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Paravertebral block

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 . Paravertebral block . History and what is it.

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Paravertebral block

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  1. 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 Paravertebral block

  2. History and whatisit • 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

  3. Indications anaesthesia – analgesia • Thoracic surgery • Liver surgeryInguinal hernia • Ambulatory surgery • open cholecystectomy • Rib fracture • Breast surgery • High risk patients

  4. 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

  5. Para vertebral space

  6. 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

  7. Technique • Conventional technique:- Loss of resistance to air • Single or continuous • Thoracic

  8. 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

  9. Point of entry

  10. Technique

  11. 2.5 cm and 1 cm Touhy

  12. Drugs –single and catheter • Each level injected with the single-injection 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

  13. One injection – levels • Spreads longitudinal • Spreads lateral • Spreads to other side • Ventral to endothoracic fascia – longitudinal • Dorsal – unpredictable

  14. Spread • The space is continuous with the intercostal space laterally, the epidural space medially and the contralateralparavertebral space through the paravertebral and epidural space • PNS • We can use nerve stimulator to see intercostal muscle contraction

  15. 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

  16. USG reports

  17. Lumbar paravertebral block • Injecting a local anesthetic solution near the lumbar plexus, which is situated in the psoas compartment, anterior to the transverse process of the lumbar vertebral body

  18. Lumbar paravertebral block

  19. Puncture and procedure

  20. 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

  21. Cervical paravertebral nerve block • Similar to interscalene block • But posterior sensory fibres are more targeted and hence • Ideal for physiotherapy in frozen shoulder

  22. 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.

  23. in the window between the levator scapulae and trapezius muscles at C6 level

  24. Loss of resistance • Nerve stimulator • USG

  25. Interscalene

  26. 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

  27. Catheter – insertion

  28. Special USG procedure • patient in lateral decubituscontralateral to the operative side, • Reach behind the ipsilateral thigh, this maneuver helping bring the shoulder down • See nerve roots • Pass needle with vision

  29. USG guided cerv. PVB

  30. Complications • Close to epidural • Close to intrathecal • Close to vessels

  31. Thank you all

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