S2:E6 "It's Crunch Time: Abdominal Wall Blocks Part II"

Whether you choose the steak or the salmon, this will be a yummy episode for regional nerds like me. I'm Jeff Gadsden. So was it curtains for the tap block, or did the rectus win the race against the tortoise? Join us for part two. I'm Amit Pawa. 

And this is Block it like it's hot. Hey, man. We're back for a second helping of abdomen stuff. Yeah. Hey, Jeff. 

What was that? Oh my god. I think I underestimated just how much we could chat. I mean, I knew we had a lot to talk about, but I had no idea that we get stuck into the whole epidural conversation and that tap debate. In fact, somebody there's a guy called fat bloke, and that's his real name. 

That's a guy called fat bloke with x. That's his that's his real Twitter name, or is his actual real name? He's I'm kind of guessing that's his real Twitter handle. That's not what I've decided to call him. But I asked the question on the last podcast about whether anybody does any single shot lumbar epidurals. 

Right. And he just reminded me of something that we we kind of didn't talk about was that there is a single shot epidural that people do, which, of course, is the caudal block. Right. Yeah. Yeah. 

Yeah. So actually that so so that was interesting looking back on that. Don't I know if you've seen there was lots of chat about intrathecal opioids and the effectiveness of surgically placed recto sheath blocks with there's a little bit of surgeon hating going on there, a bit of surgeon love saying some some people say my surgeons are really great at putting recto sheath casters in, and other people are saying they were not so great. So, yeah, there was a lot of chat after that last episode. Right? 

That's good. That's good. Yeah. Yeah. Absolutely. 

Well, listen, Jeff. Tell me, how have you been, man? I've been good, man. Thanks. It's been, it's that time of year when school's wrapping up. 

We had our last day of school on, on Wednesday. And Last day of school? Hold on. What month are we in now? We're in June. 

Your schools are your schools are done? Yeah. They they, they start a little early here. We start before Labor Day and then end mid early to mid June. But couple of graduations, we had a fifth grade graduation and an eighth grade graduation. 

So lots of Woo hoo. Congratulations, Gads and kids. Lots of celebrating. But speaking of celebrating, I happen to know somebody had a birthday on the weekend. Yeah. 

That's I'm I'm not gonna sing it. I I appreciate the song you gave for I'm not gonna sing to you. I'm gonna spare the listeners that wrap it. I'd like you to rap. How was your birthday, man? 

Do you know what? It was, it was really great. Thank you thank you so much for asking, and thank you for remembering. I've been getting up early enough to text me, on my birthday. It was it was really cool. 

So we we had a sort of an action packed, weekend. We did some on the Friday night before my birthday, my wife took a cat took me out for a really lovely meal together without the kids. That was that was something special. Yeah. And then, on this Saturday, Sofia had some an athletics competition, so we did that. 

But then afterwards, we went to go and see Sister at the Musical. Right. Yeah. Yeah. Yeah. 

I saw the pictures. How was it? That was really good. We had a lovely lunch just before that, and then went to go and see that. That was great. 

I was expecting a lot of the songs from, the film to be in there, but they were all original. And, actually, it was, it was a fantastic experience. And then on the Sunday, my mom treated us to a really lovely meal in a in a, you know, in a lovely hotel in London. So I kind of feel thoroughly spoilt and had a fabulous time. So thank you so much for asking. 

Yeah. Yeah. Yeah. You deserve it, man. I'm glad you had a good time. 

And well, I'll tell you I'll tell you what else happened. So one of our current fellows, James, he beat our local record for the gas in 27 injection knee recipe. And he did that in he did it in five minutes and fifty five seconds. That was the whole work. Lovely slick, great outcome, great effect, but he did it nice and fast. 

Hold on a second. Five minutes and fifty five seconds. That sounds a bit quick. Like, you get is there a video evidence of this? Do you know what? 

The problem is I'd I'd never record them at you you are you calling me a lot? Listen. I'm gonna say I'm gonna say the guy I'm gonna say the guy's name again because we always get a ping every time we mention his name. Bing. Robbie Erskine. 

He reckons he can do it in four minutes. Now this guy he's got a lot of experience, but but James smashed I mean, we normally, when I time the fellows when they first start and I take them through femoral triangle, QTs, geniculars, IPAC, all of that, the first time they're doing it, they end up taking about somewhere between ten and twelve minutes because of the bit of teaching. Yeah. James just individually bish bash bosh five minutes. Wow. 

Well, James, my hat's off to you. That's that's incredible. Great. Good work. But let's, I just wanna public service announcement. 

We are not advocating that you speed through these blocks. No. No. No. No. 

No. You you're absolutely right. I know I'm always worried that there's there's a there's a a macho thing that may come across about this. It's not about that. But what what we are what we're trying to demonstrate or what I've been trying to demonstrate to the fellows is whilst we love putting in our blocks because we're doing it for our patients, we want them to get great outcomes. 

