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Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi medical college and research institute – puducherry, India History and what is it • • • Injection of local anaesthetic in a space immediately lateral to where the spinal nerves emerge from the intervertebral foramina Hugo Sellheim of Leipzig in 1905. It was further refined by Lawen (1911) and Kappis (1919) 1970 – Eason increased interest Indications anaesthesia – analgesia • • • • • • • Thoracic surgery Liver surgery Inguinal hernia Ambulatory surgery open cholecystectomy Rib fracture Breast surgery High risk patients Margins wedge-shaped anatomical compartment adjacent to the vertebral bodies Antero laterally by the parietal pleura, posteriorly by the superior costo transverse ligament, medially by the vertebrae and intervertebral foramina, superiorly and inferiorly by the heads of the ribs Para vertebral space Anatomy the spinal root emerges from the intervertebral foramen and divides into dorsal and ventral rami. The sympathetic chain lies in the same fascial plane. Hence, PVB produces unilateral sensory, motor and sympathetic blockade Technique Conventional technique:- Loss of resistance to air Single or continuous Thoracic Technique sitting or lying down position the neck flexed, back arched, and shoulders dropped forward point 2.5 to 3cm lateral to the T4 spine (point of needle entry) Go PA Hit transverse process Attach syringe – LOR Caudolateral 1 cm movement – feel POP Point of entry Technique 2.5 cm and 1 cm Touhy Drugs –single and catheter Each level injected with the singleinjection technique requires 5 mL total volumes 30 mL with unilateral injections to 60 mL with bilateral injections. A continuous infusion of a lower concentration of the same drug at 5 to 15 mL/hr is commonly used for continuous analgesia One injection – levels Spreads longitudinal Spreads lateral Spreads to other side Ventral to endothoracic fascia – longitudinal Dorsal – unpredictable Spread The space is continuous with the intercostal space laterally, the epidural space medially and the contralateral paravertebral space through the paravertebral and epidural space PNS We can use nerve stimulator to see intercostal muscle contraction Complications failure rate of 6.1% Inadvertent vascular puncture (6.8%), hypotension (4%), epidural or intrathecal spread (1%), pleural puncture (0.8%) Pneumothorax (0.5%) Horners reported More with bilateral blocks USG reports Lumbar paravertebral block Injecting a local anesthetic solution near the lumbar plexus, which is situated in the psoas compartment, anterior to the transverse process vertebral body of the lumbar Lumbar paravertebral block Puncture and procedure Technique 5 cm lateral PA – slightly medial Bone hits Go inferior Quadriceps muscle contraction – loss of resistance 20 -30 ml Usually done when epidural/femoral n is not feasible USG is ideal Cervical paravertebral nerve block Similar to interscalene block But posterior sensory fibres are more targeted and hence Ideal for physiotherapy in frozen shoulder Indications anesthesia and postoperative analgesia after upper extremity surgery prolonged continuous catheter analgesia in other clinical settings involving the upper limb. management of pain due to conditions such as lung tumors infiltrating the brachial plexus (Pancoast tumors) complex regional pain syndromes. in the window between the levator scapulae and trapezius muscles at C6 level Loss of resistance Nerve stimulator USG Interscalene Technique sitting or the lateral decubitus position The patient's neck is slightly flexed forward. The anesthesiologist stands behind the patient Advanced anteromedially towards suprasternal notch Bone – LOR syringe slip anterior PNS – C5 C6 biceps Catheter – insertion Special USG procedure patient in lateral decubitus contralateral to the operative side, Reach behind the ipsilateral thigh, this maneuver helping bring the shoulder down See nerve roots Pass needle with vision USG guided cerv. PVB Complications Close to epidural Close to intrathecal Close to vessels Thank you all