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his GFR is now 35 and recovering. He is cooperative and comfortable on a PCA with hydromorphone (Dilaudid) 0.2 mg every 10 minutes. You prefer to do an awake bronchoscopy without intubation to evaluate his recent fever and infiltrate seen on the chest x‐ray. Which of the following techniques is the best option for this procedure?Give a hydromorphone (Dilaudid) bolus and start a propofol infusion while maintaining spontaneous respirations.Topicalization is contraindicated; prepare to intubate for bronchoscopy using rocuronium and propofol.Topicalization of the recurrent and superior laryngeal nerves to anesthetize the tongue, epiglottis, vocal cords, and trachea.Topicalization of the hypoglossal nerve to anesthetize the base of the tongue and arytenoids and aryepiglottic folds.Bilateral superficial cervical plexus block.Different techniques are used to sedate and anesthetize the airway for an awake bronchoscopy using a variety of medications such as benzodiazepines, short‐acting opioids (fentanyl, remifentanil), propofol, ketamine, or dexmedetomidine. In cooperative patients at risk for airway obstruction or difficult intubation, topicalization may be a good choice and should be considered. This can be achieved by anesthetizing the airway with regional techniques with or without sedation or in combination with inhaled anesthetic agents such as viscous lidocaine.Sensation to the oropharynx, and larynx and trachea must be blocked to perform an awake fiberoptic bronchoscopy or intubation. There are several ways to achieve the necessary analgesia, but the sensory nerves should be anesthetized. The superior laryngeal nerve supplies sensory innervation to the base of the tongue, epiglottis and aryepiglottic folds, and arytenoids. It also supplies motor innervation to the external branch of the cricothyroid muscle. The recurrent laryngeal nerve supplies sensory innervation to the vocal cords and trachea (choice C).The combination of narcotic bolus (Dilaudid) and propofol infusion is likely to result in apnea that would require intubation. Since this patient could have a difficult intubation (presence of cervical spine injury and a BMI of 38), this is not the best plan (choice A). Topicalization is not contraindicated in this patient and should be considered before intubation (choice A). The hypoglossal nerve is purely motor and does not need to be blocked (choice D). A superficial cervical plexus block provides anesthesia to the skin of the anterolateral neck and auricular areas and skin inferior to the clavicle. This block can be used in thyroid or clavicular surgery but would not anesthetize the airway or facilitate an awake bronchoscopy (choice E).Answer: CElmaddawy AEA, Mazy AE. Ultrasound‐guided bilateral superficial cervical plexus block for thyroid surgery: The effect of dexmedetomidine addition to bupivacaine‐epinephrine. Saudi J Anaesth. 2018; 12(3):412–8.Simmons ST, Schleich AR. Airway regional anesthesia for awake fiberoptic intubation. Reg Anesth Pain Med. 2002; 27(2):180–92.

