S1:E2 "ESPecially For You (Erector Spinae Plane Blocks)"

Whether you block in the sitting, prone, lateral, or even the supine position, we've got some hot tips and tricks to improve your erector spinae game. I'm Amit Pawa. We are seriously chuffed to be able to share this episode, which is ES special for you. I'm Jeff Gadsden. And this is Block it like it's hot. 

Hey, Jeff. We're back here now for block it like it's hot episode two. How have you been? Oh, episode two. Can't believe it. 

Yeah. Doing great, mate. Chuff levels are high. Hold on. Hold on a minute. 

Hold on. I'm doing great, mate. What is that? I mean, you you're not Australian. What was was that an Australian accent I took to the Well, accent, no, sadly. 

But I I'm feeling very Commonwealth today. I mean Okay. Yeah. I spent some time in Australia. I'm a I'm an Anglophile. 

I love all things. London is one of my favorite cities in the world. I if I could if I could live in London, that'd be amazing. But Mhmm. Do you do you use the word chuff on a regular do you is that a thing? 

Do You It's actually I think I think for The UK listeners, you gotta be careful how you use that. Yes. So we are quite often, we will be chuffed by things. So you say, you know what? I'm seeing so chuffed with myself today because I performed I performed the most perfect sciatic nerve block. 

So, yeah, we can be chuffed about things. The reason why I say you you gotta be careful is that one of my good friends can also use the term in a derogatory manner. That was a load of chuff. I see. But I think I know where you're getting it. 

So, yeah, I feel when I'm having a great day, I'm feeling chuffed. Is that where you're going with that? Yeah. Exactly. So I so I used it I used it a couple months ago in the block area at at in exactly the same way. 

Yeah. Mate, that that was a I'm so chuffed about the spread of that Q L six block or whatever it was. Yeah. Yeah. And and I had a bunch of blank stares. 

And so I had to I had to explain what feeling chuffed was, and I ended up drawing out a chuff chart. You have a chuff chart? Well, now you see with a whiteboard where we keep all our, you know, notes in a block area. So I go, alright. Get a marker out, draw a chuffed chart. 

So here here I am at 06:30 in the morning, starting out feeling good. My chuffed levels are like a seven, but then, you know Start off at a seven. You're starting chaff levels at seven. I think so. I think so most days. 

Yeah. You know? Is that is that after coffee or before coffee? It's well, that's I have coffee on the way to work, and then there's a a group sort of coffee break at about 08:30 or so. So that's probably So your pre caffeine chuff level is a seven. 

That is that is why you're always a happy guy because I reckon my pre coffee chuff levels are probably a two. Oh, really? Oh, wow. Okay. Yeah. 

Okay. But then, you know, as as as I was illustrating how at the day, you know, the chuff levels go up and down. And so, you know, block doesn't work, and you're just down to a two. And then, you know, I had a good discussion with the trainee up back up to a nine, etcetera, etcetera. So now it's become a thing now. 

And I'm I'm proud to say that I've we've we're now documenting and and sharing chuff levels, amongst our team. Great idea. What a great idea. How you been? Well, you know, I've had I've actually had a great week. 

Lots of fun, lots of teaching, a bit of lecturing, which is great fun. But you know what? I had a day where my chuff levels dropped to about a two because I had a I had a obviously, I can't share many of the details, but let's just say I did a block, and everything looked good. And at the end of the operation, it didn't work so much. So that was that was quite a leveler. 

You know, people say you're only as good as your last block. So there's one thing that sticks out in my mind, and that was, yeah, that was quite a humbling experience. Oh. So I had a a a chuff down. Oh, man. 

That is a That sounds terrible. That's a that's a bummer. What's what's it like having a fail block? Oh, yeah. Very funny. 

So you mean never in the life of Gadsden have you ever experienced one of those? I I I'd be lying. Don't answer the question. No. No. 

It's, it it is it is humbling. Right? Like, I mean, you I mean, I I figured I had everything lined up. I did everything that I would do normally. All of the the standard indicators of success were there. 

However, it did not translate into postoperative analgesia. So, you know, that was we had to crack out some some opiate, and we had to use some of that. I use the o word now. And, actually, everything was fine. Everything was fine. 

Everyone was safe. Everyone got happy, but it it was just something to kind of, it leveled me a bit. So I didn't block it like it was that hot on that tape. You know, it it happens. And there are times when I'm like, I'll say to the surgeon or I'll say to the the trainee, look, I'm 85% confident this is gonna be great. 

Yeah. But it it wasn't a great image and for whatever reason. But once in a while, get a head scratcher. You're like, man, that looked really good. And I just don't know why it didn't set up the way it should have. 

But Yeah. You're human like the rest of us, Amit. I can't Apparently. Apparently. And and and maybe, I don't know, it might feature at some point later on in, in 2023, but we'll talk more about that later. 

Jeff, tell me what tell me what your week was like. Please tell me it was better than mine. Yeah. Chuff levels were good. Yeah. 