Ultimately, we have to realize, certainly in the NHS, without a block room type setup, we've got to think about the efficiency of the service as well. Right. And so you gotta be safe and effective with great outcomes. But if we can think about things to streamline our process, then that's important. And, actually, James had modified the technique that I'd initially taught him so that he was doing certain blocks to certain positions to speed things along. 

And, actually, you know, I I like that innovation. You take something you like from from a teacher and then modify it yourself to make it a bit quicker. So, yeah, there we go. That's that's, we want you to be safe. It's not about speed, but think about being effective. 

Do know what? I'm gonna go off piece to you, man. I've got you know, we weren't meant to be talking about this, but I'm gonna go slightly off piece. I'm conscious of the time. Okay. 

Somebody shared a video with me on x recently about an orthopedic surgeon in Canada, and he was having fun. He was mocking, doing a little video of himself, pretending to be the orthopedic surgeon that he is, and then pretending to be his anesthetist. He he kinda said, oh, we're gonna do this case. And then it flips over to the anesthetist. The nieces said, yeah. 

We'll do a block for that. And then he said, we're gonna do this case. And then he said, oh, we'll do a block for that. And it was very funny because the whole kind of joke was every time every time you mentioned a procedure, Dionysius said, I'll do a block. We have a block for that. 

Right. Yeah. You know, and a block here, block there everywhere, block block, that kind of thing. And somebody shared that with me on x, and I actually seen his feed on Instagram. And I went in, I did a bit of a deep dive, and there was a lot of negative emotions towards regional anesthesist or anesthesia service doing blocks. 

So I guess this is what this is the link was. I was thinking, we've gotta do what we think is great for our patients. You know, sometimes blocks take a bit of time, and we have to accept that. But, ultimately, we've gotta remember we're working on our team, and not everybody necessarily appreciates the troubles and struggles that we go through. So I don't wanna give the guy any credit to for people to check it out, but I just wanted to flag that. 

Have you come across any negative attitudes towards doing blocks, or how do you deal with that? Yeah. We have we have over the years. And and the main thing that is the problem is their concern is time. So we did a study of orthopedic surgeons' attitudes towards regional anesthesia, we pulled them and said, hey, if you were in your office in front of a patient about to get an ACL or a rotator cuff repair, would you advocate they would get a block? 

And about thirty percent said yes, which was disappointing, right? To see the only a third. And then we gave it a bit of time and then re asked the same surgeons, hey, if you were getting an ACL or a rotator cuff, would you want to block? And over 50% of them said yes. Yeah, that's really interesting. 

That's really interesting. Which kind of shows that it's the decisions that they are making are not always entirely patient centered. And so but to your point, I think I have those cringey moments when I'm taking a fellow or a resident, usually a resident, through a Uh-huh. Block procedure and it's not going smoothly and the surgeon's tapping their toes and I'm I'm trying to like give them the little side eye saying, oh man, hey, I I know what you I know we're late. Just give us a couple of minutes. 

We'll be through this. So it you're you're to your point, there's there's a balance there between providing a good service to the patient and doing the right thing for the patient and making sure that the service gets gets completed in in a timely manner. Yeah. No. For sure. 

Listen. I think we could I could talk about this for hours because, I mean, this may be something that can come up under our, controversies episode that we're gonna have at some But the last thing I wanted to talk about before we get into the good stuff is, you know what? I was at home recently just prior to my birthday, and I found some old photographs of me from school and university. And what was crazy is I managed to relive some of my old haircut. I forgot I had curtains. 

You know that curtain style center passing with hair dangling down the side. You know that? You remember that? Oh, very very boy band. Like, nice and nice. 

Band. Exactly. In fact, I put a picture of that on my Instagram feed recently, but I also had ponytails and undercuts. So I used have my long hair, bob blank. I used to have it in a ponytail, I to have it undercut. 

So that was, yeah, that was a real, trip down memory lane seeing some of those power haircuts of the past. I went through and scanned all my parents' photos onto into Google Photos at one point, number of years ago. So I've got them all on my phone. So my kids are like, what was the what were the eighties like? And so I'll pull pull up a photo of me With a mullet? 

With a with a mullet. Yes. Absolutely. Mullet. I wasn't cool enough to have curtains or undercuts or whatever whatever you London blokes were doing. 

No. I had a I had a good old mullet. Well, listen. I I think at some stage, we're gonna have to pull some of these pictures together and put them on some kind of, some kind of video release. So that's some that's a project of the future. 

But, dude, listen. I've talked too much. Let's get into the let's get into the nuts and bolts. Yeah. Sounds good. 

So listen. I wanted to revisit something that we you talked about in in a from an important point of view. I was talking about the subcostal oblique tap block, and then you, and then we talked about the external oblique intercostal. So I know we covered it in brief, but I just wanted to rewind so that we could give our listeners some insight into how to actually perform the block. So, you know, I think it's, you know, sometimes we forget that this being an audio thing, people may you know, we'll we'll talk about some, but we don't actually give some tips. 

