"Caveat Emptor": As an INDIRECT method of achieving local anesthetic delivery to the ventral rami and spinal nerves, there will inevitably be a large range of effectiveness for in any individual patient. This is the trade-off for enhanced safety and feasibility. The ESP block should therefore always be just ONE component of a multimodal analgesic/anesthetic strategy. Also note, the block videos in this talk have been deliberately chosen to show that the imaging with the ESP block is not always as straightforward as many of us make it out to be!
Dr Chin, If possible, please you could provide us with a separate video for lumbar erector spinae block. We use it for lumbar erector spinae block and I feel it is a lot more difficult. Any tips and tricks to improve success would be most appreciated. BTW, we from Singapore are proud of you and look upto you.
What is the protective dressing you have under the pajunk e-cath at 10:07 ? I have seen issues with pressure injuries with erector spinae blocks with this set but this looks like a good protective measure
It's a dressing designed for epidural catheters originally, (itsinterventional.com/products/epi-guard/) but Pajunk has indeed adopted it for its e-caths, and they market it now as the Fixocath - pajunk.com/products/regional-anaesthesia/accessories/fixocath/
Dexmedetomidine is cost prohibitive there? One vial of dexmedetomidine, containing 2ml or 200mcg of dexmedetomidine, costs roughly 25€ here. If you use 50mcg per 20mL syringe (which is the largest ammount I am personally comfortable with), 1 vial should be sufficient for 4 20mL syringes of analgetic mixture, making it 6,25€/syringe. How much does it cost there, if cost is the deciding factor? Worth noting: the combination of dexamethasone and dexmedetomidine affects duration of blocks performed with ROPIVACAINE far more than it does bupivacaine or levobupivacaine (I am unable to explain quite why that is). I am able to achieve up to 72h of complete analgesia with full mobility in IPACK and adductor canal blocks for total knee arthroplasty this way, for example. I have insufficient data on duration of ESP blocks using these 2 adjuvants at the moment. Hope this helps. Thank You for sharing this amazing content!
Thank you so much for sharing your insights! Gao et al (Front Med (Lausanne). 2021 Nov 25;8:577885. doi:10.3389/fmed.2021.577885. PMID: 34901039; PMCID: PMC8655682) have confirmed your impressions of the dexa-dexmed combi in a RCT. Definitely worth exploring. Do you have any concerns with hypotension or bradycardia at the doses of dexmed you use?
@@uramalakia we don't have it yet in Canada, so no direct experience. Not sure about how suitable it is for anterolateral torso, since bulk of the depot will remain in the ESP and dorsal rami (based on MRI images).
Thank you for another informative video- answered many questions I had regarding needle placement and catheter technique. Do you have any tips for trainees regarding US and needle visualisation? As the back is not a flat surface I often need to angle my probe medially to acquire a good image, but at the cost of losing my needle.
Hi Lisa! You are very astute with your comment on probe angulation! I find exactly the same - I am often angling/tilting my probe (which is an unconscious move that one acquires with experience in USGRA generally) to get the best possible image of the fascial layer. And so I too am often not inserting my needle in-line with the beam initially, despite it apparently being in the center of the probe's short edge. If this happens, I usually slide my probe medial-lateral to ascertain whether the needle is lying medial or lateral to the beam; then I either withdraw and adjust the needle insertion site (if the error is very large), or more often I pivot the needle trajectory into the beam so that the needle is slightly tangential, with the needle tip visualized but not the proximal shaft. Accuracy of initial needle insertion can be improved by using the LA infiltration needle as a finder, before inserting the block needle.
Hello, Thank you for this very didactic video. What hard data do you have on the real efficacy of adding epinephrine to ropivacaine to decrease Cmax and Tmax in fascial plane blocks? Is this effect real? Or do we have to settle with the hope that it will act as a marker of intravscular injection? 10.1016/J.BJAE.2019.05.001 and 10.1011/anae.15641 Also, DUKE RAP was advocating Adrenaline 2,5mcg/mL in one of their videos. In what way is 5mcg/mL better? Thank you for your answers.
Yes the effect is real and shown in studies, e.g. J Anesth. 2014 Aug;28(4):631-4. doi: 10.1007/s00540-013-1784-4. Its purpose is not as a marker of intravascular injection as this is highly unlikely. It is there to inhibit systemic absorption. This is also why the higher 1:200,000 or 5 mcg/ml concentration is advocated. This should not be confused with the modern use of 1:400,000 oro 2.5mcg/ml epinephrine for peripheral nerve blocks, where the purpose is indeed to serve as a marker of intravascular injection, and to minimize the theoretical concern of vasoconstriction of vasa nervorum (neural blood vessels) that might increase risk of neural deficits. This last point was why there was a move away from 5 mcg/ml which had been traditionally used in PNBs. Furthermore in PNBs, total LA dose is usually not close to max limits, nor are the surrounding tissues as well-vascularized as muscle, so systemic absorption causing LAST is not generally a concern. These are good questions. My personal approach to decision-making in questions like this is to drill down as far as possible to identify the fundamental concerns and issues, and to determine the most scientific and logical principles to apply, and then deciding how much importance to apply to each consideration in a specific given situation/scenario, especially where they are conflicting.
!["How-To" Guide - Paraspinous Lumbar Puncture / Spinal Anesthesia [Lateral Position]](/img/n.gif)
"Caveat Emptor": As an INDIRECT method of achieving local anesthetic delivery to the ventral rami and spinal nerves, there will inevitably be a large range of effectiveness for in any individual patient. This is the trade-off for enhanced safety and feasibility. The ESP block should therefore always be just ONE component of a multimodal analgesic/anesthetic strategy. Also note, the block videos in this talk have been deliberately chosen to show that the imaging with the ESP block is not always as straightforward as many of us make it out to be!
