1. NEUROLYTIC BLOCKS Dr.R.SILAMBAN MADRAS MEDICAL COLLEGE

2. NEUROLYTIC BLOCKS  Involves blocking of sympathetic chain at various levels  Prevents transmission of pain impulses from the target organs to the brain

3. NEUROLYTIC BLOCKS  The nerves have the tendency to regenerate  Blocking effect is temporary

4. DURATION  3 months to 24 months

5. COMMON NEUROLYTIC BLOCKS  Stellate ganglion block  Thoracic sympathetic chain block  Coeliac plexus block  Lumbar sympathetic block  Superior hypogastric block  Ganglion impar block

6. STELLATE GANGLION BLOCK Stellate ganglion formed by union of  Middle cervical  Lower cervical  First thoracic segment

7. STELLATE GANGLION BLOCK Pain relief to structures of  Neck  Face  Upper limb  Upper thorax upto T 5

8. THORACIC SYMPATHETIC CHAIN BLOCK  Not used widely  High risk of pneumothorax  Middle and lower thoracic region

9. LUMBAR SYMPATHETIC BLOCK  Needle introduced at the level of L 2 or L 2 + L 4  Pain relief to pelvis and lower limb  Volume required – 8 to 10ml

10. SUPERIOR HYPOGASTRIC PLEXUS BLOCK  From splenic flexure of colon to middle 3 rd of rectum  Pain relief to pelvis and lower limb

11.  Most difficult block to perform  Needle has to enter through a small triangular space between iliac crest and transverse process of L 5  Volume required - 7ml for each side SUPERIOR HYPOGASTRIC PLEXUS BLOCK

12. GANGLION IMPAR BLOCK  Walther’s ganglion - lies in front of S 2, S 3  Pain relief for lower rectum, anal canal and perineum including vulva and vagina

13.  Patient in lithotomy or lateral position  Bent 10cm needle introduced in front of the coccyx  Finger inserted into rectum to guide the needle close to the sacral curvature  Volume required - 10ml GANGLION IMPAR BLOCK

14. Coeliac plexus block

15. HISTORY 1914 – KAPPIS – first block in lateral position 1920 – WELDING – anterior approach. 1927 – LABAT – now followed retrocrural approach in prone position. 1982 – SINGLERS – CT guided transcrural approach 1983– ISCHIA – posterior transaortic approach

16. LOCATION

17. FORMATION

18. AREA OF SUPPLY  LOWER END OF ESOPHAGUS UPTO SPLENIC FLEXURE.  LIVER,SPLEEN  RETROPERITONEAL STRUCTURES LIKE PANCREAS, KIDNEY.

19. INDICATIONS Chronic malignant & non malignant visceral pain 1. Upper g.i. malignancy 2. Chronic pancreatitis 3. Acute pancreatitis 4. Repeated abdominal surgeries 5. HIV related sclerosing cholangitis 6. Diagnostic purposes 7. Abdominal angina

20. ROLE IN CHRONIC PANCREATITIS Controversial Useful in  Few selected cases  Acute exacerbations

21. ROLE IN ACUTE PANCREATITIS  Steroids improved morbidity and mortality  Continuous infusion for pain relief

22. CONTRAINDICATIONS ABSOLUTE  Anti coagulant therapy  Coagulopathy  Anti-blastic cancer therapy  Bowel obstruction  Patient on disulfuram therapy

23. CONTRAINDICATION RELATIVE  Drug seeking behaviour to pain  Patient on CNS depressant drugs

24. TECHNIQUE Posterior approach Anterior approach  Retrocrural  Antecrural  transaortic

25. RETROCRURAL APPROACH

26.  Bilateral Posterior approach  Splanchnic block  Drug deposited behind the crus of diaphragm

27. MARKINGS

31. ANTECRURAL APPROACH

32.  Unilateral approach  Right sided only  Needle placed anterior to crus of diaphragm. ANTECRURAL APPROACH

33. MARKINGS

37. CONTINUOUS PLEXUS BLOCK

39. COMPLICATIONS MINOR  HYPOTENSION  POSTURAL HYPOTENSION  DIARRHEA  PAIN  CHEMICAL COMPLICATIONS

40. COMPLICATIONS CHEMICAL ALCOHOL FACIAL FLUSHING, PALPITATIONS, DIAPHORESIS PHENOL TRANSIENT TINNITUS, FLUSHING,MALAISE CNS STIMULATION, MYOCLONUS, SEIZURES,HYPERTENSION,ARRYTHMIAS,HEPAT IC &RENAL INSUFFICIENCY

41. COMPLICATIONS  VISCERAL INJURY  EJACULATION FAILURE  NERVE ROOT INJURY MODERATE

42. COMPLICATION  PARAPLEGIA  LUNG INJURY  VASCULAR TRAUMA  EPIDURAL & SUB ARACHNOID INJECTION MAJOR

43. EFFICACY OF COELIAC PLEXUS BLOCK Controversy Regarding  Efficacy relative to opioid therapy  Efficacy relative to various approaches  Comittment to neurolysis despite remote risk of paraplegia

44. ADVANTAGE OF COELIAC PLEXUS NEUROLYSIS  Better long term pain relief  Decrease drug dose for maintainance  Better quality of life  Improved performance status  Overcomes the G.I.T effects of opioids  In weight and survival rate

45.  Delayed application  Tumour extension  Poor technique FAILURE DUE TO

46. DRUGS  ALCOHOL  PHENOL  LOCAL ANAESTHETICS

47. ALCOHOL  COMMONLY USED  HYPOBARIC  CEPHALAD SPREAD RADIOGRAPHICALLY  USED IN CONCENTRATION OF 50-100%  VOLUME REQUIRED-40 ml

48. ALCOHOL ADVANTAGES  LONGER DURATION OF ACTION  EASILY AVAILABLE  IMMEDIATE NEUROLYSIS  PAIN ON INJECTION CONFIRMS CORRECT PLACEMENT IN THE BLIND APPROACH  LESS AFFINITY FOR VASCULAR TISSUES

49. ALCOHOL DISADVANTAGES  PAIN ON INJECTION  CANNOT BE COMBINED WITH DYE

50. PHENOL  HYPERBARIC  CAUDAL SPREAD RADIOGRAPHICALLY  7.5 – 10% SOLUTION PREFFERED  MAXIMUM DOSE – 40 mg/kg

51. PHENOL ADVANTAGES  NO PAIN ON INJECTION  IMMEDIATE ANAESTHETIC EFFECT  CAN BE COMBINED WITH DYES

52. PHENOL DISADVANTAGES  NO COMMERCIAL PREPARATION  HIGH AFFINITY FOR VASCULAR TISSUES  SHORTER DURATION OF ACTION THAN ALCOHOL

53. LOCAL ANAESTHETICS  0.25% BUPIVACAINE PREFFERED FOR INTERMITTENT ADMINISTRATION  6-8 ml/hr 0F 0.1% BUPIVACAINE PREFFERED FOR CONTINUOUS ADMINISTRATION  KEPT FOR MAXIMUM OF 7 DAYS

54. SUMMARY  Very useful tool in the armamentarium of the Interventional pain specialist  Applied early for better results  Training in the PG period under expert hands is a must

55. THANK YOU