S2:E8 "Keep It On the QL: The Secrets of Abdominal Wall Blocks (Part III)"

Is three really the magic number? Join us for our third episode on abdominal wall blocks to find out about Debbie, Ducks, Pizza, and Plexi. I'm Amit Pawa. If you want your QL blocks stop glitching, you better look for that twitching. I'm Jeff Gadsden, and this is Block it like it's hot. 

Hey, man. We are back for a third helping of abdominal stuff. I know, Jeff. Can you believe we've managed to drag this out to three episodes? Let's hope. 

As the famous Delos soul said, three is the magic number. And, Jeff, do know what? We we've, we've managed to get nearly $48,000. Can you believe that? Wow. 

It's it's so amazing and humbling and and gratifying. I we're getting very close to a big number there. 50,000. Yeah. I I mean, neither of us are 50 yet. 

Right? But, I mean, it would be nice if there was some kind of a synergy between the the number of downloads in age. Yeah. I heard being 50 is, like, amazing. So Yeah. 

It's meant to be. It's meant to be. Listen, man. How have you been? I've been good. 

Yeah. I mean, we had an epic summer. As you know Yeah. One of the highlights the the highlight of our year was making it over to Europe and seeing a lot of amazing sights and and hanging out as a family together. And the cherry on top of all that was meeting up with the Powas and sharing a dinner and getting the kids to meet. 

And Cory and Kate got to meet in person. And so that was that was thank you for making time for us, man. That was incredible. Listen. I have there was no way I could let you come to this side of the world with your family and not grab just a tiny piece of your time. 

So listen. If you got the time to share, I wanna know a little bit about the different countries you've been to. I'm guaranteeing that you would have been to places that I've never been to because when you come over this side of the world, you make the most of it. But I gotta say, it was fabulous to get our families together, and to share a a meal and have some Indian food together and Ugh. And even have have some have, you know, have a little cheeky cocktails. 

That was great. That was absolutely great. So tell tell us what you got up to, man. Didn't you walk out of the restaurant with a cocktail? Is that is that possible? 

Well, we nearly. I mean, the problem about the restaurant that we went to was they had they had pretty defined time periods that you could sit at the table for. Right? But I didn't realize that we actually managed to eke an extra hour out of our time. But you and I just ordered a drink just before, you know, we had to get kicked out, and so I was given a paper cup with which to to finish the drink. 

It's like Las Vegas. Wow. Yeah. Exactly. No. 

That was that was that was incredible. One of the great things was seeing how the kids got along because it wasn't Yeah. You know, you got two teen girls and, you know, I've got these teen slash tween boys and then Gigi's just turned 11. So I but they got along amazing. So Yeah. 

That was that was good fun actually trying to work out how that dynamic was gonna play out, but, certainly, kids, at the end of day, they're always gonna end up being something common. I think they played a a card game. They ended up making if I recall correctly, they may ended up making a cocktail for you to try yourself. I'm not sure if you actually, part partook in that, but that looked like that was fun. Yeah. 

I believe it was a watered down mango lassi with bits of samosa and paneer in it, and garnished with a bit of mutton. How was your summer? Well, listen. You know, it was great. We, we hadn't been away, since our trip to Hawaii, so we had saved up. 

And you know where we went, man. We went to the the the place where we first started talking about it, on our very first introductory episode. We went back to Disney. Yeah. We went back to Disney. 

So we had we had a fabulous time. I think there's no doubt that if you were to cut me in half, you'd see a big capital d for Disney somewhere right running through my body. So so we loved that experience. And the only thing is we were kind of, joined by storm Debbie. Right. 

The first time. So literally, we landed in Florida, and you guys, that was kind of your storm slash hurricane season. We got those hurricane alerts coming through on our phones. It's a little bit scary. It was a little bit wet, but you know what? 

That kind of passed. We did all the parts. We did some of the new rides. If you have been keeping track on my Insta, you would have seen pretty much a daily post of all the experiences we had, but, you know, we absolutely loved it. So the question is how long we're gonna leave before we go back. 

But, Kate and the girls love Disney. So, yeah, we had we had a fabulous time. Thank you. That's amazing. Hey. 

Do you do you see new things every time, or do you just hit the favorites? I mean, do do things change enough that there are new rides and activities and okay. No. For sure, things change. So, actually, since we had been last two years previously, then, you know, there'd been a couple of new rides. 

We ate in a few different restaurants. We did some different experiences. We found a secret waterfall. So actually right behind Canada, a, at Epcot and the World Showcase, there's a little secret, waterfall behind one of the places that not many people know about. So when it's really hot, it's really busy, you can kind of dive down behind this place. 

And and I made a little reel, on on TikTok and put that out, and that has got about 8,000 views for me to keep teaching people at the secret hideaway. So so no no longer secret. Yeah. No longer secret. And we had a few occasions when we had a few bits of, Disney magic sprinkled, so we got onto a ride that we shouldn't go onto a ride because there's no spaces left. 

You know, the staff at Disney are amazing. So I think we've given them enough free advertising. But to answer your question, yes. We saw some, some of the old stuff, but we definitely saw some new things. That was very, very cool. 

So when you when you get to the point where you've done 25 princess breakfasts, do you get, like, a free a free stay or something? I'm sure if you tell the right people, I'm sure you get something. But, no, we we we didn't do we did do the princess breakfast, but we did do plenty of character dining. And I've got I've got lots of photographs with me with my my my favorite's kind of Pluto, but Pluto doesn't do character dining. So and I didn't get a photograph with Pluto this year. 

Definitely got Goofy, got Mickey, got, you know, got the whole work. So yeah. Pluto's a dog. Right? Pluto's the dog, and people don't understand why he's my favorite character. 

What's Goofy? Yeah. Goofy is also a dog who has Pluto as a pet dog. But That's that's messed up, man. I don't know. 

I know. It's it's I have to process that. Hey. So did you go to, the different countries at EPCOT? Yes. 

We did. Yes. We did. Did you go did you I remember Canada. I've only been once when I was in eighth grade, but Canada had, as one of one of their national dishes, nachos, which I'm not displeased about because I love nachos. 

Uh-huh. But, as a as a Canadian, I can tell you it's not a traditional dish. No. So we didn't try the nachos, but I tell you what Canada did have that was amazing was maple popcorn, some kind of maple syrup popcorn. That was by far and away the best. 

That was amazing. So that we enjoyed. Maple syrup is traditional. Yes. That's good. 

Okay. Listen, I gotta take some other some other crazy stuff. I got I I sort of discovered my love of Okay. We're gonna pause and play a game. What listeners do you think Amit discovered his love of? 

We're gonna give you five seconds. If you can guess correctly, I will send you a block it like a tot mug. Tweet us your guess. What is Ahmet's new infatuation? Shoe horns. 

Did you guess it? Yeah. Me neither. I I sort of discovered my love of shoe horns. So my my my youngest daughter, Sienna, when we went to my parents' house at one stage, my mom's home, she she saw this, the shoehorn, which for some reason she really liked. 

Don't ask me why my youngest child, who should be the most fit and most agile, has got a thing for shoe horns. But I made a comment about how much I liked it, so my mom gifted me this silver duck head shoe horn, which has now become a stable part of me getting up in the morning, put my shoes on. I don't understand how I lived without a a shoe horn. My granddad used to love these things, and now my youngest daughter loves them. And and I love them too. 

Have you have you ever used a shoehorn? Well, first of all, the fact that you love a shoehorn just fits with I mean, you wear have a top hat. So I hadn't thought about I you know, I I picture you dressing in a very dandy ish way most of the time. So I I the shoes that I wear, man, are not the kind that you would need a shoe horn for, typically. Dude, I use them for trainers, for sneakers. 

I use them for everything. I if I could just walk around in beachwear all the time as casual as possible, that would be my my ideal. I I actually well, I'll I'll say that story for another time. The Oh, it sounds interesting. I have used it a couple times when I have, like, dress shoes. 

Because sticking your finger behind your heel, that that's like an uncomfortable thing to do. That's not cool. Right? Ew. We're we're starting a new, line of block it like it's hot branded shoe horns, so just, message us. 

Hey. Wouldn't wouldn't that be a great idea? That would be a great idea. I think we need to go up for the merch, man. That is gonna be the next level. 

I think we need to go for the merch. But, yes, no. As a side, I'm I'm met Navs Navsidhu from, from Auckland to New Zealand. Oh, yeah. You know, Nav is a regional anesthesia, expert and a gastric pocus, guy. 

He's all over that. So I met him in London. He was in London in The UK for a wedding, so I got a chance to meet him. And we talked about all things regional and all things pocus, and that was that was a that was a fun meeting. But I gotta talk to you about something else. 

This is a really important question. You've heard of Crocs. Right? You know, Croc the footwear? Yeah. 

Yeah. What do you think about people who wear socks with Crocs? Because apparently, that's a thing. And I saw that all over Disney, people wearing socks with Crocs. Oh my Is that a trend you're familiar with? 

It is. Oh, because I have three boys between the ages of 15 and 12 Uh-huh. And this is what they do. And I it drives Corey and I nuts. And we actually said, you cannot do that in Europe. 

Like, this it's one thing it's one thing for you to walk in the neighborhood and go to school. And even though I think it looks bizarre I agree. It's I I said, we guarantee you, you will not see someone in Europe wearing Crocs with socks. Yeah. And sure well, sure enough. 

We just saw one person, but that person was probably one, and that person was probably American. But it's a thing these kids are doing these days. Yeah. But I but I think it's coming to The UK and Europe as well because I mentioned it to to one of the anesthetic nurses I was working with, And she said, look. That is a thing, but I don't think I could get away with it. 

We drew the line at the beach. Like, we were about to go to the beach in France, and and Reef Reef is pulling on his socks to go I said, dude, we are going to the sand in the water. I guess, what? Yeah. So So then it it makes no sense for me to have socks on. 

Wouldn't you to do that? Exactly. But hold on. Just before we go on, can you smell that? Can you can you smell Updogg? 

What's up, dog? Not much, man. What's up with you? Oh god. That's such a terrible joke. 

Do you know what? I so that was a joke that Sofia did on you when she met you, and you kind of very, yeah, very politely went along with it. I've tried that jog subsequently. I've tried that joke on lots of people. Nobody's fallen for it except for one person. 

Kareem El Baghdadli was the only person. I was like, can you smell hot dog? He's like, what's up dog? And I was like, nothing much, man. What's up with you? 

And he was like, oh my god. He's the only person that's fallen for that. That's great. Speaking of food, just when you think that food cannot possibly call you on your phone, boom, onion rings. Oh my god. 

You know what I love about that? Was that was not a scripted dad joke interval, and you completely yeah. That's very good. I've got some loaded in the chamber here, man. Just ready to go. 

Okay. So let's when we get to that point, I just wanna hear because I don't know if you noticed. Apparently, in the last episode, I won the joke off with performance enhancing rugs, so just letting you know. Yeah. It it was a good one. 

I Yeah. I forget. Think Evan Yates was saying that he he had to stop riding his bike because he was laughing so hard or something. Is that did I did I read that? Yeah. 

I did. Evan, thank you for that's one win. I didn't realize this was a contest. I'm gonna try harder if this is a No. I don't know if it's a contest, but bearing in mind that, I generally tend to pop I I'd research my jokes in advance. 

I think I've got an unfair advantage. But listen. Let's get into it because some of our we might have lost some of our, listeners by now because of this the the drivel that we enjoy talking about. But, so, Jeff, we've got to the third part of abdominal wall blocks, and I've saved possibly some of the most contentious blocks to the end. What are we gonna start off with? 

We are going to talk about the quadratus lumborum block and the e to the s to the p. Exactly. So so we, you know, we we know that there are some folks that love ESP as much as us, and there are some that maybe don't so much. But I thought it'd be really useful to to pick these two blocks and hopefully have a little bit of time to talk through them. So the quadratus lumborum block, so we used to do that whole thing that we did with all of the other blocks. 

We used to give them numbers. Right? But we're gonna try and stick to the new nomenclature. We're gonna start talking about the lateral, the posterior, and the anterior quadratus lumborum block. So first of all, do you use these for abdominal surgery? 

We do. So we make use of this when we have more extensive abdominal procedures. So things where there's I think I've talked about my little algorithm before. If it's midline, then it's rectus sheath. If it's outside the midline but below the umbilicus, that's that's a tap block typically. 

