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Anyone doing erector spinae blocks or catheters?

Discussion in 'Anesthesiology' started by T-burglar, May 14, 2018.

  1. T-burglar

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    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?
     
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  3. DocVapor

    DocVapor Big Schwartz
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    Did a lobectomy the other day where my attending placed one. The block was amazing.
     
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  4. AdmiralChz

    AdmiralChz ASA Member
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    Open, VATS or *shudder* robot?

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

    DocVapor Big Schwartz
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    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.
     
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  6. pgg

    pgg Laugh at me, will they?
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  7. dchz

    dchz Avoiding the Dunning-Kruger
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    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

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    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.
     
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  9. dchz

    dchz Avoiding the Dunning-Kruger
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    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 Snitches get zero vicryl
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    Lemme guess, they wanted pt extubated at the end of their forever procedure.
     
  11. JobsFan

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    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

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    PM'd you.
     
  13. AdmiralChz

    AdmiralChz ASA Member
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    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
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  15. dchz

    dchz Avoiding the Dunning-Kruger
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    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. d9sccr

    d9sccr ASA Member
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    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.
     
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  17. dchz

    dchz Avoiding the Dunning-Kruger
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    This was bil T4 catheters?
     
  18. thinkorswim

    thinkorswim Mr. Monster
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    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.
     
  19. d9sccr

    d9sccr ASA Member
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    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.
     
  20. JobsFan

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    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 ...
     
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  21. sethco

    sethco Senior Member
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    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
     
  22. T-burglar

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    I tend to think field and tissue plane blocks are fine to do asleep
     
  23. epidural man

    epidural man ASA Member
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    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.
     
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  24. d9sccr

    d9sccr ASA Member
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    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
     
  25. d9sccr

    d9sccr ASA Member
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    We do them asleep. No different than asleep TAPs. Just takes some effort to roll the patient
     
  26. BLADEMDA

    BLADEMDA ASA Member
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    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.
     
  27. JobsFan

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    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
     
  28. JobsFan

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    yep - i do them asleep too
     
  29. d9sccr

    d9sccr ASA Member
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    We don't use much bupi at our institution. For the ESBs we used ropi 0.5% and bolused the catheters 20mL per side after surgery. For the infusion, we used 0.2% ropi (I believe at 10ml/hr). Anecdotally and subjectively, the patient had more complete dermatomal coverage with boluses vs the infusion. I'd guess this had something to do adequately opening the fascial plane?
     
  30. leaverus

    leaverus New Member
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    would this block be of any use to those big fatties with severe OSA who don't know why they have back problems and need spine surgery?
     
  31. Timeoutofmind

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    What diagnosis did u use them for in chronic pain?
     
  32. AdmiralChz

    AdmiralChz ASA Member
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    For you guys doing ESP blocks for robotic lung cases - do y’all do them at the start or end of the procedure? Some of our robotic cases can last 6-8+ hours, and without Exparel available I’d worry about the duration.
     
  33. dchz

    dchz Avoiding the Dunning-Kruger
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    Whether or not you do it before or after depends on whether you're a believer in preemptive analgesia (or benefit of not reving up the pain pathways).

    I'm a huge believer, so I advocate for doing it before, even if your duration is short post op, it's still most beneficial to the pt.
     
    #32 dchz, May 22, 2018
    Last edited: May 22, 2018
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  34. T-burglar

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    Agreed, anecdotally avoiding the windup effect does a lot for post op pain
     
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  35. epidural man

    epidural man ASA Member
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    chest wall/post thoracotomy pain.

    Did several on a patient with chronic pain after a pluerodesis.
     
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  36. BLADEMDA

    BLADEMDA ASA Member
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    Send to



    Scand J Pain. 2017 Oct;17:325-329. doi: 10.1016/j.sjpain.2017.08.013. Epub 2017 Sep 12.
    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.
     
  37. BLADEMDA

    BLADEMDA ASA Member
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    The block is performed approximately 2.5 cm lateral to the midline by walking off the transverse process; a bad back or lumbar stenosis should have no effect on the block or its safety.

    I like to do this block on patients with high BMIs as it is much easier than a paravertebral or thoracic epidural to perform with excellent efficacy.
     
  38. BLADEMDA

    BLADEMDA ASA Member
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    Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane.
    Adhikary SD1, Pruett A1, Forero M2, Thiruvenkatarajan V3,4.
    Author information

    Abstract
    Post-operative pain after minimally invasive video-assisted thoracoscopic surgery (VATS) in adults is commonly managed with oral and parenteral opioids and invasive regional techniques such as thoracic epidural blockade. Emerging research has shown that the novel erector spinae plane (ESP) block, can be employed as a simple and safe alternative analgesic technique for acute post-surgical, post-traumatic and chronic neuropathic thoracic pain in adults. We illustrate this by presenting a paediatric case of VATS, in which an ESP block provided better analgesia, due to greater dermatomal coverage, as well as reduced side-effects when compared with a thoracic epidural that had previously been employed on the same patient for a similar procedure on the opposite side.
     
  39. BLADEMDA

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  40. BLADEMDA

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  41. BLADEMDA

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  42. leaverus

    leaverus New Member
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    Blade, my question was poorly worded. I meant using ESB specifically for treatment of postop pain after spine surgery (lamis, etc.)
     
  43. BLADEMDA

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