Celiac plexus Block

[painfre]

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During my fellowship I did few celiac plexus blocks trans aortic approach under CT guidance along with my Attending and only once Retro crural approach at L1 under fluroscopy. Now my first patient as an attending has chronic pancreatitis. He was referred for a procedure. I am planning to do Retrocrural approach C' plexus block at L1.

I have done numerous lumbar symp blocks at L3 but they are different as you place the needle tip at anterolateral surface of vertebral body and not behind the aorta. What is your usual technique for celiac plexus block. How often you accidentaly pierce the aorta. Do you really feel transmitted pulsations as described in books.

I was planning to use 22 g Chiba needle and Omnipaue. 10 ml of ropiv and 40 kenalog. what precautions you take for an out patient apart from stop blood thinners and normal creatinine. ? NPO ? No sedation ? IVF
Thanks

 

[clubdeac]

There's another thread where most of your questions are answered. Can't remember if it's under splanchnic nerve block or celiac plexus block or neurolysis or something but I specifically remember a number of these questions being answered b/c i was the one asking them. I would answer your questions if I could but I just do bilateral splanchnics now.

 

[Jcm800]

i offer only this...

dont do it.

or at least dont do the neurolyitic for chronic pancreatitis...

do the "diagnostic" or whatever. Its easy as an L3, just go at L1, if you hit the aorta, no biggie if you identify that you've done it.

i have done them under CT and flouro, now i just do them at L1 under flouro. VOlume of injectate is dependent on your spread of contrast. Low volumes often work well and run less of a risk.

You can mix the ropiv with lido also to lessen the "burden" of ropivicaine, which is better than marcaine, but you know...i personaly dont use steroid, as i am doing a diagnostic block, then i ETOH it...
but not in pancreatitis... i usually decline. since most pancreatitis are ETOH related, not usually good patients...

if they have a scorpion bite, well then maybe...

During my fellowship I did few celiac plexus blocks trans aortic approach under CT guidance along with my Attending and only once Retro crural approach at L1 under fluroscopy. Now my first patient as an attending has chronic pancreatitis. He was referred for a procedure. I am planning to do Retrocrural approach C' plexus block at L1.

I have done numerous lumbar symp blocks at L3 but they are different as you place the needle tip at anterolateral surface of vertebral body and not behind the aorta. What is your usual technique for celiac plexus block. How often you accidentaly pierce the aorta. Do you really feel transmitted pulsations as described in books.

I was planning to use 22 g Chiba needle and Omnipaue. 10 ml of ropiv and 40 kenalog. what precautions you take for an out patient apart from stop blood thinners and normal creatinine. ? NPO ? No sedation ? IVF
Thanks

 

[painfre]

I am just planning to do block with bupivacaine or Lidocaine mixed with kenalog. No alcohol. how much do you usually inject ? NPO ? sedation ? IVF ?
while doing retrocrural technique if you happen to enter aorta do you pull back the needle or double puncture aorta a
nd inject anterior to Aorta ?

 

[powermd]

Are you simply advocating that he not do the neurolytic because he's unfamiliar with the block? Or that one should kick neurolytics up to tertiary care centers (let them take the risk). I'm a little confused because you later indicate that you will do etoh.

Does anyone have some good fluoro images of the dye spread for a celiac? I'll check the image forum, but if there aren't any there it would be great if someone could post a few.

i offer only this...

dont do it.

or at least dont do the neurolyitic for chronic pancreatitis...

do the "diagnostic" or whatever. Its easy as an L3, just go at L1, if you hit the aorta, no biggie if you identify that you've done it.

i have done them under CT and flouro, now i just do them at L1 under flouro. VOlume of injectate is dependent on your spread of contrast. Low volumes often work well and run less of a risk.

You can mix the ropiv with lido also to lessen the "burden" of ropivicaine, which is better than marcaine, but you know...i personaly dont use steroid, as i am doing a diagnostic block, then i ETOH it...
but not in pancreatitis... i usually decline. since most pancreatitis are ETOH related, not usually good patients...

if they have a scorpion bite, well then maybe...

