thoracic and abdominal blocks - spa · · 2016-03-02thoracic and abdominal blocks ... rectus...
TRANSCRIPT
Gio was a 2nd year resident
1995
Gio was a pediatric anesthesia fellow
1997
Gio is in Paris
1998 2001
Gio is back at CHOP
Sciatic block Axillary block
pix
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Femoral, sciatic, interscalene, infraclavicular
RAGIONAL ANESTHESIA AND DR CUCCHIARO
• SCIENTIFIC PROGRAM • 7:00-7:45 am Registration Breakfast with Exhibitors
and Poster Viewing • 7:45-8:00 am Opening Remarks Valerie E. Armstead,
MD, FAAP, CRCP & Jayant K. Deshpande, MD, MPH • 8:00-8:45 am Anesthetic Gases and the Developing
Nervous System Mervyn Maze, MD • 8:45-9:30 The Science of Regional Anesthesia in
Infants and Children Charles B. Berde, MD, PhD • 9:30-10:10 Regional Anesthesia Data: UK
and US Databases Tony Moriarty, MD & Giovanni Cucchiaro, MD
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WHICH BLOCK THEN? Old Way • Epidurals • Spinals • Caudals • Ilio-inguinal, ilio-hypogastric • Penile blocks
New Way • Paravertebral blocks • Serratus anterior blocks • Rectus sheath blocks • TAP blocks • Quadratus Lumborum block
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VISCERAL INNNERVATION ORGAN INNERVATION SPINE LOCATION LIVER Celiac Ganglia
Phrenic Ganglia Vagus
T5-T9 C3-C5 CN XI
STOMACH-PANCREAS Celiac Ganglia T5-T9
SMALL AND LARGE INTESTIN
Celiac Ganglia Superior Mesenteric Ganglia Inferior Mesenteric Ganglia Vagus
T5-T9 T9-T12 L1-L2 CN XI
KIDNEY AND URETERS Least and Lesser thoracic nerves T10-T12 CN XI
PELVIC VISCERA T11-L4
BLADDER Pelvic Splanchnic Nerves Upper Lumbar Splanchnic Nerves
S2-S4 L1-L2
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RECTUS SHEATH BLOCK
13 Source: Rajwani KM 2014
Author # patients
Age (years)
Pain scores PACU
After PACU
Morphine use
Dingeman 2013
52 3-12 LAI>RSB 0 pain: RSB>LAI
LAI=RSB
LAI=RSB
Gurnaney 2011
54 5-18 LAI=RSB
LAI=RSB
LAI>RSB (perioperative
Isaac 2006 13 1-8 LAI=RSB
LAI=RSB
LAI=RSB
TAP BLOCK
15 Source: Zoka M, 2011
LTOP: Lumbar Triangle of Petit MAL: mid-axxilary line SC: subcostal
head
lateral
• mid-axillary approach for infra-umbilical incisions
• subcostal approach for incisions between the levels of T7 and T11
TAP BLOCK: meta-analysis (Charlton S, 2010)
GIVEN… • Few small studies • Moderate methodological quality • Participant numbers were too few • Important inconsistencies among
studies
TAP block vs conventional or TAP placebo
• At 2 hrs: morphine requirements are the same
• At 24 hrs: reduced opioids consumption • Prolonged the time until first request for
additional analgesia • Overall lower pain scores • No difference in postop nausea/vomiting
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SERRATUS BLOCK (Blanco R, 2013)
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• Thoracic intercostal nerves T2-T12: lateral cutaneous branches cover antero-lateral chest wall.
Superficial serratus plane
Deep serratus plane
• Lateral+Medial Pectoral nerves
QUADRATUS LUMBORUM BLOCK
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Source: Carney J, 2011
Rostral distribution (L3)
Paravertebral spread T4
Dorsal spread L2
Paravertebral spread T6
QL muscle QL muscle
Paravertebral spread 5th thoracic
Why are we doing what we are doing everyday?
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“Life is pretty simple: You do some stuff. Most fails. Some works. You do more of what works. If it works big, others quickly copy it. Then you do something else. The trick is the doing something else. ”
“The greatest deception men suffer is from their own opinions”
BIG DATA • National Surgical Quality Program (NSQIP), • Society of Thoracic Surgeons (STS) National Database, • Closed Claims Registry of settled malpractice cases, • Multicenter Perioperative Outcomes Group (MPOG)
• Anesthesia Quality Institute's National Anesthesia Clinical Outcomes
Registry (NACOR) • Wake up Safe • PRAN
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