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Dr.R.SILAMBAN MADRAS MEDICAL COLLEGE

NEUROLYTIC BLOCKS. Dr.R.SILAMBAN MADRAS MEDICAL COLLEGE. NEUROLYTIC BLOCKS. Involves blocking of sympathetic chain at various levels Prevents transmission of pain impulses from the target organs to the brain. NEUROLYTIC BLOCKS. The nerves have the tendency to

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Dr.R.SILAMBAN MADRAS MEDICAL COLLEGE

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  1. NEUROLYTIC BLOCKS Dr.R.SILAMBAN MADRAS MEDICAL COLLEGE

  2. NEUROLYTIC BLOCKS • Involves blocking of sympathetic chain at various levels • Prevents transmission of pain impulses from the target organs to the brain

  3. NEUROLYTIC BLOCKS • The nerves have the tendency to regenerate • Blocking effect is temporary

  4. DURATION • 3 months to 24 months

  5. COMMON NEUROLYTIC BLOCKS • Stellate ganglion block • Thoracic sympathetic chain block • Coeliac plexus block • Lumbar sympathetic block • Superior hypogastric block • Ganglion impar block

  6. STELLATE GANGLION BLOCK Stellate ganglion formed by union of • Middle cervical • Lower cervical • First thoracic segment

  7. STELLATE GANGLION BLOCK Pain relief to structures of • Neck • Face • Upper limb • Upper thorax upto T5

  8. THORACIC SYMPATHETIC CHAIN BLOCK • Not used widely • High risk of pneumothorax • Middle and lower thoracic region

  9. LUMBAR SYMPATHETIC BLOCK • Needle introduced at the level of L2 or L2 + L4 • Pain relief to pelvis and lower limb • Volume required – 8 to 10ml

  10. SUPERIOR HYPOGASTRIC PLEXUS BLOCK • From splenic flexure of colon to middle 3rd of rectum • Pain relief to pelvis and lower limb

  11. SUPERIOR HYPOGASTRIC PLEXUS BLOCK • Most difficult block to perform • Needle has to enter through a small triangular space between iliac crest and transverse process of L5 • Volume required - 7ml for each side

  12. GANGLION IMPAR BLOCK • Walther’s ganglion - lies in front of S2, S3 • Pain relief for lower rectum, anal canal and perineum including vulva and vagina

  13. GANGLION IMPAR BLOCK • Patient in lithotomy or lateral position • Bent 10cm needle introduced in front of the coccyx • Finger inserted into rectum to guide the needle close to the sacral curvature • Volume required - 10ml

  14. Coeliac plexus block

  15. HISTORY 1914 – KAPPIS – first block in lateral position 1920 – WELDING – anterior approach. 1927 – LABAT – now followed retrocrural approach in prone position. 1982 – SINGLERS – CT guided transcrural approach 1983– ISCHIA – posterior transaortic approach

  16. LOCATION

  17. FORMATION

  18. AREA OF SUPPLY • LOWER END OF ESOPHAGUS UPTO SPLENIC FLEXURE. • LIVER,SPLEEN • RETROPERITONEAL • STRUCTURES LIKE PANCREAS, KIDNEY.

  19. INDICATIONS Chronic malignant & non malignant visceral pain 1. Upper g.i. malignancy 2. Chronic pancreatitis 3. Acute pancreatitis 4. Repeated abdominal surgeries 5. HIV related sclerosing cholangitis 6. Diagnostic purposes 7. Abdominal angina

  20. ROLE IN CHRONIC PANCREATITIS Controversial Useful in • Few selected cases • Acute exacerbations

  21. ROLE IN ACUTE PANCREATITIS • Steroids improved morbidity and mortality • Continuous infusion for pain relief

  22. CONTRAINDICATIONS ABSOLUTE • Anti coagulant therapy • Coagulopathy • Anti-blastic cancer therapy • Bowel obstruction • Patient on disulfuram therapy

  23. CONTRAINDICATION RELATIVE • Drug seeking behaviour to pain • Patient on CNS depressant drugs

  24. TECHNIQUE Posterior approach Anterior approach • Retrocrural • Antecrural • transaortic

  25. RETROCRURAL APPROACH

  26. RETROCRURAL APPROACH • Bilateral Posterior approach • Splanchnic block • Drug deposited behind the crus of diaphragm

  27. MARKINGS

  28. ANTECRURAL APPROACH

  29. ANTECRURAL APPROACH • Unilateral approach • Right sided only • Needle placed anterior to • crus of diaphragm.

  30. MARKINGS

  31. CONTINUOUSPLEXUS BLOCK

  32. COMPLICATIONS MINOR • HYPOTENSION • POSTURAL HYPOTENSION • DIARRHEA • PAIN • CHEMICAL COMPLICATIONS

  33. COMPLICATIONS CHEMICAL ALCOHOL FACIAL FLUSHING, PALPITATIONS, DIAPHORESIS PHENOL TRANSIENT TINNITUS, FLUSHING,MALAISE CNS STIMULATION, MYOCLONUS, SEIZURES,HYPERTENSION,ARRYTHMIAS,HEPATIC &RENAL INSUFFICIENCY

  34. COMPLICATIONS • VISCERAL INJURY • EJACULATION FAILURE • NERVE ROOT INJURY MODERATE

  35. COMPLICATION MAJOR • PARAPLEGIA • LUNG INJURY • VASCULAR TRAUMA • EPIDURAL & SUB ARACHNOID INJECTION

  36. EFFICACY OF COELIACPLEXUS BLOCK Controversy Regarding • Efficacy relative to opioid therapy • Efficacy relative to various approaches • Comittment to neurolysis despite remote risk of paraplegia

  37. ADVANTAGE OF COELIAC PLEXUS NEUROLYSIS • Better long term pain relief • Decrease drug dose for maintainance • Better quality of life • Improved performance status • Overcomes the G.I.T effects of opioids • In weight and survival rate

  38. FAILURE DUE TO • Delayed application • Tumour extension • Poor technique

  39. DRUGS • ALCOHOL • PHENOL • LOCAL ANAESTHETICS

  40. ALCOHOL • COMMONLY USED • HYPOBARIC • CEPHALAD SPREAD RADIOGRAPHICALLY • USED IN CONCENTRATION OF 50-100% • VOLUME REQUIRED-40 ml

  41. ALCOHOL ADVANTAGES • LONGER DURATION OF ACTION • EASILY AVAILABLE • IMMEDIATE NEUROLYSIS • PAIN ON INJECTION CONFIRMS CORRECT PLACEMENT IN THE BLIND APPROACH • LESS AFFINITY FOR VASCULAR TISSUES

  42. ALCOHOL DISADVANTAGES • PAIN ON INJECTION • CANNOT BE COMBINED WITH DYE

  43. PHENOL • HYPERBARIC • CAUDAL SPREAD RADIOGRAPHICALLY • 7.5 – 10% SOLUTION PREFFERED • MAXIMUM DOSE – 40 mg/kg

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