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What is an epidural?

What is a paravertebral block?

Injection of local anaesthetic via a catheter inserted into the epidural space

Unilateral block of the spinal nerve including the dorsal and ventral rami

  • In dwelling catheter allows an infusion of local anaesthetic over a prolonged period of time (usually 2-3 days)
  • Initial dose 10 - 20mL
  • May be performed anywhere in the vertebral column
  • Onset ~ 5 minutes, anywhere from 15 - 25 minutes to reach full anaesthetic effect to the dermatomes immediately surrounding the injection site
  • 3 - 5mL of local anaesthetic (< if bilateral)
  • 10 - 15mL will spread 1 - 2 paravertebral levels above and below the injection site
  • May require multiple injections for a multisegmental anaestehtic
  • In dwelling catheter may be used for an ongoing infusion

EPIDURAL

How does it work?

Preferentially acts on afferent sensory receptors

E.g. In labour the female may not feel pain but will feel the pressure

Clinical Use

However, an epidural will block other types of nerve fibers in a dose dependent manner

Unilateral or bilateral anaesthsia or analgesia

  • Breast surgery
  • Thoracotomy
  • Open cholecystectomy
  • Open nephrectomy
  • Abdominal surgery

PARAVERTEBRAL

Patients where hypotension or sympathetic blockade from epidural would be particuarly detrimental

Paravertebral block is preferbale to epidural in patients with coagulopathy

Clinical Use

  • May be combined with spinal anaesthetic
  • Initally used as an anaesthetic intra-operatively, and then analgesic post operatively
  • Obstetrics - During child birth
  • Abdominal surgeries
  • Orthopaedics - Lower limb
  • Vascular surgery - Lower limbs, amputations
  • Gynecology and Urology surgeries

Adverse effects

Adverse Effects

The Bromage Score for motor blockade

  • Hypotension (rare)
  • Vascular puncture
  • Pleural puncture
  • Pneumothorax
  • Paravertebral muscle pain
  • Nerve injury
  • Neurotoxicity
  • CNS complications: Damage to neural structures, epidural haemotoma, epidural abcess, dural puncture, cerebral ischemia (CSp), meningitis
  • Infection
  • CV effects: Cardiac arrest, tachycardia, hypotension
  • Respiratory effects: Respiratory compromise if phrenic nerve is blocked

Clinical Studies

Tummala, et al (2015). A comparative study-efficacy and safety of combined spinal epidural anesthesia versus spinal anesthesia in high-risk geriatric patients for surgeries around the hip joint

  • Combined spiral and epidural anesthesia showed a significantly less incidence of hypotension (p < 0.01)
  • Combined spinal and epidural anaesthesia showed prolonged analgesia when compared to spinal anaesthesia alone

Salaman, et al (2012). Combined Spinal-Epidural Anesthesia with Epidural

Volume Extension causes a Higher Level of Block than Single-Shot Spinal Anesthesia

  • Sensory block had the fastest onset, lasted the longest and was higher in group 2 (combined spinal epidural anaesthesia with saline) compared to group 1 (single shot spinal spinal anaesthesia)

Zhang et al, 2014. Single-Dose, Bilateral Paravertebral Block Plus Intravenous Sufentanil Analgesia in Patients With Esophageal Cancer Undergoing Combined Thoracoscopic– Laparoscopic Esophagectomy: A Safe and Effective Alternative

Implications for Physiotherapy

Be aware of the potential complications

  • Grade I motor block persists; need to consider is this due to neurotoxicity OR is there an underlying CNS complication.
  • Post operative VAS score lower in the paravertebral block (PVB) group compared to ' conservative Management' - PCA + oral opiods alone
  • Lower PCA access in the PVB group
  • Three day post operative pulmonary function better in the PVB group (p <0.05)
  • Quicker hospital discharge in the PVB group ( p < 0.05)
  • Depending on the level of the epidural need to consider respiratory compromise
  • Monitor clinical signs and symptoms of CVS complications

Implications for Physiotherapy

  • Respiratory complications
  • Likely less sedation, nausea, constipation and vomitting than opiod based analgesia
  • Pt's may progress faster, mobilise earlier and discharge from hospital sooner

Local Anaesthetics

Toxicity

What is a TAP block?

