Payment for 64999 nerve blocks (IPACK, PENG, Erector Spinae)

[yossarian22]

How are your groups handling insurance (CMS included) denials for payments for newer nerve blocks. We have transitioned to IPACK, PENG, and erector spinae blocks for a vast majority of our patients. Per the AMA instructions, they are coded as 64999, but we are still frequently are not paid for them. They often are rebuked by saying it is "experimental." Any guidance would be appreciated.

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[Maz777]

This is probably the solitary one time I will ever agree with any insurance company. "Blocks" that do not do anything other than maybe provide a muscular/interfascial depot of long-acting anesthetic that slowly becomes intravascular over an 8-12 hour period (i.e. low-dose IV bupivacaine infusion).

 

[yossarian22]

The same argument can be said for every block. However it is a risk and provides superior benefit compared to the alternatives (epidural, fascia ilia a, sciatic nerve block) . It undoubtedly should be covered.

 

[Maz777]

The same argument can be said for every block. However it is a risk and provides superior benefit compared to the alternatives (epidural, fascia ilia a, sciatic nerve block) . It undoubtedly should be covered.

When you actually visualize and target a nerve, that's one thing. When you just willy nilly make up a fascial plane with no innervation, and then deposit a lot of local, that's another thing. You are trying to bill for fake/questionable "blocks" to make money and then get upset that they don't get reimbursed? Maybe stick to seeing nerves and depositing local around said nerves.

 

[DesiredMemberName?]

Is it clear that ACB + IPACK is superior to ACB + local infiltration by surgeon? I think there are a few studies suggesting that the IPACK is no better than surgeon local infiltration.

 

[yossarian22]

The AMA has provided guidance. TAP blocks, fascia Iliaca are reimbursed and are the same concept. This isn’t quackery as you suggest. And IPACK is superior to local by surgeon, no need for a study .

 

[UscGhost]

Anyone who says that TAP, ESP, pec or ipack blocks don't work are simply wrong.

I can't count the number of times I have done rescue blocks on patients in pacu because the surgeons local didn't work. Could they have just slammed in more opioid? Sure, but then patient is nauseated in pacu or has a prolonged stay.

Just three days ago, my surgeon refused a block for her mastectomy patient because "she would do one". I then needed to give 300mcg of fentanyl during the case (I normally expect 50-100 if I block) and patient had 7/10 pain upon arrival in pacu.

I did a rescue pec block on her and she was back at 0/10 pain a few mins later.

That being said...if the anesthesiologist isn't skilled at them..then yes they are useless

 

[Dawkter]

This is probably the solitary one time I will ever agree with any insurance company. "Blocks" that do not do anything other than maybe provide a muscular/interfascial depot of long-acting anesthetic that slowly becomes intravascular over an 8-12 hour period (i.e. low-dose IV bupivacaine infusion).

These blocks work very well if you understand the anatomy and achieve appropriate spread. I have been able to extubate someone with multiple rib fractures after placing an ESP catheter.

 

[sevoflurane]

I did a bunch of ipacks a few years ago. One surgeon still request them. However, I think the local infiltration at the correct time during a tka is just as good. Ipacks can hurt awake.

I’ve had great success w ESP blocks- even for cardiac cases. TAPs are helpful but tend to miss visceral component of pain.

 

[anbuitachi]

peng block and erector block. works great. honestly like it more than tap block

 

[Southpaw]

When you actually visualize and target a nerve, that's one thing. When you just willy nilly make up a fascial plane with no innervation, and then deposit a lot of local, that's another thing. You are trying to bill for fake/questionable "blocks" to make money and then get upset that they don't get reimbursed? Maybe stick to seeing nerves and depositing local around said nerves.

