Dismiss Notice
SDN members see fewer ads and full resolution images. Join our non-profit community!

Anyone doing erector spinae blocks or catheters?

Discussion in 'Anesthesiology' started by T-burglar, May 14, 2018 at 5:32 PM.

  1. T-burglar

    Joined:
    May 13, 2017
    Messages:
    50
    Likes Received:
    63
    Status:
    Attending Physician
    This seems like a new interesting block as an alternative to thoracic epidural in cases where Hemostasis might be questionable .

    Anyone doing these or tried them but didn’t continue? Do they work?
     
  2. Thread continues after this sponsor message. SDN Members do not see this ad.

  3. DocVapor

    DocVapor Big Schwartz
    Physician Gold Donor Classifieds Approved

    Joined:
    Oct 4, 2012
    Messages:
    2,097
    Likes Received:
    3,302
    Status:
    Resident [Any Field]
    Did a lobectomy the other day where my attending placed one. The block was amazing.
     
    BLADEMDA likes this.
  4. AdmiralChz

    AdmiralChz ASA Member

    Joined:
    Sep 8, 2008
    Messages:
    2,340
    Likes Received:
    1,464
    Status:
    Fellow [Any Field]
    Open, VATS or *shudder* robot?

    - just finished a 10 hour robot lobe today. It was just so painful.
     
  5. DocVapor

    DocVapor Big Schwartz
    Physician Gold Donor Classifieds Approved

    Joined:
    Oct 4, 2012
    Messages:
    2,097
    Likes Received:
    3,302
    Status:
    Resident [Any Field]
    Open. Started with mediastinoscopy, then bronch, then exchanged for DLT and repositioned lateral for the left upper lobectomy. Block placed ~ 7:30 am in holding. No narcotic required at all after the mediastinoscopy and had good pain relief until next day mid-morning. Pretty sure it was 0.5% ropiv + decadron, dunno final volume.
     
    Newtwo likes this.
  6. pgg

    pgg Laugh at me, will they?
    Moderator

    Joined:
    Dec 14, 2005
    Messages:
    11,165
    Likes Received:
    5,630
    Status:
    Attending Physician
    CopaceticOne and dchz like this.
  7. dchz

    dchz Avoiding the Dunning-Kruger
    Gold Donor Classifieds Approved

    Joined:
    Sep 25, 2012
    Messages:
    285
    Likes Received:
    211
    Status:
    Resident [Any Field]
    There are two points worth discussing when it comes to Erector Spinae:

    How lateral do you go: do you hit transverse process of the vertebral bodie? or do you go out to the ribs?

    Do you do the layer deep to the erector spinae muscle? or superficial to it?
     
  8. anaesthetic

    Joined:
    Sep 22, 2014
    Messages:
    97
    Likes Received:
    161
    Status:
    Resident [Any Field]
    We place it regularly now. The single shot can be done pretty quickly (resident + attending <5 minutes prep to injection), and the catheter takes a bit longer just due to opening the epidural/catheter kit and securing it after placement. One of our thoracic surgeons almost always requests them for his cases, and it's safer than an epidural/paravertebral.

    We find rib laterally and then find transverse process medially and use that as the landmark. We always try to go deep to the ES and get lift off from the bone to block or create space for the catheter, but IDK if it makes a difference.
     
    dchz likes this.
  9. dchz

    dchz Avoiding the Dunning-Kruger
    Gold Donor Classifieds Approved

    Joined:
    Sep 25, 2012
    Messages:
    285
    Likes Received:
    211
    Status:
    Resident [Any Field]
    The original authors postulated that the deeper layer covers more visceral and the superficial layer covers more somatic pain.

    Also may i ask what institution you're at?
     
  10. Psai

    Psai Account on Hold
    Physician

    Joined:
    Jan 2, 2014
    Messages:
    10,220
    Likes Received:
    20,320
    Status:
    Resident [Any Field]
    Lemme guess, they wanted pt extubated at the end of their forever procedure.
     
  11. JobsFan

    Joined:
    Jan 19, 2005
    Messages:
    918
    Likes Received:
    422
    Status:
    Attending Physician
    i do them - mostly for rib fractures. have done only about 10 now, early days ... my impression is they’re safer to do than paravertebrals - have slower onset but work nearly as well as paravertebral
     
  12. anaesthetic

    Joined:
    Sep 22, 2014
    Messages:
    97
    Likes Received:
    161
    Status:
    Resident [Any Field]
    PM'd you.
     
  13. AdmiralChz

    AdmiralChz ASA Member

    Joined:
    Sep 8, 2008
    Messages:
    2,340
    Likes Received:
    1,464
    Status:
    Fellow [Any Field]
    Anyone mind posting some references? I’d like to give this a try, and I’m a little tied up to go searching myself. Sorry for the laziness!
     
  14. dhb

    dhb Member
    Lifetime Donor Classifieds Approved

    Joined:
    Jul 12, 2006
    Messages:
    3,431
    Likes Received:
    620
    Status:
    Attending Physician
    dchz likes this.
  15. dchz

    dchz Avoiding the Dunning-Kruger
    Gold Donor Classifieds Approved

    Joined:
    Sep 25, 2012
    Messages:
    285
    Likes Received:
    211
    Status:
    Resident [Any Field]
    I love this block, but tbh I opt for the thoracic epidural every time. Just need the reps... This block is way easy to execute.
     
