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Truncal Blocks Study online at https://quizlet.com/_ffu3eo 1. What are indica- Procedures that require analgesia of the pec major tions for PECS 1 muscle: Block? - Breast implantation - Implantable cardiac d...

Truncal Blocks Study online at https://quizlet.com/_ffu3eo 1. What are indica- Procedures that require analgesia of the pec major tions for PECS 1 muscle: Block? - Breast implantation - Implantable cardiac device 2. What is the Landmark: anatomical land- - Place a high-frequency (> 7MHz) linear array trans- mark for PECS ducer in sagittal orientation beneath the clavicle at the 1? Where is lo- coracoid process (similar to an infraclavicular block). cal anesthetic in- jected in PECS 1 Injection site = fascial plane between the: block? - Pec major and pec minor 3. What are indica- Everything covered by PECS 1 tions for PECS 2 Block? Procedures that also require analgesia of the axilla: - Mastectomy - Sentinel node biopsy - Tumor resection 4. Where is local Injection site = fascial plane between the: anesthetic inject- - Pec major and pec minor (injection 1) ed in PECS 1 - Pec minor and serratus anterior (injection 2) block? 5. What are the target Breast reconstruction with latissimus dorsi flap and indications for 1 / 13  Truncal Blocks Study online at https://quizlet.com/_ffu3eo Serratus Anterior Plane Block? 6. What is the Landmark: anatomical land- - Place a high-frequency (>7 MHz) linear array trans- mark for SAP ducer over the mid-axillary line in the upper region of Block? Where is the lateral chest wall. The transducer should be in the local anesthetic in- transverse orientation. jected? Injection site = fascial plane between the: - Latissimus dorsi and serratus anterior 7. What are the ad- Advantages: PECS blocks eliminate the risks associated vantages of PECS with paravertebral or intercostal blockade and SAP blocks? What are the com- Complications plications? What - Inadvertent puncture, vascular injury, hematoma, and doses are recom- LAST. mended? - Pneumothorax can occur due to the close proximity of the needle the pleural space. Doses: 0.2 mg/kg for PECs and 0.4mg/kg for SAP blocks. 8. What is an anatom- The intercostal nerves travel beneath the rib alongside ical considera- the corresponding intercostal artery and vein. tion of intercostal nerves? The nerve's proximity to these vascular structures has implications for local anesthetic toxicity. 9. 2 / 13  Truncal Blocks Study online at https://quizlet.com/_ffu3eo What regions are T2 - T6: innervate the skin covering the chest wall, inter- innervated by in- costal muscles, and parietal pleura. tercostal nerves? T7-T11: innervate the skin over the anterior abdomen, abdominal muscles, and parietal peritoneum. 10. What are indi- Indications: rib fractures, herpes zoster, surgical proce- cations for in- dures of the chest and abdomen, and chest-tube place- tercostal nerve ment when epidural analgesia is not desired or possible. blocks? 11. What are the Advantages advantages and - Provide anesthesia and analgesia for acute and chronic disadvantages of pain syndromes. intercostal nerve - Promote normal ventilation and facilitate deep breath- blocks? ing exercises needed during postoperative recovery. - Reduce the risk of opioid-induced respiratory depres- sion by decreasing opioid consumption. Disadvantages - Provide coverage for only one dermatome level, so the procedure must be performed at each level where anesthesia is desired. 12. Where is local In the costotransverse ligament at the inferior border of anesthetic inject- the upper rib. ed in an intercostal nerve block? 13. What is a dis- Blocking T1 - T5 can be difficult due to the thickness of advantage of per- the paraspinal muscles and the proximity of the scapula forming T1 - T5 (you should use a paravertebral block instead). intercostal nerve block? What is an alternative? 3 / 13  Truncal Blocks Study online at https://quizlet.com/_ffu3eo 14. What are com- - LAST (due to high vascularity). plications of in- - Pneumothorax. tercostal nerve - Respiratory insufficiency may occur in patients with blocks? severe COPD who depend on their intercostal muscles for ventilation. 15. Describe the The paravertebral space (PVS) is a wedge-shaped area anatomy of with the following boundaries: the paravertevral 1. Anterior: Parietal pleura space 2. Medial: Vertebral body and intravertebral foramen 3. Posterior: Transverse process and superior costo- transverse ligament The medial aspect of the paravertebral space is a con- tinuation of the epidural space. This explains why the sympathetic ganglia are anesthetized by a paravertebral block. Indeed, the PVB is often referred to as a "unilateral epidural." 16. What area is tar- The paravertebral block provides segmental anesthesia geted by paraver- that targets the spinal nerves (somatic and sympathetic) tebral blocks? as they emerge from the intervertebral foramen and enter the paravertebral space. This block provides anesthesia at the respective intercostal regions. 