Rafael Blanco Corniche Hospital, UAE NYSORA 2014

U P D AT E S O N T R U N C A L B L O C K S P E C S , S E R R AT U S A N D Q L B B L O C K S

LOUVRE MUSEUM

GUGGENHEIM MUSEUM

I C A N D O T H AT !T H E C O N C E P T O F T H O R A C I C W A L L B L O C K S …

N O C O N F L I C T S O F I N T E R E S T

A L L V I D E O S A N D P I C T U R E S H AV E O B TA I N E D C O N S E N T B Y T H E PAT I E N T S

By the way…

• To locate a plane through which the local anaesthetic will reach the nerves

• To avoid potential puncture of surrounding structures

• To optimize the ultrasound to the best image it can give ( superficial planes= higher resolution)

So…

T H E P E C S B L O C K S E R I E S ( P E C S I , I I A N D S E R R AT U S P L A N E B L O C K S ) A R E E A S Y A N D R E L I A B L E S U P E R F I C I A L B L O C K S U S E D T O PA R T I A L LY B L O C K T H E H E M I T H O R A X

A N D D E S I G N A S A LT E R N AT I V E S T O T H E T H O R A C I C E P I D U R A L A N D PA R AV E R T E B R A L B L O C K S

I T I S N O T O U R A I M AT T H I S S TA G E T O E S TA B L I S H A N Y K I N D O F S U P E R I O R I T Y B E T W E E N E A C H O T H E R

A N AT O M Y O F T H E B R E A S T

Ann. Surg. Vol. 205 (5) May 1987,504-506

PECS I PECS II

1 12

SPB

Serratus plane blockModified Pecs IPecs IPECS I PECS II SPB

3 thoracic blocks…

10 ml

10+ 20 ml

30 ml

T H E O R I G I N A L A P P R O A C H F O R B R E A S T S U R G E R Y S I M P L E , FA S T A N D R E L I A B L E B L O C K

A N E A S Y R E S C U E B L O C K A G O O D B L O C K O F T H E L AT E R A L A N D M E D I A L P E C T O R A L N E R V E S

T H E R E I S A C O M M O N B U T N O T C O N S I S T E N T C O V E R O F T H E A N T E R I O R B R A N C H E S O F T H E I N T E R C O S TA L N E R V E S

!

0.4 ml / kg 0. 25%Levobupivacaine

I N D I C AT I O N S

U N I L AT E R A L S U R G E R Y F O R U P P E R T H O R A C I C P R O C E D U R E S

B I L AT E R A L B L O C K S A N D C AT H E T E R I N S E R T I O N S W I T H C O N T I N U O U S I N F U S I O N C A N B E U S E D

!B R E A S T A U G M E N TAT I O N S

E X PA N D E R S P O R TA C AT H S

I M P L A N TA B L E C A R D I O V E R T E R D E F I B R I L L AT O R S A N T E R I O R T H O R A C O T O M I E S O P E N S H O U L D E R S U R G E R Y

A P R I L - M AY 2 0 1 1

V O L 2 , N 1 6 8 9 - 9 3

T W O I N J E C T I O N S 1 : 1 0 M L O F L . A . B E T W E E N T H E P E C T O R A L M U S C L E S

2 : 2 0 M L O F L . A . U N D E R P E C T O R A L I S M I N O R M U S C L E A N D A R O U N D T H E S E R R AT U S M U S C L E

S T E P S T O L O C AT E P O I N T O F I N J E C T I O N S

1 S T I N J E C T I O N B E T W E E N P M A N D P M

A N G L E P R O B E T O L O C AT E A X I L L A R Y FA S C I A

S E C O N D S TA G E I N F I LT R AT I N G A R O U N D T H E S E R R AT U S M U S C L E

A B O V E S E R R AT U S M . U N D E R N E AT H S E R R AT U S M .

P Major

P minor

Serratus

pect branch acromiothoracic artery

R3

R4

R4

Anteromedial Latero posterior Anteromedial Latero posterior

Serratus

P minor

P Major

S E C O N D S TA G E I N F I LT R AT I N G B E L O W T H E S E R R AT U S M U S C L E

S P R E A D O F C O N T R A S T D O W N T H E R I B C A G E

S P R E A D O F C O N T R A S T P O S T E R I O R LY

I N D I C AT I O N S

U N I L AT E R A L S U R G E R Y F O R U P P E R T H O R A C I C P R O C E D U R E S

B I L AT E R A L B L O C K S A N D C AT H E T E R I N S E R T I O N S W I T H C O N T I N U O U S I N F U S I O N C A N B E U S E D

!B R E A S T A U G M E N TAT I O N S

E X PA N D E R S T U M O U R R E S E C T I O N S

M A S T E C T O M I E S S E N T I N E L N O D E D I S S E C T I O N S

A X I L L A R Y C L E A R A N C E S A N T. T H O R A C O T O M I E S

O P E N S H O U L D E R S U R G E R Y

T I M E T O F I R S T A N A L G E S I A M O R P H I N E C O N S U M P T I O N

P E C S B E T T E R P E C S B E T T E R

PA I N S C O R E S AT R E S T PA I N S C O R E S W I T H M O V E

P E C S B E T T E R F I R S T 1 2 H O U R S P E C S B E T T E R F I R S T 1 2 H O U R S

U LT R A S O U N D PAT T E R N S P B

U LT R A S O U N D PAT T E R N S P B

D ATA

I T I S A FA S C I A L M U LT I B L O C K I T R E Q U I R E S C O U N T I N G T H E R I B S T O R I B 4

I N J E C T I O N I : 3 0 M L O F L . A . A B O V E S E R R AT U S M U S C L E B E AWA R E O F T H E T H O R A C O D O R S A L A R T E R Y

S P B

A B O V E S E R R AT U S M . U N D E R N E AT H S E R R AT U S M .

