SIR 2024
Pain Management/MSK
Simon McQueen, MBBS (he/him/his)
Interventional Radiology Fellow
McGill University, Canada
Financial relationships: Full list of relationships is listed on the CME information page.
Gercois Human, MD
Interventional Radiology Fellow
McGill University, Canada
Disclosure information not submitted.
Tatiana Cabrera, MD
Interventional Radiologist
McGill University Health Centre, Canada
Disclosure information not submitted.
Louis-Martin Boucher, MD, PhD
Interventional Radiologist
McGill University Health Centre, Canada
Disclosure information not submitted.
Informed consent is obtained and time out procedures completed. The patient is positioned supine. A curvilinear ultrasound probe, scanning via an intercostal approach allows visualization of the main portal vein and surrounding echogenic periportal fat. Once needle approach is selected, 1% lidocaine is infiltrated at the skin and liver capsule. A 21g Chiba needle is then advanced percutaneously across the liver parenchyma to the periportal fat, within 2cm of the portal bifurcation.
To avoid systemic local anesthesia administration it is imperative to confirm the needle tip is no longer in the hepatic parenchyma, and has not entered the portal vein or other intravascular space. Therefore a small volume extension set is attached to the Chiba hub, with aspiration confirming no blood drawback. A test dose of 2 cc 1% lidocaine with 1:200,000 epinephrine is administered with close observation of patient heart rate. If heart rate increases by >10%, the needle is repositioned.
Once the operator is satisfied with needle position a total volume of 20 mL of bupivicaine with epinephrine is slowly injected under ultrasound imaging with observation of the progressive enlargement of the echogenic fat layer surrounding the portal vein.
The Chiba needle is then withdrawn and planned hepatobiliary intervention completed.
1. Hepatobiliary procedures can be very painful for patients in the periprocedural period
2. A perihilar nerve block provides an alternative or supplementary option to intravenous analgesic agents.
3. While close attention to avoid intravenous systemic administration of local anesthesia must be made, the procedure is technically straightforward in the skill set of an interventional radiologist.