I had an interesting week, actually. I just got back from New Mexico, where I was teaching a workshop on cervical ESP or cervical ESP as you might say in The UK. That is very cool. Yeah. For spine surgery. 

So the this group is really interested in rolling out c spine ESPs for their for their spine surgery. That's really fascinating. But so and you were you were specifically teaching them how to do that. Right? Yeah. 

They had they had started to do, thoracic and lumbar ESP blocks and want to do c c spine ESPs, but, had not yet crossed that barrier. So I was sort of helping them out. Well, you know what? That's really, really funny because I figured that this week, for our first sort of non intro, topic, we go big and we tackle one of the most controversial aspects of modern regional anesthesia. That was my posh voice there. 

Oh, yeah. Oh, you mean the use of nerve stimulation? Hey. Hey. No. 

Not at all. I was talking about about ESP blocks. And I thought, you know what? So, I mean, you know, you've just been teaching yourself, so clearly people wanna know about it. So I thought it'd be great. 

We we talk about ESP blocks. We covered some tips and tricks, some of the controversies, and then, you know, whether we need them or not. Because, you know, I was gonna say to you, when you're working in the cervical area, what's wrong with a little bit of local lancetate by the surgeon to the skin? And maybe those are things that we could we could kind of cover. And you know what? 

We've had some questions that have come up in advance already from Twitter. There's a a chat called Gavin Sullivan on Twitter who said, you know, I want some tips for what to do when the ESP plane or the Eretz Spani plane is very deep. So what are the type of modifications, we might wanna do? So what do you think? Oh, love that. 

I think that's a a great topic. And Controversial for sure. I think there's some, it's the Marmite of blocks. Was that a fair to say? Oh, yes. 

Yeah. It's exactly the Marmite block. So so, Jeff, let's start. Let's start. When we're talking about ESP block, why do you think the block is so controversial? 

Yeah. It's interesting. Right? I think I think there are two reasons that I can think of. One is despite getting the appropriate spread as as it's described, many times we'll go and test the patient's belly or chest and they don't have a demonstrable sensory block. 

And that's that's weird and doesn't add up. And as a as a regional anesthesiologist, I'm used to putting local anesthetic next to nerves and hey, the arm goes numb or the leg goes numb. But here's a situation where I'm putting local anesthetic in a plane and I get a patch of numbness on the back but nothing on the front that I can see. And yet the patients do feel good more or less. So that's I think that's that's part of it. 

And then the other part, I think, is some accumulating cadaver evidence showing a lack of spread ventral to the transverse process. And so if we think that this block works by local anesthetic sort of spreading anteriorly in front and sort of, you know, being a backdoor to the paravertebral space You mean a paravertebral by proxy block? Yes. That's that sounds much more professional than backdoor to the yeah. Yeah. 

But so I think, you know, some of us read these cadaver studies or do these cadaver studies and think, well, we okay. If the dye is only posterior to the tipi, how is this supposed to work in the end? You know, I early on when we were, you know, learning how to do these and playing around with this, we had had some failures or at least relative failures. And I kinda got a bit skeptical and said, alright. Fine. 

Listen. I'm gonna get one of my colleagues to do an ESP on me so I can see what this feels like. Yeah. No. With local anesthetic. 

So you actually had a an active ESP block performed on yourself. Thirty mils of one and a half percent mepivacaine. And Mhmm. Yeah. And certain and sure enough, it was, so a, it was not that comfortable Wow. 

To go through it with zero sedation. Were you were you were you sitting? Were you supine? What what what oh, not supine. Were you sitting or prone or lateral? 

What position were you in? Yes. Supine would have been huff. The old through the through the bed through the bed technique. You're you know, you I've always thought of you as an innovator, and so that's I I look forward to that that case report. 

Yeah. Yeah. No. I sitting. I was sitting. 

And and so my colleague did one from from the, it was in, like, mid thoracic. And and I had a I had, sure enough, like, this numb patch on my back. I could have gotten my back tattoo that day. It would've been perfect. Hey. 

That's a great indication, man. We should we should patent that. Yeah. So it's nothing, in the front or the side. So that was a bit disappointing. 

I I I then went we sort of sort of wrapped this up, and I then went to a meeting. And I was sitting in the meeting and began to feel a bit jittery. And I'm like, oh my no. I'm gonna get last. So I pull pull out my phone and was texting. 

Hey. Please bring ambu bag to Conference Room B. It was all good. I'm not For those of you who are wondering, when he said he wanna get last, it doesn't mean he was gonna be last or left in the meeting. He was talking, of course, about local anesthetic systemic toxicity. 

So please don't try this at home. We don't wanna hear stories about anybody else. Don't replicate this experience. No. It was all fine. 

I was I didn't, I didn't, in fact, have last. But, but the fact what remains that despite a lack of profound sensory block in the anterolateral parts of the the trunk, we still seem to get an effect. Do you find the same thing? You know, I do. And, it to me, it totally makes sense that you get you you know you've seen the anatomy. 

