Thoracic surgery: PVB, SAPB, TEpi, ESP block, Precedex

Paravertebral Catheter Use for Postoperative Pain Control in Patients After Lung Transplant Surgery: A Prospective Observational Study.  JCVA February 2017. Volume 31, Issue 1, Pages 142–146.

To place the PV catheter at the T4-5 level, the authors used an in-plane transverse technique under ultrasound guidance, with the probe in a transverse orientation. After identifying the anatomic landmarks on ultrasound, a 17-gauge Tuohy needle was advanced in a lateral to medial direction, until the tip was beneath the transverse process. For all recipients in the study, the authors further confirmed correct PV catheter placement with real-time infusion of a local anesthetic (1-3 mL of 1.5% lidocaine with epinephrine 1:200,000); they were able to visualize on ultrasound the spread from the tip of the catheter.

Once it was confirmed that the tip remained in position, the PV catheter was secured with skin glue (Dermabond®, Ethicon, Inc.; Somerville, NJ). Next, at the PV catheter insertion site, the authors placed an occlusive dressing on a chlorhexidine-impregnated sponge (BioPatch®, Johnson & Johnson Wound Management, a division of Ethicon, Inc.; Somerville, NJ). The PV catheter was connected to an elastomeric pump (ON-Q®, Halyard Health, Alpharetta, GA), an infusion of 0.2% ropivacaine was started at a rate of 0.2 to 0.25 mL/kg/h; the maximum dose was 7 mL/h per side in bilateral lung transplant recipients and 14 mL/h in unilateral single-lung transplant recipients.

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From NYSORA

Ultrasound-Guided Serratus Anterior Plane Block Versus Thoracic Epidural Analgesia for Thoracotomy Pain. JCVA February 2017. Volume 31, Issue 1, Pages 152–158.

Under sterile conditions and while patients still were in the lateral position with the diseased side up, a linear ultrasound transducer (10-12 MHz) was placed in a sagittal plane over the midclavicular region of the thoracic cage. Then the ribs were counted down until the fifth rib was identified in the midaxillary line (Fig 1).18 The following muscles were identified overlying the fifth rib: the latissimus dorsi (superficial and posterior), teres major (superior), and serratus muscles (deep and inferior). The needle (a 22-gauge, 50-mm Touhy needle) was introduced in plane with respect to the ultrasound probe, targeting the plane superficial to the serratus anterior muscle (Fig 2). Under continuous ultrasound guidance, 30 mL of 0.25% levobupivacaine was injected, and then a catheter was threaded. A continuous infusion of 5 mL/hour of 0.125% levobupivacaine then was started through the catheter.

Figure-17-Nagdev-2017-ACEP-Now-Ultrasound-Guided-Serratus-Anterior-Plane-Block-Can-Help-Avoid-Opioid-Use-for-Patients-with-Rib-Fractures-
From http://painandpsa.org/rnb/

Erector Spinae Plane Block


Effect of Continuous Paravertebral Dexmedetomidine Administration on Intraoperative Anesthetic Drug Requirement and Post-Thoracotomy Pain Syndrome After Thoracotomy: A Randomized Controlled Trial. JCVA February 2017. Volume 31, Issue 1, Pages 159–165.

Adjuvants to prolong regional anesthesia

PEC 1 & 2 Blocks, Serratus Anterior Block

I’ve been hearing more and more about PEC 2 block for mastectomy.  What’s wonderful about this block is that it seems that the risk of pneumothorax is lower than for a paravertebral block.

Egyptian Journal of Anaesthesia; April 2014. Thoracic Paravertebral Block vs. Pectoral Nerve Block for Analgesia after Breast Surgery

SlideShare powerpoint: PEC 1 & 2 and Serratus Anterior Blocks

pec-i-and-pecs-ii-serratus-anterior-block-11-638

Current Anesthesiol Rep, 2015. Regional Anesthesia for Breast Surgery: Techniques and Benefits.

Rev Esp Anesthesia Reanim; 2012: Ultrasound Description of PECS 2 (modified PECS 1): A Novel Approach to Breast Surgery

Poster Summary of PECS 2

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TAP, PEC 1, & PEC 2 Blocks PPT

Anaesthesia, 2013. Serratus Plane Block: A Novel Ultrasound-Guided Thoracic Wall Nerve Block.

NYSORA 2014: Update on truncal blocks

Summary:

  • U/S guidance: probe position similar to infraclavicular block. Find 3rd, 4th rib.
  • Pt position: Head away from side of block. Ipsilateral arm abducted.
  • PEC 2: Inject 20 ml 0.25% bupi between pec minor and serratus.
  • PEC 1: Inject 10 ml 0.25% bupi between pec major and pec minor.
  • Serratus: 5th rib, mid-axillary line. Inject 30 ml 0.125% bupi along top (superficial) and bottom (deep) of serratus muscle (which is just deep to the latissmus dorsi).

YouTube: PECS 1&2 Block

YouTube: Serratus plane block


Update: Oct 24, 2018

PECs blocks in Cardiac Surgery

http://www.annals.in/article.asp?issn=0971-9784;year=2018;volume=21;issue=3;spage=333;epage=338;aulast=Kumar

http://www.apicareonline.com/ultrasoundguidedblocksforsurgeries-proceduresinvolvingchestwall-pecs-12andserratusplaneblock/

https://www.ncbi.nlm.nih.gov/m/pubmed/29016551/

 

PEC 1 & 2 Blocks, Serratus Anterior Block

I’ve been hearing more and more about PEC 2 block for mastectomy.  What’s wonderful about this block is that it seems that the risk of pneumothorax is lower than for a paravertebral block.

Egyptian Journal of Anaesthesia; April 2014. Thoracic Paravertebral Block vs. Pectoral Nerve Block for Analgesia after Breast Surgery

SlideShare powerpoint: PEC 1 & 2 and Serratus Anterior Blocks

pec-i-and-pecs-ii-serratus-anterior-block-11-638

Current Anesthesiol Rep, 2015. Regional Anesthesia for Breast Surgery: Techniques and Benefits.

Rev Esp Anesthesia Reanim; 2012: Ultrasound Description of PECS 2 (modified PECS 1): A Novel Approach to Breast Surgery

Poster Summary of PECS 2

unnamedl

TAP, PEC 1, & PEC 2 Blocks PPT

Anaesthesia, 2013. Serratus Plane Block: A Novel Ultrasound-Guided Thoracic Wall Nerve Block.

NYSORA 2014: Update on truncal blocks

Summary:

  • U/S guidance: probe position similar to infraclavicular block. Find 3rd, 4th rib.
  • Pt position: Head away from side of block. Ipsilateral arm abducted.
  • PEC 2: Inject 20 ml 0.25% bupi between pec minor and serratus.
  • PEC 1: Inject 10 ml 0.25% bupi between pec major and pec minor.
  • Serratus: 5th rib, mid-axillary line. Inject 30 ml 0.125% bupi along top (superficial) and bottom (deep) of serratus muscle (which is just deep to the latissmus dorsi).

YouTube: PECS 1&2 Block

YouTube: Serratus plane block

Paravertebral block basics and cancer recurrence #paravetebral #block #regional #ultrasound #anesthesia #cancer

From J Anaesthesiol Clin Pharmacol. 2011 Jan-Mar; 27(1): 5–11.
Why do paravertebral blocks?
Paravertebral blocks and decreased cancer recurrence
Paravertebral block techniques
From NYSORA

But wait… what about the potential side effects/adverse events from a paravertebral block?

Why not do a TIVA with propofol and dexmetetomedine and local anesthesia via surgeon?  Where’s that study to compare?

** Update **  July 20, 2016 –> What about the PEC 1&2 Blocks as well as Serratus block?

Prolonging blockade with adjuvants: