For abdominal e.g laparotomy or thoracic dermatomes e.g. thoracotomy, rib fractures
Alternative to epidural
Patient awake – sitting or prone
Identify midline (in transverse plane)
Block at level of:
- T7 level for abdominal cover, even rooftop
- T5 for thoracic cover (T2 – T9)
Scan laterally so transverse process (TP) in in middle of screen.
Rotate probe vertically to para-sagital plane
Identify layers of subcutaneous tissue, trapezius, (+/- rhomboid), erector spinae (ES)- with articulates with transverse processes
Local anaesthetic at superior entry point. Deep infiltration to level of muscle.
Use Tuohy needle or regional catheter pack needle, in plane approach
Access ESP below ES muscle, adjacent to TP. Can hit it (original description) but more painful. Create space with saline.
Then threat catheter. Leave at least 10cm in the space. Load with 20ml of 0.375% l-bupivicaine to each side.
Then run infusion 0.25% l-bupivicaine at 10ml per hour (split between both sides).
– NG @ LGH
Useful online educational resource for ICU covering, amongst other things, ECMO and echo.
“Walk in the shoes of the people we serve. Think like a patient, act like a taxpayer.”
Simon Stevens’ (CEO NHS England) speech setting out vision for NHS in the Five Year Forward View.
Systolic Anterior Motion of Mitral Valve
Functionally LVOT, can by precipitated by increased contractility + HR and reduced SVR
Classically in hypertrophic cardiomyopathy and MV repair
Principles of management:
Keep well filled
Slow HR / avoid tachycardia e.g. beta-blockers