You know you're gonna get a dorsal ramus. That's not a surprise. So why it would work to cover the posterior aspect to the back, I totally get. I am a believer that it may go a little bit deeper, but if I talk about my own personal experience, it's slightly different because I think that where you actually deposit the local anesthetic is key. And I wonder whether some of the initial people you know, people's initial experiences, what they actually maybe end up doing is an analogous to a rectus sheath block, for example, where they deposit local anesthetic between the erector spinae group of muscles and the and the sheath, but they don't go deep to the sheath. 

They don't lift the sheath up off the transverse processes because you can get that kind of pseudo intramuscular injection if you're not careful. And I think it's key that you you you're deep to that fascia. And certainly speaking to one of the the original the original authors of the technique, Kijin Chin, he talks about how key it is to be deep to that fascia. And I think you've described it in one of your Blocktobo videos as well. Right at the beginning, what people were doing was when they aiming for the periosteum of the transverse process, that's when they were maybe running into problems. 

Right? Depends what needle you're using, but that can definitely affect the quality of the analgesia you get. And you've described a really nice modification to to the endpoint or where you aim for. Tell tell us a bit more about that, Jeff. Yeah. 

So I I 100% agree. I think that where we were failing early on with ESP was coming down and hitting the top of the process and, in effect doing an intramuscular injection. And in fact, we we we did a cadaver study a while back looking looking at dye spread. When what interestingly, when we dissected open the cadaver, we could see the ES muscle laying there. Yes. 

And the dye had spread within the sheath of the muscle around to the dorsal side like it was inside the casing of a sausage. It was really interesting. There's another food reference. You and your food reference, Gadsden. I'm just always hungry. 

That's my secret. Okay. So it's like you were within the fascia, but but it surrounded the muscles within that. Okay. It was fascinating. 

So it traveled it traveled laterally and then around inside this the sheath or casing of the ES muscle, and then obviously didn't go ventral. And the implication as you just outlined it was is that you we were not deep enough. We were not through the the, epimysium of the muscle. So so I like instead of coming on the top, we we've certain since learned to come to the corner of that transverse process and just sort of, like, snick underneath the yeah. That was a yeah. 

So, yeah, you just pop through. And then, to to really make sure that you're deep to that the the ventral surface of the muscle, and that seems to to be a difference maker in terms of outcomes. So listen. I'll I'll I'll I'll let you into a secret here. So when ESP first was described, I started to you know, I wanted to look for as many opportunities as I could to use it. 

So I started using it a lot for breast surgery. And, you know, I've got to be honest, I was disappointed. So I did preemptive analgesia. I've got I got my patients in the prone position because I was often, teaching trainees, and I didn't want them to be stressed about, you know, time or the patient not being sedated whilst we the patient's well sedated in the prone position. We got them, to do the block, and I was ever so disappointed with the quality of analgesia. 

And I would say definitely was worse than my experience using interpectral and pectorisoratus blocks. Did you notice I used the word in my picture? I did. So one of the ways I used to get my, my trainees or my fellows to find, the correct plane, so deep to the fascia, was to overshoot intentionally. So can't you know, aim aim for that corner, but then overshoot intentionally where there would be in that intertransverse process place. 

And then I get to withdraw the needle and come back until you got that inject the local and so that he get that pulsatile lifting of the muscle. And then it occurred to me, well, hold on. You know, I've been involved, with some Canadian regional anesthes with describing a technique that goes deep to the erector spinae plane, but in the intertransverse process, the originally called the MTP block. So, actually, I started doing a hybrid technique where I did an erector spinae plane injection with a, you know, a bolus of local anesthetic, and I made an iatrogenic hole deep into the intertransverse space and injected about five cc's or five mils of local anesthetic there often, but not always associated with a drop in pleura, not quite a noise like you were after, but something, some some kind of reference to that. And you know what? 

That was that made a difference. And I don't know whether creating that artificial hole, you know, meant that depot of local anesthetic that I injected then had a definite route through. But when I do a hybrid technique in breast surgery, I get pretty good results. The other place where I've used it, is a limited experience in spine surgery. My initial experience in lumbar spine surgery has been pretty good, but I haven't done enough cases to really get a grip of it. 

But also rib fractures. Holy moly. It shouldn't work for rib fractures. It should not work for rib fractures. But I've got experience. 

I've got a couple of patients in my mind I remember came in in agony. And as we were sticking the catheter down and getting the pump programmed, suddenly, they developed smiles on their faces. So don't know, man. It's a it's a weird kind of thing. It works for me, in some circumstances, but not all. 

Tell tell us about your experience. Yeah. That's really interesting. I I I have we've had similar experiences, and I I think just to go back to your technical points and and tips about the making the hole and and getting deep. I think that's really, really important. 

And that's sort of, yeah, what we're doing with the getting to the corner. Just making sure you're deep to that. That's interesting about the perforated making bunch of perforations in the in the the fascia. I'm not saying we pet them, but, you know, may maybe this No. No. 

