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Semelhante a Serratus Anterior Plane Block
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Serratus Anterior Plane Block
- 1. Serratus AnteriorSerratus Anterior Plane BlockPlane Block Dr. Ananth KumarDr. Ananth Kumar Department of Anaesthesia and Perioperative medicineDepartment of Anaesthesia and Perioperative medicine Westmead HospitalWestmead Hospital
- 3. Rib # Common – esp in RTA High morbidity and mortality > 6 rib # - 29% mortality Flail chest – up to 33% mortality
- 4. Rib # Hypoventilation secondary to pain -> atelectasis + retained secretions -> pneumonia Lung contusions Altered breathing mechanics
- 5. Rib # management Ventilatory strategies ANALGESIA Simple/opioids/adjuncts (e.g. ketamine) Regional Epidural/paravertebral Serratus anterior plane block
- 6. Anatomy
- 8. What are we blocking? Intercostal nerves T2 – T9 (lateral cutaneous branches only) Long thoracic nerve (to serratus anterior muscle) Thoracodorsal nerve (to latissimus dorsi) ONLY SOMATIC ANALGESIA, NO VISCERAL ANALGESIA
- 11. Mayes et al, Anaesthesia, 2016
- 12. NYSORA.com
- 14. Nagdev et al, ACEP, 2017 Lat. Dorsi Serratus Anterior muscle Serratus Anterior muscle Rib with shadowRib with shadow
- 15. Nagdev et al, ACEP, 2017
- 16. Jadon et al, American J Anesth Clin Res. 2017
- 17. SAPB: Video
- 21. EVIDENCE?
- 23. Rib Fractures
- 25. How does SAPB work for Rib fractures? Conflicting evidence of spread to intercostal space (and therefore intercostal nerve) Possible direct spread to periosteum of rib # Or ‘splinting’ of external intercostal muscle ?systemic L.A. absorption
- 26. Mayes et al, Anaesthesia, 2016
- 27. How does SAPB work for Rib fractures? Conflicting evidence of spread to intercostal space (and therefore intercostal nerve) Possible direct spread to periosteum of rib # Or ‘splinting’ of external intercostal muscle ?systemic L.A. absorption
- 29. We use Pajunk(c) e-cath (catheter over needle) 3 sizes – 51mm, 75mm, 83mm Short-bevel Kink-resistant Needle/catheter type
- 30. Fascial plane block = High volume bolus Single shot: 20 – 40mls 0.2% - 1% ropivacaine Continuous: 20mls bolus Q4H 0.2% ropivacaine
- 31. In summary Safe, fast, effective, versatile Lateral rib # (hemithorax) 2 - 9 Superficial vs deep – go deep – possibly more effective (but make sure you can visualise needle and pleura at all times) Caution – subcutaneous emphysema Use high-volume of L.A i.e. 30-40mls (be mindful of toxic doses)
Notas do Editor
- Boxer’s muscle - Function of serratus is to bring the scapula forwards
- Linear array probe The patient’s respiration will help spread the block. Good for lateral rib #; not as good for extremely posterior or anterior – need to do erector spinae block
- https://www.youtube.com/watch?v=2wiW3mq-zaI
- 4 volunteers 0.4ml/kg of 0.125% levobupiv Sensory testing with hypodermic needle
- Quality of anaesthesia – unsure? Amount of levobupiv? And concentration
- 63 y.o.; A whole-body CT scan showed multiple, displaced fractures from the second to the ninth ribs on the right side, fracture of the contralateral clavicle, the sternum, and the first and second ribs on the left side; spinal X-ray showed an amyelic fracture of the body of L2. There are also a couple more case reports of successfully avoiding mechanical ventilation due to efficacy of block
- 6 patients Deep technique Catheters were placed for up to 5 days Only breakthrough was tramadol i.v
- A prospective, randomized, observer–blinded, controlled study. 40 patients. Compared with preoperative values, the mean arterial pressure in the SAPB group did not change significantly (p = 0.181), whereas it decreased significantly (p = 0.006) in the TEA group. VAS scores and the total dose of morphine consumed were comparable in the 2 groups.
- For SAPB – if use 40mls – can cover 6 dermatomes as opposed to 4 with 20mls