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The problem with Rectus Sheath blocks are they don't last long (6-10 hours with Bupivacaine). So, you will need a catheter or Exparel for the block. My anecdotal experience with Exparel plus Decadron is 18 hours of analgesia for a rectus sheath block.
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You can block the Rectus Sheath anywhere from the Subcostal margin (up high) to just above the Umbilicus (low). Traditionally, the Rectus Sheath block is performed just above the belly button.
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Rectus Sheath Block
The rectus sheath block was first described in 1899 and was initially used for the purpose of abdominal wall muscle relaxation during laparotomy before the adjunct of neuromuscular block.[5] Now, it is used for analgesia after umbilical or incisional hernia repairs and other midline surgical incisions.
The aim of this technique is to block the terminal branches of the 9th 10th, and 11th intercostal nerves which run in between the internal oblique and transversus abdominis muscles to penetrate the posterior wall of the rectus abdominis muscle and end in an anterior cutaneous branch supplying the skin of the umbilical area.
The most widely described approach is a blind technique, passing the needle through anterior rectus sheath and through the rectus abdominis muscle and injecting the local anaesthetic on the posterior wall of the rectus sheath.
With the patient lying supine, a point is identified 2–3 cm from midline, slightly cephalad to the umbilicus at the apex of bulge of the rectus abdominis muscle. A short-bevelled 5 cm needle, directed at right angles to the skin, is initially passed through the skin until the resistance of the anterior sheath can be felt. A definitive 'pop' should be felt as it passes through. The needle is advanced further until the firm resistance of the posterior wall is felt and injection of 15–20 ml local anaesthetic is made in 5 ml aliquots. The procedure is repeated on the opposite side of the midline.
There is a poor correlation between the depth of the posterior sheath and the age, weight, or height of patients meaning that it can be difficult to predict the depth of the rectus sheath.[5] The use of ultrasound allows non-invasive real-time imaging of the rectus sheath while the needle is placed under direct vision.
The ultrasound probe is placed in a transverse plane and positioned where there is optimum ultrasonographic visualization of the posterior rectus sheath. Either an 'in plane' or an 'out of plane' approach can be used. Local anaesthetic is injected between the rectus abdominis muscle and the posterior rectus sheath. In children, the use of lower doses of local anaesthetic has been described with ultrasound guidance compared with the landmark technique.[5]
With the posterior wall of the rectus sheath lying superficial to the peritoneal cavity, needle misplacement may lead to complications. Injection into the peritoneal cavity will lead to failure of the block and may risk bowel perforation or puncture of blood vessels, usually the inferior epigastric vessels.
In addition to incorrect placement of local anaesthetic, incomplete block may result from anatomical variance, as in up to 30% of the population, the anterior cutaneous branch of the nerves are formed before the rectus sheath and so do not penetrate the posterior wall of the rectus sheath.[2]
http://www.medscape.com/viewarticle/732996_4
The rectus sheath block was first described in 1899 and was initially used for the purpose of abdominal wall muscle relaxation during laparotomy before the adjunct of neuromuscular block.[5] Now, it is used for analgesia after umbilical or incisional hernia repairs and other midline surgical incisions.
The aim of this technique is to block the terminal branches of the 9th 10th, and 11th intercostal nerves which run in between the internal oblique and transversus abdominis muscles to penetrate the posterior wall of the rectus abdominis muscle and end in an anterior cutaneous branch supplying the skin of the umbilical area.
The most widely described approach is a blind technique, passing the needle through anterior rectus sheath and through the rectus abdominis muscle and injecting the local anaesthetic on the posterior wall of the rectus sheath.
With the patient lying supine, a point is identified 2–3 cm from midline, slightly cephalad to the umbilicus at the apex of bulge of the rectus abdominis muscle. A short-bevelled 5 cm needle, directed at right angles to the skin, is initially passed through the skin until the resistance of the anterior sheath can be felt. A definitive 'pop' should be felt as it passes through. The needle is advanced further until the firm resistance of the posterior wall is felt and injection of 15–20 ml local anaesthetic is made in 5 ml aliquots. The procedure is repeated on the opposite side of the midline.
There is a poor correlation between the depth of the posterior sheath and the age, weight, or height of patients meaning that it can be difficult to predict the depth of the rectus sheath.[5] The use of ultrasound allows non-invasive real-time imaging of the rectus sheath while the needle is placed under direct vision.