I think it's it's really interesting. I mean, it's so you're getting closer to the pervertebral space than than I think a lot of people are on purpose. So that's good. We rib fractures, hundred percent agree. And and what's what's always interesting and challenging about trauma is these patients aren't optimized for their procedures. 

They came came in on oral anticoagulants and so preclude them from getting an epidural block. We are both paravertebral lovers a 100. And so that to me that's the gold standard thoracic block. Right? That's the gold standard. 

Right? But some some of my colleagues, and I'm sure this is widespread, are a little reluctant to put do a paravertebral in someone who's anticoagulated. So the ESP has become a nice plan b block in that in that case. And I I have a very vivid recollection of a patient who came in and was really about to be intubated because he was having such trouble breathing. And then we took the CSP, and and it just was you know, he's like, alright. 

Where's my magazine? I'm ready to to just relax and and have a read. We've done it for breasts. Although, frankly, we'll do paravertebral or the Yep. The PEX blocks. 

Honestly, spine has been a complete win for us. You're talking about big, juicy spine cases. Right? Juicy, dry. So so as opposed to, a single level decompression. 

Yeah. I'm talking about a multilevel fusion. So so which what do how do you pick your spine cases? I think that's a good point. There is a there's a sweet spot there. 

Certainly, a minimally invasive single level microdiscectomy, it can be managed lots of different ways, and and maybe you don't need to put sixty mils of local anesthetic in the in the lumbar spine. So to me, think sort of three to five level decompression or fusion instrumentation case is is perfect. When you start getting into some of the more extensive deformity cases, sort of like, you know, t one down to sacrum, then you get into issues of, well, how do I apportion my local anesthetic and kinda do a single injection in the middle of that, or do I do four separate injections, two on each side? And that sounds like a that sounds like a multiple injection type scenario. Right? 

Well, you know, there's there's something else I'm I'm I'm kind of jumping in on your tips here, but I think it's useful. There's something else that I heard, Key Jin. I've this is second time I mentioned his name, but he might tell you that he's one of my, one of my regional inspirations. There's something I heard him talk about, which is actually really key. So, obviously, things are different in your setup where you may have a block room. 

But quite often, we might be in a position where, you're gonna do the blocks once the patient's anesthetized because you can, and you get them prone. And the things that my surgical colleagues would particularly dislike is them spending fifteen to twenty minutes drawing up and getting set up to do a block when they're thinking, hold on. The patient's prone. Let's go. So it's if you're gonna do these blocks post induction, it totally makes sense to be drawn up, prepped, ready, even have the probe cover on the machine so everything's ready to rock and roll. 

Right? 100%. I mean, optimizing your workflow so you're you're you're minimizing the time the surgeon's standing there tapping their foot, glaring at you is, is is helpful. We do like to do them in the preop block area. And that makes perfect sense. 

If you've got the time and the setup for that, then you're not under any pressure. You can do it in your own time, in your own way, and, and optimize positions and not feel the pressure of anybody else. Totally. And we're we're we're fortunate to have, you know, trainees and and people that facilitate that that workflow. But if but I think a lot of places will do them for spine once you're induced and flipped. 

And, and I you know, there's they're they're pretty quick to do, so it doesn't take a lot of time. They are. They are. And now are using them, for any abdominal cases? So the answer is yes, but qualified in in that I often think there are better blocks depending on the incision type. 

So if I get a call from my colleague and and say, Jeff, know, were they were aiming to go laparoscopic, but they've opened. Can you come and do one of your fancy blocks? I'll put on my cape and then run to the OR. But my first question I could just picture that. Stay tuned for that video. 

My first question, is it midline? And if it's midline, easy. Rectus sheath. And then if if it's if it's Yeah. Subumbilical and lateral, like a phantom steel incision, I I do I do like a tap block there. 

But for anything else, like if it's multiple we have we have one I mean, we have a surgeon that does Yes. We have a person. I don't wanna as well. Call anybody out here that does a robotic case with 15 port sites. And so I'm like, just open the patient up at this point. 

I mean, how is that minimally invasive? Yeah. So for So you got a lot of areas to cover. Right? You got a lot areas. 

So that's that's when I'll go to either a QL block or an ESP. And and how do I decide that? BMI. So if it's BMI over 30 Okay. Man, I I I struggle with imaging that anterior QL block a lot of times. 

Yeah. So I'll so I I think an ESP one of the reasons to to me, to my way of thinking that ESP has just taken off like wildfire is, well, a, it's safe. But b Yes. It's it's easy. It's simple to do. 

So if you're hitting a bone, it's easy to teach, easy to learn, and you feel you feel good about that. So, I mean so you're talking about, the the larger patient. Well, this will we might as well go straight into that question from Gavin Sullivan. So when you have a patient who is, with a BMI greater than thirty, and we that's a significant proportion of our patients to be fair. What are the tips? 

You know, I I I'm not afraid to pick up and use the curved array probe. That's probably the first tip I would say is sometimes, you know, you're trying to image, with a linear probe, especially one which just have you gives you that, limited footprint, the linear footprint, and you don't have the ability to enhance or augment that and turn on a virtual convex mode, then I won't be afraid to get out the curved array probe. I mean, what what do you think with those lot slightly larger patients? What do what do you use? No. 

