Truncal block questions

[waterbottle10]

Hi, I have a few block questions and I hope someone can help me answer them. Thanks!
What is the purpose of rectus sheath blocks when you can do TAP blocks? I been told if the incision is midline, do bilateral rectus sheath blocks. But shouldn't bilateral TAP blocks cover midline as well? The midline nerves come off the main nerves blocked by TAP, and TAP is a much easier block to do since rectus is right next to the peritoneum..

I've also been doing some Erector spinae blocks for abdominal cases (mostly robotic partial nephrectomies), does anyone have any experience with the result of these blocks? I been getting very hit and miss results, some wake up comfortable, some in a lot of pain. With that said, i do find it to be a difficult block to do. I understand it is supposed to be a easier version of paravertebral... I do bilateral ES blocks with about 20ml 0.5 bupivicaine on each side.

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[deleted9493]

Bilateral TAP blocks performed laterally at the triangle of Petit will reliably cover dermatomes T10 to L1. To cover dermatomes T7-T9, additional oblique subcostal TAP blocks are required. Great article describing an approach to the oblique subcostal TAP that I have used and found efficacious: http://www.anesthesiauniverse.net/s...Guided_Continuous_Oblique_Subcostal.7_[1].pdf

I don't have anything to back me up in saying this but I would guess that the bang for your buck with TAP local anesthetic spread is better than at the more medial injection site of the rectus sheath block (nerves are more spread out, medially). AND as you say, peritoneum lies in wait just below your posterior rectus sheath making that an added risk of the rectus sheath block.

I do not have any experience with ES blocks.

 

[facted]

Hi, I have a few block questions and I hope someone can help me answer them. Thanks!
What is the purpose of rectus sheath blocks when you can do TAP blocks? I been told if the incision is midline, do bilateral rectus sheath blocks. But shouldn't bilateral TAP blocks cover midline as well? The midline nerves come off the main nerves blocked by TAP, and TAP is a much easier block to do since rectus is right next to the peritoneum..

I've also been doing some Erector spinae blocks for abdominal cases (mostly robotic partial nephrectomies), does anyone have any experience with the result of these blocks? I been getting very hit and miss results, some wake up comfortable, some in a lot of pain. With that said, i do find it to be a difficult block to do. I understand it is supposed to be a easier version of paravertebral... I do bilateral ES blocks with about 20ml 0.5 bupivicaine on each side.

Regular TAP won't cover above umbilicus technically. Could do subcostal and regular tap, but honestly, rectus sheath works pretty well for midline ex-lap for example and much easier to do. With that being said, neither had visceral coverage.

I've personally stopped doing all of these and just do QL block, though ES block should be great as well (never done one).

 

[d9sccr]

Mostly working with anecdotal evidence still, but I've personally by very impressed with the ESP blocks. You can also thread catheters if you want. The block itself takes 10min to learn and is relatively safe given the backstop of the TP. We'll see what larger studies start to yield in terms of efficacy and safety but I'll be using this block for the foreseeable future

 

[jwizle]

Anyone have any good videos or literature on ESP or QL blocks? Ive done plenty of reading and watched multiple videos but just can't seem to get a good view to actually make an attempt.

 

[anbuitachi]

Mostly working with anecdotal evidence still, but I've personally by very impressed with the ESP blocks. You can also thread catheters if you want. The block itself takes 10min to learn and is relatively safe given the backstop of the TP. We'll see what larger studies start to yield in terms of efficacy and safety but I'll be using this block for the foreseeable future

Ive done a bunch of ES block and QL block. Results have been mixed. I find them to be fairly challenging blocks, esp in this country when everyones huge.. The ultrasound anatomy is just not that great given the target depth from my experience. What do you give for your ES blocks?

Also what positions are you doing ES blocks and QL blocks?

 

[Gill23]

Download the app Block Buddy from the App Store. It will answer many of your questions. Best regional app I have seen yet. Money well spent. I think it’s on android too.

 

[deleted59964]

Download the app Block Buddy from the App Store. It will answer many of your questions. Best regional app I have seen yet. Money well spent. I think it’s on android too.

Care to disclose any conflict of interest?
I note the authors don’t mention their lack of medical qualifications

 

[Psai]

Download the app Block Buddy from the App Store. It will answer many of your questions. Best regional app I have seen yet. Money well spent. I think it’s on android too.

Sounds legit

 

[anbuitachi]

It's kind of expensive...