The ultrasound probe is placed in a transverse plane and positioned where there is optimum ultrasonographic visualization of the posterior rectus sheath. Either an 'in plane' or an 'out of plane' approach can be used. Local anaesthetic is injected between the rectus abdominis muscle and the posterior rectus sheath. In children, the use of lower doses of local anaesthetic has been described with ultrasound guidance compared with the landmark technique.[5]
With the posterior wall of the rectus sheath lying superficial to the peritoneal cavity, needle misplacement may lead to complications. Injection into the peritoneal cavity will lead to failure of the block and may risk bowel perforation or puncture of blood vessels, usually the inferior epigastric vessels.
In addition to incorrect placement of local anaesthetic, incomplete block may result from anatomical variance, as in up to 30% of the population, the anterior cutaneous branch of the nerves are formed before the rectus sheath and so do not penetrate the posterior wall of the rectus sheath.[2]
http://www.medscape.com/viewarticle/732996_4
D
deleted682700
Tx blade
Btw what's the dose of exparel in mg/ kg
What nerve blocks is exparel approved
Tx
Btw what's the dose of exparel in mg/ kg
What nerve blocks is exparel approved
Tx
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Exparel is only FDA approved for local injection and hemorrhoids. That said, what type of block is a rectus sheath block? Are there any motor fibers? What's the difference between a local field sensory block on the abdomen and your rectus sheath block other than your field block is more effective than the surgeon's?
Exparel is sold as 20ml vials or 266 mg. usual dilution is to add up to 40 mls of saline to the 20 mls for a total volume of 60 mls. Or, you could add less saline if you only need a total of 40 mls. Exparel is safe up to 2 vials for adult patients over 70 kg but at $280 per vial (that's cost) most people use 1 vial.
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Old thread I know, but wanted to answer the second question with a question. Do you use morphine in your spinals? Do you use fentanyl for pedi cases? Neither drug is FDA approved for these things as far as I know, but we all do it. Why? The FDA doesn't approve all the ways we use drugs on patients and they don't have to. I have never looked to see if bupivacaine is FDA approved for spinals, epidurals, all nerve blocks that we use it for - but wonder if anyone ever got around to this - FDA or the company that brought this now generic drug to market. We started using Exparel for femoral, ACB and popliteal blocks after reviewing the literature and learning how it was being used around the US. After a conference call with the anesthesiologist who presented on ISB with Exparel at ASRA, we started trying it with our shoulder procedures. We have been very happy with Exparel so far in our ortho dept, and some in our group also do TAPS blocks for abdominal procedures. We have now used it for U/S guided supraclavicular blocks for AV fistula cases in ESRD patients and intercostal blocks for rib fracture patients. Our experience with Exparel is positive. Our surgeons are now asking us to use this product and our patients have been very happy with the duration of block which has ranged from 2- 4 days generally. My longest block was 4 days on a popliteal block for trimalleolar fracture.
disclaimer
I am not reimbursed in any way by Pacira for my comments. I am not a paid speaker for Pacira. I might in the future buy Pacira stock, but at this time have no investment in Pacira. You might look at the stock as well - I think this product is going to generate a lot of revenue for Pacira. 🙂
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Coming from the block guy of our group... They suck. Dont bother learning them. Results are shotty and short lived.
For an ex lap, epidural is the gold standard as it covers visceral and somatic pain. For outpatient/quick discharge cases that would benefit from a truncal block... Stick to b/l TAP or subcostals.
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Absolutely true in my experience.
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One indication I stumbled on: peri umbilical pain for laparoscopic surgery when for some reason the surgeons infiltration isn't sufficient (extremely rare). But did save me from transferring a patient from ASC to hospital for pain control
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Wow, that is one real big wuss!
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Yep, exhausted many options and patient was tearful. Within 5 min of block with ropivacaine practically pain free.
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Did you try Mg?
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It works for umbilical hernias, not always but about 70%
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deleted162650
Did you try giving him some Midol?
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This rectus sheeth block is overkill for small umbilical hernias. Those cases here are mac local cases and fast track recovery. If the surgeon puts in mesh usually thats a general. Patients love it because they get out of hospital faster or nurse loves it because room turnsover fast, pacu loves it because it keeps the pacu moving.
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This was at an ASC, Mg is only in crash cart, I'm sure the nurses woulda been all kinds of confused. It was easier to do the 30s block after ketamine, narcotic, Tylenol and toradol wasn't effective. I then sent him on his merry way and me onto the next 20 cases I still had to do for the day.