A 100%. I think a a curved probe is really, really useful to get those deeper views. The other thing that I I do in the thoracic region is I'll always start way out lateral. So I'm seeing seeing ribs and pleura. And because that's a that's a very easy, easy, reproducible image to get. 

And you okay. Great. That's a rib. That's pleura. Perfect. 

And And that that's how many people would teach the paravertebral. I mean, that's how I teach my paravertebral anyway. We start off the ribs so you know where you are, and you watch the transition from from rib to transverse process. Right? Exactly. 

Yeah. Right. So then then I'll then I'll start to slide medial, and then you get that transition point from rib to TP. And I'll actually go back and forth multiple times on that. So just to convince myself, alright. 

Rib, TP. Rib, TP. And to to me, that's that gives you that confidence that, okay, I'm I'm gonna be putting the needle at the right spot. So another thing that I'll do, it what's hard about finding the TPs in the lumbar region for spine is there are no ribs. So what I'll do there is is again, start way out lateral. 

So I'm only seeing muscle and you can sometimes you can see ES, QL, and psoas muscle, but sometimes you just see a big bunch of muscle and no bones and then certainly start to slide medial. And then at some point, you'll get that trident view with the tips of the transverse processes, and then Yeah. Let you know you're there. That's that's a good spot to start to to start. Versus starting I've come across people whose, for lumbar spine ESPs, will start in the midline and then start to translate out laterally. 

And I think it's easy for people to get messed up with between lamina and TP sometimes. So But it's interesting. I've seen a lot of people with ESP in generally have inadvertent drift in their in their probe, and, actually, they can slide one way or the other. So I heard Sanjeeb Adhikari, who, you will know well, described the block. He told me that when he gets his residence to perform ESP blocks, once he's happy that they've identified the correct position, he will actually get a marker pen, a sterile marker pen, and draw a box around the probe. 

And the trainees are not allowed to let the probe leave the box, and that's one way of making sure they don't let their probe drift medial or lateral. Have you ever heard of that before? Yeah. That's really smart. I like that. 

I I hadn't. Yeah. It's clever. Right? Because quite often, I'll see yeah. 

Irrespective of what position the the patient's in, you know, you'll because you've been doing enough times, you can glance at the screen and appreciate from, from the pattern recognition that the the the person performing the block is at the right place. And then often what will happen is people will turn around to pick up some local anesthetic and then come back to to put local in the skin, and, actually, they've moved. Totally. But they won't necessarily have recognized that. So this this drawing a box around is something that, you know, I haven't used yet, but I think it's a clever idea. 

And I'm imagining it, like, being a bit like the the operation game. So as soon as someone drifts out of that box, it's yeah. Be a great idea. So so I guess the other question is and I don't know what you will think about this. So I'm I'm asking, and and I'm I'm interested genuinely in your response. 

Oh, controversy. Does it matter if the probe is slightly more medial towards what would be a retro lamina block or slightly more lateral, so you'd be doing the ES over the ribs as opposed to transverse processes? Do you think that that fundamentally changes the outcome that you'll get with that block? Personally, I don't. So you mean I've been giving my trainees a hard time the whole time when they're drifting? 

Well, you know, I I so in terms of outcome and what you'll get out of the block, I I'm not convinced that will make a difference. In terms of safety and staying away from the neuraxis and making entering the tissues at a at an appropriate spot, that might make a difference. But, you know, having dissected cadavers after putting dye in that space, you were talking about millimeters sometimes difference. And so I I don't I'm not convinced that it, you know, changes the block dynamics much. But I like like you, I will be compulsive about saying, no. 

No. You're too medial. Go back and to get that transition, and then I want you at the lateral most aspect of that transverse process. Yeah. But maybe we're being a bit too obsessive. 

I don't know. I I like to I like to replicate what I think is, you know, the original described technique and and not necessarily add in that many variations apart from that little hybrid technique I talk about. But but maybe we're obsessing about things that we don't need to. Perhaps. I also don't want someone doing a a thoracic epidural or thoracic spinal inadvertently without that volume of local anesthetic. 

So so I think I think that's that to me, that's the the safety, you know, lens looking at where to do that. Oh, and what's your what's your favorite position, to have the patients in? Obviously, supine as I incorrectly said earlier on, but prone lateral sitting. Do you have a preference? I do I do I do like doing them either lateral or prone. 

I sitting, I find what what's tough for me with sitting is I find that my I do get some drift and because I can't rest my elbow on something something firm like the bed. And from our workflow point of view, there are sometimes when I'm doing this at the end of a case. And so I'll I'll say, you know Yes. Fine. I'll be there in two minutes. 

Turn the patient on the side if you can, and then once I'm done, the block will flip them back and extubate. Yeah. So lateral becomes a convenient place. Prone is prone is great. I like prone. 

Prone is great if you can do that, you know, before that makes a big difference. The other thing about sitting position, of course, from an ergonomic point of view, you're lifting your arm away from your trunk. You're elevating it, and there's a easy point at which you can get fatigued. Right? And that will exacerbate that drift. 

So that's one of the things about, being having the patient sitting that can be an issue. And, also, if you're gonna be needling from from cordad to keffalad or cordad to cephalad, as you guys would say, you have to have the patient quite high up. So then, you know, people then tend to to to needle from the cephalad or kephalad part. Do you think it makes a difference whether you needle from below down or from or from below up or up down? Does it make a difference in your in your mind? 

We we haven't found a difference. I mean, we've we've done both, and it it just depends on What do you prefer? Whatever ergonomically makes the most sense for me at the time. So I'll I'll just Yeah. And and there are times when in the lumbar ones where the bulk of the booty gets in the way of the needle pass from from codex. 

So I'll come I'll come from kefalad in that in that, instance. But Are you saying kefalad especially for me, or would you say sendering normally? Especially. What? He's actually, for e. 

For you. Exactly. So listen, Jeff. There's I've I've interrupted you, but there's one thing that that's kinda being also great to me. What I see a lot of people do is draw up their local anesthetic in a syringe their choice, whether they're using a 20 or 30 or even a 60 cc syringe. 

They connect it up, and they're trying to find the space, and they're injecting as they go, and they go, no. Not there. A bit a bit more a bit more. And, actually, by the time they get down to what they consider to be the sweet spot, there's no local anesthetic left. So what should we do to minimize that? 

We're talking the same language here. I that's also a pet peeve of mine. So I'm a huge user of saline. So I'll put a I'll put a 10 mil saline flush on my, tubing for not just for ESPs, but for for most of the blocks we do. Because I don't I said I don't wanna waste that precious local anesthetic, especially if I'm looking at someone who's only forty five kilos and I dosing limits are are quite constrained. 

So, you know, get your needle partial away into the target, give it a little puff of saline, and you see the little whoop. It opens up. Advance your needle. There's another sound there, guys. You hear the whoop. 

Oh, that was that was too high pitched. There we go. Then you're free to to to puff away with the saline until you see that you're in the right spot, and then then switch to local. So what about is is there a critical point at which a volume of saline administered into that space will impact on the subsequent injection of local anesthetic? I mean, I think if you're limiting yourself to ten ccs, probably that makes no difference whatsoever. 

But what happens if somebody's really struggling to find it for whatever reason? They inject twenty mil or twenty ccs of saline and then try and put the low clonidine. Do you think that has a meaningful meaningful impact? I mean, think yeah. I think, practically, there's there's a limit to where how much you can put. 

But, really, I mean, the I put a ten cc on because it's convenient, but we're really usually only using a couple cc's. Because you because you can on the ultrasound screen, you can appreciate the deposition of, you know, half a mil or one mil. Smallest about smallest volumes. Yeah. Completely. 

So let's just say, so so you talked about spine. You talked a bit about breast, and you talked about abdominal surgeries. But have you performed ESPs at any of the other areas? So tell me about the neck. Tell me about the sacrum. 

I'm I'm curious to know. So I I I'm aware people are doing sacral ESPs. I haven't myself. So I'd I'd be interested to hear anybody's experience. If if you, if you have if you have experience and thoughts, please share it with because surprise, surprise, there are some case reports. 

In fact, there's case reports for probably every part of body, of these people. But but but I've heard a lot of people talking about for urogenital procedures, using sacral ESP. So I'm I'm curious to hear about that. As am I. But tell me about the cervical spine. 

So have you used it? Have you used it up there? Yes. Yeah. It's it's been, so our our spine surgeons were so impressed with our results for lumbar and thoracolumbar procedures that they're they came to us and said and it's usually the other way around. 

Usually, we're trying to push push the boundaries for this. But they came to us and hey. What do you guys think about doing this? And and I have to admit, I was a little nervous at the beginning about putting a decent volume of local in the cervical area. I mean, it's there's a lot of precious real estate there. 

Brachyplexus, phrenic nerve, lot of big vessels or so I'm told. And so As as well especially as some people using a cervical ESP as a as a by proxy technique for doing stuff at the front and getting brachial plexus blocks by proxy. So you put a large volume of local anesthetic around the neck. I mean, there's a lot of things that you can potentially interact with. Right? 

And you end up with a bilateral paralysis of the upper limb, for example. Agree. And I think that so one thing that we've done with the spine ESP procedure compared to our goals for, say, thoracoabdominal indications, we are hitting the top of the transverse process there and and just Yes. Putting it dorsal because I actually don't want to get any ventral spread. All I want is that is that dorsal ramus. 

And so for, you know, for lumbar ESPs, that is practically oftentimes the only way I can do it because it's so deep and the muscle is so thick. I Yes. I have a hard time appreciating that plane. So I'll just come down and hit the hit the transits process. But for cervical, I'll I'll find my ribs, count up to the first rib, and then slide over till I'm at t one, and I can see t one t one and c seven. 