17. Surgical Procedures: - Thoracic 4 / 13  Truncal Blocks Study online at https://quizlet.com/_ffu3eo What are indica- - Breast tions of paraverte- - Cholecystectomy bral blocks? - Herniorrhaphy - Appendectomy Pain Management: - Rib fractures - Flail chest - Blunt abdominal trauma - Osteoporotic vertebral fractures - Herpes zoster where coverage of more than one der- matome is needed 18. Where is local Injection: in the paravertebral space. anesthetic inject- ed in a paraver- Landmarks: tebral block? What - At each level, draw a 2.5 cm line laterally from the are the landmarks spinous process (this approximates the location of each for block without transverse ultrasound? process). - Once you contact bone, redirect the needle slightly superior and medial (to reduce the risk of pneumotho- rax), and advance it 1 cm deeper than the depth of bone contact. 19. What is a disad- You can perform the PVB at any level (thoracic or lum- vantage of lum- bar). However, the lumbar approach may be difficult due bar paravertebral to the block? increased depth of the PVS, even when using ultra- sound. 20. - LAST (the PVS also contains the intercostal vessels) - Pneumothorax. 5 / 13  Truncal Blocks Study online at https://quizlet.com/_ffu3eo What are compli- - Intrathecal injection (spinal anesthesia) cations of paraver- - Post-dural puncture headache is a documented com- tebral block? plication of PVB. 21. Describe the Anatomy anatomy and func- The erector spine consists of three paired muscles that tion of the Erector extend Spinae muscles from the sacrum to the skull base. 1. Iliocostalis 2. Longissimus 3. Spinalis Function - Help the vertebral column stay upright. - They also assist in moving the vertebral column (exten- sion and lateral flexion). 22. What are indica- Indications: neuropathic pain, rib fractures, lumbar tions of the erec- spine surgery, thoracic surgery, cardiac surgery, breast tor spinae block surgery, (ESB)? bariatric surgery, and numerous abdominal procedures. 23. Where is local The erector spinae block (ESB) is a fascial plane tech- anesthetic inject- nique that targets the dorsal and ventral rami of the ed in an erec- thoracolumbar tor spinae block nerves at the level of injection. (ESB)? Injecting local anesthetic deep to the erector spine mus- cle group and superficial to the transverse process caus- es significant craniocaudal spread. 6 / 13  Truncal Blocks Study online at https://quizlet.com/_ffu3eo 24. How many der- A single injection at the thoracic level covers approxi- matomes are cov- mately 8 - 11 dermatome levels. ered with thoractic and lumbar ESB? A single injection at the lumbar level covers approximate- ly 3 - 4 dermatome levels. 25. What are compli- There are few risks associated with an ESB block be- cations of ESB? cause the landmarks are easily identifiable, and the pleu- ra is away from the injection site. - At the lumbar level, the facet joints align with the trans- verse processes. This makes it easy to mistake the facet joint for the transverse process, which can contribute to a failed block. - Several case studies document pneumothorax during thoracic ESB due to the provider losing sight of the needle during block placement. 26. What are the 4 Four paired muscles form the anterolateral abdominal muscles of the ab- wall: dominal wall? 1. Rectus abdominis (RA) 2. Transversus abdominis (TA) 3. External oblique (EO) 4. Internal oblique (IO) 27. 7 / 13  Truncal Blocks Study online at https://quizlet.com/_ffu3eo What is an anatom- The inferior lumbar triangle (triangle of Petit) provides a ical landmark for a key anatomic reference point for performing a TAP block TAP block? - Posterior border = Latissimus dorsi - Anterior border = External oblique - Inferior border = Iliac crest - Inside of the triangle (floor) = Internal oblique (the transverse abdominis is deep to the IO) 28. What are indi- Indications for TAP include hernia repair, open appen- cations for TAP dectomy, laparoscopic abdominal procedures, radical bock? prostatectomy, gynecologic surgeries, and cesarean section. The TAP block provides analgesia to the abdominal wall (skin and muscle) and the parietal peritoneum. 29. Where is local - The TAP block is a fascial plane block. The goal is anesthetic inject- to place local anesthetic in the fascial plane between ed in TAP block? the internal oblique (IO) and transverse abdominis (TA) muscles. - The thoracolumbar nerves arising from T6 - L1 inner- vate the IO and TA muscles. 