advanced regional subtleties questions

[cleansocks]

A few subtle/advanced questions about regional that I've been thinking about:

1. regional for severe pain s/p SIJ fusion in opiate intolerant pt - No literature out there about this. I did a parasacral catheter at the greater sciatic notch which worked extremely well but the patient hated the foot drop. Wondering if anyone's tried lumbar plexus block for SIJ fusion pain? I would think there's some contribution of L4, L5 to the joint, but missing S1-S2 in this case might be bad which is why i went with sacral plexus / proximal sciatic approach instead.

2. severe pain after 1st CMC surgery in opioid intolerant or suboxone patient (posterior thumb pain) - I've been trying out a couple approaches to supraclav cath's; I really like supraclav caths generally as I find I can anchor them extremely well by threading through the trapezius and dependable anatomy is nice. I've found that leaving cath in corner pocket has great ulnar coverage but can spare radial nerve which is key for this surgery. Threading catheter above the plexus instead of below has worked well in a couple patients, but not well in a couple more; wondering if I failed to enter the paraneural sheath in those cases. I'm thinking of just switching permanently to an infraclav approach so I can put the cath right between the artery and posterior cord. However, sometimes finding the perfect anatomy for the infraclav approach is elusive for me, and anchoring it to the lateral chest/shoulder region has been less dependable for me from a dislodgement standpoint. Alternatively, has anyone ever done a radial nerve cath at the mid arm?

thanks for any advice from my regionally inclined colleagues

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[BLADEMDA]

A few subtle/advanced questions about regional that I've been thinking about:

1. regional for severe pain s/p SIJ fusion in opiate intolerant pt - No literature out there about this. I did a parasacral catheter at the greater sciatic notch which worked extremely well but the patient hated the foot drop. Wondering if anyone's tried lumbar plexus block for SIJ fusion pain? I would think there's some contribution of L4, L5 to the joint, but missing S1-S2 in this case might be bad which is why i went with sacral plexus / proximal sciatic approach instead.

2. severe pain after 1st CMC surgery in opioid intolerant or suboxone patient (posterior thumb pain) - I've been trying out a couple approaches to supraclav cath's; I really like supraclav caths generally as I find I can anchor them extremely well by threading through the trapezius and dependable anatomy is nice. I've found that leaving cath in corner pocket has great ulnar coverage but can spare radial nerve which is key for this surgery. Threading catheter above the plexus instead of below has worked well in a couple patients, but not well in a couple more; wondering if I failed to enter the paraneural sheath in those cases. I'm thinking of just switching permanently to an infraclav approach so I can put the cath right between the artery and posterior cord. However, sometimes finding the perfect anatomy for the infraclav approach is elusive for me, and anchoring it to the lateral chest/shoulder region has been less dependable for me from a dislodgement standpoint. Alternatively, has anyone ever done a radial nerve cath at the mid arm?

thanks for any advice from my regionally inclined colleagues

1. Try the Lumbar Plexus block- I've had patients ambulate without much difficulty after 0.2% rop following a lumbar plexus block with catheter. It's definitely worth a shot. I'm also curious if an Erector Spinae block with catheter at L4 would work here. It's never been done for SI pain but I'd try that next after the Lumbar Plexus.

2. I prefer the ICB over the SCB for getting the radial nerve. I'd place 20 ml of Liposomal Bupivacaine with PF dexamethsaone (4 mg) in this situation. I'd use full concentration Liposomal Bupivacaine with the 4 mg Dex as that should last 72 hours. I'd repeat the block again at 72 hours if needed (total 6 days). I agree with placing the injection posterior to the artery (the entire 20 mls). I've read about different approaches to the ICB vs the standard approach and I believe some "experts" are approaching the plexus in a direction similar to placing a subclavian central line. This allows easier placement of catheters but may be a bit more technically difficult to do. The lung is also a bit closer to the needle as you approach the plexus but it's a very "doable" technique IMHO.

 

[BLADEMDA]

Abstract PR489: Ultrasound-Guided Infraclavicular Block... : Anesthesia & Analgesia

 

[BLADEMDA]

You can also use the posterior approach (in plane or out of plane)

Another approach is to rotate the probe 180 degrees from the picture above then place the needle in plane.

 

[BLADEMDA]

RAPTIR (Retroclavicular Approach to The Infraclavicular Region)

RAPTIR

 

[BLADEMDA]

CostoClavicular Approach:

 

[BLADEMDA]

You can also use the posterior approach (in plane or out of plane)

Another approach is to rotate the probe 180 degrees from the picture above then place the needle in plane.