Yeah. And they're fairly easy to see prominent transits processes. And so I'll just come down on either one of those. It doesn't seem to matter which one. With 20 mils, you should get spread up to c three or c two and then down to about t four, t five. 

Wow. You know? The first couple ones I did with this, I was I was my heart was in my mouth as I'm putting this patient off to sleep and waking them up at the end and thinking, have I caused brainstem anesthesia? Have I but no. We haven't seen any evidence of epidural spread. 

No influence on neuromonitoring for the case in terms of, you know, evoked potentials. And we haven't seen it and we haven't seen any brachial plexus block either. So so we're just and that and, again, I I am sticking to hitting the top of the transist process, the dorsal surface, and keeping it in the dorsal plane. So I I'm not trying to do the, perforator technique of getting underneath. Yeah. 

Yeah. Okay. So listen. I'm gonna play devil's advocate here. So before we talk about management of catheters and all the rest of it, why what is wrong in the cervical area when you don't have a large area? 

What's wrong with local anesthetic by the surgeon either at the beginning or the end? And there's an there's another interesting technique that's come out, which you may have heard. One of our Spanish colleagues, Vicente Roques, has described this wallant or wallant type technique, essentially using, he's done it initially with using, adrenaline in saline, but I'm sure it will migrate to to, you know, dilute local anesthetic with adrenaline to minimize blood loss. But what's wrong with pre incisional local anesthetic? Why do you think that cervical ESP may have a role? 

I'm I'm just curious. No. It's a great question. And and, certainly, you know, this this discussion goes beyond just ESPs. And if you have a surgeon that can infiltrate well, then sometimes that's hard to beat. 

You know? Inguinal herniorography. Yeah. Like, there is if you use a good local anesthetic technique done by the surgeon, I can't beat that, with a TAP blocker, ilioinguinal iliohypogastric. So anyway, back to ESP. 

We did a cadaver study that we presented at ASR a couple years ago where we we did a lumbar ESP with 30 mils of dye and then had a surgeon infiltrate the other side of a cadaver using his technique that he would do for spine surgery. And the goal was to to open it up then and see where this guy was. And shocker, the ESP did a did a good job with good spread up and up to l one and down to to l five, would clearly have worked for that spine procedure. Whereas the surgeon infiltration of that the soft tissue was was scant. It was, like, not very good staining of of any of the muscle fibers. 

And the surgeon was doing this pre pre dissection. So pre incision, he just like, this is what I would normally do if I was gonna do pre incisional. We said here here's your here's your syringe. Do what you would normally do. And, now this isn't a clinical study. 

We couldn't ask that cadaver how he or she felt afterwards, obviously. But Correct. Looking at the pattern of dye on the surgical side, it was clear that it was there were patches that would have been missed. And so I I do think Yeah. And this is my bias as a as a regional anesthesiologist. 

With ultrasound guidance, putting the local in a fascial plane like we do, we're likely to get more con at least more consistent results than than a than Yeah. Plain old surgical infiltration. I think that's I think that's good enough for me. I I I I get that. I guess the other situation is what I'm wondering about because most of the the spine surgeons that I've been working with, they they kinda split fifty fifty. 

Some of them will put local anesthetic pre incision, and I don't have any control of where that goes. And some of them will do at the end, but what I haven't ever got surgeons to do is once they finish their dissection is at that point, when they've got everything exposed to do their variation of of it local inclinatory infiltration. So I I guess I'm talking about an ESP under direct vision or an, or a retro laminar block under direct vision. I I don't know whether then they would be keen to do that, but that's that's something to consider. But let's say when you're gonna pop a catheter in, what are the things that you think are key tips for people putting catheters in? 

So what's the sweet spot for local anesthetic in for catheter insertion, and what regimes do you think work best? I've got an idea in my mind what I think is the right what what we do, but what what do you think works best? Yeah. That's a great question. And we'll do, at our center, we're doing ESP catheters for a lot of the thoracoscopic procedures. 

So and typical Oh, right. Pick the sort of midpoint of the expected Mhmm. Surgical action, say t six, and then direct the needle in there, open up the space with with your bolus, and then thread a catheter in and and aim to not thread it in very much. Right? So we don't want it skiving off either medial or laterally. 

So I I just I just put a few centimeters with a catheter in there. And then the Yeah. The trick to that, in our experience, is having the right infusion regimen. And to me, that means an intermittent bolus every so often to sort of reinflate that space with the local as opposed to a a continuous slow drip that's only gonna ever get that one that one dermatome. Because it's a big space. 

Right? And part of the success part of the way you initiate the block is by giving that initial bolus. So, you know, you could establish it. The local anesthetic will then have a duration of action based upon the mass of drug you've injected and depends upon how long that it takes that drug to get redistributed. But if you're only ever resupplying that space with five to to seven to ten to fifteen cc's of local assay an hour, you can't see how you can get that I I don't see how you can reachieve anything as good as that initial bolus. 

