ESP vs Paravertebral blocks

[codeb1ue]

I know these blocks have been around for some time now but I do not have much experience with them. I want to incorporate them more into my practice however as I recently had a post VATS patient in tremendous pain but I could not do a post-op thoracic epidural due to recent eliquis use. Researching comparison between the two blocks reveals much conflicting results. Many threads here seem to tout ESP is superior to PVB in every way which makes me wonder if there is any benefit at all to learning PVB. Hoping to gather some of your thoughts.

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[GassYous]

Pvb is better but harder

 

[dhb]

Pvb is better but harder

I think spread is more limited with a pvb so generally less useful.

 

[deleted697127]

Ranting off topic a bit but:

Erector spinae can be less than satisfying. I wouldn’t expect train tracks during a vats for obvious reasons and found it hard to tell if they helped at all for VATS when I used to do them (no longer cover thoracics). For breast cases, i find them less likely than PECS to get train tracks but some still appear to work (surgeon reporting patient satisfaction and that the patients didn’t need any opiates after going home) despite observed stimulation with incision. Variable loss of sensation to ice when doing ESP in holding and checking prior to induction. My PECS seem to work more reliably but i recognize this could be technique. Common problem with ESP is injecting over rib rather than transverse process. This also has complicated assessment in the literature. I believe I saw someone was attempting to assess outcomes injecting over rib vs TP but this study seems inherently difficult to do and I’m not sure if the study is out yet.

With any of these blocks, repitition, the ANSO app, and watching YouTube videos before and after your blocks is the way to improve. Taking the time to check for appropriate changes in sensation can be interesting.

You won’t get better if you don’t take the initiative. Wouldn’t recommend new awake blocks on anxious patients on anticoagulation. It doesn’t hurt to check in with your surgeons for feedback. Some of our ortho docs have noticed improved pain control with PENG and IPACK and now request them. Breast surgeons with ESP. I have also had success with ESP and PENG for rescue.

For PENG, try 15mL for PENG and dropping 5mL in fascia iliaca on skinny old hip fractures. Belly gets in the way on higher BMI which becomes less of an issue the more you do. Skip fascia iliaca if you don’t want to risk motor block. If you’re doing a PENG for fracture, check pain score before and after for affirmation of block success. If they’re coming in for elective hip and have pain, they often see a decrease in pain and increase in range of motion after the block

 

[deleted697535]

Anyone for sap block? Really easy

 

[Lecithin5]

Although pvb is technically more challenging to perform with a bit more risk, the image acquisition is the same for both. If you can do one, you should be able to do the other (but with more precision needed for the pvb).

btw, I suspect that in many cases, ppl think they are performing a true esp block, but they are too lateral and mistaking rib for transverse process.

 

[deleted162650]

they are too lateral and mistaking rib for transverse process.

TP’s are flat. Ribs are domed.

 

[GassYous]

Although pvb is technically more challenging to perform with a bit more risk, the image acquisition is the same for both. If you can do one, you should be able to do the other (but with more precision needed for the pvb).

btw, I suspect that in many cases, ppl think they are performing a true esp block, but they are too lateral and mistaking rib for transverse process.

It is super easy to make that mistake. I like to start with a horizontal scan before I turn it vertical and place the needle.

 

[Volatile]

I personally feel ESP blocks are easier to perform than PVB. I was also under the impression PVB’s shouldn’t really be attempted in anticoagulated patients but ESP could, maybe I made that up

 

[26B]

Anyone for sap block? Really easy

They are great blocks. We also do a similar block (TTP) for sternotomy pain in cardiac cases.

Pvb is better but harder

I personally don't feel like PVB is much more technically challenging than ESP. The ultrasound views of the two blocks are essentially the same. With PVB you do have to be careful to maintain constant visualization of the needle tip to prevent pneumothorax, but really you should be maintaining a good view of the needle with any ultrasound-guided block.

Agree that PVB is generally more effective than ESP though. Conflicting evidence on the reason. Some sources suggest PVB has more spread into the epidural space.

One important point with ESP blocks is to be sure you are not injecting intramuscularly. Sometimes an IM injection can also seem to have a "unzippering" appearance, but it will lead to block failure. You have to see the ESP being lifted off the transverse process with injection.

I know these blocks have been around for some time now but I do not have much experience with them. I want to incorporate them more into my practice however as I recently had a post VATS patient in tremendous pain but I could not do a post-op thoracic epidural due to recent eliquis use. Researching comparison between the two blocks reveals much conflicting results. Many threads here seem to tout ESP is superior to PVB in every way which makes me wonder if there is any benefit at all to learning PVB. Hoping to gather some of your thoughts.

Per ASRA guidelines, PVB is considered equivalent to epidural when it comes to anticoagulation guidelines, so it wouldn't really be ideal in that particular patient anyway.

 

[deleted875186]

Ranting off topic a bit but:

Erector spinae can be less than satisfying. I wouldn’t expect train tracks during a vats for obvious reasons and found it hard to tell if they helped at all for VATS when I used to do them (no longer cover thoracics). For breast cases, i find them less likely than PECS to get train tracks but some still appear to work (surgeon reporting patient satisfaction and that the patients didn’t need any opiates after going home) despite observed stimulation with incision. Variable loss of sensation to ice when doing ESP in holding and checking prior to induction. My PECS seem to work more reliably but i recognize this could be technique. Common problem with ESP is injecting over rib rather than transverse process. This also has complicated assessment in the literature. I believe I saw someone was attempting to assess outcomes injecting over rib vs TP but this study seems inherently difficult to do and I’m not sure if the study is out yet.

With any of these blocks, repitition, the ANSO app, and watching YouTube videos before and after your blocks is the way to improve. Taking the time to check for appropriate changes in sensation can be interesting.

You won’t get better if you don’t take the initiative. Wouldn’t recommend new awake blocks on anxious patients on anticoagulation. It doesn’t hurt to check in with your surgeons for feedback. Some of our ortho docs have noticed improved pain control with PENG and IPACK and now request them. Breast surgeons with ESP. I have also had success with ESP and PENG for rescue.

For PENG, try 15mL for PENG and dropping 5mL in fascia iliaca on skinny old hip fractures. Belly gets in the way on higher BMI which becomes less of an issue the more you do. Skip fascia iliaca if you don’t want to risk motor block. If you’re doing a PENG for fracture, check pain score before and after for affirmation of block success. If they’re coming in for elective hip and have pain, they often see a decrease in pain and increase in range of motion after the block

This guy knows what’s he’s talking about.

I like the ESB blocks, but agree that they have a relatively speaking higher failure rate due to many of the above mentioned issues. In my mind, do an ESB if your on anticoagulation. If You need more than just do a thoracic epidural. I have never done a PVB, but don’t understand why Yoj wouldn’t just place an epidural, do they have less hemodynamics effects?

 

[GassYous]

This guy knows what’s he’s talking about.

I like the ESB blocks, but agree that they have a relatively speaking higher failure rate due to many of the above mentioned issues. In my mind, do an ESB if your on anticoagulation. If You need more than just do a thoracic epidural. I have never done a PVB, but don’t understand why Yoj wouldn’t just place an epidural, do they have less hemodynamics effects?

less risk of hematoma

 

[AnesRunner]

ESPBs are a very poor man's PVB. That being said, I wouldn't do a PVB for someone on Eliquis. Just do a crappy ESPB and call it a day. The only people that think that ESPBs are equivalent to a PVB are those that cannot do a proper PVB.

 

[deleted162650]

do they have less hemodynamics effects?

Unilateral blocks yes. Bilateral potentially similar to an epidural.

 

[yerhuckleberry]

If pleura can be visualized with ultrasound, I take a lateral approach paravertebral every time. ES blocks are super simple but have a middling effect, at best...maybe enough to get the rib fracture patient discharged but unlikely to make their pain 0/10 for any period of time like a well-place paravertebral would.

 

[J Peterman]

Have found ESP’s in general very unimpressive and would only do one if anticoagulation was in play. Conversely, you can get a patient through a VATs (or even conversion to thoractomoy) with minimal intraop and postop opioids with well sited TPVBs covering the incision and chest tube site.

Having trouble with needle tip visualization in a TPVB? Try the curvilinear probe. You can visualize the needle tip in BOTH skinny and obese patients much better at the steep angles often required to navigate between TP’s and avoid the “double-fulcrum” issue. I don’t even bother with a linear probe in obese patients, especially because these blocks are often already done in the lateral position (certainly easier to perform when sitting).

 

[AnesRunner]

If pleura can be visualized with ultrasound, I take a lateral approach paravertebral every time. ES blocks are super simple but have a middling effect, at best...maybe enough to get the rib fracture patient discharged but unlikely to make their pain 0/10 for any period of time like a well-place paravertebral would.

If you are seeing pleura, you are doing a proximal intercostal block. Not a PVB. Unfortunately, a lot of these studies being done comparing fascial plane blocks to "PVBs" are showing non-inferiority simply because people aren't doing proper PVBs. Their pictures of their ultrasound-guided "PVB" views clearly show a proximal intercostal block. A block that works, just not a proper dense PVB. You should not be seeing a superficial pleura line if are doing a PVB at the level of mid-to-proximal TP.

 

[Wolverines83]

for what it's worth, ESP blocks seem to work well on kids. Then again, most plane blocks seem to work better. Probably because you can actually see their anatomy because they haven't had 50 years of McDonald's.

