us 2014 gray trunk1s.pptx [read-only]
Post on 01-Feb-2022
1 Views
Preview:
TRANSCRIPT
Trunk AnesthesiaPart 1: Anterior Approach
Andrew Gray, M.D., Ph.D.San Francisco General HospitalSan Francisco, CA
Lecture Objective
For the target audience to:
• 1. Describe the ultrasound anatomy of the anterior abdominal wall for regional blocks.
• 2. Be able to identify adverse events and artifacts that can occur during these ultrasound guided regional anesthetics.
Anterior Abdominal Wall
1. Transversus Abdominis Plane (TAP)2. Ilioinguinal Nerve Blocks (ILIH)3. Rectus Sheath Blocks (RSB)
Anterior Abdominal Wall
1. Transversus Abdominis Plane (TAP)2. Ilioinguinal Nerve Blocks (ILIH)3. Rectus Sheath Blocks (RSB)
Transversus Abdominis Plane (TAP)
Clinical Trial ReferenceCesarean Delivery Multiple
Open Prostatectomy O’Donnell et al., 2006
Total Abdominal Hysterectomy
Carney et al., 2008
Open Appendectomy Niraj et al., 2009
Iliac Crest Bone Graft Chiono et al., 2010
Open Inguinal Hernia Repair Aveline et al., 2010
Transversus Abdominis Plane (TAP)
Rozen, W.M. et al., Clin Anat 2008;21:325-33
“The optimal plane for infiltration of anesthetic is between this fascial layer and the transversusabdominis muscle layer.”
“A fascial layer between the internal oblique and transversus abdominis muscles required elevation to expose the neurovascular structures on its deep surface.”
Transversus Abdominis Plane (TAP)
Anatomic Structure Sonography Reference
External Oblique Often Hyperechoic Hebbard 2007
Internal Oblique Thickest Muscle Rankin 2006
Transversus Abdominis Thinnest MuscleHypoechoic
Rankin 2006Hebbard 2010
Retroperitoneal Fat Fibro-fatty Echoes Gore 1982
Quadratus Lumborum Hypoechoic Callen 1979
Peritoneum Very HyperechoicComet-Tail ArtifactGut Sliding
Hanbidge 2003
Transversus Abdominis Plane (TAP)
Key points:
• 1 Perform TAP block near the posterior corner of the transversus abdominis muscle between the costal margin and iliac crest in the mid-axillary line.
• 2 Extend the injection by advancing the block needle within the TAP.
• 3 These blocks are best used for surgical procedures of the lower abdominal wall as part of multimodal pain management.
Anterior Abdominal Wall
1. Transversus Abdominis Plane (TAP)2. Ilioinguinal Nerve Blocks (ILIH)3. Rectus Sheath Blocks (RSB)
Ilioinguinal Nerve Blocks (ILIH)
Key points:
• 1 Best visibility of the ilioinguinal and iliohypogastricnerves is medial to the iliac crest (1 to 2 cm).
• 2 The ilioinguinal nerve is often accompanied by the deep circumflex iliac artery (DCIA).
• 3 These blocks are best used for selective diagnostic purposes.
Anterior Abdominal Wall
1. Transversus Abdominis Plane (TAP)2. Ilioinguinal Nerve Blocks (ILIH)3. Rectus Sheath Blocks (RSB)
Rectus Sheath Blocks (RSB)
Key points:
• 1 Inject between the rectus abdominis muscle and underlying double layer.
• 2 For supraumbilical injections the transversus abdominislies under the lateral corner of the rectus abdominis.
• 3 Bilateral injections are necessary because the linea alba is normally a complete midline barrier.
top related