Surgical Critical Care and Emergency Surgery

22 Considering the appropriateness of nerves blocked to the procedure performed, which patient's pain is more likely to be adequately controlled?Abdominal wall reconstruction with bilateral TAP indwelling catheter.Large bowel resection with bilateral TAP block injection.Cervical fusion with erector spinae block single injection.Esophageal reconstruction with a neurolytic celiac plexus block.Shoulder surgery with axillary nerve block.Transverse Abdominis Plane (TAP) nerve blocks with indwelling catheters provide adequate somatic analgesia for abdominal wall surgery (choice A). In contrast, quadratus lumborum (QL) nerve blocks provide visceral in addition to somatic analgesia for the abdominal wall and the lower thoracic wall segments. This is because QL nerve blocks spread to the paravertebral space and sometimes achieve epidural spread. In large bowel resection, bilateral TAP block injections will not provide adequate analgesia for deep visceral pain (choice B). Erector spinae (ESP) block results in decreased postoperative pain and opioid requirement for a wide array of thoracic and abdominal procedures including in the management of rib fractures. It does not relieve somatic pain for cervical fusion (choice C). Choice D, celiac plexus block places the either a local anesthetic or neurolytic solution directly on the celiac ganglion anterolateral to the aorta. When used, for example, to manage pain in terminal pancreatic cancer, a neurolytic agent is chosen. Choice E is incorrect since the axillary nerve block will not provide adequate coverage for the shoulder joint surgery. Axillary nerve block will provide adequate analgesia from the mid upper arm extending to the hand ( Figure 12.3). Figure 12.3 Transverse abdominis plane block. QL: quadratus lumborum; EO: external oblique; IO: internal oblique; TA: transverse abdominis; K: kidney; P: psoas major; LD: latissimus dorsi; IL: iliocostalis lumborum; Lo: longissimus; Mu: multifidus.Answer: ATsai HC, Yoshida T, Chuang TY, Yang SF, Chang CC, Yao HY, Tai YT, Lin JA, Chen KY. Transversus abdominis plane block: an updated review of anatomy and techniques. Biomed Res Int. 2017; 2017:8284363.Saadawi M, Layera S, Aliste J, Bravo D, Leurcharusmee P, Tran Q. Erector spinae plane block: A narrative review with systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks. J Clin Anesth. 2020; 68:110063.

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