  16. Thread continues after this sponsor message. SDN Members do not see this ad.

  17. d9sccr

    d9sccr ASA Member

    Joined:
    Apr 23, 2012
    Messages:
    140
    Likes Received:
    66
    Status:
    Resident [Any Field]
    Using both single shots and catheters at my institution and I plan on using this after graduation. Most of them are done by 1 attending and everyone else is rather hesitant still.

    We used bilateral catheters in a patient that was undergoing a liver resection. The incision was initially midline and vertical but before the surgery was done, it stretched essentially from xiphoid down to a line perpendicular to ASIS and then laterally out to ASIS...essentially a HUGE flap. We placed bilateral catheters before emerging and took the patient to the ICU. Catheters worked great and the patient was ambulating the next morning with them.
     
    DocVapor likes this.
  18. dchz

    dchz Avoiding the Dunning-Kruger
    Gold Donor Classifieds Approved

    Joined:
    Sep 25, 2012
    Messages:
    285
    Likes Received:
    211
    Status:
    Resident [Any Field]
    This was bil T4 catheters?
     
  19. thinkorswim

    thinkorswim Mr. Monster

    Joined:
    Dec 11, 2006
    Messages:
    82
    Likes Received:
    41
    We do them for VATS cases, always place a catheter and run ropivacaine throughout the procedure. Usually just identify the lateral part of the transverse process and inject deep to the erector spinae muscle. If you ask me, I prefer epidurals.
     
  20. d9sccr

    d9sccr ASA Member

    Joined:
    Apr 23, 2012
    Messages:
    140
    Likes Received:
    66
    Status:
    Resident [Any Field]
    No, we dropped further inferior to place these, around T8/9 IIRC. You can expect 4-6 level dermatomal spread according to the initial paper. A few months later there was a case series about using ESPB SS for abdominal cases as well. One attending here has adopted it for both intra-thoracic and intra-abdominal cases and just changes the level, T5 and T9 respectively. Given the large spread, you don't have to be super picky about the level, but rather go where you have the best target.
     
  21. JobsFan

    Joined:
    Jan 19, 2005
    Messages:
    918
    Likes Received:
    422
    Status:
    Attending Physician
    I don’t do bilateral - would do an epidural instead.
    Are you getting a demonstrable block to ice?
    Sometimes I Find the patients get analgesia but not a block to ice ...
     
    AdmiralChz likes this.
  22. sethco

    sethco Senior Member

    Joined:
    Dec 12, 2003
    Messages:
    1,001
    Likes Received:
    91
    Status:
    Attending Physician
    I have done about 15 now. Always SS, no catheters for political reasons. Usually reserve this block for Robotic VATs, Thorocotomies, and VATs with higher chance of open conversion. I use about 30 mL 0.375% Bupi + decadron. Question though, am I the only one that does these post-induction? It seems most academic places are doing these with pt awake. I treat these as I treat tap blocks and just do it with pt asleep
     
  23. T-burglar

    Joined:
    May 13, 2017
    Messages:
    50
    Likes Received:
    63
    Status:
    Attending Physician
    I tend to think field and tissue plane blocks are fine to do asleep
     
  24. epidural man

    epidural man ASA Member

    Joined:
    Jun 3, 2007
    Messages:
    2,810
    Likes Received:
    551
    Status:
    Attending Physician
    I've used them in both the chronic pain clinic, and in the OR - with Exparel.

    works well.

    I have done both above the muscle and below -now I dump in both places each time. I don't think there is much difference.
     
    dchz likes this.
  25. d9sccr

    d9sccr ASA Member

    Joined:
    Apr 23, 2012
    Messages:
    140
    Likes Received:
    66
    Status:
    Resident [Any Field]
    The patient had a contraindication to an epidural so we did bilateral blocks. Would agree that the epidural is the better choice but this our fallback option and it worked well
     
  26. d9sccr

    d9sccr ASA Member

    Joined:
    Apr 23, 2012
    Messages:
    140
    Likes Received:
    66
    Status:
    Resident [Any Field]
    We do them asleep. No different than asleep TAPs. Just takes some effort to roll the patient
     
  27. BLADEMDA

    BLADEMDA ASA Member

    Joined:
    Apr 22, 2007
    Messages:
    16,527
    Likes Received:
    2,700
    Status:
    Attending Physician
    Asleep is fine. These are field blocks like TAP. I like to do them preop but doing them asleep in the O.R. is perfectly acceptable practice.
     
  28. JobsFan

    Joined:
    Jan 19, 2005
    Messages:
    918
    Likes Received:
    422
    Status:
    Attending Physician
    ah I see ... I haven't had an indication for bilateral that's also contraindicated to have an epidural yet .
    you use 0.125% bupivicaine? just thinking about the LA dose for bilateral
     
  29. JobsFan

    Joined:
    Jan 19, 2005
    Messages:
    918
    Likes Received:
    422
    Status:
    Attending Physician
    yep - i do them asleep too
     

Share This Page