 

[Gill23]

Care to disclose any conflict of interest?
I note the authors don’t mention their lack of medical qualifications

Disclosures: none. I feel silly bringing it up, because I thought it would have been well known by now. Most of my colleagues and I have it. There are only two regional apps that I know of. “Block Guru” and “Block Buddy”. Guru was out for awhile, but is rather basic, and doesn’t update. Block buddy seems to update regularly and stays with the times. Everything I have seen in the app I have verified with the available literature that I can find, and it seems legit.

 

[Gill23]

It's kind of expensive...

How much is it up to now? I bought it a year and half to two years ago when it was $10. Well worth the money for quick reference IMHO.

 

[anes121508]

Ive done a bunch of ES block and QL block. Results have been mixed. I find them to be fairly challenging blocks, esp in this country when everyones huge.. The ultrasound anatomy is just not that great given the target depth from my experience. What do you give for your ES blocks?

Also what positions are you doing ES blocks and QL blocks?

Esp: Lateral asleep after the case in thoracic. vs pvb I like them because the view is easier. You having a hard time with esp view?

 

[anbuitachi]

How much is it up to now? I bought it a year and half to two years ago when it was $10. Well worth the money for quick reference IMHO.

I think 15?

Esp: Lateral asleep after the case in thoracic. vs pvb I like them because the view is easier. You having a hard time with esp view?

Yea prob not enough experience. what local volume do you use?

 

[BLADEMDA]

I do them sitting up approximately 2.5 cm lateral from the midline. You simply inject just above the transverse process/rib. Once the space is dilated placing a catheter is fairly simple.

 

[BLADEMDA]

 

[BLADEMDA]

 

[facted]

I do them sitting up approximately 2.5 cm lateral from the midline. You simply inject just above the transverse process/rib. Once the space is dilated placing a catheter is fairly simple.

Can you link this video? Thanks

 

[BLADEMDA]

 

[BLADEMDA]

Lateral Position (I find the sitting position much easier on obese patients):

 

[BLADEMDA]

Start Video at 14 minutes:

 

[BLADEMDA]

Best Video on the web:

I recommend if you want the short version start at 15 minutes until 25 minutes (10 minutes).

I think the key is not to inject too far lateral from the CostoTransverse Ligament. This is a type of paravertebral block so if the injection is too far lateral it doesn't work as well (IMHO). You can inject a little lateral to the transverse process but not too far lateral. I prefer using 2.5 cm-3 cm lateral to the midline.

 

[BLADEMDA]

Hi, I have a few block questions and I hope someone can help me answer them. Thanks!
What is the purpose of rectus sheath blocks when you can do TAP blocks? I been told if the incision is midline, do bilateral rectus sheath blocks. But shouldn't bilateral TAP blocks cover midline as well? The midline nerves come off the main nerves blocked by TAP, and TAP is a much easier block to do since rectus is right next to the peritoneum..

I've also been doing some Erector spinae blocks for abdominal cases (mostly robotic partial nephrectomies), does anyone have any experience with the result of these blocks? I been getting very hit and miss results, some wake up comfortable, some in a lot of pain. With that said, i do find it to be a difficult block to do. I understand it is supposed to be a easier version of paravertebral... I do bilateral ES blocks with about 20ml 0.5 bupivicaine on each side.

Let's review why your blocks most likely fail at times:

1. Level- For abdominal surgery/Nephrectomy T7 or T8 level. For Chest wall/VATS/Breast/Thoracotomy T4 or T5.

2. Injection- the local must be underneath the erector spinae muscles or just above the transverse process on the U/S. This means you must get very very close to the transverse process or contact it prior to the injection. I've seen providers inject the local in the wrong plane.

3. Too far lateral- This is a type of paravertebral block and BEST performed at the transverse process or very close to the transverse process. If the injection is performed too lateral (more than 4 cm from the midline) the block is likely to be patchy or not work at all.

 

[BLADEMDA]

I really like the blocks: TAP, Subcostal Tap, QL2 and QL3, ESP, etc

But, a properly placed Epidural is still superior for the the first 24-48 hours in terms of pain relief. That said, I typically perform one of these blocks over a Thoracic Epidural because they are adequate for postop pain control without any of the issues of a thoracic epidural. Anti-Coagulation is not an issue postop either which is a major plus.

 

[BLADEMDA]

You just need to get close to the correct level: