Transcript Paravertebral block mgmc

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
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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
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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
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Para vertebral space
Anatomy
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the spinal root emerges from the
intervertebral foramen and divides into
dorsal and ventral rami.
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The sympathetic chain lies in the same
fascial plane.
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Hence, PVB produces unilateral
sensory,
motor
and
sympathetic
blockade
Technique
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Conventional technique:- Loss of
resistance to air
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Single or continuous
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Thoracic
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Technique
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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
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One injection – levels
Spreads longitudinal
 Spreads lateral
 Spreads to other side
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Ventral to endothoracic fascia –
longitudinal
 Dorsal – unpredictable
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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
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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
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USG reports
Lumbar paravertebral block
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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
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Cervical paravertebral nerve block
Similar to interscalene block
 But posterior sensory fibres are more
targeted and hence
 Ideal for physiotherapy in frozen
shoulder
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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.
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in the window between the levator
scapulae and trapezius muscles at
C6 level
Loss of resistance
 Nerve stimulator
 USG
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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
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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
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USG guided cerv. PVB
Complications
Close to epidural
 Close to intrathecal
 Close to vessels
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Thank you all