are they worth the hype - pacsa 2020
TRANSCRIPT
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ARE THEY WORTH THE HYPE ?
13 -15th November 2020 Virtual PACSA
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Outline the concept of fascial plane blocks made possible since advent of ultrasound
Describe anatomy that delineates the spread of local anesthesia within these tissue planes
Suggest potential indications, dosage and review complications
Explain the hype
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Landmarks
•“Pops”
•Volume
Nerve
Stimulator
•Motor nerves
• Insulated needle
• (Non insulated)
•Less volume
Ultrasound
•Accuracy
improved
• Innovative
techniques
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TAP
•Landmark
•US
QL
•Ultrasound
• Innovation
ESP
•Ultrasound
•Serendipity
• Innovation
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Forero et al RAPM 2016 Path of spinal nerves. 1 = needle site superficial to ER, 2 = needle site deep to ESM
Dorsal ramus ->
travels through
erector spinae
to branch into
medial and
lateral posterior
cutaneous
branches
Spinal nerves divide into dorsal
and ventral primary rami
Ventral ramus -> travels deep to
intercostal muscles to branch into lateral and
anterior cutaneous branches
The rami communicantesbranch off the
ventral rami to the sympathetic chain
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Elsharkawy H et al Anesthesiology 2019
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TAP
•Subcostal
•Posterior
QL
•1-5
•Anterior
•Lateral
•Posterior
ESP
•Retrolaminar
•Mid TP
Determines spread and area of coverage
“Paravertebral by proxy”
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Costache et al Anaesthesia 2018
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Schwartzman Can J Anesth 2018
Ivanusic J RAPM 2018 Yang H Anaesth 2018
Adhikary S RAPM 2018 Vidal E Rev Esp Anest 2018
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Evolved from TAP
QL 1-5 caused confusion◦ Anterior
◦ Posterior
◦ Lateral
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Extent of sensory loss to cold over after 20 mL of 0.5% ropivacaine deep to erector spinae muscle. The black arrow indicates midline. Inset picture depicts the site of the patient’s chronic pain.
Forero. RAPM
First described by Forero et al 2016
T5 level injection with
T3-T9 spread
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A paraspinous column of muscle that extends from the sacrum and lumbar spinous processes to the thoracic and cervical spine.
A group of 3 paraspinousmuscles:
• Spinalis
• Longissimus thoracis
• Iliocostalis
K Chin. ESP. ESRA conference 2017
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Overlying muscles:
• Rhomboid: ends around T6-7
• Trapezius: ends around T10-12
• Might see latissimus dorsi and thoracolumbar aponeurosis more caudal
K Chin. ESP. ESRA conference 2017
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Spinous process
Lamina
Transverse process
Rib
Superior costotransverse ligament
Lateral costotransverse ligament
Erector spinae muscle fascia
Erector spinae fascial
plane space
Govender S thesis in prep
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Govender S et al RAPM 2020
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Govender S et al RAPM 2020
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Lateral view of a three-dimensional volume
rendered CT reconstruction of contrast injectate
spread in a fresh neonate. Green arrows –
represent the cranio-caudal spread within the
erector spinae fascial plane space at vertebral
level T8. Yellow arrows – represents the cranio-
caudal spread within the erector spinae fascial
plane space and posterior to the erector spinae
muscle at vertebral level T10.
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Simple and easy to perform
Safety ◦ Distant from spinal cord and pleura
Applications ◦ Thorax
◦ Abdomen
◦ Neck
◦ Coagulation disorders
Liver transplant
Cardiac sx
Albrecht and Chin Anaesthesia 2020
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164 children Oct 2017 –May 2019◦ 5.2 ±6.1y (2days-19yrs) 2.3 -94.7kg◦ Majority placed in <10min◦ 0.25-0.5% bupivacaine with epi 1:200000
0.5ml.kg±0.2ml.kg unilateral or 0.3ml±0.1ml.kg
◦ Only 20% had long acting opioids intraop (fentanyl)
0.1ml.kg.dermatome in infants
33 publication 128 children◦ 2 RCT’s - remainder case reports◦ No complication
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Types of Surgery ThoracicAbdominal(Cervical)
Types of Patients Contraindication to an epiduralSpine issues (previous hardware,abnormalities)Current or potential coagulopathyFailed epidural or PVBPatient fearful of neuraxial proceduresUnclear epidural vascular anatomyRib fractures
Types of Pain Acute post surgicalTrauma Chronic pain
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ESP Epidural Paravertebral QL TAP
Spread Extensivedermatome spread in muscle plane
Spread in fat filled space can be limited,unilateral, patchy
Less extensive spread, multipleinjections needed
PosteriorapproachFewer dermatome
More distal –fewer dermatomes covered
NeuraxialRisk
Avoidance of neuraxial space
Neuraxialcomplications (bleeding, infection, nerve injury)
Neuraxialcomplications
Avoids neuraxialspace
Avoids neuraxialspace
PNX Risk PNX n=1(adult) PNX Hematoma n=2 (child)
Peritonealinjury
Absorption Moderatesystemic absorption(? epinephrine)
Less systemicabsorption
Moderate systemic absorption(?epineph)
Moderatesystemic absorption(?epineph)
Less systemic absorption(?epinephrine)
Coverage Somatic and visceral
Somatic and visceral
Somatic and visceral
Somatic? visceral
Only somatic
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20 catheter placements excluded from study
◦ Infant to teenager
Pectus excavatum - Nuss repair
Thoracotomy
Laparotomy
◦ Chronic pain
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21year old Alaskan female - chronic hip pain ◦ Metastatic neuroblastoma
◦ Multiple analgesics
◦ Sleep deprived
◦ Wedding hospital chapel
Block suggested◦ Epidural contraindicated – low platelets!
◦ ESP block performed
Slept well that night!
Married the next day unassisted down aisle
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