Dr Chin, If possible, please you could provide us with a separate video for lumbar erector spinae block. We use it for lumbar erector spinae block and I feel it is a lot more difficult. Any tips and tricks to improve success would be most appreciated. BTW, we from Singapore are proud of you and look upto you.
What is the protective dressing you have under the pajunk e-cath at 10:07 ? I have seen issues with pressure injuries with erector spinae blocks with this set but this looks like a good protective measure
It's a dressing designed for epidural catheters originally, (itsinterventional.com/products/epi-guard/) but Pajunk has indeed adopted it for its e-caths, and they market it now as the Fixocath - pajunk.com/products/regional-anaesthesia/accessories/fixocath/
@@KiJinnChin Brilliant thank you for this
Thank you. Which dexamethasone do you use in LA?. Could we use the type, we use in IV injection, sir.?
교수님 항상 잘 보고 있습니다
Dexmedetomidine is cost prohibitive there? One vial of dexmedetomidine, containing 2ml or 200mcg of dexmedetomidine, costs roughly 25€ here. If you use 50mcg per 20mL syringe (which is the largest ammount I am personally comfortable with), 1 vial should be sufficient for 4 20mL syringes of analgetic mixture, making it 6,25€/syringe. How much does it cost there, if cost is the deciding factor? Worth noting: the combination of dexamethasone and dexmedetomidine affects duration of blocks performed with ROPIVACAINE far more than it does bupivacaine or levobupivacaine (I am unable to explain quite why that is). I am able to achieve up to 72h of complete analgesia with full mobility in IPACK and adductor canal blocks for total knee arthroplasty this way, for example. I have insufficient data on duration of ESP blocks using these 2 adjuvants at the moment. Hope this helps. Thank You for sharing this amazing content!
Thank you so much for sharing your insights! Gao et al (Front Med (Lausanne). 2021 Nov 25;8:577885. doi:10.3389/fmed.2021.577885. PMID: 34901039; PMCID: PMC8655682) have confirmed your impressions of the dexa-dexmed combi in a RCT. Definitely worth exploring. Do you have any concerns with hypotension or bradycardia at the doses of dexmed you use?
@@KiJinnChin Do You have access to liposomal bupivacaine? Reading about it seems like it would make all this alchemy redundant. 😊
@@uramalakia we don't have it yet in Canada, so no direct experience. Not sure about how suitable it is for anterolateral torso, since bulk of the depot will remain in the ESP and dorsal rami (based on MRI images).
@@KiJinnChin That's an interesting point I hadn't thought of.
i'll second KJC to ask - do you encounter any issues with bradycardia/hypotension with that concentration/dose of dexmedetomidine for PNB?
Excellent video!
Could ESP block replace almost epidural catheter oneday, sir.
Excellent!
Thank you for another informative video- answered many questions I had regarding needle placement and catheter technique. Do you have any tips for trainees regarding US and needle visualisation? As the back is not a flat surface I often need to angle my probe medially to acquire a good image, but at the cost of losing my needle.
Hi Lisa! You are very astute with your comment on probe angulation! I find exactly the same - I am often angling/tilting my probe (which is an unconscious move that one acquires with experience in USGRA generally) to get the best possible image of the fascial layer. And so I too am often not inserting my needle in-line with the beam initially, despite it apparently being in the center of the probe's short edge.
If this happens, I usually slide my probe medial-lateral to ascertain whether the needle is lying medial or lateral to the beam; then I either withdraw and adjust the needle insertion site (if the error is very large), or more often I pivot the needle trajectory into the beam so that the needle is slightly tangential, with the needle tip visualized but not the proximal shaft.
Accuracy of initial needle insertion can be improved by using the LA infiltration needle as a finder, before inserting the block needle.
@@KiJinnChin Thanks very much!
Thank you so much! As always, excellent explanations and tips.
Great video! Thank you!
Thanks for sharing your knowledge. Always very didactic.
Hello, Thank you for this very didactic video. What hard data do you have on the real efficacy of adding epinephrine to ropivacaine to decrease Cmax and Tmax in fascial plane blocks? Is this effect real? Or do we have to settle with the hope that it will act as a marker of intravscular injection? 10.1016/J.BJAE.2019.05.001 and 10.1011/anae.15641 Also, DUKE RAP was advocating Adrenaline 2,5mcg/mL in one of their videos. In what way is 5mcg/mL better? Thank you for your answers.
Yes the effect is real and shown in studies, e.g. J Anesth. 2014 Aug;28(4):631-4. doi: 10.1007/s00540-013-1784-4. Its purpose is not as a marker of intravascular injection as this is highly unlikely. It is there to inhibit systemic absorption. This is also why the higher 1:200,000 or 5 mcg/ml concentration is advocated.
This should not be confused with the modern use of 1:400,000 oro 2.5mcg/ml epinephrine for peripheral nerve blocks, where the purpose is indeed to serve as a marker of intravascular injection, and to minimize the theoretical concern of vasoconstriction of vasa nervorum (neural blood vessels) that might increase risk of neural deficits. This last point was why there was a move away from 5 mcg/ml which had been traditionally used in PNBs. Furthermore in PNBs, total LA dose is usually not close to max limits, nor are the surrounding tissues as well-vascularized as muscle, so systemic absorption causing LAST is not generally a concern.
These are good questions. My personal approach to decision-making in questions like this is to drill down as far as possible to identify the fundamental concerns and issues, and to determine the most scientific and logical principles to apply, and then deciding how much importance to apply to each consideration in a specific given situation/scenario, especially where they are conflicting.
@@KiJinnChin thank you so much for your thorough answer... you Never disappoint! take care.
Many thanks prof
Very informative, thank you :)