 

[codeb1ue]

If you are seeing pleura, you are doing a proximal intercostal block. Not a PVB. Unfortunately, a lot of these studies being done comparing fascial plane blocks to "PVBs" are showing non-inferiority simply because people aren't doing proper PVBs. Their pictures of their ultrasound-guided "PVB" views clearly show a proximal intercostal block. A block that works, just not a proper dense PVB. You should not be seeing a superficial pleura line if are doing a PVB at the level of mid-to-proximal TP.

Sorry but I'm confused by this. How is it possible to do a safe PVB if you can't visualize the pleura? Isn't that the most important landmark for this block (avoid PTX and watching it depress with the local)?

 

[Hoya11]

Sorry but I'm confused by this. How is it possible to do a safe PVB if you can't visualize the pleura? Isn't that the most important landmark for this block (avoid PTX and watching it depress with the local)?

i think he is saying you dont see the pluera if done "properly" because your approach is medial to the pleura and the pleura is laterally outside of your US beam . And the idea is that if you are seeing pleura, you are so far lateral that you are not in the true "paravertebral" space but have migrated laterally now into the intercostal space. Epidural --> PV --> intercostal. Personally I think its all or nothing, epidural or intercostal. PVBs are inconsistent and probably provide the same analgesia as intercostal blocks. The best PVB catheter I ever saw was in the epidural space.

 

[yerhuckleberry]

If you are seeing pleura, you are doing a proximal intercostal block. Not a PVB. Unfortunately, a lot of these studies being done comparing fascial plane blocks to "PVBs" are showing non-inferiority simply because people aren't doing proper PVBs. Their pictures of their ultrasound-guided "PVB" views clearly show a proximal intercostal block. A block that works, just not a proper dense PVB. You should not be seeing a superficial pleura line if are doing a PVB at the level of mid-to-proximal TP.

This approach results in a very dense block. No, the needle tip can not be visualized behind the transverse process in an inline/lateral to medial approach...that does not mean that it is not in the paravertebral space. A paravertebral injection as you describe, causes pleural depression exactly as the above approach does. You are making a distinction without any difference.

 

[AnesRunner]

i think he is saying you dont see the pluera if done "properly" because your approach is medial to the pleura and the pleura is laterally outside of your US beam . And the idea is that if you are seeing pleura, you are so far lateral that you are not in the true "paravertebral" space but have migrated laterally now into the intercostal space. Epidural --> PV --> intercostal. Personally I think its all or nothing, epidural or intercostal. PVBs are inconsistent and probably provide the same analgesia as intercostal blocks. The best PVB catheter I ever saw was in the epidural space.

Sorry, I do over a thousand PVBs a year (SSs and caths). A proper PV cath truly in the PV space is infinitely better than a PICB. I can't remember the last time a mastectomy patient has needed opioids postop.

 

[AnesRunner]

View attachment 336499

This approach results in a very dense block. No, the needle tip can not be visualized behind the transverse process in an inline/lateral to medial approach...that does not mean that it is not in the paravertebral space. A paravertebral injection as you describe, causes pleural depression exactly as the above approach does. You are making a distinction without any difference.

I wouldn't recommend a lateral to medial approach. Plenty of these catheters are probably threading into the epidural space. With a parasagittal approach, you will see anterior depression of an ill-defined deep pleural layer. Not a superficial pleural layer with clear lung sliding (that is a PICB). Once you have traversed the last of the costotransverse ligaments, you get the anterior spread that guarantees you are in the PV space. If you are not seeing your needle tip in any proximity to where pleura may be, you probably should not be doing that.

 

[AnesRunner]

Ill-defined deep pleural layer (correct medial view):

PICB view with clear pleural layer (incorrectly described as PVB all the time):

 

[deleted875186]

Ill-defined deep pleural layer (correct medial view):

PICB view with clear pleural layer (incorrectly described as PVB all the time):

I have to say, I still think it makes sense to just do a less risky ESB block that likely works the same way as a PVB with a small amount of local going anterior, or the much more reliable and easy to place epidural.

 

[J Peterman]

I have to say, I still think it makes sense to just do a less risky ESB block that likely works the same way as a PVB with a small amount of local going anterior, or the much more reliable and easy to place epidural.

The difference is that the less risky ESP block will do next to nothing for a surgical patient, and in addition lasts a very short period of time due to reabsorption and distance from the purported effect site.

Outside of academia it may be difficult follow and manage an epidural in a community hospital setting where floor nurses have no idea how to deal with them, and there is no crew of residents or NP’s to run an acute pain service.

As far as single shot blocks go with negligible hemodynamic effects, good duration of action and ability to cover visceral and somatic innervation to the thorax...tPVB is the way to go. No plane block is going to do that.