THORACIC AND ABDOMINAL BLOCKS

Giovanni Cucchiaro MD MPP The Children’s Hospital Los Angeles

1

CONFLICTS OF INTEREST???

•NONE •ZERO

2

John Fiadjoe

3

DIFFERENT ANSWERS TO MY DILEMMA

4

• WHICH?

• WHAT?

• WHY?

5

Gio was a 2nd year resident

1995

Gio was a pediatric anesthesia fellow

1997

Gio is in Paris

1998 2001

Gio is back at CHOP

Sciatic block Axillary block

pix

6

Femoral, sciatic, interscalene, infraclavicular

RAGIONAL ANESTHESIA AND DR CUCCHIARO

• SCIENTIFIC PROGRAM • 7:00-7:45 am Registration Breakfast with Exhibitors

and Poster Viewing • 7:45-8:00 am Opening Remarks Valerie E. Armstead,

MD, FAAP, CRCP & Jayant K. Deshpande, MD, MPH • 8:00-8:45 am Anesthetic Gases and the Developing

Nervous System Mervyn Maze, MD • 8:45-9:30 The Science of Regional Anesthesia in

Infants and Children Charles B. Berde, MD, PhD • 9:30-10:10 Regional Anesthesia Data: UK

and US Databases Tony Moriarty, MD & Giovanni Cucchiaro, MD

7

WHICH BLOCK THEN? Old Way • Epidurals • Spinals • Caudals • Ilio-inguinal, ilio-hypogastric • Penile blocks

New Way • Paravertebral blocks • Serratus anterior blocks • Rectus sheath blocks • TAP blocks • Quadratus Lumborum block

8

PARAVERTEBRAL BLOCKS

9

Beyaz SG Dicle Med J, 2012

VISCERAL INNNERVATION ORGAN INNERVATION SPINE LOCATION LIVER Celiac Ganglia

Phrenic Ganglia Vagus

T5-T9 C3-C5 CN XI

STOMACH-PANCREAS Celiac Ganglia T5-T9

SMALL AND LARGE INTESTIN

Celiac Ganglia Superior Mesenteric Ganglia Inferior Mesenteric Ganglia Vagus

T5-T9 T9-T12 L1-L2 CN XI

KIDNEY AND URETERS Least and Lesser thoracic nerves T10-T12 CN XI

PELVIC VISCERA T11-L4

BLADDER Pelvic Splanchnic Nerves Upper Lumbar Splanchnic Nerves

S2-S4 L1-L2

10

T6 PARAVERTEBRAL BLOCK: LOCAL ANESTHETIC SPREAD VS SENSORY BLOCK

11

Marhofer D. 2013

RECTUS SHEATH BLOCK

12

Source: ect laboratory SUNY downstate

RECTUS SHEATH BLOCK

13 Source: Rajwani KM 2014

Author # patients

Age (years)

Pain scores PACU

After PACU

Morphine use

Dingeman 2013

52 3-12 LAI>RSB 0 pain: RSB>LAI

LAI=RSB

LAI=RSB

Gurnaney 2011

54 5-18 LAI=RSB

LAI=RSB

LAI>RSB (perioperative

Isaac 2006 13 1-8 LAI=RSB

LAI=RSB

LAI=RSB

TAP BLOCK

14 Source: Rozen W, 2011

TAP BLOCK

15 Source: Zoka M, 2011

LTOP: Lumbar Triangle of Petit MAL: mid-axxilary line SC: subcostal

head

lateral

• mid-axillary approach for infra-umbilical incisions

• subcostal approach for incisions between the levels of T7 and T11

TAP BLOCK: meta-analysis (Charlton S, 2010)

GIVEN… • Few small studies • Moderate methodological quality • Participant numbers were too few • Important inconsistencies among

studies

TAP block vs conventional or TAP placebo

• At 2 hrs: morphine requirements are the same

• At 24 hrs: reduced opioids consumption • Prolonged the time until first request for

additional analgesia • Overall lower pain scores • No difference in postop nausea/vomiting

16

SERRATUS BLOCK (Blanco R, 2013)

17

• Thoracic intercostal nerves T2-T12: lateral cutaneous branches cover antero-lateral chest wall.

Superficial serratus plane

Deep serratus plane

• Lateral+Medial Pectoral nerves

SERRATUS BLOCK (Blanco R, 2013)

18 PEC I PEC II

Superficial serratus plane

Deep serratus plane

QUADRATUS LUMBORUM BLOCK

19 Source: Gadsen J, 2015

QUADRATUS LUMBORUM BLOCK

20

Source: Carney J, 2011

Rostral distribution (L3)

Paravertebral spread T4

Dorsal spread L2

Paravertebral spread T6

QL muscle QL muscle

Paravertebral spread 5th thoracic

QUADRATUS LUMBORUM BLOCK

21

0.3 ml/kg 0.6 ml/kg

Source: Carney J, 2011

Why are we doing what we are doing everyday?

22

“Life is pretty simple: You do some stuff. Most fails. Some works. You do more of what works. If it works big, others quickly copy it. Then you do something else. The trick is the doing something else. ”

“The greatest deception men suffer is from their own opinions”

BIG DATA • National Surgical Quality Program (NSQIP), • Society of Thoracic Surgeons (STS) National Database, • Closed Claims Registry of settled malpractice cases, • Multicenter Perioperative Outcomes Group (MPOG)

• Anesthesia Quality Institute's National Anesthesia Clinical Outcomes

Registry (NACOR) • Wake up Safe • PRAN

23

BIG DATA

24

Where we all come from…….

25

Chicago

Saint Paul

San Francisco

Philadelphia Cincinnati Pittsburgh

Akron Washington DC

Los Angeles

Denver

Boston St Louis Milwaukee

Indianapolis