O P T I M A L P O I N T O F I N J E C T I O N

I N D I C AT I O N S

U N I L AT E R A L S U R G E R Y F O R U P P E R T H O R A C I C P R O C E D U R E S

B I L AT E R A L B L O C K S A N D C AT H E T E R I N S E R T I O N S W I T H C O N T I N U O U S I N F U S I O N C A N B E U S E D

!B R E A S T A U G M E N TAT I O N S

T U M O U R R E S E C T I O N S M A S T E C T O M I E S S E N T I N E L N O D E

A X I L L A R Y C L E A R A N C E S R I B F R A C T U R E S

!C H R O N I C PA I N

( P O S T R A D I O T H E R A P Y )

L AT T I S I M U S D O R S I F L A P S U P P E R A B D O M I N A L ? ?

M I D C A B S ? M I N I M A L LY I N VA S I V E D I R E C T C O R O N A R Y A R T E R Y B Y PA S S

C O N C L U S I O N S F O R T H E T H O R A C I C B L O C K S

• They work and they are easy to perfom

• There is evidence that they work better than PVB

• For 50 years there was no real alternative to EPI/PVB

T H A N K Y O U I N A R A B I C …

“Sucran”

R E C O M M E N D E D R E A D I N G

F R E E T E X T O N L I N E ! !

Abdominal blocks

PosteriorBlanco R, Tap block under ultrasound guidance: the description of a “no pops” technique Reg Anesth Pain Med 2007, Volume 32, Issue 5, Pages 130-130

Studies on the spread of local anaesthetic solution in transversus abdominis plane blocks. Carney J, Finnerty O, Rauf J, Bergin D, Laffey JG, Mc Donnell JG. !

2011 Nov;66(11):1023-30

The posterior approaches, using both landmark and ultrasound identifications, resulted in predominantly posterior spread of contrast around the quadratus lumborum to the paravertebral space from T5 to L1 vertebral levels.

•Classic blind approach •Anterior oblique-subcostal approach •Mid-axillary approach •Posterior approach ( anterolateral border of Quadratus lumborum)

QLB I

TAP ant vs QLB I

!

Figura 2. Valores de escala visual analógica (EVA) en reposo en ambos grupos de estudio

Figura 3. Valores de escala visual analógica (EVA) en movimiento en ambos grupos de estudio

Figura 4. Nivel de dermatoma sensitivo alcanzado. !

Figura 5. Nº pacientes que precisaron analgesia de rescate a los 10, 30, 60, 90 minutos y a las 24 h del postoperatorio.

QLB II

Continuous postoperative analgesia via quadratus lumborum block - an alternative to transversus abdominis plane block. Visoiu M, Yakovleva N. Source

Department of Anesthesiology, Acute Interventional Perioperative Pediatric Postoperative Pain Service, Children's Hospital of University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA.

Abstract Different transversus abdominis plane blocks techniques cause variations in postoperative analgesia characteristics. We report the use of unilateral quadratus lumborum catheter for analgesia following colostomy closure. The catheter was placed under direct ultrasound visualization and had good outcomes: low pain scores and minimal use of rescue analgesic medication. No complications were reported in this pediatric patient. More studies are needed to evaluate the effectiveness and safety of this regional anesthesia technique. © 2013 John Wiley & Sons Ltd.

Mihaela Visoiu

•QLB catheter •Anterior border of QL •10 ml Ropivacaine 0.5% catheter inserted at 13.5 cm from ss •Infusion 5 ml/h 0.2% Ropivacaine •Discharge Day 4 •Mean pain score 0.42/10 •Median pain score 1/10

Directed communication at ASRA by a trainee under Consultant’s guidance

Laparotomy for duodenal tumour excision

QLB+ Fent PCA NRS 0/10 recovery VAS 4/10 and 6/10

Ultrasound guided Quadratus lumborum (QL) block !Case report Dr Vasanth Rao Kadam!University of Adelaide, South Australia, Australia

Introduction!!Quadratus lumborum (QL) block for regional analgesia has not been reported. A Radiological study demonstrated the spread of dye from QL plane up to T4 paravertebral plane1.We report its use in this case report.

ANZCA 2013

Ultrasoung guided Transmuscular Quadratus Lumborum blockade

DARA / ESRA Nederland !February 2013!

Heeze.

Jens Børglum

Onset at 30’ TPV and tQLB were faster, at 120’ QLB max distribution

T4/L1 in TPV

T7/L1 plus posterior dermatomes in QLB

T7/L1 but not posterior dermatomes in tQLB

Handbook of ultrasound regional anaesthesia

QLB type I QLB type II

2013

We need to compare TAP a to QLB II

We need to compare QLB I to QLB II

Conclusions

• Diffusion blocks work

• Diffusion blocks are fast, volume based and easily taught

• They only need linear probes and depth is an average of 2 cm ( therefore real potential with new high frecuency probes!)

• Complication are lower down to the minimum as no vital structures are involved

• Ultrasound combined with MRI research have made this a new area to explore