Another great presentation. I have found a Tuohy needle helpful. With a non-Tuohy needle I had a few injections into the transverse process periosteum which is really painful. Also helps with tip visualisation as the Tuohy needle tip is so distinctive.
Our vascular surgeon often performs upper extremity arteriovenous fistula surgery for hemodialysis access with a medial arm incision high in the upper arm, where the interscalene block does not provide surgical anesthesia. In these patients, if they're thin, I administer a T2 ESB and advise the surgeon that ES blocks only provide proximal medial arm analgesia not surgical anesthesia like the interscalene or supraclavicular blocks provide for the remainder of the upper extremity. For obese patients, I perform an old-fashioned "intercostobrachial" (field block) of the upper medial arm. This arrangement seems to work well for proximal medial AV fistula surgery. Anybody care to comment? Thank you Dr. Chin.
I Always use the ultrasound guided Supraclavicular plus an intercostobrachial nerve block for that surgery and so far I´ve been very successful , I used to rely on a subcutaneous infiltration for the medial side of the arm but with the ultrasound you get way better results.
Hi do you do this for breast recon surgery? Do you then put a catheter in so that the duration of the block will outlast the surgery which typically will take 10 hours?
Hi Shin Yuet! Major breast recon (TRAM or LD flap) is not done at my hospital, so I have no direct experience. As a general princple, you could certainly insert an ESP catheter to allow for topups and to prolong duration. The question is what level to place the catheter at - and that will depend on where the majority of the postop pain is coming from. Which may vary from surgery to surgery - and this is where your own experience will come in. Happy to connect and discuss offline if you like.
@@shinyuetchong4070 most available data suggests effect of something like bupivacaine or ropivacaine is most evident within the first 12h. Colleagues who utilize manual intermittent boluses tend to go with top-ups every 6 or 8 hours. This is also limited/determined by manpower availability. Those who use programmed intermitted bolus infusion pumps use intervals of anywhere from 3-6 hours typically (0.2% ropivacaine or similar)
No I haven't. This is mainly because our surgeons would be uncomfortable with this. Personally though, I don't see a big advantage in avoiding placing an LMA or ETT in most patients - which would be the only major difference between my current GA technique (light propofol-remi TIVA) and a sedation technique (I don't believe there are many breast cancer surgery patients who want to remain truly awake). I don't use volatile agents, and 'm not giving any long-acting opioid anyway. I would say that a paravertebral block will offer more consistent and reliable anesthesia if you want to go that route - check out the video by Dr Amit Pawa, who is a master at this. ua-cam.com/video/I1t3URriOsI/v-deo.html
Sorry I don't do this block so I can't really comment. But I think the scapula would prevent you from accessing this level more laterally as in a true RISS.
I don't place catheters for this indication. But as a general rule, I deliver the entire loading bolus (e.g. 20ml) and then thread the catheter. I try to have at least 3-4cm within the target ESP space.
Thank you for your precious lecture. In 1:28, my friend is coming! I am very glad he is fine!
Another great presentation. I have found a Tuohy needle helpful. With a non-Tuohy needle I had a few injections into the transverse process periosteum which is really painful. Also helps with tip visualisation as the Tuohy needle tip is so distinctive.
Thanks for the useful tip!
@chris wong: Do you abrade your tuohy needle for better usg visualisation
@@markoselparet No, an 18G Tuohy is usually well visualised and the tip is so distinctive
@@markoselparet Interesting. How do you abrade the needle?
Our vascular surgeon often performs upper extremity arteriovenous fistula surgery for hemodialysis access with a medial arm incision high in the upper arm, where the interscalene block does not provide surgical anesthesia. In these patients, if they're thin, I administer a T2 ESB and advise the surgeon that ES blocks only provide proximal medial arm analgesia not surgical anesthesia like the interscalene or supraclavicular blocks provide for the remainder of the upper extremity. For obese patients, I perform an old-fashioned "intercostobrachial" (field block) of the upper medial arm. This arrangement seems to work well for proximal medial AV fistula surgery. Anybody care to comment? Thank you Dr. Chin.
I Always use the ultrasound guided Supraclavicular plus an intercostobrachial nerve block for that surgery and so far I´ve been very successful , I used to rely on a subcutaneous infiltration for the medial side of the arm but with the ultrasound you get way better results.
@@intestinomedicinoyeah ultrasound is definitely the way to go
Great presentation! if inserting a catheter, usually how many centimetre past the needle tip?
I'd say at least 2cm to minimize dislodgement; and not more than 4cm to avoid it going somewhere else.
@@KiJinnChin Thank you! Love your work.
thank you
What about ur thoughts on cervical spread & unwanted side effects since we r injecting at higher level?
Hi do you do this for breast recon surgery? Do you then put a catheter in so that the duration of the block will outlast the surgery which typically will take 10 hours?
Hi Shin Yuet! Major breast recon (TRAM or LD flap) is not done at my hospital, so I have no direct experience. As a general princple, you could certainly insert an ESP catheter to allow for topups and to prolong duration. The question is what level to place the catheter at - and that will depend on where the majority of the postop pain is coming from. Which may vary from surgery to surgery - and this is where your own experience will come in. Happy to connect and discuss offline if you like.
@@KiJinnChin Thank you! How long does the single shot ESP last in your experience and when do you top up if you insert a catheter?
@@shinyuetchong4070 most available data suggests effect of something like bupivacaine or ropivacaine is most evident within the first 12h. Colleagues who utilize manual intermittent boluses tend to go with top-ups every 6 or 8 hours. This is also limited/determined by manpower availability. Those who use programmed intermitted bolus infusion pumps use intervals of anywhere from 3-6 hours typically (0.2% ropivacaine or similar)
@@KiJinnChin thank you!!
Have you ever tried it as a stand alone technique with sedation for oncologic vreats surgery?
No I haven't. This is mainly because our surgeons would be uncomfortable with this. Personally though, I don't see a big advantage in avoiding placing an LMA or ETT in most patients - which would be the only major difference between my current GA technique (light propofol-remi TIVA) and a sedation technique (I don't believe there are many breast cancer surgery patients who want to remain truly awake). I don't use volatile agents, and 'm not giving any long-acting opioid anyway.
I would say that a paravertebral block will offer more consistent and reliable anesthesia if you want to go that route - check out the video by Dr Amit Pawa, who is a master at this. ua-cam.com/video/I1t3URriOsI/v-deo.html
@@KiJinnChin thank you for your answer!
What about rhomboid intercostal block at level T2-T3. Will it work for analgesia following breast surgery?
Sorry I don't do this block so I can't really comment. But I think the scapula would prevent you from accessing this level more laterally as in a true RISS.
Sir how much volume do u prefer to put prior to insertion of catheter ? Secondly could u please share us ur catheter insertion depth ?
I don't place catheters for this indication. But as a general rule, I deliver the entire loading bolus (e.g. 20ml) and then thread the catheter. I try to have at least 3-4cm within the target ESP space.
@@KiJinnChin thank u!
Brilliant thanks