Ultrasound-Guided Regional Anesthesia–Current Strategies for Enhanced Recovery after Cardiac Surgery

Figure 1. (A) Parasagittal scan of thoracic paravertebral space (TPVS); (B) Transverse/oblique scan of TPVS after 75-degree anti-clockwise rotation from A. The needle tip’s target is TPVS, which, after probe rotation, appears enlarged and lies anteriorly to superior costotransverse ligament (SCTL)/IIMb (see text).TM, trapezius muscle; RM, rhomboid muscle; ESM, erector spinae muscle; EIM, external intercostal muscle; IIM, internal intercostal muscle; TP, transverse vertebral process; SCTL, superior costotransverse ligament; IIMb, internal intercostal membrane; TPVS, thoracic paravertebral space.

Figure 2. (A) Parasagittal scan—rib level; (B) Parasagittal scan—TP level (see text). TM, trapezius muscle; RM, rhomboid muscle; ESM, erector spinae muscle; TP, transverse vertebral process; ESM-to-TP, erector spinae muscle -to-transversus process plane.

Figure 3. (A) Parasagittal scan along the medioclavicular line-2nd rib level; (B) Oblique scan after a slight medial tilt with inferolateral sliding towards the midaxillary line-4th rib level (see text). PMAJOR, pectoralis major muscle; PMINOR, pectoralis minor muscle; AxA, axillary artery; AxV, axillary vein; red arrows, thoracoacromial artery and vein; SAM, serratus anterior muscle; IM, intercostal muscle; TTM, transversus thoracic muscle; P1, PECS I plane; P2, superficial plane for SAPB/PECS II; P3, deep plane for SAPB/PECS II. To elicit an adequate SAPB coverage, P2 or P3 need to be targeted at the 4th or 5th rib level.

Figure 4. (A) Sagittal parasternal scan; (B) Sagittal parasternal scan with markings. Note that TTM appears as a hypoechoic band folding over the hyperechoic pleura. PMAJOR, pectoralis major muscle; EIM, external intercostal muscle; IIM, internal intercostal muscle; INNIM, innermost intercostal muscle; TTM, thoracic transversus muscle; P1, target plane for PIFB; P2, target plane for TTMPB.