dr. devaraj acharya consultant in anaesthesia & icm west
TRANSCRIPT
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Dr. Devaraj Acharya
Consultant in Anaesthesia & ICM
West Herts Hospitals NHS Trust
02/02/2015
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• Introduction
• Anatomy – Abdominal wall
• TAP
• RSB
• Ilio-Inguinal/Ilio-Hypogastric
• Femoral/Saphenous
• Questions?
• Summary
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• Abdominal surgeries – significant pain
from abdominal wall
• Simple blocks – good analgesia
• Do not relieve visceral pain
• Know your Anatomy
• Ultrasound guidance
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ANTERIOR RAMI
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• Pre-op assessment
• Correct patient/Site, Asepsis
• Ultrasound machine – ergonomics
• Appropriate needle
• IN PLANE, COMPLETE VISION
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• Laparotomy
• Appendicectomy
• Laparoscopic surgery
• Abdominoplasty
• Caesarean section
• Operations on the abdominal wall
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• Ant. Abdominal wall – ant primary rami
of T7-12 and L1
• Terminal branches – between Internal
Oblique and Transversus abdominis
• Transversus Abdominis Plane – TAP
• Unilateral analgesia – Skin, Muscles and
Parietal Peritoneum
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EXTERNAL O
INTERNAL O
TRANSVERSUS A
TAP
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• Supine position
• Patient asleep
• 13-6 MHz, Linear probe
• Transverse on the abdomen, at the
anterior axillary line, between the costal
margin and the iliac crest
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• In Plane, TAP needle 80 mm
• Medial to lateral
• Initial 2 ml
• 20-30 ml Local anaesthetic
• Volume dependent spread
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EO
IOTA
LA
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• Few with USG
• Intra-peritoneal injection
• Bowel Haematoma
• Transient Femoral nerve palsy
• LA Toxicity
• Intravascular injection
• Failure
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• In plane
• Complete vision – at all times
• Clear separation of fascial layers
• Frequent aspiration
• Slow Injection
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• 1899 – Muscle relaxation
• Midline incisions
• Umbilical/Paraumbilical, Incisional
hernia repair
• Laparoscopic surgery
• Abdominoplasty
• Excision of urachal remnants
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• The rectus sheath encloses the rectus
abdominis muscles
• Aponeuroses of the three flat abdominal
muscles; EO,IO,TA
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Pubic Symphysis & Pubic Crest
Xiphisternum and 5-7 th costal
cartilages
Posterior sheath uninterrupted
Free spread
Arcuate ligament
Linea Alba – Medial
Linea semilunaris - lateral
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• 13 - 6 MHz, Linear probe
• Transverse plane
• Optimum visualization of the posterior
rectus sheath
• In plane
• LA between the rectus abdominis muscle
and the posterior rectus sheath
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Local anesthetic: 10 mL per side
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• Peritoneal puncture
• Perforation of the bowel
• Visceral puncture
• Mesenteric vessel puncture
• Inferior epigastric vessel puncture
• Retroperitoneal haematoma
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• Anaesthesia and postoperative analgesia for inguinal hernia repair
• Other inguinal surgery; analgesia following suprapubicincision
• Transducer position
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Blind injections – Low success rates
•Weintraud et al Study
•62 Children land mark technique
•Observed by ultrasound
•86% IM injections
•45% Overall failure rate
Weintraud et al; II IH Blocks in children
Anesth Analg 2008;106: 89-93
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• Supine
• High frequency linear probe
• Probe 5 cm cranial to the ASIS
• Iliac crest at the lateral view
• High probability 90% nerves betweein
IO and TA muscle
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• In Plane
• LA between the Transversus abdominis
and internal oblique muscle planes, in
the vicinity of the two nerves
• Volume: 10 mL per side
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• Indications: anterior thigh, femur, and knee surgery
• Goal: LA spread adjacent to the femoral N.
• Local anaesthetic: 10-20 mL
• Anaesthesia of the anterior and medial thigh down to the knee, variable strip of skin on the medial leg and foot
LARGEST NERVE OF LUMBAR PLEXUS - L2,3,4
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• Transverse probe position
• Supine, Inguinal crease
• Lateral to the Femoral Artery
• Hyperechoic, roughly triangular or oval
• Sulcus in the iliopsoas muscle underneath
the fascia iliaca
• Depth of 2 - 4 cm
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V A
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COMPLICATIONS:
• Infection
• Haematoma formation
• Intravascular injection
• Nerve Injury
• LA Toxicity
• Failure
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• In plane
• Patient- unable to bear weight
• Inject posterior first
• Visualise spread
• Frequent aspiration
• Slow injection
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• LOW TECH block
• Anterior thigh, knee surgery, analgesia following hip and knee procedures
• Transverse, close to the femoral crease, lateral to the femoral artery
• Goal: medial-lateral spread of local anaesthetic underneath fascia iliaca
• LA: 30-40 mL of dilute local anesthetic
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• Saphenous vein stripping or harvesting
• Supplementation for medial foot/ankle surgery in combination with a sciatic nerve block
• Transducer position: transverse on anteromedial mid thigh
• Goal: LA deep to the Sartorius muscle Local anesthetic: 5-10 mL
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• Anaesthesia of a variable strip of skin on
the medial leg and foot
• Strictly sensory block
• Partial motor block of the vastus medialis
• Caution - unsupported ambulation after
proximal saphenous block
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• Various blocks
• Multimodal analgesia
• Anatomy
• Ultra Sound advantages
• Complications