THORACIC AND ABDOMINAL BLOCKS. Giovanni Cucchiaro MD MPP The Children s Hospital Los Angeles
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1 THORACIC AND ABDOMINAL BLOCKS Giovanni Cucchiaro MD MPP The Children s Hospital Los Angeles 1
2 CONFLICTS OF INTEREST??? NONE ZERO 2
3 John Fiadjoe 3
4 DIFFERENT ANSWERS TO MY DILEMMA 4
5 WHICH? WHAT? WHY? 5
6 RAGIONAL ANESTHESIA AND DR CUCCHIARO 1995 Gio was a 2 nd year resident Sciatic block 1997 Gio was a pediatric anesthesia fellow Axillary block Gio is in Paris Femoral, sciatic, interscalene, infraclavicular Gio is back at CHOP pix 6
7 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
8 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
9 PARAVERTEBRAL BLOCKS Beyaz SG Dicle Med J,
10 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 BLADDER Pelvic Splanchnic Nerves Upper Lumbar Splanchnic Nerves T11-L4 S2-S4 L1-L2 10
11 T6 PARAVERTEBRAL BLOCK: LOCAL ANESTHETIC SPREAD VS SENSORY BLOCK Marhofer D
12 RECTUS SHEATH BLOCK Source: ect laboratory SUNY downstate 12
13 RECTUS SHEATH BLOCK Author # patients Age (years) Pain scores PACU After PACU Morphine use Dingeman LAI>RSB 0 pain: RSB>LAI LAI=RS B LAI=RSB Gurnaney LAI=RSB LAI=RS B LAI>RSB (perioperative Isaac LAI=RSB LAI=RS B LAI=RSB Source: Rajwani KM
14 TAP BLOCK Source: Rozen W,
15 TAP BLOCK head lateral LTOP: Lumbar Triangle of Petit MAL: mid-axxilary line SC: subcostal mid-axillary approach for infraumbilical incisions subcostal approach for incisions between the levels of T7 and T11 Source: Zoka M,
16 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
17 SERRATUS BLOCK (Blanco R, 2013) Superficial serratus plane Thoracic intercostal nerves T2-T12: lateral cutaneous branches cover antero-lateral chest wall. Lateral+Medial Pectoral nerves Deep serratus plane 17
18 SERRATUS BLOCK (Blanco R, 2013) Superficial serratus plane Deep serratus plane PEC I PEC II 18
19 QUADRATUS LUMBORUM BLOCK Source: Gadsen J,
20 QUADRATUS LUMBORUM BLOCK L muscle QL muscle Rostral distribution (L3) Dorsal spread L2 Paravertebral spread 5 th thoracic Paravertebral spread T4 Paravertebral spread T6 Source: Carney J,
21 QUADRATUS LUMBORUM BLOCK 0.3 ml/kg 0.6 ml/kg Source: Carney J,
22 Why are we doing what we are doing everyday? 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 22
23 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
24 BIG DATA 24
25 Where we all come from. Saint Paul St Louis Boston Milwaukee Indianapolis Denver Chicago San Francisco Pittsburgh Akron Washington DC Cincinnati Los Angeles Philadelphia 25
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