In my opinion you're missing the point. It is not the role of the insurance company to determine appropriateness. It is their role to collect premium and distribute payment. The waters have been muddied, and insurance companies like to paint the picture as 'doctors are greedy' (which an extreme minority are, and practice as such, but that isn't what we are talking about here) when in fact the reality is that physicians are doing the best they can for their patients (plane blocks are a perfect example) and insurance companies are continually trying to find ways to not reimburse for service. Since these are companies have such a simple job, and yet their revenue is in the billions, it's plain as day the imbalance that has developed between collect premium and distribute payment.

If a physician determines that X will be helpful for the patient, and they take on the training and liability necessary to perform X, and they do X for the patient, they should be fairly reimbursed.

 

[Dr. Rude]

If a physician determines that X will be helpful for the patient, and they take on the training and liability necessary to perform X, and they do X for the patient, they should be fairly reimbursed.

May I suggest that you purchase a time machine. please set for 1970s-1980s

 

[vector2]

If a physician determines that X will be helpful for the patient, and they take on the training and liability necessary to perform X, and they do X for the patient, they should be fairly reimbursed.

I wish this could be the case, but the amount of fraud (or just plain unethical behavior in medicine in general) is just too widespread to make this the standard.

Just imagine the number of pain practices that would be billing anesthesia and the pain procedure if they still could, or the number of times practices were doing PNB + neuraxial opioid + GETA because you could collect for all three.

 

[vector2]

The same argument can be said for every block. However it is a risk and provides superior benefit compared to the alternatives (epidural, fascia ilia a, sciatic nerve block) . It undoubtedly should be covered.

My 2c, PENG is trash. IPACK is no better than surgeon generously infiltrating posterior capsule. ESP usually works but the reliability/predictability isn't 100% even when you think the spread looks good.

But the idea that these are "superior" to fascia iliaca, sciatic, thoracic epidural, or targeted somatic nerve / neuraxial blocks is absolutely laughable.

 

[Southpaw]

I wish this could be the case, but the amount of fraud (or just plain unethical behavior in medicine in general) is just too widespread to make this the standard.

Just imagine the number of pain practices that would be billing anesthesia and the pain procedure if they still could, or the number of times practices were doing PNB + neuraxial opioid + GETA because you could collect for all three.

Yeah I agree with you but I don’t agree it’s the insurance company’s role to play policeman. We have other entities for that. That’s like asking the rat what should be tossed in the trash.

 

[vector2]

Yeah I agree with you but I don’t agree it’s the insurance company’s role to play policeman. We have other entities for that.

Agreed. Insurance companies definitely should not be the final authority on pre-auths or what procedures get paid for.

 

[UscGhost]

My 2c, PENG is trash. IPACK is no better than surgeon generously infiltrating posterior capsule. ESP usually works but the reliability/predictability isn't 100% even when you think the spread looks good.

But the idea that these are "superior" to fascia iliaca, sciatic, thoracic epidural, or targeted somatic nerve / neuraxial blocks is absolutely laughable.

Depends a bit on how you determine superiority.

Thoracic epidurals take longer to place, more difficult and require postop rounding ,etc. So not worthwhile unless severe pain. And then you have issues with anticoagulants..etc

Fascia iliaca have a higher risk of motor loss.

And not all surgeons do satisfactory posterior capsule injections

 

[nimbus]

Try 64450?

 

[Hoya11]

Anyone who says that TAP, ESP, pec or ipack blocks don't work are simply wrong.

I can't count the number of times I have done rescue blocks on patients in pacu because the surgeons local didn't work. Could they have just slammed in more opioid? Sure, but then patient is nauseated in pacu or has a prolonged stay.

Just three days ago, my surgeon refused a block for her mastectomy patient because "she would do one". I then needed to give 300mcg of fentanyl during the case (I normally expect 50-100 if I block) and patient had 7/10 pain upon arrival in pacu.

I did a rescue pec block on her and she was back at 0/10 pain a few mins later.