Peripheral nerve block designed to anaethetise the nerves supplying the anterior abdominal wall (T6-L1)

Clinical use

Injection of local anaesthetic into the deep fascial plane between the internal oblique and the transversus abdominus

Used as an adjunct for post operative pain control

  • Abdominal
  • Gynecological
  • Urological

Surgery in the T6 - L1 distribution

  • Bilateral TAP blocks are used for midline incisions
  • Placement of a catheter for a continuous TAP block

Blind landmark technique OR ultrasound guided technique

Benefits of TAP block;

  • Decreased need for post operative opioid use
  • Less adverse effects
  • No invasion of the spinal cord; no risk of CNS adverse effects
  • Longer term pain relief with or without the use of ongoing TAP block
  • Can be injected pre, intra or post operatively

Adverse Effects

  • Variable effectiveness of TAP block
  • Transient femoral nerve palsy
  • Haemotoma and infection
  • Peritoneal puncture
  • Local anaesthetic toxicity
  • Laceration to liver, kidney, spleen

Clinical studies

Sinah et al. 2013; The efficacy of ultrasound-guided transversus abdominis plane block after laparoscopic bariatric surgery

  • Median VAS at 1, 3, 6, 12 & 24 hours post op at rest and with movement was lower in the USG-TAP group compared to the control group
  • Time to ambulate was 6.3 (+/- 1.8) in the USG-TAP group, compared to 8 (+/- 1.8) in the control group

Calle et al. 2014; Transversus abdominus plane block after ambulatory total laprascopic hysterectomy: Randomized controlled trial

Implications for Physiotherapy

IF TAP BLOCK WORKS

IF TAP BLOCK DOES NOT WORK

Ineffective pain management

Effective pain management

= Greater compliance with PT Rx

Pt less likely to mobilise, cough, exercise secondary to high pain levels

Greater opioid use for pain management

Decreased need for opioids

= less nausea, respiratory depression, drowsiness

TRANSABDOMINAL PLANE BLOCK (TAP)

Better outcomes for your patient

The pt will either have little/no pain OR have high levels of pain

What is a Spinal block?

Total numbness of the spinal levels above and below the injection sight

  • Single injection = single dosage
  • Small dose of 1.5 - 3mL
  • Below L2 to avoid damage to the spinal cord
  • Onset ~ 5 minutes, within 10 minutes complete anaesthesia of the injected distribution
  • Lasts ~ 2 hours

How does it work?

Clinical use

Lower abdomen and below;

  • Lower limb orthopaedic surgery
  • Laprascopic bowel surgery
  • Lower limb vascular surgery
  • Abdominal or vaginal hysterectomies
  • Prostatectomy

May be used in conjuction with a general anaesthetic, or in isolation.

SPINAL BLOCK

Useful for patients with severe respiratory distress e.g. COPD

Local anaesthetic injected through the dura into the cerebrospinal fluid

Adverse effects

  • Cephalad spread of local anaesthetic
  • Hypotension
  • Cauda equina
  • Cardiac arrest
  • Spinal canal haemotoma
  • Epidural abscess

Implications for Physiotherapy

  • An increase in injection sight of one spinal level can have a significant increase the cephalad spread of the local anaesthetic
  • BE AWARE
  • Females have a lower density CSF
  • At extremes of age there is an increase in the maximum spread
  • Higher level of block in obese patients

Regional Anaesthesia

References

References

e-Books;

Barash, P. G., Cullen, B. F., Stoelting, R. K., Calahan, M. K., Stock, C. M. (2009). Clinical Anesthesia (6th ed.). Philadelphia, PA. Wolters Kluwer

Web pages;

Websites;

(https://en.wikipedia.org/wiki/Spinal_anaesthesia)