      21 An 89‐year‐old man fell off a ladder and fractured ribs 3, 4, 5, and 6 on the left side. He is a smoker and has a history of chronic obstructive pulmonary disease (COPD). His pain score is 9/10 and he is taking shallow breaths. He takes antiplatelet medications for atrial fibrillation but cannot remember his last dose. His SpO 2 reads 92% on a 30% face mask. His vital signs are stable. What intervention do you want to recommend to control his pain?Lidocaine patchOxycodoneHydromorphone (Dilaudid) PCAErector spinae block (ESP) plus hydromorphone (Dilaudid) PCA and gabapentinIntercostal nerve block (ICNB)Given his age and pre‐existing COPD, this patient is at risk for pulmonary complications of thoracic trauma. He is in significant pain and appears to be splinting with hypoventilation. The side effects of narcotics such as increased risk for ICU delirium, constipation, and nausea also make these agents a less attractive option when used alone (choices B and C). Erector spinae (ESP) blocks work through a combination of different mechanisms, particularly anesthetic spread to the thoracic paravertebral space. There is evidence to suggest that ESP block results in decreased postoperative pain and opioid requirement for a wide array of thoracic and abdominal procedures including in the management of rib fractures. Intercostal nerve blocks (ICNB) for multiple rib fractures require multiple injections of local anesthetics increasing the risk of toxicity. Choice E, ICNB alone is not the best choice as multimodal approach is recommended to control pain in patients with blunt thoracic trauma. Moreover, being on antiplatelet therapy increases the risk of bleeding for intercostal nerve block (choice E). Choice A, lidocaine patch would not provide sufficient pain relief and continued splinting with shallow breathing may contribute to atelectasis. The patch may cause some numbness to the skin but because of its superficial site of action, it does not decrease fracture pain. Erector spinae blocks in combination with narcotics and gabapentin would establish a multimodal pain control regimen and is conditionally recommended by latest EAST guidelines (choice D) (Figure 12.2).Figure 12.2 Erector spinae plane block. ES: erector spinae; LD: latissimus dorsi; IL: iliocostalis lumborum; Lo: longissimus; Mu: multifidus.Answer: DGalvagno SM Jr, Smith CE, Varon AJ, Hasenboehler EA, Sultan S, Shaefer G, To KB, Fox AD, Alley DE, Ditillo M, Joseph BA, Robinson BR, Haut ER. Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society. J Trauma Acute Care Surg. 2016; 81(5):936–51.Saadawi M, Layera S, Aliste J, Bravo D, Leurcharusmee P, Tran Q. Erector spinae plane block: A narrative review with systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks. J Clin Anesth. 2020; 68:110063.

      22 Considering the appropriateness of nerves blocked to the procedure performed, which patient's pain is more likely to be adequately controlled?Abdominal wall reconstruction with bilateral TAP indwelling catheter.Large bowel resection with bilateral TAP block injection.Cervical fusion with erector spinae block single injection.Esophageal reconstruction with a neurolytic celiac plexus block.Shoulder surgery with axillary nerve block.Transverse Abdominis Plane (TAP) nerve blocks with indwelling catheters provide adequate somatic analgesia for abdominal wall surgery (choice A). In contrast, quadratus lumborum (QL) nerve blocks provide visceral in addition to somatic analgesia for the abdominal wall and the lower thoracic wall segments. This is because QL nerve blocks spread to the paravertebral space and sometimes achieve epidural spread. In large bowel resection, bilateral TAP block injections will not provide adequate analgesia for deep visceral pain (choice B). Erector spinae (ESP) block results in decreased postoperative pain and opioid requirement for a wide array of thoracic and abdominal procedures including in the management of rib fractures. It does not relieve somatic pain for cervical fusion (choice C). Choice D, celiac plexus block places the either a local anesthetic or neurolytic solution directly on the celiac ganglion anterolateral to the aorta. When used, for example, to manage pain in terminal pancreatic cancer, a neurolytic agent is chosen. Choice E is incorrect since the axillary nerve block will not provide adequate coverage for the shoulder joint surgery. Axillary nerve block will provide adequate analgesia from the mid upper arm extending to the hand (Figure 12.3).Figure 12.3 Transverse abdominis plane block. QL: quadratus lumborum; EO: external oblique; IO: internal oblique; TA: transverse abdominis; K: kidney; P: psoas major; LD: latissimus dorsi; IL: iliocostalis lumborum; Lo: longissimus; Mu: multifidus.Answer: ATsai HC, Yoshida T, Chuang TY, Yang SF, Chang CC, Yao HY, Tai YT, Lin JA, Chen KY. Transversus abdominis plane block: an updated review of anatomy and techniques. Biomed Res Int. 2017; 2017:8284363.Saadawi M, Layera S, Aliste J, Bravo D, Leurcharusmee P, Tran Q. Erector spinae plane block: A narrative review with systematic analysis of the evidence pertaining to clinical indications and alternative truncal blocks. J Clin Anesth. 2020; 68:110063.

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