That being said...if the anesthesiologist isn't skilled at them..then yes they are useless

i disagree and i think i am good at regional lol
those "soft" blocks are always in the context of a spinal or GA or some other multimodal cocktail where their inefficacy can hide..

personally i have never seen or done a rescue block with one of those and had the results you are describing.. sometimes success is in the eye of the beholder

 

[anaesthetic]

i disagree and i think i am good at regional lol
those "soft" blocks are always in the context of a spinal or GA or some other multimodal cocktail where their inefficacy can hide..

personally i have never seen or done a rescue block with one of those and had the results you are describing.. sometimes success is in the eye of the beholder

I’ve done rescue TAPs and ESPs. The ESP blocks have had tremendous success in our rib fracture patients who have failed more conservative treatments in the ICU. We get calls on those every once in a while, and patients experience relief almost 100% of the time (anecdotally). Easy to do, safe to perform, great results, IMO.

 

[potcake76]

How are your groups handling insurance (CMS included) denials for payments for newer nerve blocks. We have transitioned to IPACK, PENG, and erector spinae blocks for a vast majority of our patients. Per the AMA instructions, they are coded as 64999, but we are still frequently are not paid for them. They often are rebuked by saying it is "experimental." Any guidance would be appreciated.

Not sure if this helps, but Aetna requires IPACK blocks to be billed with 64450. If you’re billing 64999, that could be the reason for the denial. At least for Aetna cases.

 

[abolt18]

Same. ESP and TAP, best way to see efficacy is to do it in PACU when the patient is in pain. (Not that it's ideal for the patient, but it's what has confirmed for me that they actually have value, because I had serious doubts otherwise)

 

[UscGhost]

i disagree and i think i am good at regional lol
those "soft" blocks are always in the context of a spinal or GA or some other multimodal cocktail where their inefficacy can hide..

personally i have never seen or done a rescue block with one of those and had the results you are describing.. sometimes success is in the eye of the beholder

I have had pacu nurses come ask me to do rescue blocks on other patients.

Similarly our surgeons request them once they realize we can do them and they frequently complain that nobody knows how to do them at their other sites..

Different experiences I guess

Data also supports them

 

[vector2]

Depends a bit on how you determine superiority.

Thoracic epidurals take longer to place, more difficult and require postop rounding ,etc. So not worthwhile unless severe pain. And then you have issues with anticoagulants..etc

Fascia iliaca have a higher risk of motor loss.

And not all surgeons do satisfactory posterior capsule injections

Superiority is essentially decided by the balance between the efficacy of pain relief from the block vs the risks/side effects/technical difficulties that you describe.

From an efficacy standpoint, a somatic nerve block or a working neuraxial catheter is orders of magnitude more efficacious at relieving surgical pain than various plane/capsule/interfascial blocks. There is no question there.

But as far as the downsides, I think some of the ERAS sht for many surgical subspecialties has gotten out of hand, and a side effect of that is we have lost our minds trying to find vaguely efficacious novel blocks solely in the effort of being able to give one more dose of lovenox, or avoid one missed day of ambulation, or reduce the 48h postop cumulative tramadol dose to 508.25 ± 20.6 mg from 550.25 ± 20.6 mg

If all these regional gurus want us skeptics to believe some of these novel blocks are so great, then publish the literature to back it up. And by literature I don’t mean regional’s favorite child, the retrospective case series. I mean true double blinded, randomized trials that involve a sham block and aren’t plagued by 20 anesthetic/multimodal confounders.

 

[Maz777]

Superiority is essentially decided by the balance between the efficacy of pain relief from the block vs the risks/side effects/technical difficulties that you describe.

From an efficacy standpoint, a somatic nerve block or a working neuraxial catheter is orders of magnitude more efficacious at relieving surgical pain than various plane/capsule/interfascial blocks. There is no question there.

But as far as the downsides, I think some of the ERAS sht for many surgical subspecialties has gotten out of hand, and a side effect of that is we have lost our minds trying to find vaguely efficacious novel blocks solely in the effort of being able to give one more dose of lovenox, or avoid one missed day of ambulation, or reduce the 48h postop cumulative tramadol dose to 508.25 ± 20.6 mg from 550.25 ± 20.6 mg

If all these regional gurus want us skeptics to believe some of these novel blocks are so great, then publish the literature to back it up. And by literature I don’t mean regional’s favorite child, the retrospective case series. I mean true double blinded, randomized trials that involve a sham block and aren’t plagued by 20 anesthetic/multimodal confounders.

You are 100% correct. These are academic regionalists that want to make a name for themselves. Inventing fascial plane nonsense just to prop up their careers. ASRA is full of these people.

For ESPBs, for example, there is no way a well done, highly powered sham-controlled study would show superiority of ESPBs for any acute pain indication (when the comparator is local infiltration of the same amount of bupi/ropi) at the site. If you are skilled and do real nerve blocks, the difference is night and day. Suggesting that an ESPB is even remotely comparable to a well done PVB is ludicrous.

Stick to localizing and blocking actual nerves if you want to bill these as peripheral nerve blocks. Or don't waste your time or the patient's time/deductible. We all know this is billing fraud. How can I make more wRVUs without assuming the risk of doing an actual nerve block? Oh, I know, I'll randomly inject a crap ton of local in a space in which zero innervation exists (PECS and TAPs excluded, I guess).

 

[yossarian22]

You are 100% correct. These are academic regionalists that want to make a name for themselves. Inventing fascial plane nonsense just to prop up their careers. ASRA is full of these people.

For ESPBs, for example, there is no way a well done, highly powered sham-controlled study would show superiority of ESPBs for any acute pain indication (when the comparator is local infiltration of the same amount of bupi/ropi) at the site. If you are skilled and do real nerve blocks, the difference is night and day. Suggesting that an ESPB is even remotely comparable to a well done PVB is ludicrous.

Stick to localizing and blocking actual nerves if you want to bill these as peripheral nerve blocks. Or don't waste your time or the patient's time/deductible. We all know this is billing fraud. How can I make more wRVUs without assuming the risk of doing an actual nerve block? Oh, I know, I'll randomly inject a crap ton of local in a space in which zero innervation exists (PECS and TAPs excluded, I guess).

I have little interest in placing 2-3 paravertebral blocks with a higher risk of bleeding, pneumothorax, etc. if I have been achieving great pain control with an ESP catheter for thoracic surgery. Risk benefit for ESP, in my opinion, is clearly in its favor. I understand you are unable to recognize that there are different ways to practice anesthesia, but saying we are committing fraud is heedless.

Is there anyone who can answer the original question posted? I would like to support our group to make sure we are correct in how we are billing and that we are compensated for the work that is being done.

 

[UscGhost]

You are 100% correct. These are academic regionalists that want to make a name for themselves. Inventing fascial plane nonsense just to prop up their careers. ASRA is full of these people.

For ESPBs, for example, there is no way a well done, highly powered sham-controlled study would show superiority of ESPBs for any acute pain indication (when the comparator is local infiltration of the same amount of bupi/ropi) at the site. If you are skilled and do real nerve blocks, the difference is night and day. Suggesting that an ESPB is even remotely comparable to a well done PVB is ludicrous.

Stick to localizing and blocking actual nerves if you want to bill these as peripheral nerve blocks. Or don't waste your time or the patient's time/deductible. We all know this is billing fraud. How can I make more wRVUs without assuming the risk of doing an actual nerve block? Oh, I know, I'll randomly inject a crap ton of local in a space in which zero innervation exists (PECS and TAPs excluded, I guess).

Nonsense.

There is a ton of literature showing benefits with ESP blocks. They even use them in the ER to treat acute LBP and show lower rates of admissions versus standard therapy. I myself have done a couple for physicians with acute LBP and they were substantially better 15 mins later.

Is it as good as a paravertebral or epidural? No, but it's safer, easier and faster to perform. So it has a role.

 

[vector2]

Nonsense.

There is a ton of literature showing benefits with ESP blocks. They even use them in the ER to treat acute LBP and show lower rates of admissions versus standard therapy. I myself have done a couple for physicians with acute LBP and they were substantially better 15 mins later.

Is it as good as a paravertebral or epidural? No, but it's safer, easier and faster to perform. So it has a role.

ESP is definitely better studied than most novel blocks, both in cadavers (showing dye spread to roots) and in randomized trials of ESP catheters vs thoracic epidurals where efficacy was demonstrated. That block does have its place.

 

[Shimmy8]

Anyone in PP doing these routinely for rib fractures, poly-trauma patients?

 

[dchz]

I’ve had great success w ESP blocks- even for cardiac cases.

Walk me through this please. Do you do it awake or asleep? Do you use exparel?

 

[Lecithin5]

Anyone in PP doing these routinely for rib fractures, poly-trauma patients?

We have a robust acute pain service in our private practice, with one of the highest rib fracture patient admissions in the Midwest. I spend a tremendous amount of time on this service, and regularly place thoracic epidurals, esp blocks/caths, pvb’s, and serratus blocks/caths, depending on various factors. Our patients, intensivists, and higher ups are thrilled with our services.

Reality is that there is no magic bullet for rib fx patients- multimodal works best, which includes the aforementioned blocks.

 

[pgg]

Walk me through this please. Do you do it awake or asleep? Do you use exparel?

We were putting ESP catheters in our minimally invasive mitral valve cases until the local anesthetic shortage came along. Awake, preop. No Exparel, just plain ropivacaine.

Seemed like a good option for the thoracotomy pain.

 

[Maz777]

Nonsense.

There is a ton of literature showing benefits with ESP blocks. They even use them in the ER to treat acute LBP and show lower rates of admissions versus standard therapy. I myself have done a couple for physicians with acute LBP and they were substantially better 15 mins later.

Is it as good as a paravertebral or epidural? No, but it's safer, easier and faster to perform. So it has a role.

ESPBs maybe have a role in anticoagulated patients in which neuraxial procedures or PVBs are contraindicated. That's it. I've done thousands of ESPBs. I've published RCT data on ESPBs. They are garbage. They are no better than local infiltration. If you design a study with the preconceived notion that something is non-inferior (or superior), your "results" will bear that out.

Very similar to the people that are convinced that Exparel is efficacious. Anyone that suggests otherwise doesn't know how to do a proper block. If your comparator is crap, ESPBs will show non-inferiority (or potentially superiority).

I guarantee if you did a sham-controlled, double-blinded RCT comparing ESPBs to an intramuscular injection (i.e. just jabbing a needle into trapezius) of an equivalent amount of local anesthetic, there would be no difference in pain scores or opioid consumption for the duration of the block. They function as low-dose bupi/ropi reservoirs with slow-ish serum uptake). An inconsequential amount of that local anesthetic maybe actually ever reaches/anesthetizes an intercostal nerve or ventral ramus. Maybe is a stretch though.

Regional anesthesia has become "how do I avoid doing an actual block and do this easier made-up block because it's safer than me doing an actual nerve block."

See a nerve, block a nerve.

 

[UscGhost]

ESPBs maybe have a role in anticoagulated patients in which neuraxial procedures or PVBs are contraindicated. That's it. I've done thousands of ESPBs. I've published RCT data on ESPBs. They are garbage. They are no better than local infiltration. If you design a study with the preconceived notion that something is non-inferior (or superior), your "results" will bear that out.

Very similar to the people that are convinced that Exparel is efficacious. Anyone that suggests otherwise doesn't know how to do a proper block. If your comparator is crap, ESPBs will show non-inferiority (or potentially superiority).

I guarantee if you did a sham-controlled, double-blinded RCT comparing ESPBs to an intramuscular injection (i.e. just jabbing a needle into trapezius) of an equivalent amount of local anesthetic, there would be no difference in pain scores or opioid consumption for the duration of the block. They function as low-dose bupi/ropi reservoirs with slow-ish serum uptake). An inconsequential amount of that local anesthetic maybe actually ever reaches/anesthetizes an intercostal nerve or ventral ramus. Maybe is a stretch though.

Regional anesthesia has become "how do I avoid doing an actual block and do this easier made-up block because it's safer than me doing an actual nerve block."

See a nerve, block a nerve.

So wait..you have done thousands of blocks despite the fact that you "know" they don't work??

 

[Shimmy8]

We have a robust acute pain service in our private practice, with one of the highest rib fracture patient admissions in the Midwest. I spend a tremendous amount of time on this service, and regularly place thoracic epidurals, esp blocks/caths, pvb’s, and serratus blocks/caths, depending on various factors. Our patients, intensivists, and higher ups are thrilled with our services.

Reality is that there is no magic bullet for rib fx patients- multimodal works best, which includes the aforementioned blocks.

What type of results are you seeing after block? Relief for a day or so? Blocking them multiple days in a row? I'm in a relatively small but very busy, high acuity place. Will never have a real pain service, but I'm trying to see how we can incorporate this into our practice and workflow.

 

[DocVapor]

What type of results are you seeing after block? Relief for a day or so? Blocking them multiple days in a row? I'm in a relatively small but very busy, high acuity place. Will never have a real pain service, but I'm trying to see how we can incorporate this into our practice and workflow.

:But why meme here:

 

[deleted875186]

TAP, PEC and ESP clearly work. Clearly better than local infiltration. I don’t see why insurance shouldn’t pay for these, there needs to be a new CPT code for some. They obviously should pay less than traditional upper and lower extremity blocks.

Perhaps the bigger question is should we be wasting our time doing these blocks? I don’t think these facial plane blocks should be routinely done. But I think they’re low risk and do help people. Obviously it’s tough to see sometimes because it’s operator dependent, and there’s no clear endpoint like a femoral block where the leg goes limp.

 

[GassYous]

TAP, PEC and ESP clearly work. Clearly better than local infiltration. I don’t see why insurance shouldn’t pay for these, there needs to be a new CPT code for some. They obviously should pay less than traditional upper and lower extremity blocks.

Perhaps the bigger question is should we be wasting our time doing these blocks? I don’t think these facial plane blocks should be routinely done. But I think they’re low risk and do help people. Obviously it’s tough to see sometimes because it’s operator dependent, and there’s no clear endpoint like a femoral block where the leg goes limp.

They don't always help a lot but sometimes I'll have a patient with zero pain after a tap or peng/femoral block and that's nice

 

[Justice4all]

There is a role for the fascia plane blocks!!! I agree we need to be skeptical but also understand that having alternatives is OK. Not every block needs to be a home run!

 

[repititionition]

They don't always help a lot but sometimes I'll have a patient with zero pain after a tap or peng/femoral block and that's nice

Sure, but one is a per-nerve block and the others aren’t.

 

[Lecithin5]

What type of results are you seeing after block? Relief for a day or so? Blocking them multiple days in a row? I'm in a relatively small but very busy, high acuity place. Will never have a real pain service, but I'm trying to see how we can incorporate this into our practice and workflow.

Epidurals are there best for obvious reasons, but also can potentially be the trickiest/riskiest to place and gotta have a mechanism in place to tweak in case of hemodynamic issues (for our group, we have 2-3 in house anesthesiologists overnight, so any epidural concerns get turfed to them after-hours).

There are definitely times where we place the peripheral catheters and don’t see the effect that we’d hope to see. But we do our best with the options we have. At worst, these blocks don’t help, but frequently we see positive results, which is why broadly speaking the folks who consult us are pleased with us, and they continue to keep us busy.

We do frequently have to bolus our catheter- we are working towards get those infusion pumps that can bolus (and be sent home with pts), as opposed to the continuous rate onQ balls. Fascial plane blocks usually need some amount of (re)bolusing for obvious reasons.

 

[Maz777]

So wait..you have done thousands of blocks despite the fact that you "know" they don't work??

Correct. In order to publish an RCT on the matter, you have to do the block many times. I know. It's crazy. Anecdotal evidence with minimal patient follow-up is so much better though.

 

[Vandalia]

I've done thousands of ESPBs. I've published RCT data on ESPBs.

So where is this publication?

Then the people here can determine its validity.

 

[UscGhost]

Correct. In order to publish an RCT on the matter, you have to do the block many times. I know. It's crazy. Anecdotal evidence with minimal patient follow-up is so much better though.

Like these ones?

Ultrasound-guided erector spinae plane block for postoperative analgesia: a meta-analysis of randomized controlled trials

Ultrasound-guided Erector Spinae Plane Block (ESPB) has been increasingly applied in patients for postoperative analgesia. Its effectiveness remain uncertain. This meta-analysis aimed to determine the clinical efficacy of ultrasound-guided ESPB in adults ...

www.ncbi.nlm.nih.gov

Analgesic effect of erector spinae plane block in adults undergoing laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trials - BMC Anesthesiology

Background Laparoscopic cholecystectomy is the gold standard surgical procedure for treating gallstone disease. Despite it being minimally invasive, various medications and methods are used to alleviate postoperative pain, and some patients still experience moderate-to-severe pain. This is a...

bmcanesthesiol.biomedcentral.com

Now have I meticulously reviewed every article? Nope. But generally speaking, if a large proportion of the literature supports something that matches with my own clinical experience, as well as the experience of my colleagues, then I don't have much reason to question it.

And ESP, Taps, pecs,etc are all fast and easy to perform blocks at our shop. Do paravertebrals and epidurals provide better analgesia? Sure. But they also require more expertise, higher risk, hypotension, require postop rounding, etc.

Should epidurals and PVB reimburse more? Absolutely

Should the lesser blocks also reimburse? Absolutely

 

[yossarian22]

Like these ones?

Ultrasound-guided erector spinae plane block for postoperative analgesia: a meta-analysis of randomized controlled trials

Ultrasound-guided Erector Spinae Plane Block (ESPB) has been increasingly applied in patients for postoperative analgesia. Its effectiveness remain uncertain. This meta-analysis aimed to determine the clinical efficacy of ultrasound-guided ESPB in adults ...

www.ncbi.nlm.nih.gov

Analgesic effect of erector spinae plane block in adults undergoing laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trials - BMC Anesthesiology

Background Laparoscopic cholecystectomy is the gold standard surgical procedure for treating gallstone disease. Despite it being minimally invasive, various medications and methods are used to alleviate postoperative pain, and some patients still experience moderate-to-severe pain. This is a...

bmcanesthesiol.biomedcentral.com

Now have I meticulously reviewed every article? Nope. But generally speaking, if a large proportion of the literature supports something that matches with my own clinical experience, as well as the experience of my colleagues, then I don't have much reason to question it.

And ESP, Taps, pecs,etc are all fast and easy to perform blocks at our shop. Do paravertebrals and epidurals provide better analgesia? Sure. But they also require more expertise, higher risk, hypotension, require postop rounding, etc.

Should epidurals and PVB reimburse more? Absolutely

Should the lesser blocks also reimburse? Absolutely

We need to let it go. Their ivory tower salary is funded by magic. We are just lowly criminals.

 

[anes121508]

I’ve done rescue TAPs and ESPs. The ESP blocks have had tremendous success in our rib fracture patients who have failed more conservative treatments in the ICU. We get calls on those every once in a while, and patients experience relief almost 100% of the time (anecdotally). Easy to do, safe to perform, great results, IMO.

same experience, shocked at the relief in rib fractures first time i did it for ribs