Regional Anesthesia for the
Neuroaxis, Chest, Abdomen
Regional/APS Rotations
(Slides by Randall Malchow, MD)
Regional Anesthesia for
Chest and Abdomen
Thoracic Epidurals
Intercostals
Paravertebral Block
Ilioinguinal, Iliohypogastric
Blocks
TAP/Rectus Sheath Blocks
Caudals
Thoracic Dermatomes
note C4-T2 interface
Thoracic Spine
Sharply angulated sp proc
  Min flexion of spine (facets)
  Thin ligamentum flavum
  Thin epidural space 3-4 mm
(5-6 mm in lumbar)
  Interspace:
–  T4- Upper Rib Fxs
–  T6- Thoracotomies
–  T10- Laparotomies
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Midline Thoracic
Epidural
Spinous Process
at Trans Process
of level below
  Angle 60-75 deg
cephalad
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Paramedian
Approach
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Esp impt at mid-thor
region (Thoracotomy,
MIDCABG)
Lg aperture
1 cm contralat to upper
T6 sp proc
Touch side of sp proc,
then adv needle
perpendicular to lamina
Adv 15-30deg med; 45
deg cephalad
TEA: for Cardiac
Surgery
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Timing: Day Before vs
DOS
Consider periop anticoag
(eg Valves)
Preinduction placement/
Test Dose
T3- Sternotomy
Arrow Flex-tip?
Induction: Midaz 0.2mg/
kg; Panc
Limit advancement, 3cm
Secure catheters well
Half rate during CPB
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Opioid: hydrophilic to
maximize other dermatomes
UE numbness common
LE deficits concerning
Duration: 72hrs; remove p
CT’s out
USG Lumbar Epidural (parasag)
Note 3 branches of Intercostal Nerves:
-posterior
-lateral
-anterior
Intercostal Nerve Block
USG
InterCostal
Block
Paravertebral Blocks:
Anatomy
Spinal Process:
–  extend to trans
process below
  Superior
costotransverse lig
–  paravert space deep
to ligament
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Paravertebral Space
Actual PVB Space: very small
Paravertebral Blocks
Technique
C7-T5 Spinal
Processes
  2.5cm lat to s.p.
  Adv 21gu x 4in
stimuplex to
trans proc
  Trans Process:
2-4 cm depth
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Primary Tech: T1-5 separate levels
Postop Analg: T2,T5 Breast Surgery
Paravertebral Block:
Technique
Adv inferior to trans
process, <1.25cm,
sup costotrans lig
(addl 1cm to pleura)
  Paresthesia possible
  5-15cc of local anes
  Onset: 10min
  Surgical anesthesia:
30-45min
  Add Superficial CPB
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Paravertebral Block:
(remain in sagital plane)
Too medial, CNB
Too lateral, PTX
PVB: Risks
Failure 10%
  Hypotension 4%
  Vascular Puncture 4%
  Epidural Spread
1-30% (depends on vol)
  Spinal <1% (with laminar technique)
  Pneumothorax 0.2% (1:300)
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Paravertebral (USG Assist)
Identifying Trans
Processes
USG Paravertebral Block
(currently not recommended)
USG PVBs- ? Benefit
TP
Lower Abdomen - Anatomy
Peripheral Nerves
–  Iliohypogastric
–  Ilioinguinal
–  Genitofemoral
–  Subcostal
  Dermatomes
–  Paravertebral
levels
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Lumbar
Plexus
Anatomy
Genitofemoral
Ilioinguinal/
Iliohypogastric
LFCN
Obturator
Femoral
IH & II: thru
psoas, atop
iliacus, then
TA, IO, EO
  Other:
–  GF
–  Other
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Lower AbdomenNeuroanatomy
IH: thru TA, then
thru IO at ASIS
  II: parallel to IH;
pierces layers
more medially;
then w/ cord
  GFN: fem branch
over fem n area;
gen branch w/
cord, lat scrotum
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USG
TAP
Bloc
Anatomy at ASIS:
Aponeurosis of Ext Obl.
  Internal Oblique m. Between Ilioinguinal
and Iliohypogastric nerves
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USG TAP (lower)
Rectus Sheath Block
Intercostals
Subcutaneous Tissue
Rectus Abdominus
Peritoneal Cavity
Rectus Sheath Block
Paravertebral Blocks: Hernias
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PVB’s for Hernia:
–  T10-L2 levels
–  Trans proc lie between spinal processes
–  Blocks sympathetics (peritoneal sac)
–  Wassaf:
  T12,
L1, L2 levels only
  No supplementation in 80% (60% w/ field blk)
  100% patient satisfaction (87% w/ field blk)
USG
Caudals
USG Caudal- Probe Long Axis
Sacrococcygeal Lig
Ant Sacrum