Retrieved on; 13.08.2015

Military Advanced Regional Anesthesia and Analgesia. (2008). The Military Advanced Regional Anesthesia and Analgesia Handbook. Retrieved on 16.08.2015, Retrieved from; http://www.dvcipm.org/clinical-resources/dvcipm-maraa-book-project

Byram, S. W. (2013). Medscape: Nerve Block. retreieved on 16.08.2015. retrieved from; http://emedicine.medscape.com/article/2000541-overview#a3

(https://en.wikipedia.org/wiki Epidural_administration)

Journal Articles;

Retrieved on; 13.08.2015

Chawla, J., (2013). Medscape: Epidural Nerve Block. Retrieved 14.08.2015, retrieved from; http://emedicine.medscape.com/article/149646-overview#a9

Calle, G. A., López, C. C., Sánchez, E., Los Ríos, J. F., Vásquez, E. M., Serna, E., ... & Almanza, L. A. (2014). Transversus abdominis plane block after ambulatory total laparoscopic hysterectomy: randomized controlled trial. Acta obstetricia et gynecologica Scandinavica, 93(4), 345-350.

(http://www.pitt.edu/~regional/Epidural/epidural.html)

Retrieved on 13.08.2015

Mukhtar, K. (2009). Transversus abdominis plane (TAP) block. The Journal of New York School of Regional Anesthesia, 12, 28-33.

(http://bonesmart.org/forum/threads/anaesthetics-spinals-femoral-blocks-gas-and-everything-else.5579/).

Retrieved on 15.08.2015

Liou, L. S., (2013). Medline Plus: Spinal and Epidural anesthesia. Retrieved 14.08.2015. retrieved from; http://www.nlm.nih.gov/medlineplus/ency/article/007413.htm

Salman, C., Kayacan, N., Ertuğrul, F., Bıgat, Z., & Karslı, B. (2013). Combined spinal-epidural anesthesia with epidural volume extension causes a higher level of block than single-shot spinal anesthesia. Revista Brasileira de Anestesiologia, 63(3), 267-272.

(http://www.google.com/search?client=safari&rls=en&q=factors+affecting+distribution+of+spinal+anaesthesia&oe=UTF-8&gfe_rd=cr&hl=en&sa=X&as_q=&spell=1&ved=0CBEQvwVqFQoTCNqa1qD_rMcCFQgZpgodqBcA2Q)

Retrieved on 14.08.2015

Tighte. S, M. (2010). Continuing care in anaesthesia, critical care and pain: Paravertebral block. Retrieved 16.08.2015, retrieved from; http://ceaccp.oxfordjournals.org/content/10/5/133.full

Sinha, A., Jayaraman, L., & Punhani, D. (2013). Efficacy of ultrasound-guided transversus abdominis plane block after laparoscopic bariatric surgery: a double blind, randomized, controlled study. Obesity surgery, 23(4), 548-553.

Tummala, V., Rao, L. N., Vallury, M. K., & Sanapala, A. (2015). A comparative study-efficacy and safety of combined spinal epidural anesthesia versus spinal anesthesia in high-risk geriatric patients for surgeries around the hip joint. Anesthesia: Essays and Researches, 9(2), 185.

Wisanen, M. T., (2013). Medscape: Transversus Abdominus Plane Block. Retrieved 14.08.2015, retrieved from; http://emedicine.medscape.com/article/2000944-overview

( http://www.nysora.com/techniques/neuraxial-and-perineuraxial-techniques/landmark-based/3077-thoracic-paravertebral-block.html). Retrieved on 16.08.2015

Zhang, W., Fang, C., Li, J., Geng, Q. T., Wang, S., Kang, F., ... & Wei, X. (2014). Single-Dose, Bilateral Paravertebral Block Plus Intravenous Sufentanil Analgesia in Patients With Esophageal Cancer Undergoing Combined Thoracoscopic–Laparoscopic Esophagectomy: A Safe and Effective Alternative. Journal of cardiothoracic and vascular anesthesia, 28(4), 978-984.

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