30. What are the 3 dif- There are 3 approaches (subcostal, lateral, and posteri- ferent approaches or), and you can use them individually or in combination. to TAP block? The location of the surgical procedure informs the ap- proach you select: - Subcostal approach: procedures above the umbilicus - Lateral and posterior approach: procedures below the umbilicus 8 / 13  Truncal Blocks Study online at https://quizlet.com/_ffu3eo 31. What are land- - Place the transducer lateral to the xiphoid process and marks for sub- parallel with the lower margin of the rib cage. costal TAP Block? - The rectus abdominis (RA) will appear as an elliptical structure on the medial side of the screen. - Scanning laterally, the posterior rectus abdominis fas- cia (i.e., linea semilunaris) gives rise to the external and internal oblique muscles (EO and IO). 32. What are land- Place the transducer at the mid-axillary line, superior and marks for lateral parallel to the iliac crest. TAP Block? 33. What are land- Place the transducer in the same position as the lateral marks for posteri- approach, then slide past the midaxillary line until you or TAP Block? see the aponeurosis of the tensor fascia latae (TFL). 9 / 13  Truncal Blocks Study online at https://quizlet.com/_ffu3eo 34. What are compli- - Block failure: local anesthetic injected into the wrong cations of a TAP fascial plane block? - Injury to the abdominal organs can occur if the needle enters the peritoneum 35. What factors that - A large volume of local anesthetic injection at each site. contribute to LAST - Accidental intravascular injection into a thoracic inter- during TAP block? costal artery or deep circumflex iliac artery. - An increased rate of local anesthetic absorption due to the compact area of the fascia. 36. Describe the The thoracolumbar fascia consists of 3 layers: anterior, anatomy of middle, and posterior. the thoracolumbar fascia (TLF) Quadratus lumborum muscle - Resides between the anterior to the middle layers of the TLF, deep in the posterior abdominal wall. - It originates on the posterior aspect of the iliac crest and iliolumbar ligament and extends to the 12th rib and the transverse processes of L1 - L4. 37. Where is local The quadratus lumborum (QL) block is a fascial plane anesthetic inject- block that's often described as an "indirect paravertebral ed in quadra- block." tus lumborum (QL) block? The quadratus lumborum muscle is a key anatomic land- mark, and the thoracolumbar fascia is the target area for 10 / 13  Truncal Blocks Study online at https://quizlet.com/_ffu3eo depositing local anesthetic. - QL 1 ’ LA is injected lateral to the QLM - QL2 ’ LA is injected posterior to the QLM - QL 3 ’ LA is iniected anterior to the QLM 38. What are the in- QL1: Abdominal surgery below the umbilicus dications for the quadratus lumbo- QL2 & 3: Abdominal surgery below or above the umbili- rum (QL) block? cus (up to T6) 39. What are land- - Position transducer in transverse orientation above the marks for QL 1 iliac crest at the midaxillary line. block? - Slide the transducer posteriorly until you identify the TLF lateral to the QLM and the aponeurosis of the exter- nal oblique, internal oblique, and transversus abdominis muscles. 40. What are land- - Position transducer above the iliac crest in a transverse marks for QL 3 orientation. block? - The "shamrock sign" is formed by the L4 transverse process, the erector spinae muscle group, QL muscle, and psoas muscle. - The injection site is in the fascial plane between the QL and psoas muscles. 11 / 13  Truncal Blocks Study online at https://quizlet.com/_ffu3eo 41. What are compli- - Puncture of the peritoneum (less with QL3) cations of the QL blocks? - Injury to the liver, kidney, or spleen 42. Describe the - It's comprised of the aponeurosis (fibrous tissue) of anatomy of the the external oblique, internal oblique, and transverse rectus sheath abdominis muscles. - The linea alba is a thickened region of the anterior rectus sheath that extends vertically from the xiphoid process to the pubic symphysis. - The linea semilunaris runs vertically along the lateral edges of the rectus abdominis. - Tendinous intersections run horizontally across the rec- tus abdominis. 43. What is the tar- Like the TAP block, the rectus sheath block is a fascial get of the rectus plane block that targets the thoracolumbar nerves and sheath block? the anterior cutaneous branches that provide sensory innervation to the anterior abdominal wall (it doesn't provide visceral coverage). 12 / 13  Truncal Blocks Study online at https://quizlet.com/_ffu3eo 44. What are indica- The rectus sheath block is used in procedures that re- tions for rectus quire a midline abdominal incision. sheath block? Indications include umbilical hernia repair in the pediatric population, cesarean section when a midline incision is required, and postpartum laparoscopic tubal ligation. 45. Where is local Between the rectus abdominis muscle and the posterior anesthetic inject- rectus sheath. ed in rectus sheath block? 46. What are compli- - Failed block due to injection in the wrong fascia cations of the rec- - LAST tus sheath block? - Peritoneal injury 13 / 13