Uh-huh. But if it's more than that, it's certainly involving like two or three or four quadrants and especially if it's got a lot of visceral component to it, like, you know, they're digging around in the belly a lot. That to me seems like a good a good opportunity to use a a QL block. Cause as we'll get into in a second, there's a feeling that, and there's certainly some cadaveric and clinical evidence for this, that a QL done correctly will promote spread of the local anesthetic up into the lower thoracic paravertebral gutters, and you get some of the sympathetic fibers. Okay. 

So listen. I think, it's worthwhile kind of picking apart some of what you talked about there because I, like you Pick away. Yeah. So I kind of had a yeah. I've got a strategy when I'm thinking about what blocks I wanna do if I'm not doing a central neuraxial block or if I'm augmenting a central neuraxial block and thinking about postoperative analgesia. 

But I kind of I've got an issue with the quadratus lumborum block. Oh. And the issue I have is that we tend to we're we're doing it in the lumbar area. Right? And we're doing it around the back in the paraspinal region. 

And when we're I'm gonna I'm gonna start with the most contentious blocks. I'm gonna start about the with the anterior quadratus lumborum block, which to remind our listeners involves injecting local anesthetic in that space between the quadratus lumborum muscle and the psoas major muscle. So often that you the needle's coming from the posterior aspect of the patient, and you're driving it through, the, the quadratus lumborum muscle, and you're trying to find that space between QL and psoas. Right. But right in that area, Jeff, is the lumbar plexus. 

So how are these blocks, which are performed in the vicinity of the lumbar plexus, helping abdominal surgery? So I just want to get your take on that, and then we'll talk about your tips and tricks. Yeah. That's a great question. And and to be clear, this is a high stakes real estate area. 

Like you point out, there is a lot of important stuff. Lumbar plexus, you're very close to the spine. There's a big blood vessel there as well, right? Yeah, you see it sometimes when you're scanning, oh what's that? That's the aorta. 

This is why this is not a beginner block and so you want to make sure your ability to get a needle into a fascial plane, the correct fascial plane is on point. But if you do, we see this clinically, you get the entire abdomen. It was hard to get my head around that, when I first started thinking about, on a second, how is this local anesthetic put here near the tenderloin muscle, you know, supposed to get the abdomen and all that kind stuff? But what it took me to understand this was realizing how close you are to the twelfth rib and the little passageway between the fascial plane that you're putting it in, which is clearly in the abdomen, in the flank, and then the local can sneak up into, like I said, that lower thoracic zone. It's really just a convenient way to get local into the paraspinous space and with enough volume, and we always use thirty mils each side, that will get enough cephalad spread that you you get not just the lower spinal roots like t eleven, twelve, and maybe l one, but you get ten, nine, eight, seven, etcetera. 

So this is another paravertebral by proxy approach. Right? But but, you know, there's a there's a pathway by which your local anesthetic injected from the abdomen, around the lumbar area is gonna track up towards the paravertebral space from below. Yeah. Yeah. 

That's kind of the idea. But, again, you have to do it right. And and that brings us around to the different approaches to the QL block. And so Mhmm. I'm just gonna say it upfront. 

I think there is only one that really works. If you do the lateral approach, aka the QL one, my feeling is that's a TAP block. That gets me the same results as if I do a TAP block. So lower abdomen, there's no expectation there of any cranial spread up to the lower thoracic zone. I agree with you. 

I I know. I I definitely think a lateral, quadratus lumborum block a k q l one is like a tap block, and that is literally if you were to look at a cross section of the muscle and you follow the tap plane back, it's just at the lateral edge of the muscle just as QL interacts with that abdominal musculature. And there's a little gap right between a QL muscle and where the transverse abdominis ends, and that's where it gets a bit fluffy. And there's a potential to make a few air errors there. So there's something called the the perinephric and parinephric fat, and and that's where if you're not careful, if you're coming from the anterior aspect, you can make a mistake with, mistake with quadratus lumborum blocks. 

Right? Absolutely, and this is why when I teach this to the trainees, you know, I've said this before, bones don't lie. If you get someone who's got a BMI of thirty five or forty and you start scanning, you know, the lateral abdomen and starting to think, well, there's my, there's that muscle and is that muscle and what's that soft tissue space there? I've been fooled lots of times, but if you start at the back, there's spinous process, there's transduce process, and we know that the QL muscle flies like a flag off the tip of the transduce process, Guy the bones guide you to exactly the right spot. So I don't I I really am a big proponent of scanning using from the posterior part and using the bones and then bringing your probe around to the the correct position on the obliquely on the flank. 

Well, so this is interesting. I think we're gonna come back to this in a second, but what I wanna just revisit is that I think it sounds like you and I are both you know, we'll either do a tap block, but we're not gonna do necessarily a lateral lateral QL block. So a tap block, we know what the landmarks are. We need to go back to that furthest point of transversus abdominis is is is tapering off, and that's where we're do a tap block. So we may be gonna park the lateral QL block to one side. 

Right. Before we talk about the anterior, what are your thoughts about the posterior quadratus lumborum block, which was then originally called the QL two, which is over at that posterior aspect, the dorsal aspect of the muscle. So kind of continuing in line from its lateral aspect, you're injecting right at posterior aspect of the muscle. What are your thoughts about that? Assuming you can find the right plane. 

Right. Well, that's that's it. And, I mean, know I'm a simpleton, but I don't know how that's supposed to work because the nerves run-in the front, in the anterior surface of the QL muscle, between QL and psoas. So how is putting local behind the psoas meant to work? Unless the mechanism of the block is something that we're that we've missed. 

And people have proposed that maybe just dumping a bunch of local in and around the thoracolumbar fascia anesthetizes the fascia which is richly innervated blah blah blah blah blah. But again, I don't see how putting local anesthetic there, it may improve your pain score somehow. Yeah. But I don't expect that to get me a demonstrable sensory block of the abdomen. Well, so so, professor Jens Borglum is a is a big proponent of the QL blocks, but I don't think he's done very much with the posterior area. 

He's all very much an anterior, a q l three kind of guy. I don't know people that are singing about the posterior chordaeus lumborem block, massively. I don't know there's lots of people that talk about it. Although I have to tell you, I can do, and I used to do a lot of essentially a a sort of a hybrid between a posterior tap block and the posterior chordaeus lumborem block for my, abdominal plastic surgery. So whenever they used to do the DFT flap, the deep inferior of the gastric perforator flaps with mastectomies, they used to get like a it's kind of a hip to hip incision. 

So I used to have the patient supine. Used to use a curved array probe. I used to increase the depth and scan as far post to a lateral as I could. I might even use a wedge underneath the hip so I could scan to the poster aspect. And I would increase the depth so I could see the virtual body in the transverse process, and I was able to get into the that poster aspect to the muscle with the patient supine just because it was a bit of a faff to turn them from one side to another. 

So I used to do, you know, posterior chordatus lumborum blocks for those patients, and they worked well. They weren't like a a really dense tap block, and the patients never complained of pain in the chest as they often don't after mastectomy and reconstruction, but they certainly just only complained of abdominal tightness. So I kinda do like the posterior QL blocks, and I know some of our colleagues are are doing these for of even for renal, transplant patients, they're using them. But the thing that I that gets me about the the anterior quadratus lumborum block, So you're when you tend to insert your needle from the poster aspects and find that space between QL and psoas is the faff of of moving the patient around. And, you know, you if you turn them on one side, then you're gonna flip them to the other side. 

And so so so how do you deal with that? Well, we we yeah. So it does require you bring a needle in from the from the back. And so what we'll do is we'll we'll turn the patient on their side, either in preoperative, doing it in preoperative, or or once they're anesthetized, or at the end of the case, frequently, we'll just I'll tell the resident or the CRNA in the room, hey. Just, you know, once the banded dressings are on, just have the patient turned on their side. 

We'll be there in two minutes. And then bring the machine around. The machine's on one side, and you're standing on behind the patient. Uh-huh. And you can do both sides with with one position. 

You don't have to turn them the other way. What the sigma? What what the what? You can do both you can do both sides with, with the patient on one side? Yeah. 

Yeah. Yeah. Again, I like to start in the midline with my curvilinear probe, and then the upside is easy, right? Because you just bring the probe around and you're coming in. Yeah. 

The downside, you'll just bring the probe down towards the bed, and oftentimes my hand is just resting against the bed and but with that oblique direction of the beam back up towards the midline. Uh-huh. And, it's great. You know mean? The needle the needle comes from from medial to lateral, and it's easy. 

I'm gonna have to check out one of your videos to see this because, I I I know you've taught this, a few times, and I definitely know it features somewhere in one of your videos. And I think some of our colleagues have also shared this technique, but it's but, you know, we're so used to I'm so used to doing it from the uppermost, the non dependent side where you can get into that anterior quadratus lumborum plane. I'm just trying to work out things must look a bit squished and a bit different when you do them on the side that's in closest contact with the bed. The two sides can look a bit different, but ironically, sometimes the dependent side looks a bit better. I did because of maybe because because of the squishing. 

Not sure. Well, listen. I'm gonna I'm gonna be trying this. I'm definitely gonna be trying this. Oh, I I think you should. 

And I think it's less of a faff sometimes than walking around to the other side of the patient and putting a bump under that hip and jamming the probe underneath. Then where's your ultrasound machine? Do have to move that around to the opposite side and that sort of thing? Yeah. Yeah. 

You get once you try it a couple times, get used to it. You're like, oh, this is this is actually pretty easy. Okay. So I'm kind of you know, I I told you I did the posterior QR block, with pretty good results. But Yeah. 

You're now making me feel interested slash intrigued about the anterior chordaeus lumborem block. But listen, people talk about the thoracolumbar fascia and the middle thoracolumbar fascia. Now where exactly does the needle tip need to be when you're performing these QL blocks in order to make sure you're in the right space? Can we see it with our naked eyes? And how can we make sure we're in the right place? 

Because clearly, if you go too far and you cross the psoas fascia, you're likely to pick up branches of the lumbar plexus. Been there. Done that. So I've Okay. I remember the a case we had a patient who had some sort of gynecologic procedure, and we did a QL block at the end of the case. 

And in the recovery room, she felt great. And young young woman and got up to go to get dressed and go home and one leg was weak on their inner quads. I'm like, oh, man, this sucks because Right. Of course, we used EXPAREL as we often do for these things. I think, man, have just have I just bought this person a forty eight plus hour knee immobilizer? 

So now she was a a nurse anesthetist student, so she was a an educated customer. So we gave her a knee immobilizer so she was safe and let her go home. And I said, listen. I'm gonna call you every day and just figure out how you're doing. Next morning I called her and she said, oh, no. 

Took the immobilizer off, my quads power is right back to normal. And I was like, what? That's kind of disappointing, like, our block only lasted twelve hours? And she goes, oh, No. My belly feels numb. 

And it did so for seventy two hours. Wowzers. That got me thinking about how to avoid getting inadvertent local into the psoas muscle because I think that's what what happened. Our needle was just a little bit too far. We were in the psoas on that one side, and, clearly, we got some spread to the lumbar lumbar nerve roots. 

And so what what we ended up doing was to use, and you're gonna love this, on my friend, the nerve stimulator. Ah, yes. This was this is actually the first time I tried doing using the nerve you know I like using nerve stimulator to stimulate muscle sometimes. Yes. This this is it. 

This is this is where I had that moment and and said, if my goal is to not put it in a muscle, and I know that if you crank the current up and stimulate the muscle, I'll get a little visible twitch on the screen. Now this is this is what we do for all QL blocks. Yeah. Crank the current up to like two milliamps. And as your needle's coming across, you'll see the dink dink dink of the ES muscle and then the dink dink of the QL. 

Okay. And then you'll kind of lose it. And the implication is you're likely within the exact plane between psoas and QL. Sometimes you go too far and you're like dink dink dink of the psoas muscle. Hopefully you're not eliciting a quadriceps twitch. 

That would mean you're actually, you know, very close to the lumbar plexus, but you see the psoas muscle itself twitch, And just pull back gently until it stops. And then Right. We'll give it a little bit of saline and 10 times out of 10 when when you've done it that way, it peels open nicely. So that that's a way to stay in the correct plane. And we haven't had, knock on wood, any quads weakness since doing it this way. 

I like that. I do like that because and, like, in a way, I'm hoping the the added implication is if you don't have quadriceps twitches whilst you're doing that, you're sufficiently far away from lumbar plexus nerves. So that's just an extra bit of of confirmation that actually look. I've definitely not got a lot, quads twitching. I've lost the cure twitching, and I'm just in that space. 

Okay. I like that. And presumably, if you wanted to, when you finish your injection, if you rotated your probe through 90 degrees, you'd see local on-site tracking along one side of the QL muscle. Do you often have you ever done that? Do you do that? 

Sometimes. And Hashem Elshakawi was the one that I think first thought about that and sort of he wrote some case reporter That's right. On that and he got us thinking about, look, can track this up to the twelfth rib and then see how it is actually spreading cephalon. We don't do it all the time. I'll be honest with you, the QL block can be technically challenging in patients that are bigger. 

If it's a BMI of thirty five plus, I'll give it a go sometimes, but I will tell the trainees and the surgeons and whoever else that like we're gonna try the QL, but I feel reluctant to, notwithstanding the nerve stimulation bit, dump a bunch of local into a space that I'm not really confident about and it looks all mushy because I I'm not getting a great image. And in those cases, I'll flip to an ESP. Okay. Alright. We're gonna come onto that in a second. 

But I think the thing that I find confusing with this, we've got so many options for abdominal wall, fascial plane blocks. So to try and work out which one to choose is a bit that I'm finding confusing here. But it seems to me that if there's a lot more involved and you wanna kind of do a one and done on both sides, you know, bilaterally that you go for the QL, whereas it's very purely just kind of a midline thing, you go for tap. If it's upper abdominal, you can link it. You know, the the main analgesic to that, you go for external oblique intercostal. 

But it's kind of it's nice to have those tools, but let's close-up on the QL block, Jeff, by, this is a volume block. Right? So what volume are you using? You said 30 cc's, I think, if I remember correctly. That's right. 

Yeah. So we're using 30 per side. So you gotta be considerate about your concentrations and and, that sort of thing. So we'll use a try to use a low concentration solution. And what about adjuvants, adrenaline? 

I know you told me that you'll you often use it with liposome or bupivacaine, but, what are your thoughts on using adrenaline containing solutions when you're using a large volume injection in these spaces? Any any role for that? I'm a big fan. Not because I believe it's gonna extend the duration of the block as much, but it just as a vascular marker. Okay. 

I like dexamethasone. So if you're if you're gonna use sort of Uh-huh. Point two percent ropivacaine or quarter percent bupivacaine, I think a little dexamethasone does squeeze out another six to eight hours out of it, which is sometimes just enough to get them through the night. And how dilute will you go with your local anesthetic? You just stay at point two percent Ripivacaine, or would you go even more dilute with that if you're doing multiple blocks and there's a trauma patient for example? 

We've gone to point one at times, but that's more of an effort to spare motor Right. In a peripheral nerve block. For the fascial plane blocks, I think point two percent Rupivacaine or quarter percent Rupivacaine is probably fine. Because most most patients that are adults can tolerate a sixty mil volume of that concentration. Okay. 

What about catheters? Do you ever put catheters in this place? I know you somebody who uses an extended release preparation, you don't have to. But have you done catheters, and how reliable are they here? We I I have I have done a QL. 

Not very often, though. I think that they can be challenging for a couple of reasons. One is getting the catheter to find the right spot and stay in the right spot. Yeah. When the patient's moving in their trunk, I think it's a lot of potential to It's a of muscle movement, right? 

You can pull it out. Right. Wiggle that catheter tip out of the correct plane, then you've got an intramuscular catheter in QLR or something like that. But the other challenge sometimes is how do you run those catheters? And we talked about before in terms of fascial plane catheters and intermittent boluses and that sort of thing, but it can reestablishing. 

If it takes 30 to get you a good block of the entire abdomen, how do you keep that going with a catheter? It it can be it can be tough. But the only person I know that's had a good result with, with quadratus lumbrance catheters is Nadia Hernandez. In fact, she showed a video, at Ezra at the World Congress in, regional anesthesia that was held by Ezra in Paris last year. Showed a video of her posters there in section. 

Literally, I mean, it must have been hours posters there in section, walking around, moving around, with these bilateral QR catheters in, and she, you she had a great result. But I, I don't know. I I'm I'm not a 100% comfortable with that idea just because large volume bolus sticking a catheter, you gotta have an intermittent bolus program. And as you say, the chance the catheter's coming out seems high enough for me. So but I do know at least one person that had a good result. 

The other consideration I'll just mention is toxicity. And so we don't do a lot of lumbar plexus catheters for a couple of reasons. Yeah. But one of the reasons is cases that I've heard where patients have had a fatal toxic event at home using a catheter, most of those catheters were lumbar plexus catheters. I remember reading those papers. 