Completely. A 100%. So and we're fortunate to have pumps that are electronic that can do a an intermittent bolus of twenty mils every three hours, and that that seems to work great. But, you you know, you can have a clinician bolus. You can have someone go around, and and Yeah. 

Just manually in inject twenty mils every you know, whatever your interval is that you want. And that works that works great. So okay. So we let's come back to the Marmite, of local anesthetic. So so you and I have both thought of some indication, some places where we could use them. 

And, you know, and the trauma was a, in a way, was an easy setting because people coming in with pathology such as rib fractures and maybe they're on DOACs or direct oral anticoagulant agents. They used to be called NOACs. Right? When did that change happen from NOACs to DOACs? So these patients may come in on that. 

Of course, now rib fractures sometimes means that getting a patient to move around is not that easy. So an ESP, by definition, unless I can invent that posterior supine access to the ESP, you've gotta move the patient around. So it's not always easy in the trauma situation. But that being said, trauma is an indication I get. So what how do how do you answer those people? 

And we we've we've all got friends and colleagues who think, you know, if you want some decent thoracic analgesia, do a thoracic epidural or a thoracic paravertebral. Don't waste your time doing something that you don't know how it works. So apart from that trauma situation that I've described then, how do we answer that? I mean, it's not our duty to to necessarily answer or justify it, but I'm just trying to for our listeners, for them to justify why they're gonna do a technique. And, certainly, when they know there are some people that don't necessarily promote a certain technique, how how do you justify continuing to perform the block when we don't necessarily know how it works? 

So, yeah, it's a good question. And I think that just because we don't know how it works doesn't mean that it doesn't. And we've I've certainly had, good success with it, if if not if not perfect success. So I I think more of the question to answer your question, it becomes an issue of, is a block better than no block? And so if and this sort of gets around to that the idea of the plan a blocks versus plan b, c, and d. 

And and, yeah, in a perfect world, everyone had would have the hands of Amit Pahwa and could do a paravertebral block, for thoracic, all these indications. But there's a reason why the paravertebral block is not a plan a block. Right? Because not everybody necessarily has the confidence to do that. Or the hands of Amun Pawa. 

So or yeah. And and and there there's times when, you know, putting a needle next to the pleura is is scary sometimes if if you're not doing it every day. The fact that ESP is is safe, it's versatile, you can do it at cervical, thoracic, lumbar, sacral, and it's and it's simple and therefore scalable. If if something's simple, then it's not just the the omits of the world that are doing it. It's it's all of us. 

So that's that I think that to me, if I had a choice, if my my brother was getting a a procedure and and that, Anesthetist said, look. I could do no block or I could do an ESP. Hey. Please give him an ESP. Yeah. 

You take that. Right? And maybe it's about marginal gains. So, you know, it's not gonna be the be all and end all. But, you know, if it reduces the amount of opioid requirement, if it if it just enhances that recovery, reduces some of the drop you get in your quality of recovery points. 

It does something to make you feel better, maybe it's worthwhile. What I find is fascinating is both you and I are paravertebral enthusiasts, and yet we're still saying it's worthwhile learning this technique. And it's fascinating. You know, you can be a paravertebral enthusiast. You can be a proponent of the paravertebral and still support this technique because we also appreciate that not everybody's gonna have the time or the skill or the ability to employ the efforts to get good at doing a paravertebral, whereas this is maybe something that's a bit more achievable. 

Right? Totally agree. Yep. I feel that we've ended this podcast on a positive. Right? 

Chuffed levels are high. Yeah. Yeah. So so, you know, you've taken my chuffed levels from a two pre coffee. Probably, I'm a 10 plus now. 

I I am totally I'm I'm up there. So I'm chuffed to hear that. Well, I'm I'm chuffed that you're chuffed. What do you reckon? Do do you reckon we should wrap up this, this in a second leg? 

And if listen. If any of you have any experiences, questions, thoughts, attitudes, beliefs about ESP that you wanna share with us, please hit us up on any of our social media accounts. We've got Twitter. Absolutely. Because we, you know, we got Twitter. 

What what are we on Twitter? We are at block it underscore hun underscore hot underscore pod. And what else have got, Jeff? We've got YouTube at block it like it's hot. Yeah. 

Why did you take the easy one? Because then I now I've gotta say insta at block it like it's hot with an underscore between each of those words. So block underscore it underscore like, etcetera. I'm not gonna say the whole thing, man. And we want people to get engaged. 

We want people to tweet us. We want us to use the hashtag. And if they ask us questions, we'll definitely bring them up on the next episode. Right? Yep. 

We want us to be interactive. Yeah. We want it's gotta be interactive and, you know, and it actually gives us some extra to talk about. Otherwise, it's just you and I talking dad jokes, which we still haven't told. Okay. 

Next time, there's gonna be a dad joke. Deal? Every episode must feature a dad joke from now on. Okay. So, Jeff, till the next episode, what do we hope they all do? 

Block it like it's hot. Until next time, guys. See you. See you next time.