Truncal Blocks

Question 1

What is the goal of truncal blocks?

Answer 1

Postoperative pain control. Thus, use 1/4 or 1/8% so we can use more volume to ensure greater spread

Question 2

**What is the indication for a rectus sheath block?

Answer 2

Umbilical hernia

T8 - T12

Question 3

What are your worries w/rectus sheath block?

Answer 3

Epigastric arteries

Peritoneum

Question 4

What is the anatomy with a rectus sheath block?

Answer 4

1. Ventral rami leave vertebral foramen in the neck
2. Forms brachial plexus
3. Thoracic region, ventral rami become subcostal nerves and intercostal nerves
4. As they leave the costal margin they run in a plane of transverse abdominal and posterior fascia

Question 5

What nerves innervate the abdominal wall

Answer 5

T6 - T10/L1

Question 6

How much LA w/rectus sheath block?

Answer 6

10 mL between rectus abdominis and posterior fascia plane

Question 7

**What are the indications for a TAP block?

Answer 7

alternative for low to mid abdominal wall surgery when an epidural and/or intrathecal opioids are contraindicated or refused

Question 8

TAP block provides somatic anesthesia to….

Answer 8

abdominal wall T7 - L1

highly dependent on interfascial spread

Question 9

T6 - L1

Answer 9

full abdomen

Question 10

T9 - L1

Answer 10

more lateral abdomen

Question 11

TAP Block technique

Answer 11

1. Transducer btw costal margin + iliac crest midaxillary in transverse orientation
2. Slide transducer medially + laterally until the three muscle layers (external oblique, internal oblique, transverse abdominis) are identified
3. Needle inserted to penetrate fascia btw internal oblique and transversus abdominis

Question 12

How much LA per side for TAP block?

Answer 12

20 mL

Question 13

Subcostal TAP block indicated for…

Answer 13

any procedures above umbi

somatic, not visceral coverage

Question 14

Erector Spinae block indicated for:

Answer 14

back surgery

Question 15

Erector Spinae muscles include:

Answer 15

spinalis
longisimus
iliocostalis

Question 16

ESB risks

Answer 16

retroperitoneum
kidneys
pleura

Question 17

What does the ESB target?

Answer 17

dorsal rami and potentially ventral rami

Question 18

What type of block is ESB

Answer 18

fascial plane block deep to the spinae muscle group
sensory block (somatic if you hit ventral rami)

Question 19

Technique for ESB

Answer 19

1. Parasaggital plane to determine optimal block level
2. Volume dependent block
3. Slide transducer laterally to identify transverse process
4. Needle cephalad to caudal
5. Incremental injections of 5 mL for a total of 20 mL
6. Repeat on opposite side

Question 20

What is the superior border of QL muscle

Answer 20

12th rib L1 - L5

Question 21

What is the inferior border of QL muiscle

Answer 21

posterior border of ileac crest

Question 22

ESB complications

Answer 22

hematoma
infection
tissue trauma/pneumo
HD instability
LAST
LP block

Question 23

Quadratus Lumborum Block Indications**

Answer 23

large bowel resections, appy, chole
c-sx
total abdominal hysterectomy
prostatectomy
renal tx, nephrectomy
abdominoplasty, iliac crest bone graft
ex-lap

Question 24

What does the QL block target?

Answer 24

Iliohypogastric
Ilioinguinal
Subcostal n that cross psoas muscle + transverse fascia
Lateral femoral cutaneous

Question 25

TAP vs QL block

Answer 25

TAP - somatic coverageT7 -L1 --->good for lower abdominal wall surgery QL B- iliohypo, ilioinguinal, subcostal, lat femoral cutaneous

Question 26

QL 3 Technique

Answer 26

1. Patient lateral decubitus w/hips + knees flexed 2. Curvilinear transducer placed mid-axillary line cephalad to iliac crest 3. Slide transducer posteriorly, tilt caudad until "shamrock sign" is visualized 4. LA btw QL and psoas

Question 27

What is the "shamrock sign"

Answer 27

L4 transverse process = stem | Erector spinae, QL, Psoas major = trefoil

Question 28

Where does the lower pole of kidney lie

Answer 28

anterior to QL muscle and can reach L4 w/deep inspiration

Question 29

PEC I & II indications

Answer 29

analgesia following breast surgery | great alternative to paravertebral or thoracic epidural, thus decreases risk of pneumo/spinal

Question 30

What nerves does PECS 1 block

Answer 30

medial and lateral pectoral nerves

Question 31

PECS 2

Answer 31

extension of PEC I and provides additional blockade of upper intercostal nerves

Question 32

PECS 1 technique

Answer 32

1. supine + abducted arm 2. cephalad medial and caudad lateral orientation @ caracoid process 3. costal margines, PM, Pmi, serratus anterior muscles identified 4. Cephalad to caudad insertion until tip penetrates fascia btw PM and Pmi

Question 33

PECS 2

Answer 33

already did pecs I 1. slide transducer caudad to 2nd rib and angle inferolaterally until Pmi, serratus anterior muscles are identified 2. further lateral to identify 3 + 4 ribs 3. LA injected between PmI and serratus anterior

Question 34

if you block ventral rami of cervical vertebrae what do you block

Answer 34

phrenic n

Question 35

intercostal vs paravertebral

Answer 35

intercostal is one level and paravertebral is the epidural space, thus bilateral paravertebral targets the paravertebral space (PVS) which contains spinal nerves, branches, symp. trunk

Question 36

paravertebral indications

Answer 36

periop analgesia for thoracic, chest wall or breasts | rib fx pain management

Question 37

PVS anatomy

Answer 37

wedge-shaped area formed medially by vertebral body inferiorly by parietal pleura anteriorly by costotransverse ligament

Question 38

Paravertebral technique

Answer 38

patient in lateral decubitus 1. transverse oreintation at desired level lateral to sp. process 2. once TP and ribs are identified, slide transducer caudad into the intercostal space

Question 39

Intercostal Nerve Block indications

Answer 39

analgesia following breast, thoracic, upper abd sx | pain management of rib fx

Question 40

INB targets ...

Answer 40

intercostal nerves resulting in ipsilateral anesthesia at specific levels single dermatome coverage!!

Question 41

INB technique

Answer 41

patient sitting, lateral decub, prone 1. sagittal plane 6 - 8 cm from midline btw ribs 2. 7 - 12 ribs 3. in plane, tip btw internal and innermost ic muscles

Question 42

INB pearls

Answer 42

hard to perform above t7 d/t scapula | inadequate as a surgical anesthetic