Erector Spinae Plane Block

After speaking to a colleague of mine regarding regional anesthesia for thoracotomy and mastectomy, I am reading up on Erector Spinae Plane (ESP) block.

Indications:

• Rib fractures
  • Erector spinae plane block for pain relief in rib fractures. BJA March 2017: Volume 118, Issue 3, Pages 474–475.)
  • How I Do It: Erector Spinae Block for Rib Fractures: The Penn State Health Experience. ASRA News February 2018.
  • Other blocks for Rib Fractures
• Thoracotomy/VATs
  • Continuous Erector Spinae Plane Block for Rescue Analgesia in Thoracotomy After Epidural Failure: A Case Report. A & A Case Reports. 8(10):254–256, MAY 2017.
  • The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Regional Anesthesia and Pain Medicine. Volume 41, Number 5, September-October 2016.
  • The Ultrasound-Guided Continuous Erector Spinae Plane Block for Postoperative Analgesia in Video-Assisted Thoracoscopic Lobectomy. Regional Anesthesia and Pain Medicine: July/August 2017 – Volume 42 – Issue 4 – p 537.

  • 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. Indian J Anaesth. 2018 Jan; 62(1): 75–78.

• Esophagectomy
  • Erector spinae plane block as a multiple catheter technique for open esophagectomy: a case report.  Rev Bras Anestesiol. 2018; xxx(xx): xxx—xxx.
• Mastectomy/Breast reconstruction
  • Continuous erector spinae plane block
    provides effective perioperative analgesia for breast reconstruction using tissue expanders: A report of two cases. Journal of Clinical Anesthesia 44(2018)1-2.

  • The Erector Spinae Plane Block Provides Complete Surgical Anesthesia in Breast Surgery.  A Case Report. A&A Practice: October 1, 2018 – Volume 11 – Issue 7 – p 186–188

• Abdominal surgery
  • Continuous Erector Spinae Plane (ESP) Analgesia In Different Open Abdominal Surgical Procedures: A Case Series. Journal of Anesthesia and Surgery. https://doi.org/10.15436/2377-1364.18.1853.

  • Bilateral Continuous Erector Spinae Plane Block Contributes to Effective Postoperative Analgesia After Major Open Abdominal Surgery: A Case Report. A&A Practice: December 1, 2017 – Volume 9 – Issue 11 – p 319–321

  • The analgesic efficacy of pre‐operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair. Anaesthesia, Volume72, Issue4. April 2017. Pages 452-460.

  • Ultrasound-Guided Erector Spinae Plane Block in Patients Undergoing Open Epigastric Hernia Repair: A Prospective Randomized Controlled Study. Anesthesia & Analgesia: July 2019 – Volume 129 – Issue 1 – p 235-240

• Cardiac surgery
  • Continuous Erector Spinae Plane (ESP) Block for Postoperative Analgesia after Minimally Invasive Mitral Valve Surgery. October 2018Volume 32, Issue 5, Pages 2271–2274.
  • Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery.  Ann Card Anaesth 2018;21:323-7.
  • Bilateral Continuous Erector Spinae Plane Blocks for Median
    Sternotomy in a Pediatric Cardiac Patient.  ASRA World 2018 Poster.

Continuous Peripheral Nerve Catheters – What is the Current Thinking? March 2015 PPT.

Other regional blocks

Continuous ESP block catheter (my current regimen and what I’m able to get at my institution):

• Braun Periflex catheter through 17g epidural needle
• Cranial-to-caudal approach @ T5 (mastectomy, vats, rib fractures)
• 20ml 0.25% bupi + epi prior to catheter
• Catheter 5cm in space
• 5 ml 0.25% bupi + epi after catheter placed
• Mix: 0.125% bupi + fentanyl @ 10 ml/hr
• If PCEA available, bolus 15ml every 3 hours; continuous as mix above.