Ultrasound-Guided Costoclavicular Brachial Plexus Block: Sonoanatomy, Technique, and Block Dynamics. - PubMed - NCBI

 

[BLADEMDA]

A few subtle/advanced questions about regional that I've been thinking about:

1. regional for severe pain s/p SIJ fusion in opiate intolerant pt - No literature out there about this. I did a parasacral catheter at the greater sciatic notch which worked extremely well but the patient hated the foot drop. Wondering if anyone's tried lumbar plexus block for SIJ fusion pain? I would think there's some contribution of L4, L5 to the joint, but missing S1-S2 in this case might be bad which is why i went with sacral plexus / proximal sciatic approach instead.

2. severe pain after 1st CMC surgery in opioid intolerant or suboxone patient (posterior thumb pain) - I've been trying out a couple approaches to supraclav cath's; I really like supraclav caths generally as I find I can anchor them extremely well by threading through the trapezius and dependable anatomy is nice. I've found that leaving cath in corner pocket has great ulnar coverage but can spare radial nerve which is key for this surgery. Threading catheter above the plexus instead of below has worked well in a couple patients, but not well in a couple more; wondering if I failed to enter the paraneural sheath in those cases. I'm thinking of just switching permanently to an infraclav approach so I can put the cath right between the artery and posterior cord. However, sometimes finding the perfect anatomy for the infraclav approach is elusive for me, and anchoring it to the lateral chest/shoulder region has been less dependable for me from a dislodgement standpoint. Alternatively, has anyone ever done a radial nerve cath at the mid arm?

thanks for any advice from my regionally inclined colleagues

So, there is a lot of sacral innervation to the SI joint. But, does that mean the lumbar plexus or Erector Spinae block won't help reduce the pain? I'd give it a try.

Erector Spine Block for Back Surgery

https://www.spinecenter.com/assets/sacroliac.pdf

 

[BLADEMDA]

 

[The Physician Philosopher]

A few subtle/advanced questions about regional that I've been thinking about:

1. regional for severe pain s/p SIJ fusion in opiate intolerant pt - No literature out there about this. I did a parasacral catheter at the greater sciatic notch which worked extremely well but the patient hated the foot drop. Wondering if anyone's tried lumbar plexus block for SIJ fusion pain? I would think there's some contribution of L4, L5 to the joint, but missing S1-S2 in this case might be bad which is why i went with sacral plexus / proximal sciatic approach instead.

2. severe pain after 1st CMC surgery in opioid intolerant or suboxone patient (posterior thumb pain) - I've been trying out a couple approaches to supraclav cath's; I really like supraclav caths generally as I find I can anchor them extremely well by threading through the trapezius and dependable anatomy is nice. I've found that leaving cath in corner pocket has great ulnar coverage but can spare radial nerve which is key for this surgery. Threading catheter above the plexus instead of below has worked well in a couple patients, but not well in a couple more; wondering if I failed to enter the paraneural sheath in those cases. I'm thinking of just switching permanently to an infraclav approach so I can put the cath right between the artery and posterior cord. However, sometimes finding the perfect anatomy for the infraclav approach is elusive for me, and anchoring it to the lateral chest/shoulder region has been less dependable for me from a dislodgement standpoint. Alternatively, has anyone ever done a radial nerve cath at the mid arm?

thanks for any advice from my regionally inclined colleagues

1. Lumbar plexus may work. We do this for posterior Total Hip patients. I think that there are probably sacaral contributions to the SI joint, though, that may be missed.

2. I prefer infraclavicular catheters at 6 o'clock position because they stay seated better and generally provide analgesia to the entire arm, but supra-catheters are fine. For infra cath I usually use the small curvi-linear probe as opposed to the normal linear probe used for most other blocks. This helps you "get around the corner" for your view. Have to come down the chest a bit and "rock back" towards yourself, but works pretty well. Haven't ever really had much of an issue with sparing as long as you get a posterior or medial cord response (And NOT a lateral cord response, which can cause sparing).

 

[BLADEMDA]

A few subtle/advanced questions about regional that I've been thinking about:

1. regional for severe pain s/p SIJ fusion in opiate intolerant pt - No literature out there about this. I did a parasacral catheter at the greater sciatic notch which worked extremely well but the patient hated the foot drop. Wondering if anyone's tried lumbar plexus block for SIJ fusion pain? I would think there's some contribution of L4, L5 to the joint, but missing S1-S2 in this case might be bad which is why i went with sacral plexus / proximal sciatic approach instead.

