Extra Regional

Question 1

Intercostal nerves are…

Answer 1

T1-T11 (T12 is SUBcostal)

Question 2

Intercostal blocks are useful in what procedures?

Answer 2

upper abdominal and thoracic superficial procedures like gastrostomy tube placement and minor breast surgery, ESWL, and pacemaker placement.

Question 3

Extremely useful for what?

Answer 3

Pain control for fractured ribs

Question 4

Intercostal nerves run where in relation to the artery and vein?

Answer 4

generally the most inferior to the vein and artery; ventral portion is what wraps around the rib and the dorsal portion provides sensation to paravertebral muscles.

Question 5

Position for intercostal block

Answer 5

best placed prone with pillow under abdomen and arms dangling

Question 6

What are landmarks for intercostal blocks?

Answer 6

12th and 7th ribs

Question 7

Intercostal blocks are at an increased risk for?

Answer 7

LAST secondary to increased blood flow to the area

Question 8

Which portion of the nerve is wrapped around the rib?

Answer 8

ventral

Question 9

Which portion provides sensation to the paravertebral muscles?

Answer 9

dorsal

Question 10

where are ribs marked after palpation?

Answer 10

lateral to the edge of the sacrospinous muscles where the ribs are most superficial

Question 11

Distance from spine-posterior

Answer 11

6-8cm

Question 12

What gauge needle is used for intercostal block?

Answer 12

22g

Question 13

Where is needle inserted for intercostal block?

Answer 13

inferior to rib at a 20 degree cephelad angle until contact with bone is made (usually 1cm), walk the needle off inferiorly.

Question 14

Where is contact with bone typically made?

Answer 14

1cm

Question 15

After needle is walked off inferiorly, how far is the needle advanced?

Answer 15

3mm

Question 16

How much local is injected to each desired level?

Answer 16

3-5mL

Question 17

What should always be avoided when performing intercostal block?

Answer 17

Needle should never be disconnected from tubing or syringe

Question 18

What could happen as a result of disconnecting needle from tubing or syringe?

Answer 18

inadvertent puncture of parietal pleura (pneumo) because it pulls air in through the needle

Question 19

Who should not receive an intercostal block?

Answer 19

those in which a pneumo would have devastating consequences.

Question 20

Paravertebral blocks should be performed for what procedures?

Answer 20

surgical or post op analgesia for involvement in thoracic or abdominal wall, VASTS, mastectomy, and in those with rib fractures

Question 21

Where can paravertebral blocks be performed?

Answer 21

cervical, thoracic or lumbar levels

Question 22

What are complications of paravertebral blocks?

Answer 22

sympathetic blockade in thoracolumbar region, pneumo, intrathecal/epidural injection

Question 23

where is local injected in paravertebral blocks?

Answer 23

paraverterbal space where spinal nerves emerge from intervertebral foramina

Question 24

How is patient positioned for paravertebral block?

Answer 24

sitting or lateral decubitus

Question 25

what serves as landmarks for paravertebral blocks?

Answer 25

each spinous process - each is palpated and a mark is made 2.5cm lateral to the spinous process

Question 26

How much local in injected in paravertebral block?

Answer 26

6-10mL (dilute local)

Question 27

Where is local injected in paravertebral block?

Answer 27

in subcutaneous tissue of paravertebral muscles

Question 28

What size needle should be utilized in paravertebral block?

Answer 28

18-20g Touhy

Question 29

Where is needle placement for paravertebral blocks?

Answer 29

inserted until contact with transgerse process is made then needle is direced caudal or cephelad and advanced 1-1.5cm

Question 30

When should the needle not be advanced more cephelad in paravertebral blocks?

Answer 30

if you are above T7 secondary to increased risk of pneumo

Question 31

What is the correct needle depth for lower lumbar paravertebral blocks?

Answer 31

3-8cm?

Question 32

What is the correct needle depth for high thoracic paravertebral blocks?

Answer 32

6-8cm

Question 33

What is the correct needle depth for lower thoracic paravertebral blocks?

Answer 33

3-4cm

Question 34

Pop or loss of resistance may be felt during paravertebral block when the needle penetrates what?

Answer 34

costotransverse ligament

Question 35

How much local should be administered during paravertebral block after negative aspiration?

Answer 35

5mL at each level blocked

Question 36

Why should midline angling be avoided during paravertebral block adminsitration?

Answer 36

SAB/epidural injection

Question 37

Alternative technique to paravertebral block?

Answer 37

marking distance to transverse process when withdrawing needle to skin and readvancing and additional 1cm caudad or cephelad

Question 38

Transverse adbominis plane blocks what nerves?

Answer 38

lower thoracic nerves T7-T11 subcostal T12 ilioinguinal L1 iliohypogastic L1 *ipsilateral abdomen below the umbilicus*

Question 39

Normally what does a TAP block cover?

Answer 39

T10 and below

Question 40

Where do most of the thoracic and lumbar nerves covered in a TAP block lie?

Answer 40

Between the internal oblique and transverse abdominus muscles

Question 41

TAP blocks should be performed for what procedures?

Answer 41

Superficial procedures on lower abdomen or post op for procedures below the abdomen.

Question 42

How are TAP blocks best performed?

Answer 42

With ultrasound

Question 43

What is the best position for TAP block performance?

Answer 43

Supine or lateral decubitus

Question 44

Which way is the ultrasound positioned for a TAP block?

Answer 44

Longitudinally

Question 45

Where is the ultrasound probe held for a TAP block?

Answer 45

In the flank between lower rib and iliac crest

Question 46

How do muscles appear under ultrasound?

Answer 46

Marbled and transverse

Question 47

What size need is utilized in a TAP block?

Answer 47

21g

Question 48

What direction is a needle inserted for a TAP block?

Answer 48

Medial to lateral using in plane technique

Question 49

Where is the pop felt for TAP block insertion?

Answer 49

Entering plane between two muscle layers

Question 50

How much LA is inserted during TAP block?

Answer 50

20 mL

Question 51

Where is LA injected for TAP block?

Answer 51

Between internal oblique and transverse abdominis

Question 52

A rectus sheath block covers what areas?

Answer 52

Intercostal nerves 9,10 and 11

Question 53

Where are the 9th,10th and 11th intercostal nerves located?

Answer 53

Between the rectus abdominus muscle and posterior rectus sheath

Question 54

What can a rectus sheath block be used for?

Answer 54

Intra and post op analgesia for abdominal surgery with midline incision

Question 55

Examples of procedures done with rectus sheath blocks

Answer 55

Incisional and umbilical hernia repair, tubal ligation, c section

Question 56

How is the ultrasound probe positioned in a rectus sheath block?

Answer 56

Transverse

Question 57

Where is the ultrasound probe placed for rectus sheath block?

Answer 57

Transverse immediately lateral and above umbilicus

Question 58

What direction is the needle advanced for a rectus sheath block?

Answer 58

Medial to lateral

Question 59

What position is a patient placed in for rectus sheath block?

Answer 59

Supine

Question 60

What size needle is utilized for a rectus sheath block?

Answer 60

22g

Question 61

Where is the needle passed through for a rectus sheath block?

Answer 61

Through skin and sub q tissue until it meets firm resistance of anterior rectus sheath.

Question 62

How is the penetration of the sheath and belly muscle performed?

Answer 62

Firm pressure

Question 63

How much local is injected in a rectus sheath block?

Answer 63

10-20 mL using the posterior sheath as the back board

Question 64

How does the sheath appear under ultrasound?

Answer 64

Bright hyperechoic structure surrounding the muscle