Celiac Plexus Block

 

Indications

Indicated to control pain of the epigastric viscera, especially due to primary or metastatic upper abdominal cancers.

The most frequent pathology associated with use of this block is pancreatic cancer and associated metastasis.

Not frequently used for chronic pancreatitis or to provide anesthesia for intraabdominal surgery.

 

Drugs utilized

For a sensory block:

0.25% Bupivacaine with or without 1:200,000 epi.

 

For a neurolytic block:

50% - 100% Alcohol diluted with sterile water or local anesthetic.

Total volume to be no more than 15-20 ml for each injection.

Overfilling the space may cause the alcohol to leak and spread posteriorly, resulting in alcohol neuritis.

 

Anatomy

The celiac plexus is situated retroperitoneally in the upper abdomen.

It is at the level of the T12 and L1 vertebrae, anterior to the crura of the diaphragm.

It encases the anterolateral surface of the abdominal aorta and the celiac and superior mesenteric arteries.

It continues inferiorly as the superior mesenteric plexus and then as the inferior mesenteric plexus.

The vena cava lies anteriorly on the right, the aorta anteriorly on the left.

 

For further anatomy visual visit http://www.pitt.edu/~anat/Abdomen/Abdomen/Abd.htm

 

Innervations

Contains ganglia that receive sympathetic fibers from the greater, lesser, and least splanchnic nerves.

Receives parasympathetic fibers from the vagus nerve.

 

Autonomic nerves supplying the liver, pancreas, gallbladder, stomach, spleen, kidneys, intestines, and adrenal glands, as well as blood vessels, arise in the celiac plexus (sympathetic efferent fibers).

 

 

 

Techniques

The retrocrural and transcrural celiac plexus block are the most frequently used approaches.

CPB can be performed anatomically (blind), or with fluoroscopic or CT guidance.

Other techniques include:

Transaortic approach

Anterior approach

Paramedian approach at T-12

Transdiscal approach

 

Retrocrural Approach

Patient is placed in the prone position with a pillow beneath the abdomen and hips to flatten the lumbar lordosis.

Lines are drawn connecting the spine of T12 with points 7-8 cm lateral at the edges of the 12th ribs.

Identifying the 11th rib instead of the 12th rib significantly increases the risk of pneumothorax!

The block is performed with a 15-cm, 20-22 G needle.

The left sided needle is placed first because the aorta is a helpful landmark to assist with correct placement.

After sterile preparation, infiltrate the skin, subcutaneous, and muscle layers with 0.5 % lidocaine along the anticipated course of the block needles.

Use a 25-G, 5-6 cm needle to inject 4 to 5 ml per side.

Use the previously drawn line between the needle entry site and T12 to guide the needle direction, and advance it at a 45 angle from the horizontal plane toward the body of T12 or L1 (see diagram below).

Bony contact should be made at an average depth of 7-9 cm.

Observe the distance that the vertebral body is contacted.

Withdraw the needle, not through the skin, and reinsert it at an increased angle of 5-10 to allow the tip to slide off the vertebral body anterolaterally.

The needle is advanced approximately 1.5-2 cm past the original insertion depth.

Stop advancing the needle at the first sign of increased tissue resistance, because this probably represents the aorta.

Aortic pulsations can be felt as they are transmitted along the needle when it is correctly placed.

Repeat the procedure on the right side.

    The aorta is not present on the right

    The needle is advanced approximately 1 cm deeper on the right

Observe the needles for leakage of blood, urine, or CSF.

After careful aspiration, inject 5-10 ml of a diagnostic test dose containing 0.25 % bupivacaine with 1:200,000 epinephrine through each needle.

If the patient receives good pain relief from the test dose above then a neurolytic block can be performed:

    Inject 10-20 ml of 50-100% alcohol slowly through each needle.

    Flush needles with anesthetic or air then remove the needles.

The patient should be well hydrated and observed for a sufficient time after the block to ensure that postural hypotension is not a problem.

 

Assessment of Efficacy

Subjective

Patient reports relief of pain.

 

Objective

Decreased narcotic usage after the block.

 

Complications

Related to needle insertion/technique

Pneumothorax

    Needle placed too far cephalad

Puncture of surrounding structures, mainly kidneys

Bleeding

    Due to puncture of the aorta or vena cava

Paraplegia (most serious)

    Related to damage of the artery of Adamkiewicz

Related to sympathetic block/neurolytic agent

    Hypotension MOST COMMON

    Systemic toxicity

        Transient mild diarrhea (lasting up to 2 weeks)

        Paraplegia (rare but most serious) - related to use of alcohol damaging the artery of Adamkiewicz

 

References

 

Questions