This ASG video tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. Hi, this is Preeti Perera with the ASGE tip for EOS guided select plexus nerve blocks. These are my relevant disclosures. So today we'll be covering both indications and contradications for celiac plexus nerve blocks. We'll also be looking at techniques for the celiac plexus nerve blocks and factors to consider both with patient selection and post-procedural considerations. The celiac plexus nerve block as a background is administration of a local anaesthetic agent and a glucocorticoid and you're really going for the celiac plexus. The goal here is for short-term relief as opposed to neuralysis and typically this is used on patients with chronic pancreatitis pain where the pain is severe enough that narcotics aren't strong enough to cover it or there's significant adverse reactions to narcotics or you really want to minimize opioid requirements. Again the goal of this is short-term pain relief with the medium duration of pain relief around about 10 weeks. Contradications for celiac plexus nerve blocks, obviously if the patient is hemodynamically unstable or there is anticoagulopathy i.e. a platelet of less than 50,000, INR greater than 1.5 or anticoagulation use outside of aspirin 81 milligrams that cannot be held for any reason. For patient prep you will need to give antibiotic prophylaxis to prevent any kind of infection. Typically we use a fluoroquinolone which is given during the procedure and also can be given up to three days after the procedure is completed. Although not as significant as with celiac neuralysis there can be issues with hypotension basically due to disruption of the sympathetic tone leading to unopposed parasympathetic tone and so we typically use IV fluids and give hydration prior and during the procedure with at least one liter of normal saline. You'll also need this to be done with anesthesia, general versus MAC anesthesia. You will need a facility that has hemodynamic monitoring post-procedure as well as a 20 gauge plexus needle if you're doing the unilateral technique or a 22 gauge FNA needle if you're doing the bilateral technique. In terms of supplies if you're using the unilateral technique versus the bilateral technique both will require IV antibiotics discussed previously. With a unilateral technique you're going to use a 20 gauge plexus injection needle. You're going to need 8 milliliters of bupivacaine 0.25 percent, triamcinolone 80 milligrams and a 5 milliliter flush. With the bilateral technique it's the same volume which is divided up into two different portions so you'll need you know two times four milliliters of the bupivacaine and two of the 40 milligrams of the tricimolone and two flushes. So what you're aiming for again is the celiac plexus that's located above the celiac takeoff. You're going to go with your linear echo endoscope. You're going to advance it to the lesser curvature of the gastric fundus to identify the aorta and you're going to follow this down to identify both the celiac trunk and the SMA. For the technique if you're doing unilateral this is with the 20 gauge plexus injection needle you're going to advance the needle just above the celiac artery takeoff. Before putting the needle down you want to flush it to clear itself of air. Once the needle is in place you want to aspirate to ensure there is no blood and you're going to inject about eight millimeters of bupivacaine, 0.25 percent. You can then switch needles, syringes even, and inject triamcinolone 80 milligrams followed by a three to five milliliter flush with normal saline. You can decide to aspirate before the triamcinolone but if you maintain the same position you can just inject. The importance of the flush is to clear the needle of the medication but again this is more relevant in patients undergoing neurolysis. With the bilateral injections you're going to aim for either side of that celiac artery takeoff. So once again you visualize the celiac artery takeoff, you're going to rotate your scope clockwise until you lose the celiac artery SMA and then place the needle and aspirate again to ensure no blood. You're going to inject this time four milliliters of bupivacaine followed by the 40 milligrams of triamcinolone and once you inject you're going to withdraw the needle, get yourself back to the celiac artery takeoff and this time rotate counterclockwise and advance the needle again adjacent to the celiac plexus. Again with this one you inject three to five milliliters flush with normal saline. And so this is a picture here that shows that you will get some disruption of this haziness with the injection. So it's very important to just maintain visualization the whole time. After the procedure it is not atypical for patients to experience worse abdominal pain that can last up to 48 hours that actually could mean a good thing, you actually hit the plexus. Sometimes they'll get transient hypertension so usually in these cases what we would do is get fluids and check orthostatics before they leave. They could sometimes have diarrhea again for the unopposed parasympathetic tone. And if it's not successful you can actually reattempt another time to see if it works. So in conclusion celiac nerve plexus blocks have a role in patients with chronic pancreatitis to avoid or reduce opioid escalation. Again short-term relief is what we're looking for. We use the corticosteroid and anesthetic agent and we discuss both unilateral and bilateral techniques and you can repeat if you have no initial effect.

Braintree

Preeti Perera

EOS-guided select plexus nerve blocks

celiac plexus nerve blocks

chronic pancreatitis pain