 

[Ligament]

I am just planning to do block with bupivacaine or Lidocaine mixed with kenalog. No alcohol. how much do you usually inject ? NPO ? sedation ? IVF ?
while doing retrocrural technique if you happen to enter aorta do you pull back the needle or double puncture aorta a
nd inject anterior to Aorta ?

Sedation is needed by most people for this procedure, primarily because you may graze the left L1 periosteum which is very painful.
Would recommend 10cc of 0.5% Ropivicaine with Kenalog.
Yes NPO for all procedures!
Yes IVF! Patients will routinely get parasympathetic overdrive and will get hypotensive. In addition, there is very low incidence of aortic rupture or high spinal with this procedure. You should run a liter into this patient while you are doing the procedure and probably will need a liter afterwards.
Double puncture the aorta and inject immediately ventral to the ventral aortic wall. This will give you an antero-crural celiac plexus block.

 

[Jcm800]

Are you simply advocating that he not do the neurolytic because he's unfamiliar with the block? Or that one should kick neurolytics up to tertiary care centers (let them take the risk). I'm a little confused because you later indicate that you will do etoh.

Does anyone have some good fluoro images of the dye spread for a celiac? I'll check the image forum, but if there aren't any there it would be great if someone could post a few.

i dont do neurolytics for pancreatitis that is not malignancy related...

i have done many neurolytic blocks, but only in cancer patients. i am advocating not doing it in THIS PATIENT...

the block is not difficult.

 

[drf]

i dont do neurolytics for pancreatitis that is not malignancy related...

i have done many neurolytic blocks, but only in cancer patients. i am advocating not doing it in THIS PATIENT...

the block is not difficult.

I have never done a neurolytic for benign pain. I have cRFed some splanchnics for cancer pain, but also injected etoh so I'm not sure which worked. Stim was concordant, which was kinda fun.

These anecdotal results have made me curious for pRF for benign pain with positive celiac diagnostic block. Anyone have more experience?

Also, anyone here tried neurolytics for benign pain? In fellowship I learned that the pts do better for a few months but then the pain comes back with a vengeance, so we did not do neurolytics for benign pain patients. As I've never done it I'm curious about real-world experience.

 

[Jcm800]

I have never done a neurolytic for benign pain. I have cRFed some splanchnics for cancer pain, but also injected etoh so I'm not sure which worked. Stim was concordant, which was kinda fun.

These anecdotal results have made me curious for pRF for benign pain with positive celiac diagnostic block. Anyone have more experience?

Also, anyone here tried neurolytics for benign pain? In fellowship I learned that the pts do better for a few months but then the pain comes back with a vengeance, so we did not do neurolytics for benign pain patients. As I've never done it I'm curious about real-world experience.

my partner has done enough for me to know not to do it...

 

[hashstudent]

Does anyone has any experience of anterior approach to celiac plexus and its possible complications?

 

[Jcm800]

Does anyone has any experience of anterior approach to celiac plexus and its possible complications?

i have seen two. did not hold the needle in either. they were done under CT as i cant see any other way to do it.

both survived the procedure. I have heard of severe peritonitis as a complication.

I see no advantage in this approach. And many would be glad to crucify you for it. I recommend against it. I think the risk of aortic injury is much less than that of bowel injury. Both can be bad, obviously. Both may not show up for a while either. tried and true posterior. Under CT it is pretty damn easy, but lots of radiation and tedious. umder fluoro also quite easy if you are careful. I understand the interest in the anterior approach as the trajectory seems so easy, but it scared the **** outta me...maybe im a weeny.

 

[lovebailey2001]

I hv seen a few ant. approaches USG guided! advantage- real time needle trajectory and drug/dye spread, supine position, no x-ray exposure, comfortable to patient, possible bedside, intravascular can be avoided by Doppler.

Though no complication was reported, but I am really scared about going through all the viscera and possible infecion!

 

[drf]

I hv seen a few ant. approaches USG guided! advantage- real time needle trajectory and drug/dye spread, supine position, no x-ray exposure, comfortable to patient, possible bedside, intravascular can be avoided by Doppler.

Though no complication was reported, but I am really scared about going through all the viscera and possible infecion!

Ask your GI colleagues to help. endoscopic US guided celiac is a piece of cake for someone who can't tolerate prone.