ARE THEY WORTH THE HYPE ?

13 -15th November 2020 Virtual PACSA

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

Landmarks

•“Pops”

•Volume

Nerve

Stimulator

•Motor nerves

• Insulated needle

• (Non insulated)

•Less volume

Ultrasound

•Accuracy

improved

• Innovative

techniques

TAP

•Landmark

•US

QL

•Ultrasound

• Innovation

ESP

•Ultrasound

•Serendipity

• Innovation

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

Elsharkawy H et al Anesthesiology 2019

TAP

•Subcostal

•Posterior

QL

•1-5

•Anterior

•Lateral

•Posterior

ESP

•Retrolaminar

•Mid TP

Determines spread and area of coverage

“Paravertebral by proxy”

Costache et al Anaesthesia 2018

Schwartzman Can J Anesth 2018

Ivanusic J RAPM 2018 Yang H Anaesth 2018

Adhikary S RAPM 2018 Vidal E Rev Esp Anest 2018

Evolved from TAP

QL 1-5 caused confusion◦ Anterior

◦ Posterior

◦ Lateral

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

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

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

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

Govender S et al RAPM 2020

Govender S et al RAPM 2020

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.

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

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

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

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

20 catheter placements excluded from study

◦ Infant to teenager

Pectus excavatum - Nuss repair

Thoracotomy

Laparotomy

◦ Chronic pain

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