FASCIAL PLANE BLOCKS - arkansascrnas.comPECS I & II BLOCKS PEC I - Targets pectoralis major by...
Transcript of FASCIAL PLANE BLOCKS - arkansascrnas.comPECS I & II BLOCKS PEC I - Targets pectoralis major by...
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FASCIAL PLANE BLOCKS
TOM BARIBEAULT MSN, CRNA
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TECHNIQUES
Abdominal Wall
TAP
Rectus Sheath
Quadratus Lumborum
Erector Spinae
Chest
PECS I & II
Erector Spinae
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TECHNIQUES
Knee
Ipack/LIA
Hip
Fascia Iliaca
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TRANSVERSUS ABDOMINUS
PLANE
INFILTRATION
Subcostal
T7 -T12
Mid-axillary
T10-L1
Ilio-inguinal &
Iliohypogastric
L1
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DISTRIBUTION
Sub-Costal
T7-T11Mid-Ax
T10-L1
II/IH
L1
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ANATOMY
Anterior - Rectus
Abdominus Muscle (RAM)
Lateral - External
oblique muscle (EOM),
Internal oblique
muscle (IOM), &
Transversus abdominus
muscle (TAM)
Neuro-fascial TAP
plane
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Sub-
Costa
l
TAP
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MID-AXILLARY
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ILIO-INGUINAL
ILIO-
HYPOGRASTRIC
EOM
IOM
TAM
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RECTUS SHEATH
Anterior abdominal wall block
covering T7-T12
Bilaterally for midline incisions
Unilaterally for para-median
incisions
Provides only somatic pain relief
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RECTUS SHEATH
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RECTUS
SHEATH
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QUADRATUS LUMBORUM
Alternative approach to TAP blocks, B/L or
U/L
QL1, QL2, & QL3
QL 3 may provide the most reliable spread of
local within the thoracic para-vertebral
space
Allows for somatic & visceral analgesia from
T6 - L1
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ANATOMY
Lateral abdominal wall
- IOM, EOM, TAM
Posterior abdominal
wall - Quadratus
lumborum (QL), Psoas
major (PM), Erector
Spinae (ES), Latissimus
Dorsi (LD)
Thoracolumbar fascia
Transverse process
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QUADRATUS LUMBORUM
QL1, QL2 QL3
Anterior Posterior
T6-L1
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QUADRATUS LUMBORUM QL1
QL1
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QUADRATUS LUMBORUM
QL2
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QUADRATUS LUMBORUM
QL3
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PECS I & II BLOCKS
PEC I - Targets pectoralis major by blocking
the medial & lateral pectoral nerves
PEC II - Targets intercostal nerves T2-6, for
anesthesia of the skin of the anterolateral
chest, axilla, medial & upper arm, & the long
thoracic nerve which covers serratus anterior
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ANATOMY
Anterior chest wall -
Comprised of the
pectoralis major and
pectoralis minor
muscles
Lateral chest wall -
Serratus anterior
muscle is deep to
pectoralis minor
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ANATOMY
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PECS I & II
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PECS I & II SONOANATOMY
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PECS I & II
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PECS I & II
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ERECTOR SPINAE
Injection at T5 covers
C7-T8
Injection at T7 covers
T6-L3
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ANATOMY
Trapezius
Base of Skull to T12
Rhomboid
T2-6
Erector Spinae
Cervical-Sacral
spine
Middle and posterior
thoracolumbar fascia
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ANATOMY
Ventral and Dorsal
Ramus
Sympathetic chain
visceral relief
May have some
hypotension
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SONOANATOMY
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SONOANATOMY
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INJECTION
Deep or superficial to
erector spinae
Deep may have better
results
30 ml local anesthetic
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TECHNIQUE
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IPACK
Injection between the
Popliteal artery and the
Capsule of Knee
Provides anesthesia to
the posterior knee
Preserves motor function
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IPACK ANATOMY
Posterior condyles
of the femur
Popliteal artery &
usual vein
Articular branches
of the tibial nerve
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IPACK
Patient is positioned
supine with the extremity
externally rotated
Mid or low frequency probe
is placed transverse along
the medial aspect of the
distal thigh, just above
the medial condyle of the
femur
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IPACK ANATOMY
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IPACK SONOANATOMY
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IPACK
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LIA
Local Infiltration Analgesia
Provides anesthesia to the
anterior knee
Two needle passes, one deep &
one superficial
Preserves motor function of
the quadricep muscles
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LIA
Blocks the articular and muscular
branches of the femoral nerve
Done in place of surgeon’s injection
at the field
Injection tends to be painful and is
preferably done with either a short
acting femoral block or following
spinal or general anesthesia
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iPACK LIA
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LIA SONOANATOMY
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FASCIA ILIACA
Analgesia to hip,
anterio/lateral thigh and
anterior knee
Hip fracture,
replacement, arthroscopy
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ANATOMY
Femoral, lateral femoral
cutaneous nerve
Sartorius, internal
oblique, and iliacus
muscles
Fascia lata, and fascia
iliaca
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PROBE POSITION
Cephalad to caudad
orientation, lateral
to anterior superior
iliac spine, directed
slightly towards
umbilicus
Slide probe
cephalad/caudad to
find “bowtie”
Fascia lata/iliaca
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SONO-ANATOMY
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INJECTION
Needle inferior to
superior
Spread of local
anesthetic cephalad
50 ml low
concentration local
anesthetic
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PHARMACOLOGICAL
SELECTIONS
Bupivicaine
Liposomal
Bupivicaine
Ropivicaine
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PHARMACOLOGICAL SELECTIONS
Bupivicaine: 0.25, Decadron (PF) 5-10 mg
Max dose 3mg/kg
Ropivicaine: 0.2%, Decadron (PF) 5-10 mg
Max dose of 3mg/kg
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PHARMACOLOGICAL SELECTION
Liposomal Bupivacaine (LB): 20 mL vial of
Exparel,(1.3%, 266 mg/20 mL), can be administered
undiluted or expanded up to a total of 300 mL (normal
saline or lactated Ringer’s)
Bupivicaine can be mixed with LB for administration
in field techniques using the same volumes as
described with each block
Max dose is 266mg or 20 ml
DO NOT exceed 150 mg of Bupivicaine per 20ml of 1.3%
LB
DO NOT mix with lidocaine or other non-bupivicaine
locals
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CONTRAINDICATIONS
Absolute: Patient refusal, allergy to local
anesthetics, localized infection at injection site
Relative: Anti-coagulation or coagulopathy, surgery or
hernia at the injection site, inability to visualize
proper anatomy with ultrasound, & specific to iPACK;
anatomic deformity of the knee (posterior knee cyst, or
popliteal artery aneurysm)
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SPECIAL THANKS/REFERENCES
Western Reserve Anesthesia
Education
Block Buddy App
Kellie Deeter MSN, CRNA