2. severe pain after 1st CMC surgery in opioid intolerant or suboxone patient (posterior thumb pain) - I've been trying out a couple approaches to supraclav cath's; I really like supraclav caths generally as I find I can anchor them extremely well by threading through the trapezius and dependable anatomy is nice. I've found that leaving cath in corner pocket has great ulnar coverage but can spare radial nerve which is key for this surgery. Threading catheter above the plexus instead of below has worked well in a couple patients, but not well in a couple more; wondering if I failed to enter the paraneural sheath in those cases. I'm thinking of just switching permanently to an infraclav approach so I can put the cath right between the artery and posterior cord. However, sometimes finding the perfect anatomy for the infraclav approach is elusive for me, and anchoring it to the lateral chest/shoulder region has been less dependable for me from a dislodgement standpoint. Alternatively, has anyone ever done a radial nerve cath at the mid arm?

thanks for any advice from my regionally inclined colleagues

You probably want to try a suprasacral plexus block or an erector spinae block over a plain, simple lumbar plexus in this situation. I'd likely go with the Erector Spinae but take a look at this study:

The suprasacral parallel shift vs lumbar plexus blockade with ultrasound guidance in healthy volunteers – a randomised controlled trial - Bendtsen - 2014 - Anaesthesia - Wiley Online Library

 

[BLADEMDA]

 

[The Physician Philosopher]

You probably want to try a suprasacral plexus block or an erector spinae block over a plain, simple lumbar plexus in this situation. I'd likely go with the Erector Spinae but take a look at this study:

The suprasacral parallel shift vs lumbar plexus blockade with ultrasound guidance in healthy volunteers – a randomised controlled trial - Bendtsen - 2014 - Anaesthesia - Wiley Online Library

Being a regional guy at an academic center, I just haven't bought into the ES completely yet. Our most common use for it is actually in rib fracture patients who are not candidates (usually because of anticoagulation) for a thoracic epidural or paravertebral.

That said, haven't done many lower ES blocks. Usually favor QL or LP in that region, but not necessarily for what we are talking about, obviously.

 

[BLADEMDA]

1. Lumbar plexus may work. We do this for posterior Total Hip patients. I think that there are probably sacaral contributions to the SI joint, though, that may be missed.

2. I prefer infraclavicular catheters at 6 o'clock position because they stay seated better and generally provide analgesia to the entire arm, but supra-catheters are fine. For infra cath I usually use the small curvi-linear probe as opposed to the normal linear probe used for most other blocks. This helps you "get around the corner" for your view. Have to come down the chest a bit and "rock back" towards yourself, but works pretty well. Haven't ever really had much of an issue with sparing as long as you get a posterior or medial cord response (And NOT a lateral cord response, which can cause sparing).

Regarding your number "2" that will work just fine. But, so will this technique:

 

[BLADEMDA]

Being a regional guy at an academic center, I just haven't bought into the ES completely yet. Our most common use for it is actually in rib fracture patients who are not candidates (usually because of anticoagulation) for a thoracic epidural or paravertebral.

That said, haven't done many lower ES blocks. Usually favor QL or LP in that region, but not necessarily for what we are talking about, obviously.

Erector Spinae Blocks work just fine for postop pain relief:

Visualization Superior for Ultrasound-Guided Proximal Intercostal Over Paravertebral Block


Washington—A modified ultrasound-guided proximal intercostal block in women undergoing breast surgery offers sonoanatomic and technical advantages over the traditional ultrasound-guided paravertebral block, without compromising pain-related outcomes, an analysis has found.

The simple addition of ultrasound guidance to traditional thoracic paravertebral blockade does not necessarily provide both safety and technical ease.

“Our findings demonstrate that the proximal intercostal block approach allows a clearer simultaneous visualization of block needle, parietal pleura, bony landmarks and injectate spread,” said Kristin Schreiber, MD, PhD, an anesthesiologist and clinical researcher at Brigham and Women’s Hospital, in Boston. “It also looks as though we were able to achieve comparable analgesia with this technique.”

As she explained, an ideal ultrasound technique would be easy to perform, avoiding neuraxial injection and lung injury, while permitting real-time visualization of needle tip and injectate spread. Although thoracic paravertebral blockade is an accepted technique to provide analgesia during and after breast surgery, its use with ultrasound guidance has not been extensively studied. Many anesthesiologists have been trained in the use of landmark-based paravertebral placement, Dr. Schreiber said, but there has been a recent institutional push for the use of ultrasound with this technique.

Nevertheless, there are safety concerns. “We had noticed [with the paravertebral approach] that with the traditional parasagittal view over the transverse process, it can be difficult to visualize the pleura and your needle because of bony shadowing,” Dr. Schreiber said. “We noticed that with a slightly more lateral parasagittal approach over the proximal intercostal space, the ribs cast a narrower shadow, and the pleura and needle were easier to see.”

Therefore, Dr. Schreiber and her colleagues proposed a modified ultrasound-guided proximal intercostal block approach at the level of the proximal ribs as an alternative to the traditional paravertebral approach, which is at the level of the transverse processes.

Ultrasound Imaging Rating Scale

To determine whether targets are better visualized with the proximal intercostal block approach or the traditional paravertebral blockade, the researchers devised an ultrasound image rating scale based on visualization of parietal pleura, bony landmarks, relevant ligaments, block needle and injectate spread. Ultrasound images were obtained before and after needle placement, including videorecording of local anesthetic injection.

The study’s primary outcome was overall ultrasound imaging score (0-18), as determined by an independent reviewer. Secondary outcomes included block performance times, postoperative pain scores (measured at one and 24 hours) and opioid consumption in the first 24 hours after surgery. The T-test or Mann-Whitney U test was used to compare groups, as appropriate. Women undergoing total mastectomy were randomly assigned to receive paravertebral blockade (n=10) or proximal intercostal block (n=8) preoperatively at two to four block sites, with a total of 2.5 mg/kg ropivacaine.

As Dr. Schreiber reported at the 2017 annual meeting of the International Anesthesia Research Society (abstract 1461), overall image-rating scores were superior for the proximal intercostal block compared with paravertebralblockade.

“There was definitely more variability in image-rating scores with the traditional paravertebral block, and we had a few patients who were very difficult to see with this technique,” Dr. Schreiber said. “Although there was also variability with the proximal intercostal approach, scores were clustered toward the top of the visual ratings.”

According to the researchers, the higher overall score for the proximal intercostal approach was attributable to better visualization of bony landmarks and pleura. Although the study was not powered to find a difference in analgesic outcomes, postoperative pain scores and opioid consumption were low for both block techniques, Dr. Schreiber reported. She noted that technical performance times also were similar for both blocks. Somewhat unexpectedly, however, investigators observed that needle depth at the skin was actually greater for the proximal intercostal block. “Perhaps we’re coming at a shallower angle with the needle because we have more space in between to work with,” she said.

Moderator of the session Richa Wardhan, MD, assistant professor of anesthesia at the University of Florida College of Medicine, in Jacksonville, observed that she was not surprised by the better visibility of the proximal intercostal block. “In the sagittal plane—and in bigger pa tients especially—the view of the paravertebral space is very poor. Rather than putting your probe in the sagittal plane, however, a transverse visualization of this space may provide a better view, and you would probably have a longer path there.”

“The resistance of some practitioners to the lateral to medial transverse approach is [related to] the potential for placement of the catheter in the epidural space,” Dr. Schreiber said.

 

[BLADEMDA]

Being a regional guy at an academic center, I just haven't bought into the ES completely yet. Our most common use for it is actually in rib fracture patients who are not candidates (usually because of anticoagulation) for a thoracic epidural or paravertebral.

That said, haven't done many lower ES blocks. Usually favor QL or LP in that region, but not necessarily for what we are talking about, obviously.

Erector spinae plane block for radical mastectomy: A new indication? - PubMed - NCBI

Bilateral ultrasound-guided erector spinae plane blocks in breast cancer and reconstruction surgery - ScienceDirect

 

[BLADEMDA]

Being a regional guy at an academic center, I just haven't bought into the ES completely yet. Our most common use for it is actually in rib fracture patients who are not candidates (usually because of anticoagulation) for a thoracic epidural or paravertebral.

That said, haven't done many lower ES blocks. Usually favor QL or LP in that region, but not necessarily for what we are talking about, obviously.

I'm performing Serratus Anterior plane blocks for rib fractures. I'd say analgesia is very good (not as good as a Thoracic epidural) but good enough without any of the issues of a thoracic epidural. The analgesia is impressive considering how simple and easy the block is to do on patients in the ICU.

PECS/SERRATUS

http://www.ajemjournal.com/article/S0735-6757(16)30415-6/pdf

Serratus Plane Block for Rib Fractures

http://scireslit.com/Anesthesia/A-ID13.pdf

 

[anbuitachi]

Being a regional guy at an academic center, I just haven't bought into the ES completely yet. Our most common use for it is actually in rib fracture patients who are not candidates (usually because of anticoagulation) for a thoracic epidural or paravertebral.

That said, haven't done many lower ES blocks. Usually favor QL or LP in that region, but not necessarily for what we are talking about, obviously.

What blocks do you still do on anticoagulation? Asra recommends following neuraxial guidelines for deep blocks. Is ES not considered a deep block?

 

[The Physician Philosopher]

What blocks do you still do on anticoagulation? Asra recommends following neuraxial guidelines for deep blocks. Is ES not considered a deep block?

It's placed posterior the transverse process and is performed under ultrasound guidance. It is also a new block. We do not view it as a "deep" block. It's not that dissimilar to a PECS block in terms of depth or technique (in plane US approach).

Sent from my XT1710-02 using Tapatalk

 

[The Physician Philosopher]

I'm performing Serratus Anterior plane blocks for rib fractures. I'd say analgesia is very good (not as good as a Thoracic epidural) but good enough without any of the issues of a thoracic epidural. The analgesia is impressive considering how simple and easy the block is to do on patients in the ICU.

PECS/SERRATUS

http://www.ajemjournal.com/article/S0735-6757(16)30415-6/pdf

Serratus Plane Block for Rib Fractures

http://scireslit.com/Anesthesia/A-ID13.pdf

The problem, IMO, is the limited duration.

You are the first I've heard of using exparel and Dex. That's an interesting concept.

We have definitely done ES blocks for mastectomies where the mass was large enough (fungating) and a PECS was not an option. We don't do SS paravertebral blocks for breasts anymore.

Sent from my XT1710-02 using Tapatalk

 

[The Physician Philosopher]

Regarding your number "2" that will work just fine. But, so will this technique:

I mean, I don't know where you work... But unlike the block jocks down in Jacksonville at the beach, id imagine our average BMI for our patients is substantially larger than theirs.

As the BMI goes up, doing this block with a linear probe becomes more and more difficult because of the angle of your needle. I've done it plenty of times with a linear transducer... But given our patients' size in the south I tend towards the small curvilinear probe.

Sent from my XT1710-02 using Tapatalk

 

[BLADEMDA]

What blocks do you still do on anticoagulation? Asra recommends following neuraxial guidelines for deep blocks. Is ES not considered a deep block?

I would do a Serratus Anterior and/or PECS1 plus PECs2. TAP blocks are safe as well.

The problem, IMO, is the limited duration.

You are the first I've heard of using exparel and Dex. That's an interesting concept.

We have definitely done ES blocks for mastectomies where the mass was large enough (fungating) and a PECS was not an option. We don't do SS paravertebral blocks for breasts anymore.

Sent from my XT1710-02 using Tapatalk

We performed the serratus anterior place block under ultrasound guidance and placed a catheter for continuous infusion of local anaesthetic and opioid. The patient had significant pain relief following a single bolus of the drug. The infusion was started thereafter, which provided excellent analgesia and facilitated an uneventful recovery. Here, we describe the successful management of thoracotomy pain using the serratus anterior plane block.

Serratus anterior plane block: a new analgesic technique for post-thoracotomy pain. - PubMed - NCBI

Ultrasound-Guided Serratus Anterior Plane Block Versus Thoracic Epidural Analgesia for Thoracotomy Pain. - PubMed - NCBI

 

[Scotty_G]

Hmm i always was taught to place infra cath around posterior cord position. Looks like these guys put it more towards the medial cord. Anyone do it this way... better results?

 

[The Physician Philosopher]

Hmm i always was taught to place infra cath around posterior cord position. Looks like these guys put it more towards the medial cord. Anyone do it this way... better results?

Posterior cord and medial cord are both acceptable and will work. Only one you shouldn't take with a great deal of excitement is the lateral cord. If you can get a medial cord response, it'll be money, particularly for procedures/injuries distal to the elbow.

 

[BLADEMDA]

Hmm i always was taught to place infra cath around posterior cord position. Looks like these guys put it more towards the medial cord. Anyone do it this way... better results?

Back in the day I used to perform these blocks "blind" with just a nerve stimulator. If i got the Posterior cord or the medial cord the block typically worked just fine; but, if I got a twitch to the lateral cord there was a much higher probability of an inadequate surgical block. Despite using 30-35 mls of local a single injection technique of just the lateral cord didn't cut the mustard.

Typically, I got a twitch to the medial cord more often than the posterior cord and the block was successful. Back in those days it was usually a single injection nerve stimulator only technique.

Infraclavicular brachial plexus block for regional anaesthesia of the lower arm. - PubMed - NCBI

 

[cleansocks]

Hey thanks a lot for all the information. It's really cool Blade that were able to reference a recently developed suprasacral block that targets the lumbosacral trunk which is exactly what I think is needed. I read through the technique. It looks a little dangerous at this relatively unstudied stage. LOR, steep out of plane, etc. Why exactly can't you get a false LOR in the fibroosseous tunnel? And this trepidation is coming from someone pretty comfortable with things some others find scary. For example I love landmark based lumbar plexus blocks with stim, and landmark based thoracic paravertebrals, but with thoracic paravertebrals I walk under the TP 1cm further - none of that LOR stuff, as studies have shown that you can get intrapleural pretty easily relying on that. I would have a similar level of fear about LOR in the suprasacral block too, especially with that fibroosseous tunnel. The way the find the image is a little funny too - why not just find the normal "trident sign" a little more cephalad and then slide inferiorly?

Erector spinae block looks super interesting if it could actually help post-op spine patients. That'd be awesome.

That "proximal intercostal block" for thoracic paravertebrals is definitely my preferred way of doing PVB's under u/s. Didn't realize it had been named. I always called it the paravertebral-intercostal junction. But I achieve the view by tilting laterally rather than sliding laterally if that makes sense.

In that blockjocks video, see how they basically tunnel it through the shoulder musculature? I have found that with that insertion point, the catheter dislodgment rate is a bit higher due to how mobile their shoulder can be after surgery. I'll see if rocking upwards more can get me a better view a little more medially.

I'm still working on getting a reliable costoclavicular block view. That's been tricky for me to visualize even with the recommendation to go below the clavical and tilt cephalad.

 

[Hoya11]

A few subtle/advanced questions about regional that I've been thinking about:

1. regional for severe pain s/p SIJ fusion in opiate intolerant pt - No literature out there about this. I did a parasacral catheter at the greater sciatic notch which worked extremely well but the patient hated the foot drop. Wondering if anyone's tried lumbar plexus block for SIJ fusion pain? I would think there's some contribution of L4, L5 to the joint, but missing S1-S2 in this case might be bad which is why i went with sacral plexus / proximal sciatic approach instead.

2. severe pain after 1st CMC surgery in opioid intolerant or suboxone patient (posterior thumb pain) - I've been trying out a couple approaches to supraclav cath's; I really like supraclav caths generally as I find I can anchor them extremely well by threading through the trapezius and dependable anatomy is nice. I've found that leaving cath in corner pocket has great ulnar coverage but can spare radial nerve which is key for this surgery. Threading catheter above the plexus instead of below has worked well in a couple patients, but not well in a couple more; wondering if I failed to enter the paraneural sheath in those cases. I'm thinking of just switching permanently to an infraclav approach so I can put the cath right between the artery and posterior cord. However, sometimes finding the perfect anatomy for the infraclav approach is elusive for me, and anchoring it to the lateral chest/shoulder region has been less dependable for me from a dislodgement standpoint. Alternatively, has anyone ever done a radial nerve cath at the mid arm?

thanks for any advice from my regionally inclined colleagues

For case 1: Id do either a regular lumbar epidural catheter or a caudal catheter if epidural ineffective. Maybe even just do a single shot caudal.

For case 2: Id do a single shot supraclavicular. If for some reason I needed a catheter here, id put it low in the plexus almost under the artery. I thread the catheter as soon as my needle tip enters the plexus surrounding tissue (not abutting but just punctures). I find that, with this technique, the catheter ends up curling around/within the plexus vs finding another odd path. I would then suture the catheter and run it at a high volume like 10-14 to improve coverage...

 

[gasman2014]

At my house we're doing TEs for liver resections. We've had some varied responses to the efficacy of this, though admittedly this could be due resident/staff issues. Any suggestions for alternatives? This info in this thread has been a great read this morning!

 

[BLADEMDA]

Hey thanks a lot for all the information. It's really cool Blade that were able to reference a recently developed suprasacral block that targets the lumbosacral trunk which is exactly what I think is needed. I read through the technique. It looks a little dangerous at this relatively unstudied stage. LOR, steep out of plane, etc. Why exactly can't you get a false LOR in the fibroosseous tunnel? And this trepidation is coming from someone pretty comfortable with things some others find scary. For example I love landmark based lumbar plexus blocks with stim, and landmark based thoracic paravertebrals, but with thoracic paravertebrals I walk under the TP 1cm further - none of that LOR stuff, as studies have shown that you can get intrapleural pretty easily relying on that. I would have a similar level of fear about LOR in the suprasacral block too, especially with that fibroosseous tunnel. The way the find the image is a little funny too - why not just find the normal "trident sign" a little more cephalad and then slide inferiorly?

Erector spinae block looks super interesting if it could actually help post-op spine patients. That'd be awesome.

That "proximal intercostal block" for thoracic paravertebrals is definitely my preferred way of doing PVB's under u/s. Didn't realize it had been named. I always called it the paravertebral-intercostal junction. But I achieve the view by tilting laterally rather than sliding laterally if that makes sense.

In that blockjocks video, see how they basically tunnel it through the shoulder musculature? I have found that with that insertion point, the catheter dislodgment rate is a bit higher due to how mobile their shoulder can be after surgery. I'll see if rocking upwards more can get me a better view a little more medially.

I'm still working on getting a reliable costoclavicular block view. That's been tricky for me to visualize even with the recommendation to go below the clavical and tilt cephalad.

Nice post. I'm glad to read about your experiences as they line up with mine over the years. I've placed a few intrapleural catheters in my day doing thoracic paravertebral blocks without ultrasound. So, these days I use U/S for that procedure.

I realize this thread is for discussion purposes so I've posted a lot of info. On a practical basis I find an undiluted concentration of liposomal bupivacaine will last 48-72 hours for a infraclavicular block. I'd add some dexamethasone to the mix and call it a day. I'd place the majority of the local poster to the artery to ensure a long lasting block of the radial nerve.

If I were to place a catheter then I'd go from caudad to cephalad in relationship to the u/s probe with the catheter ending up just posterior to the artery. This way the catheter is secured on the chest wall of the patient.

 

[BLADEMDA]

At my house we're doing TEs for liver resections. We've had some varied responses to the efficacy of this, though admittedly this could be due resident/staff issues. Any suggestions for alternatives? This info in this thread has been a great read this morning!