So when you're performing the external oblique intercostal, block for upper abdominal incisions, Can you just talk us through roughly what you do? How you set up? Whether you needle from caudad to keflat, caudad to caudad, you know, where do you position probe, that kind of stuff? Of course. And and just to set the stage for those that, that missed it the first time, this is a block that we'll do to get the upper abdomen, so the upper quadrants of the abdomen. 

As opposed to a subcostal tap, which is something that we used to do, but we don't anymore because we have this block and it's easier to do. It's out of the way of the of the abdomen and the surgical incision and relatively shallow and and so on. So we will landmark the xiphoid process. That's our cephalad caudad landmark. And then we'll go lateral just past the nipple line and put a probe in the rib. 

And the rib is probably the seventh rib or so, but doesn't really we find it doesn't really matter. So sci fi process, go lateral just past the nipple line, slap the probe on, and I like to orient the probe usually at 90 degrees to the ribs, so that you're you see a rib in good cross section. So I say here, you see the rib there? Yep. See the pleura? 

Yep. You can see the little of muscle over top of the rib. Yeah. Yes. And then we'll take the probe, and I'll slide down over the costal margin onto the abdomen to prove to them that that is the external oblique muscle. 

It's a neat trick. Right? Because everyone thinks that external oblique is just abdominal. No one thinks about extending up onto the costal margin up towards the ribs. Yeah. 

I didn't. I I was I was when this is first described by Likewise. Hashem Elshakawi and and colleagues, I was like, what? Wait. What? 

And, and then we go back. Oh, so they prove that, and then we go back up onto the ribs, and then we just drive a needle in, in plane. It's then it's like an ESP or, any block where you're sort of hitting a bone and popping the muscle up. It feels a lot like a like a parasternal. Yeah. 

It makes intuitive sense to me to try to come from cephalad to caudad and then try to push the local down because I'm trying to get the abdominal components of the spinal nerves rather than the thoracic, although you'll get a bit of both. And Mhmm. The only other technical it's shallow usually, so you gotta be fairly careful with your with your trajectory. The only other thing we get that is a consideration sometimes is, breast. So Yeah. 

Yeah. You're you're right underneath the breast sometimes. Do you need to get somebody to retract the breast? Or Yes. And then on and then oftentimes sort of rotate in a in a different angle so as not to bring your needle path through the breast to get to the Right. 

To the rib. So that just feels wrong to do that. Yeah. But that's it. It's it's really easy. 

And volume. This is a volume block? So, we have been using 25 to 30 for each side, and that seems to and that was 25 was based on some of the cadaveric studies that were done. And so just practically speaking, that ends up being, you know, 25 to 30 per side, and that that works great. And so when you do that, we'll get down to about umbilicus, up to xiphoid, and then and then truly the lateral aspects, the, you know, the medial and then the lateral aspects of those upper quadrants. 

It's interesting. I have played around because I I think the first time I did it, I had somebody who in whom the breast tissue would have would have got in the way. And, I came from Kordat to Keflad. Oh. And I'm just wondering whether the whether the dynamics of the block mean that if you inject in that plane, you get some spread, via the lateral compartment towards the the posterior midline. 

I'm I'm just trying to work out in terms of are we just aiming to get the nerves within that fascial plane? Or like many of these fascial plane blocks, are we hoping we get some spread around towards the mid the posterior midline? I don't know what the answer was. The block worked well, but it's I'm I'm interested to hear that you're preferring to inject down towards the abdomen, which, of course, is where the target is as opposed to fill the plane from a more proximal area. Well, and and that's entirely just my intuition. 

I I have no evidence to say. And I'm reassured to hear that you say that coming from below seems to work as well. It makes sense. You're just putting the big volume at one spot. And it, you know, like a lot of these fascia plane blocks, as it compresses, it spreads it out in this huge pancake. 

Pancakes. But you know what? I I'm gonna have to do a deep you definitely sounded like Homer Simpson there. I'm gonna have to do a bit of a deep a bit of a deep dive into the literature and just find out whether anyone's explored that dynamics. And, and if not, maybe somebody can. 

Well, listen. While we're talking about this area and pancakes, I wanted to talk about these blocks before because you've we've talked about them before, and I had to struggle to remember the acronym. But I wanna mention here because our Turkish colleagues are doing a lot of work on these blocks. And if people are inventing new blocks, we've talked about the and and the value of inventing blocks or not or or, you know, going more and diving deeper. What about the tapper and the m tapper block? 

So for those of you who don't know, these are the thoracoabdominal nerves perichondrial approach. So I don't find it that easy to remember, but it all feels like we're doing blocks in and around the same area. And I'm not sure I can convincingly tell the difference between a tapper and m tapper and an extended beak into costal. And it's gonna be one of those things again where the most popular name wins the race. Do you do you do these blocks? 

Are you familiar with them? Because I'm not. I'm gonna put my hands up and say as a guy who loves regional, this is not something I've done. Yeah. First of all, as you're saying this, I'm just imagining some friends that we have in common whose heads are exploding right now about the nomenclature issue. 

Yeah. Me too, which is kind of why I wanted to put it in here. Yeah. I think you're right. I know. 

I I haven't I haven't done an a a TAPA or MTAPA. Although having having, you know, read briefly about it, I don't feel qualified to defend the anatomy, the approach, or anything like that. But it I remember thinking, okay. That sounds very much like what I would call an external oblique. Yeah. 

So it's it's kind of the same thing, I think. Yeah. I mean, the reason I ask is I was actually at an ASRA meeting, and I sat in one of the one of the meetings, on regional anesthesia techniques for the abdomen. And one of, one of your colleagues or our colleagues, was take talking about. And I remember just sitting there with that mind blown emoji displayed on my face thinking, why have I not heard about this before, and how is this different from the other techniques? 

Okay. So that's see, it's it's not something that you specifically do or have done actively. Well, listen. I we should throw it out to our audience. And, you know, if you guys maybe some of the authors of the blocks can chip in on the conversation and tell us how it's different or is it different and get some so we can get a bit of insight into that. 

What do you reckon? Yeah. I think so. It may be one of those things where the just the the approach vector is slightly different and and that confers some advantage and that sort of thing. So I'd love to hear from the from the authors. 

Absolutely. I wanna learn more. Okay, Jeff. We're now gonna get to the big daddy, or big mama. Oh, no. 

I've gone up there. I wish I hadn't gone there. Okay. We're get to the exciting part. We're get to the oh, god. 

This is gonna get I'm gonna get canceled. Okay. I wanna talk I wanna talk about the rectus sheath block. Yay. Yay. 

It's a great block. Right? Oh, I love a rectus sheath. It is it's like the, have you seen those little in things on Instagram where it says, like, most popular restaurants Yeah. Yeah. 

Starting starting in 1960, and it go it goes, like, fast forwards through time, and then you see, like, certain things come up the list and and the list is changing always. I have a I have sort of one of these in my head about my favorite blocks, and then popliteal is always near the top, and infraclavicular obviously is in the top, and rectus sheath is always up there. So those three are sort of, like, jockeying for first place. Such a regional nerd. No. 

You are a regional nerd, but that's why I love you, man. Yeah. But but what why why is it so good? That's what I need to know. Why is the rectus sheath so good? 

I mean, I'll I'll tell you what I like about it. I like the sheer simplicity, of, hopefully, in the in the patients where you can identify easily seeing that feather like muscle or that steak like muscle, and then peeling the local anesthetic away from the post award. Yeah. It's my god. This is gonna be the theme, man. 

Another food theme like your Blocktobo videos. But but I but I think it's a great, it's a great endpoint. Something a beautiful rectus sheath block like anything in regionalities is a real joy to watch. It is. But also, you get real great results from it. 

Like, I mean, again, like all regional. So maybe this is like any good block. But I I well, you know you know what? I've done one of these on myself. Really? 

Wow. I this is usually we're usually having this conversation the other way around. Now I get to be the I know. Now I get to be no. You didn't. 

Yeah. Well, is that is that what I sound like? So so sorry, folks. No. I don't. 

So so I I had to give a I had to give a a talk for, I think it was for a rural college released his plan a blocks webinar that I had to do. And I needed to You recorded it? Yeah. Yeah. So so we I mean, I didn't do it live, but we but as part of this webinar, I I was talking about ESP and Rectorsheath blocks. 

I needed to find a good, Rectorsheath video. And I and I was looking back in time over my ultrasound library, and, of course, I couldn't find a decent one. So I thought, hey, ho. What's the best thing to do? I'm gonna have to do a block of myself. 

Love that. So I I laid down on on the scanning couch, and I I streamed the the ultrasound image to a big TV so I could face the TV and see it. But then, of course, it's quite difficult to sit forward and then needle your abdomen. But I did one on myself. And I tell you what, it's a really weird feeling when you feel the rectus muscle peeling away from the posterior rectus. 

I felt like I was oh, I'm I'm actually can feel it now. It was really weird. It wasn't painful. I didn't use local anesthetic in the skin. I just went, boom, straight down, But it felt it felt very weird. 

And, you know, the funny thing is I did your trick, the thing that you suggest in your, in your, regional anesthesiology and acute pain medicine videos, your Blocktobo videos. You said, before you think you've got to the end point, so when you're a bit intramuscular, just do a little smidge just to make sure you haven't inadvertently gone too deep. So I did that on myself. That didn't feel nice. I'll tell you that for sure. 

Oh, yeah. Intramuscular injections do not feel nice. No. That did not feel nice. And then when I popped through and I was resting on the poster, had to see it. 

I could feel that. And then injecting the local, I could feel that that space opening up. But, anyway, it looked good despite the the couple of layers of seven layer being dipped we had to put to scan through to get to my rectus sheath. It was good to do even on myself. Good for you, man. 

It gives it gives you some insights, right, into what the patient's experiencing and and that sort of thing. I was channeling my inner gangster. Did you did you actually use local or saline? No, man. Just saline. 

Just saline. Okay. Because on that particular day, I had done a few other blocks of myself, so I was worried about loss. Oh. So everything everything was like just saline. 

That's a story for a different time. Why are you doing three or four blocks in the same day? All for the video. All for the gram. Yeah. 

Exactly. The so so have you done one of these on yourself? I I have, actually. Really early on. Like, I this is back in New York, and I I did it to see how profound the blockade was. 

And, you know, not surprisingly, it was it was good. Okay. It is it is a great block. I remember seeing an article, and I'll I'll find this and put a link in this in the show notes. I think it was the Journal of the Royal College of Surgeons comparing rectus sheath catheter to thoracic epidurals, speaking of epidurals. 

And there was zero difference in terms of length of stay, quality of analgesia, and complications and that sort of thing, which is one, I think, of the first articles that I had seen showing that this technique is equivalent to the gold standard. Well, here's what I like about the rectus sheath block. It's super easy to see. Even in an obese person, can recognize the anatomy very well. And to straight shot down to that fascial plane between the muscle and the posterior rectus sheath, that's fairly easy and simple. 

But once you're there, that spread Yeah. Man, it is a viscerally satisfying experience to see that just Yes. Peel up off that. And it does it every single time. Right? 

Like, it's not like, tap locks, I struggle with as we've talked about. So, know, you're you're in, you're out, you're in, you're out. Ugh. I can't get the plane to open. But we did a cadaver experiment once looking at some injections. 

It was a it was a volume distribution type question. So, like, how much do you need to if you did it one shot of the umbilicus each side, can you get it all the way to the xiphoid and down to the pubis in one shot? This is a great question. Right. This is a great question because I would have known. 

Because I was I was in the habit of doing two per side thinking, like, it was like an ESP where I you know, the spread's okay, but it's not, like, perfect. The short answer is you can do one injection. Thirty mils Oh my god. Yeah. A thirty mils on each side, though. 

Thirty mils each side gets you yeah. It's a bit it did decent volume, but that will get you in a cadaver at least up all the way stem to stern. So that was satisfying to see that answer. But one of the other most satisfying parts of that experiment was once the injections are done, we open the cadaver up. Okay. 

So if skin's off Yeah. Make a cut on the anterior rectus sheath. So you've exposed the rectus muscle. Then we cut the rectus muscle up near the top, near the xiphoid process. Uh-huh. 

And then picked it up and then just lifted the whole thing out of the sheath like a salmon fillet. Salmon. I picture that. But but I don't know why I'm so I'm mostly hungry or something. But but but that's but and that helped ex even these little moments. 

Right? But that helped explain to me why the spread is so good. There there's nothing tacking that muscle down to the rectus sheath underneath. You can lift that muscle right at because, of course, the sick the six pack the six pack doesn't traverse right the way through to the posterior rectus sheath. Right? 

Those interdigitations of muscles don't go right and and and adhere to the posterior rectus sheath. You've got a free path for local to track. Well, here, let me show you. Listeners, I am now getting a full frontal view of Ganzley's six pack. FYI. 

I'm glad you said six pack. Oh, okay. Oh god. I think our I think our previous podcast guest is rubbing off on you here. Anyway, so that that was I I remember, like, that was one of the things I just remember and try to explain to the to the trainees. 

Like, that channel is a wide open highway from thorax to pubis. And what's really cool, I I again, here, hashtag regional nerd. Cool is a subjective word here. But if once the injection's done, if you have the time and the patience and you just hold the probe there, you can see the elastic recoil of that sheath compressing it, and you can track the local in real time going up and down. Can you massage it up and down in real time? 

Can you massage it up and down? Can you spread it? Are are you offering to massage my six pack? No. No. 

I'm just I'm just saying. If you inject it at one level, could you kind of like, brush it up and sweep it down? Would that work? I look forward to the I look forward to you publishing that study. Excuse me. 

What what are you do excuse me, ma'am. I'm just making sure the block works well. Listen. I think there's something in that. It would say, make sure well, actually, maybe reduce the volume. 

I don't know. Maybe I should just stop talking. Sorry. Did I interrupt you, Flo? Because I've got another question, but I'm not sure if need something else. 

I think I was done there. You think you were done at massage. You had me at massage. No. So the quest the question I want to ask is, we often will will do these, of course, in conjunction with catheters, and we're talking about doing these postoperatively for laparotomies or, yeah, for rescue analgesia. 

In the pack, you might do them and pop in a catheter. Yeah. Is it worth doing a single shot? Is there any value in doing a single shot, in combination with multimodal analgesia, or is this a block that it really only makes sense to do with the catheter because of the type of indications we're using it for? Well, I I think, like, lot of these fascia plane blocks, you need to do something to make that last as long as possible because you don't do the patients any favors if you're using, you know, plain ropivacaine. 

They look great in the PACU and then nine hours later, fifteen hours later, it's wearing off. And I will say that catheters in this space are super easy and reliable and fun to do because, you know, you open the space up, thread it in, it goes in well. I will for the catheters, what I'll typically do is do it 90 degrees. So instead of coming from lateral to medial, which is my typical approach, I will turn the probe so it's sagittal and then come from caudate de cephalad just just so I I I feel like it's probably fine either way, but I I like to imagine my catheter traveling up the the now expanded rectus sheath. So now this is interesting. 