PEC 1 & 2 Blocks, Serratus Anterior Block

I’ve been hearing more and more about PEC 2 block for mastectomy.  What’s wonderful about this block is that it seems that the risk of pneumothorax is lower than for a paravertebral block.

Egyptian Journal of Anaesthesia; April 2014. Thoracic Paravertebral Block vs. Pectoral Nerve Block for Analgesia after Breast Surgery

SlideShare powerpoint: PEC 1 & 2 and Serratus Anterior Blocks

Current Anesthesiol Rep, 2015. Regional Anesthesia for Breast Surgery: Techniques and Benefits.

Rev Esp Anesthesia Reanim; 2012: Ultrasound Description of PECS 2 (modified PECS 1): A Novel Approach to Breast Surgery

Poster Summary of PECS 2

TAP, PEC 1, & PEC 2 Blocks PPT

Anaesthesia, 2013. Serratus Plane Block: A Novel Ultrasound-Guided Thoracic Wall Nerve Block.

NYSORA 2014: Update on truncal blocks

Summary:

• U/S guidance: probe position similar to infraclavicular block. Find 3rd, 4th rib.
• Pt position: Head away from side of block. Ipsilateral arm abducted.
• PEC 2: Inject 20 ml 0.25% bupi between pec minor and serratus.
• PEC 1: Inject 10 ml 0.25% bupi between pec major and pec minor.
• Serratus: 5th rib, mid-axillary line. Inject 30 ml 0.125% bupi along top (superficial) and bottom (deep) of serratus muscle (which is just deep to the latissmus dorsi).

YouTube: PECS 1&2 Block

YouTube: Serratus plane block

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Update: Oct 24, 2018

PECs blocks in Cardiac Surgery

http://www.annals.in/article.asp?issn=0971-9784;year=2018;volume=21;issue=3;spage=333;epage=338;aulast=Kumar

http://www.apicareonline.com/ultrasoundguidedblocksforsurgeries-proceduresinvolvingchestwall-pecs-12andserratusplaneblock/

https://www.ncbi.nlm.nih.gov/m/pubmed/29016551/

 

Paravertebral Block: basics and cancer recurrence

 

From J Anaesthesiol Clin Pharmacol. 2011 Jan-Mar; 27(1): 5–11.

Why do paravertebral blocks?

• Journal of Anesthesiology Clinical Pharmacology – Paravertebral Blocks

Paravertebral blocks and decreased cancer recurrence

• BJA 2010 – Efficacy and Safety of Paravertebral Blocks in Breast Surgery: a meta-analysis of randomized clinical trials
• BJA 2010 – Effect of Anesthetic Technique and Other Perioperative Factors on Cancer Reccurence
• Anesthesiology 2006 – Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis?
• BJA 2012 – Can anesthetic and analgesic techniques affect cancer recurrence and risk?
• ASA: Paravertebral Block Ups Breast Cancer Surgery Outcomes

Paravertebral block techniques

From NYSORA

YouTube paravertebral block from LSORA

• Anesthesiology News – Paravertebral Blocks: The Evolution of a Standard of Care
• YouTube Ultrasound-Guided Paravertebral Block
• NYSORA – Paravertebral Block: Landmark Technique
• Paravertebral Block Landmark Technique
• NYSORA – Paravetebral Block: Ultrasound-Guided Technique

But wait… what about the potential side effects/adverse events from a paravertebral block?

Why not do a TIVA with propofol and dexmetetomedine and local anesthesia via surgeon?  Where’s that study to compare?

** Update **  July 20, 2016 –> What about the PEC 1&2 Blocks as well as Serratus block?

Prolonging blockade with adjuvants:

• IOSR J of Dental and Medical Sci; Dec 2015. Comparative study of bupiv with dexamethasone and bupi with clonidine through single space PVB for post op analgesia in thoracic and abdominal surgeries.
• 0.125% Bupiv + clonidine (1mcg/kg) vs 0.125% bupiv + dexamethasone (4mg): greater duration of analgesia in the dexamethasone group.