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A safer method to provide rectus sheath block
- Santhanam Suresh, MD, Chicago, IL 60614, USA (27 September 2006)
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Ultrasound guided Rectus Sheath Blocks in Adults
- Nik K Husain, Abdul Ravalia (22 August 2006)
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Needle-probe orientation for ultrasound guided rectus sheath blocks
- Steve Roberts, Amy Walker (11 July 2006)
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Santhanam Suresh, MD, Pediatric Anesthesiologist Children's Memorial Hospital, Chicago, IL 60614, USA
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I would like to commend the authors for their use of ultrasonography for rectus sheath blocks. My previous experience with the 'scratchng method' as described by Ferguson has not always been succesful due to potential difficulty in 'tactile perception'. The technique using ultrasonography has made performing this block very simple and less labor intensive. This is one block that we notice can provide good analgesia with very little local anesthetic solution. Conflict of Interest:None declared |
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Nik K Husain , Abdul Ravalia
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Editor- We have recently had a correspondence(1) accepted for publication describing the use of ultrasonography- guided rectus sheath block in adults and read with interest the study by Willschke and colleagues(2) describing the anatomical and clinical evaluation of ultrasonography- guided rectus sheath blocks in children. We commend them in highlighting several important practical considerations when performing this regional technique and the efficacy of analgesia in the paediatric population. Although our experience of rectus sheath blocks ( in combination with bilateral ilioinguinal nerve blocks) is limited to adults undergoing gynaecological procedures involving a Pfannensteil incision we feel that similar considerations need to be extended to this population. Combined rectus sheath block and bilateral ilioinguinal blocks has been well described for abdominal gynaecological procedures(3) using anatomic landmarks and tactile stimuli but unfortunately has not gained much popularity; principally because of the paucity of text books which actually describe the technique of rectus sheath block. Willschke and colleagues have found that there is poor correlation between the depth of the posterior rectus sheath and weight, height and body surface area in children. This variability is even more striking in the adult population with the attendant risk of needle misplacement, failure of rectus sheath block and , more seriously, damage to underlying structures deep to the posterior rectus sheath. We have no statistical evidence to support us but our clinical impression is that our patients are extremely comfortable post-operatively and feel that the rectus sheath block is a useful technique under-utilised in the adult population. It has even been used with success as the sole anaesthetic for an umbilical hernia repair in a morbidly obese patient with multiple co-morbidities, in whom central neuraxial blockade was contra-indicated(4). The findings of this study are transferable to adult anaesthesia and we should not forget this long overlooked regional anaesthetic technique and that ultrasonography- guided regional techniques, just like ultrasonography-guided central venous catheterisation, will probably become the standard in the future for both adult and paediatric regional anaesthesia. References: [1] Husain NKA, Ravalia A. Ultrasound Guided Ilioinguinal & Rectus Sheath Blocks for Gynaecological Surgery Anaesthesia 2006; in press [2] Willschke H, Bosenberg A, Marhofer P, et al. Ultrasonography- guided rectus sheath block in paediatric anaesthesia- a new approach to an old technique Br J Anaesth 2006; 97(2): 244-249 [3] Yentis S, Hills-Wright P, Potparic O. Development and evaluation of combined rectus sheath and ilioinguinal blocks for abdominal gynaecological surgery. Anaesthesia May 1999; 54(5): 475-479 [4] Muir J, Ferguson S. The rectus sheath block- well worth remembering. Anaesthesia 1996; 51(9): 893-894 Conflict of Interest:None declared |
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Steve Roberts , Amy Walker
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Drs Willschke et al [1] Are to be congratulated on their well thought out paper. We had initially used the cross-sectional needle-probe approach they describe, however over the past two years we have moved to an in-line needling technique (insert fig). This needling technique can be harder to master. There are a number of reasons why this is our preferred method. Firstly there is far superior imaging of the needle throughout it's length and as such greater control of the tip. Secondly there is no loss of contact between probe and skin as the needle is directed from the side (lateral to medial direction) whereas with the short axis approach contact is lost as the needle is pushed through the skin. Thirdly the needle is being inserted at a shallow angle almost parrallel to the surface of the probe, this potentially decreases the chance of puncturing the peritoneum. Although this method involves inserting two-three times the needle length (compared to the short axis approach)these blocks are usually performed under general anaesthesia so patient discomfort is not a problem. In small children the use of a probe with a larger footprint e.g L38 (SonoSite,Bothell, WA, USA)allows the probe to be positioned in a transverse plane across the midline of the abdomen, both rectus sheaths can be blocked without repositioning the probe. Reference H. Willschke, A. Bösenberg, P. Marhofer, S. Johnston, S. C. Kettner, O. Wanzel, and S. Kapral Ultrasonography-guided rectus sheath block in paediatric anaesthesia—a new approach to an old technique Br. J. Anaesth. 2006; 97: 244-249 Conflict of Interest:None declared |
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