I mean, it's almost like you knew what we're gonna be talking about in advance here because this is gonna be my next question. So it implies the fact that you'd scanning from trans from lateral to medial with a transverse orientation across the abdomen implies to me that at some stage, you might do a single shot block because why else would you describe it that way? Or maybe that's just how you identify it. But the fact that you prefer to do your catheters with a chorda keffle ad orientations or a paramedian scan up and down, that's interesting because I've always thought that made more sense. But I have put catheters in coming in from lateral to medial before. 

But you but it definitely makes sense to me to pass it up and down the long axis, the rectus sheath. But what would you do if you're doing it as a as a rescue block in Pacqui? Because the dressings will be on then. Right? So then you've gotta come from lateral to medial. 

Yeah. What's what surprised me about this block sometimes is how big slash lateral the rectus muscle is underneath the skin. So you think it's, like, tucked in really close to the midline, but then then you can come in, We'll often come in at the end of the case when the dressing's already on, and you can catch that very last little bit of the rectus muscle underneath your probe as it sits next to the the edge of the dressing. Do you find the same thing? How how it's it's much more Yeah. 

No. Absolutely. Because because occasionally when we've been asked to to do them in recovery for somebody who's not had a regional anesthetic technique and have been giving opioids and they're in pain, you go and see them and you look at the dress and you think, I'm not gonna do this. But I have been surprised at just how far laterally the rectus can extend even with a closed abdomen and dressings on. So, yeah, we have done it that way. 

And, of course, that way, you don't have the option of doing a a long axis scan along the rectus muscle. So but do you do anything clever with the needle to make sure that the catheter if you're if you're gonna be putting the catheter in from the lateral aspect, do you do anything clever with the needle, like use a two needle and rotate it 90 degrees to to ensure catheter spread? Yeah. I I that's what. And again, this is all intuitive stuff. 

I just think, well, I I want that bevel facing that way. So if I'm forced to come in from lateral, I'll kinda maybe make it at an oblique angle and then aim my TUI needle so I think the catheter is going up. We use these fairly soft PVC catheters for the most part. So it's not it's not gonna, like, poke through and go to the other side, I don't think. So even if you're not quite, you know, sagittal, it'll find its way somewhere. 

The only thing I'll say about that sagittal long axis approach is it is easy to slide it's like a it's like doing a long axis vascular access approach. It's easy to slide off and get a poor view of your muscle. So, I'll I'll often scan transverse, get the muscle, and then slowly turn 90 degrees Uh-huh. To make sure okay. Yeah. 

Right. That that is the rectus muscle for sure rather than if you're especially if you're getting a bit lateral, you can get over the very thin edge of the muscle and be confused. Now are you doing these preoperatively? Because I'm just trying to picture what happens if you put a catheter in preoperatively, and it'll be in the way. The surgeons might not like it. 

You have it sticking out the skin. No. I I'm I'm doing them, usually postoperatively. But what we'll do if we're planning to do catheters But before the dressings Yes. I'll say to the surgeons, hey, guys. 

Close the incision. But before you put the dressing on, we're just gonna glove up and put some catheters in, and then we can put the dressing on. That that answered my question. Okay. So if you weren't gonna put a catheter, can can you use adjuvants in here? 

Can you use different mixtures, different cocktails to prolong it? Have you got any experience with that? Yeah. So we we've used lots of things to extend your duration. People use dexamethasone and dexmedetomidine and buprenorphine and other things. 

We we typically use liposomal bupivacaine for a lot of our fascial blocks fascial plane blocks because it's easy. Uh-huh. And we do tend to get at least two to three days out of it, depending on the block. Sometimes sometimes longer, but that is our sort of default extender as it were. So, you know, I tried these for, for red sheath blocks. 

I've only done them once using I've used liposome or bupivacaine, for red sheath blocks just once. I got a solid twenty eight hours of complete analgesia. But then after that, it wasn't clear. I mean, the then pain started to come through after about twenty eight hours. Mhmm. 

But, probably, there was a difference about three days down the line when it got even more. So but, certainly, the patient perceived there to be a difference, or, you know, to be complete allergies for just under thirty hours. Mhmm. So I'm trying to work out, you know, for me, was that may have been a technical thing. Maybe it was a dose or a volume thing. 

But kind of, you know, if it's gonna replace catheters, really wanna reliably get what you're getting, which is, you know, three days or so. So, you know, maybe it's something to to to refine and practice with, but it's interesting to see that you've got some good results with that. Yeah. Typically. Although I I you know, one of the things with that medication is you can't use any of the local anesthetic for ninety six hours. 

So Yeah. Sometimes that influences our our planning and decision making. We'll often have, not often, but sometimes we'll have a patient come through who's got complex pain needs, getting a laparotomy, and they can't, for whatever reason, they refuse or can't get an epidural on the morning of surgery. So we think, okay, we'll do rectus sheath catheters, and that still gives us that option of the epidural in our back pocket in case postoperatively they're not doing well and they decide to consent to an epidural. Okay. 