QL blocks vs Erector spinae blocks. For liver resections I'd prefer single shot liposomal bupivacaine QL2 blocks or Erector Spinae blocks with a catheter for postop pain.

Ultrasound-guided truncal blocks: A new frontier in regional anaesthesia

Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery
looks like subcostal tap blocks would be effective

http://www.opastonline.com/wp-conte...abdominal-surgery-case-report-japm-16-019.pdf

 

[BLADEMDA]

• Format: Abstract

Send to



Anaesthesia. 2017 Apr;72(4):452-460. doi: 10.1111/anae.13814. Epub 2017 Feb 11.
The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair.
Chin KJ1, Adhikary S2, Sarwani N3, Forero M4.
Author information

Abstract
Laparoscopic ventral hernia repair is an operation associated with significant postoperative pain, and regional anaesthetic techniques are of potential benefit. The erector spinae plane (ESP) block performed at the level of the T5 transverse process has recently been described for thoracic surgery, and we hypothesised that performing the ESP block at a lower vertebral level would provide effective abdominal analgesia. We performed pre-operative bilateral ESP blocks with 20-30 ml ropivacaine 0.5% at the level of the T7 transverse process in four patients undergoing laparoscopic ventral hernia repair. Median (range) 24-h opioid consumption was 18.7 mg (0.0-43.0 mg) oral morphine. The highest and lowest median (range) pain scores in the first 24 h were 3.5 (3.0-5.0) and 2.5 (0.0-3.0) on an 11-point numerical rating scale. We also performed the block in a fresh cadaver and assessed the extent of injectate spread using computerised tomography. There was radiographic evidence of spread extending cranially to the upper thoracic levels and caudally as far as the L2-L3 transverse processes. We conclude that the ESP block is a promising regional anaesthetic technique for laparoscopic ventral hernia repair and other abdominal surgery when performed at the level of the T7 transverse process. Its advantages are the ability to block both supra-umbilical and infra-umbilical dermatomes with a single-level injection and its relative simplicity.

 

[BLADEMDA]

Scand J Pain. 2017 Sep 11. pii: S1877-8860(17)30185-4. doi: 10.1016/j.sjpain.2017.08.013. [Epub ahead of print]
Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series.
Forero M1, Rajarathinam M2, Adhikary S3, Chin KJ4.
Author information

Abstract
BACKGROUND AND AIMS:
Post thoracotomy pain syndrome (PTPS) remains a common complication of thoracic surgery with significant impact on patients' quality of life. Management usually involves a multidisciplinary approach that includes oral and topical analgesics, performing appropriate interventional techniques, and coordinating additional care such as physiotherapy, psychotherapy and rehabilitation. A variety of interventional procedures have been described to treat PTPS that is inadequately managed with systemic or topical analgesics. Most of these procedures are technically complex and are associated with risks and complications due to the proximity of the targets to neuraxial structures and pleura. The ultrasound-guided erector spinae plane (ESP) block is a novel technique for thoracic analgesia that promises to be a relatively simple and safe alternative to more complex and invasive techniques of neural blockade. We have explored the application of the ESP block in the management of PTPS and report our preliminary experience to illustrate its therapeutic potential.

METHODS:
The ESP block was performed in a pain clinic setting in a cohort of 7 patients with PTPS following thoracic surgery with lobectomy or pneumonectomy for lung cancer. The blocks were performed with ultrasound guidance by injecting 20-30mL of ropivacaine, with or without steroid, into a fascial plane between the deep surface of erector spinae muscle and the transverse processes of the thoracic vertebrae. This paraspinal tissue plane is distant from the pleura and the neuraxis, thus minimizing the risk of complications associated with injury to these structures. The patients were followed up by telephone one week after each block and reviewed in the clinic 4-6 weeks later to evaluate the analgesic response as well as the need for further injections and modification to the overall analgesic plan.

RESULTS:
All the patients had excellent immediate pain relief following each ESP block, and 4 out of the 7 patients experienced prolonged analgesic benefit lasting 2 weeks or more. The ESP blocks were combined with optimization of multimodal analgesia, resulting in significant improvement in the pain experience in all patients. No complications related to the blocks were seen.

CONCLUSION:
The results observed in this case series indicate that the ESP block may be a valuable therapeutic option in the management of PTPS. Its immediate analgesic efficacy provides patients with temporary symptomatic relief while other aspects of chronic pain management are optimized, and it may also often confer prolonged analgesia.

IMPLICATIONS:
The relative simplicity and safety of the ESP block offer advantages over other interventional procedures for thoracic pain; there are few contraindications, the risk of serious complications (apart from local anesthetic systemic toxicity) is minimal, and it can be performed in an outpatient clinic setting. This, combined with the immediate and profound analgesia that follows the block, makes it an attractive option in the management of intractable chronic thoracic pain. The ESP block may also be applied to management of acute pain management following thoracotomy or thoracic trauma (e.g. rib fractures), with similar analgesic benefits expected. Further studies to validate our observations are warranted.

