 and lower edges of 12th rib on both sides. Needle is inserted just cauded to 12th rib 7 cm lateral to midline, 45 degree from horizontal plane & 15 degree cephaled until bony contact with L1 vertebral body is made. Needle is withdrawn & redirected laterally about 1-2 cm, at this point aortic pulsations may be felt and the local anesthetic is injected retroaortic. Classic retrocrural technique (deep splanchnic approach)

41. Other techniques of celiac block • Posterior approaches: • Classic Retrocrural (Deep splanchnic) Approach • Transcrural (Antecrural) Celiac Block • Transaortic Celiac Neurolysis • Transintervertebral Disc approach • Anterior approaches: • Intraoperative Celiac Neurolysis • Percutaneous Anterior Celiac Neurolysis • TranscatheterNeurolysis • Endoscopic ultrasound-Guided Celiac Plexus Block

42. SUPERIOR HYPOGASTRIC BLOCK

43. The superior hypogastric plexus is a retroperitoneal structure that extends bilaterally anterior to the vertebral column between L5 and S1 vertebral bodies. It is formed by pelvic visceral afferents and efferent sympathetic nerves from branches of the aortic plexus, and fibers from the splanchnic nerves. It divides into two lateral portions which travel inferiorly to end as inferior hypogastric plexus. Anatomy of superior hypogastric nerve

44. Indications of superior hypogastric block Any pain from: • Lower urinary tract: bladder & urethra. • Lower GIT: descending colon & rectum. • Female genital tract: uterus, vagina & vulva. • Male genital tract: prostate, penis &testes. • Perineum.

45. The patient will be in prone position. Needle is introduced 6 cm lateral to spine of L4. Directed 45 degrees medial and caudal until its tip comes anterior to vertebral body of L5 under fluoroscopic guidance. Technique of superior hypogastric block

46. GANGLION IMPAR BLOCK

47. The ganglion impar is the only unpaired autonomic ganglion in the body. Marks the end of the two sympathetic chains. Located retroperitonially anterior to the sacrococcygeal joint. Anatomy of the ganglion Impar

48. Indication of ganglion Impar block Any pain from: • Perineum. • Distal rectum & anus. • Distal urethra. • Distal third of vagina & vulva. • Prostate & testes.

49. The patient in the prone position. Needle is inserted in the sacral cornu to pierce the dorsal sacrococcygeal ligament at the midline. The needle is then advanced to pierce the ventral sacrococcygeal ligament, felt as a loss of resistance. Technique of ganglion Impar block

50. QUESTIONS Patient position in intercostal nerve block can be: • Prone. • Lateral. • Supine. • All of the above. One of important indications of paravertebral block: • Patients in whom neuroaxial techniques may be containdicated owing to hypotension or coagulopathy. • Infection at site of injection. • Allergy to local anesthetic. • Tumor in paravertebral space.