Rather than if I if we use liposomal, that would have tied our hands for ninety six hours, if that makes sense. I've got you. Now in terms of running a catheter, is there an optimal catheter regime? So it seems logical to me if you're giving an initial bolus to fill up the space that you that intermittent boluses in this space make more sense like many fascial plane blocks, or do you think there's value in running running a, a continuous infusion? What's your experience with this? 

I I think this is where where an intermittent bolus really makes a lot of sense for these fascial plane blocks because it takes some hydraulic pressure to open that space up. So if you're just dribbling in local at ten mils an hour, it's gonna regress to a little a little one little spot where your catheter So tip we'll use point two percent Rupivacaine as our infuse eight and run it at no background infusion, just twenty mils as a bolus every three hours. And the other thing we'll do is we'll we'll stagger those doses. So we'll give one at time zero and then to the right side and the left side goes that bolus at ninety minutes later. And then ninety minutes after that, we're back to the right side again. 

And so back and forth. That way, they're not getting a full double bolus at the same time just as a in an effort to try to reduce peak plasma levels. Okay. Well, this is interesting because we actually got a question in advance from Thomas Hall on x. And he, he asked the question, how are people running their rectus sheath catheters, in terms of volume and concentration? 

And he'd heard that a four hundred milligram maximum dose of bupivacaine, the maximum daily dose of bupivacaine or the equipment can be can be challenging for smaller patients. So he's just asking what are what the practices were. So I was trying to imagine, I think pediatric regional disease is a whole different ballgame, but let's just pick the average, I don't know, forty kilogram adults. That's a relatively small adult. Right? 

So if you were doing three hourly bonuses as opposed to four hourly boluses Yeah. That means they could have eight boluses within twenty four hours. What volume of bolus would you give? 20 cc's, did you say? That 20 is our sort of adult size bolus. 

Yeah. And is that is that and that would get done by a splitter. So 10 would go into one side, you hope, and 10 would go into the other side. We actually have two separate pumps. Yeah. 

Because the splitters, I think, what happens there is the compliance is gonna be a bit different naturally, and one side's gonna end up getting You might preferentially. Yeah. So does that mean each side is gonna administer ten mils then, or you're do 20 mils per side? 20 mils per side. Okay. 

So that's so that's interesting. So if you're doing 20 mils per side, and they're getting eight catheters of 20 eight eight boluses of 20 mils, that's a 160 mils per side. Right? So eight times 20 is one sixty. So that's 320 in twenty four hours. 

Is that right? Have I done the math right there? Yes. Yes. So, okay. 

So 320 of what and you're using point 2%? Point two. Yeah. Yeah. So what's what's the maths on that? 

That is are we are we gonna be above? 640. So the maximum daily dose of ropivacaine is seven hundred and seventy milligrams. So you're fine for ropivacaine? Yeah. 

And I guess if you're if you're using point one percent of bupivacaine, you would still probably be okay. Right? Because that'd be yeah. So, actually, so that works. Yeah. 

I'll I'll say just when we set up our pediatric catheter pump library, we we sort of mirrored the same programs with a point two reprovacaine and then had a separate sub library with point 1% reprovacaine just to allow us to get some of that volume in there without being concerned that we're gonna exceed any max doses. So we usually use point two for adults, but for some kids, we'll use point one. Okay. Now that's really, really useful. So, hopefully, Thomas, that's answered your question. 

As I said, pediatric regional disease is a whole different ballgame, and I suspect the volumes would mean that you still would stay within the safe area. The one last thing I wanted to touch on on the, rectus sheath block is I have heard some people so if we think about that cross section of the rectus sheath, you got your adipose tissue at the top, then you've got your anterior rectus sheath. If we go from top to bottom, then the rectus muscle, then the posterior rectus sheath, and then deep to the posterior rectus sheath, you've got the transversalis fascia, then you've got the peritoneum. Right? Now we are talking about the endpoint of a block being between the rectus sheath muscle and the posterior rectus sheath. 

But have you heard about some people talking about injecting between the posterior rectus sheath and the transversalis fascia? Because I have. Yeah. I had this discussion once with a surgeon, I believe, about the the ideal plane for spread, and they were convinced that that that would be advantageous to get one layer deeper or, you know, below the sheath and have it spread. You know, it's it's interesting. 

We're talking about the spread down to the pubis. There's the the arcuate line. Right? But Yeah. Below the umbilicus where there's the deficiency of the posterior rectus sheath. 

So at some point, when we when we pulled that salmon fillet out of the cadavers, you could see that arcuate line and the but the dye kept going over top of the transversalis fascia just like you're saying down to the pubis. So it does it does still travel. I just wouldn't wanna do the block there because there's no that posterior rectus sheath is a nice safety backstop. It's pretty tough. Right? 