Copyright © 2017 Scandinavian Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

 

[nimbus]

Hey thanks a lot for all the information. It's really cool Blade that were able to reference a recently developed suprasacral block that targets the lumbosacral trunk which is exactly what I think is needed. I read through the technique. It looks a little dangerous at this relatively unstudied stage. LOR, steep out of plane, etc. Why exactly can't you get a false LOR in the fibroosseous tunnel? And this trepidation is coming from someone pretty comfortable with things some others find scary. For example I love landmark based lumbar plexus blocks with stim, and landmark based thoracic paravertebrals, but with thoracic paravertebrals I walk under the TP 1cm further - none of that LOR stuff, as studies have shown that you can get intrapleural pretty easily relying on that. I would have a similar level of fear about LOR in the suprasacral block too, especially with that fibroosseous tunnel. The way the find the image is a little funny too - why not just find the normal "trident sign" a little more cephalad and then slide inferiorly?

Erector spinae block looks super interesting if it could actually help post-op spine patients. That'd be awesome.

That "proximal intercostal block" for thoracic paravertebrals is definitely my preferred way of doing PVB's under u/s. Didn't realize it had been named. I always called it the paravertebral-intercostal junction. But I achieve the view by tilting laterally rather than sliding laterally if that makes sense.

In that blockjocks video, see how they basically tunnel it through the shoulder musculature? I have found that with that insertion point, the catheter dislodgment rate is a bit higher due to how mobile their shoulder can be after surgery. I'll see if rocking upwards more can get me a better view a little more medially.

I'm still working on getting a reliable costoclavicular block view. That's been tricky for me to visualize even with the recommendation to go below the clavical and tilt cephalad.

It’s funny you guys are talking about this....I feel the same way. This just showed up in my inbox.

http://www.anesthesiologynews.com/P...r-Paravertebral-Block/45323/ses=ogst?enl=true

 

[anes121508]

cool thread guys. blade, as always thanks for your wisdom. been doing ESP lately and it's worked great (big abdominal incisions at T7 and thoracotomies at T5). trying to convince some of my partners how easy it is.

i was recently reading up on ESP and it mentioned that it "might" provide visceral coverage. what's your opinion on this? i thought it did somatic and visceral hence it's superiority for large abd cases.

also, any pearls to share for ESP? (pitfalls, best uses, limitations, confirming needle is in the right plane?

 

[cleansocks]

cool thread guys. blade, as always thanks for your wisdom. been doing ESP lately and it's worked great (big abdominal incisions at T5 and thoracotomies at T7). trying to convince some of my partners how easy it is.

i was recently reading up on ESP and it mentioned that it "might" provide visceral coverage. what's your opinion on this? i thought it did somatic and visceral hence it's superiority for large abd cases.

also, any pearls to share for ESP? (pitfalls, best uses, limitations, confirming needle is in the right plane?

I think it probably does provide visceral coverage. In this dye study, they found dye tracking all the way back to the ventral/dorsal rami. If it can get all the way back there, it can probably get to the grey and white rami slightly more proximally

http://edus.ucsf.edu/sites/edus.ucsf.edu/files/wysiwyg/9.14.16 The Erector Spinae Plane Block.pdf
http://www.dkcraniosacral.com/images/ANS/ans6.jpg

Also, there's an ultra steep landmark based 'paravertebral' technique that probably is actually a ES block and nonetheless often seemed to work well for patients for major abdominal surgery (b/l) or thoracic surgery. So I think I've empirically seen it provide visceral coverage.

 

[anes121508]

I think it probably does provide visceral coverage. In this dye study, they found dye tracking all the way back to the ventral/dorsal rami. If it can get all the way back there, it can probably get to the grey and white rami slightly more proximally

http://edus.ucsf.edu/sites/edus.ucsf.edu/files/wysiwyg/9.14.16 The Erector Spinae Plane Block.pdf
http://www.dkcraniosacral.com/images/ANS/ans6.jpg

Also, there's an ultra steep landmark based 'paravertebral' technique that probably is actually a ES block and nonetheless often seemed to work well for patients for major abdominal surgery (b/l) or thoracic surgery. So I think I've empirically seen it provide visceral coverage.

yeah I was thinking about exactly what you said about the landmark technique. in residency i was initially taught to hit the TP back off and inject. not positive but to me it seems like this is the same thing being described in the ESP

 

[gasman2014]

blade...thanks for the articles!

I feel like we tend to do a, somewhat, decent amount of "this-is-what-we've-always-done-here" stuff, so threads like this are wonderful breaths of fresh air!