Yeah. But it's a nice, like, compartment to store the local anesthetic like a depot as opposed to injecting it over a large, large potential space. So I so I never thought about I I never thought that was the right place, but I just wanted to know if you had any experience of that saying. No. I haven't. 

And and the other thing is, of course, when you're needling certainly, when you go below the ocular line, if you look in the area of the posterior rectus sheath or where it's becoming deficient, you've got the, the inferior epigastric vessels. So, again, this is a block where you gotta stick the color Doppler on to make sure you don't inadvertently prang one of those guys. Oh, absolutely. And there's at least one case report of a very of a life threatening rectus hematoma rectus sheath hematoma because of the epigastric, vessels, you know, got got damaged. Something to I always put Doppler on before I stick my needle in just in case I don't see the vessel with my my naked eye. 

Yeah. No. Absolutely. So that sounds like a a really a really sensible thing to do. Listen. 

On that serious note, I think we should we should, finish up on some jokes. What do you reckon about that? Oh, yeah. Yeah. It's about that time. 

Okay. Well, listen. Before we get into the jokes, I did get a message from an old colleague of mine, Harry Ackerman, who who'd listened to the knee episode, and thought we you know, he gave us some lovely compliments. He loved the podcast, but he wanted to ask why we never talked about doing posterior obturator nerve blocks for total knee replacements or total knee arthroplasties. And he showed me a reference to Thomas Benson's paper showing opioid reduction when adding a posterior obturator nerve to femoral triangle block. 

Have you have you ever done those? Because I haven't. I used to when we did femorals. So we did femoral nerve catheters and a sciatic nerve block, and about five percent of the patients in the PACU were still uncomfortable. And it was always that posterior medial part of their knee. 

And so we would, we'd roll the ultrasound machine around to the PACU, do a single shot obturator nerve block, and boom, that went away. But it's I think I don't know. I get enough pushback doing my 17 blocks without adding an eighteenth in there. So I think if I was to pass on one, maybe that would be it. Because because it was only about five percent of us of the patients that had that issue. 

So what you're saying is it's not a significant enough a problem in your practice for you to consider doing that. Right. And and the other thing is I I got a phone call from John McDonald who listened to our abdomen episode part one, and he, he actually, he was disappointed that I didn't do an Irish accent. Joke. He said, thank god you didn't do that. 

But he loved the discussion. In fact, he had and he confirmed to me that story about the first time he did a tap block was a 100% true, about the lady disappearing in the morning from the ward because she'd gone out to go for a cigarette. Yeah. And I think he'd love to so he loved the podcast. He'd love to join us, I think, as a guest on one of these episodes. 

That's something to line up. But I did Oh, that sounds great. Did promise some jokes. Okay. So do you know, I, I met one of my teachers from school the other day. 

She was called missus Turtle. Okay. Funny name. Yeah. Funny name, but she taught she taught us well. 

Taught us. Taught us. Nice. Come on. That's alright. 

Right? Have you got one for me? Well, I've been I in my spare time, I've been messing around with with cloning and and my cloning experiments have finally paid off. I'm happy to tell you, man. I'm I'm so excited. 

I'm beside myself. Oh my god. I didn't even know where you're gonna go with that, but that that was very good. Okay. Okay. 

I've got I've got this is I can't not do this for for for today. What do you call a Yeti with a six pack? No. I don't know. The abdominal snowman. 

Oh, that's good. Yeah. I I I thought I thought that was that was relevant. Too. How do you do this? 

How do you find these ones that are I have no life. What can I say? Well, Jeff, you know, I can't believe it. We've actually managed to talk for, about probably forty five minutes, and there's so much more that we need to talk about. I wanted to talk about QLB, QRB blocks that go and go there and talk about all of those, and then, of course, talk about the use of ESP blocks for abdominal surgery. 

I think we're going to have to have an episode three on abdominal blocks. Is that okay with you? It's warranted. I mean, I think there's so many so we could dive really deep into each one of these ones. So but for sure, QL, I think, deserves a good a good solid episode by itself. 

Okay. So let's make that episode three. Yeah? Yeah. Done. 

Okay. Well, listen. I really enjoyed that as always. Always pick up something new. Always learn something. 

So Yeah. Likewise, man. Thank you very much. Well, folks, you know what the deal is. Please like, subscribe, and rate our podcast from your usual podcast provider, and leave us some comments. 

Let us know what you want us to do. And, Jeff, where can they follow us? Well, we are on x or Twitter at block it underscore hot underscore pod. You can listen to this these episodes on YouTube at block it like it's hot. And and we also have an Instagram channel where we share some some thoughts and some insights and some promo, and we're gonna start putting some more video content, out. 

And that Instagram tag is block it like it's hot with underscores in between each word and no apostrophe. And don't forget, we've got a hashtag, haven't we, Jeff? Yes. It's, hashtag block it like it's hot or abbreviated hashtag b I l I h. And do get involved in the conversations online. 

This is, I think, one of my favorite parts of this whole process apart from just chatting with you, my friend is Absolutely. Seeing the questions and the little debates that come up after after the episode. So until the next episode, we hope you all block it like it's hot.