Yeah. Yeah. That tenderloin muscle, man, it's really, really vascular. And, so the absorptive the absorptive I can't talk. The absorptive capac Absorptive capacity. 

Absorption. Exactly. That's what I'm yeah. What you said is high. Yeah. 

So I I just get a little bit nervous. I would be Yeah. I'd be nervous about sending somebody home with a catheter in that part of the body. Yep. That that makes sense to me. 

Now just to finish up on the nomenclature bit, I just had to say as an acronym guy, one thing I love is is Jens Borglum's group calling the q l three the tequila block, the transmuscular q l. I mean, it just it rolls off the tongue. It does. Right? Makes me do a little dance. 

Do a tequila block. Yeah. And you can hear. Right. Yeah. 

Oh, I wish I wish the people at home could see you dancing. That is great. That was the best dad dancing. And that the thing is that was natural, so that that's the way I move. Think of PB Herman in that movie, right, on top of the bar. 

Oh my goodness. That has brought back the worst imagery. Is that really what I look like? Thank god we don't do a video recording of this podcast yet. Listen. 

I think we've kind of drifted nicely into a into a little joke break. And, you know, I just wanted to share something with you. My daughter, Sofia, tried to cook me a Hawaiian pizza last night. The problem was, sadly, she got it burnt. Oh, no. 

And I said to her, do you know what? You should have cooked it on aloha temperature. I like that one. I think I think you might win with that one. Well, no. 

Well, listen. I haven't heard what you've got for me. So this is a an ongoing thing, but my wife, Corey, was saying I need to do more chores around the house. And I said I I she caught me at a moment of weakness. I said, can we just change the subject? 

And she said, okay. More chores around the house need to be done by you. Oh, a grammar joke. I did not see that one coming. Very good. 

Well, you don't that's very good, man. I like it. We're kinda mixing it up a bit. But I'm gonna go back to the restaurant theme. Did you hear about, the restaurant they just recently put on the moon? 

No. Well, you know what? The food was great, but there was no atmosphere. That's good. That was the most forced joke listeners. 

You heard Jeff, that was the most forced joke you had to do just to make sure there was no silence. No. I like that one. That was that was good. Well, listen. 

Are we gonna what do you think? Should we get back into it? Well, I I there's one thing else. There's one more thing I wanna share with the listeners. Oh. 

Have you donated blood ever? I have not. I need to. I haven't. It's one of those things. 

Right? Like, you I feel like I it's it's I should do it more than I than I have it. The last time before this week was, like, I was in university, so I thought Okay. I thought I'll I'll go. So I went never again. 

Oh, no. Too many stupid questions. Whose blood is it? Where did it come from? Why is it in a bucket? 

What? Oh, no. Oh, Jeff. Oh, god. I I don't think I don't think you're gonna win with that, but we're gonna have a lot of confused listeners. 

I have a lot of questions gonna be asked about that. Oh god. I think my laugh might have just literally broken the, the audio thing here. Okay. Right. 

Let's let's get into this controversial thing. So the erector spinae plane block, the ESP, the beloved ESP, we already know there are some people, that think it's a waste of time. But some people that don't do the blocks are like, hey. It doesn't work. What a waste of time. 

If you want it to work, you do a thoracic epidural, or you do a spinal, you do a paravertebral. What is the point in doing something that they believe either doesn't work at all, or if it does work, works via systemic absorption? I'm not gonna name those guys, but those guys and gals who feel that way know who they are. But I was intrigued when Kijin Chin in the early days published, some work about the use of ESP blocks in, laparoscopic bariatric surgery, and he had some reasonable results. I also know that some people have tried the ESP block in lieu of what we would have considered to be the standard, such as a thoracic epidural or intrathecal injection, injection. 

And I know these people have been dreadfully disappointed. So is the ESP block better than intravenous lidocaine, and does it have a successful role or a useful role in abdominal surgery? Because I'm kind of on the fence about this. Tell me what you think. Okay. 

Here's my hot take. Anything is better than IV lidocaine. I'm not a not a fan. The toxic potential is substantial. I know of one death and two other cardiac arrests because someone thought this is the best way to use local anesthetic for this ERAS patient rather than doing a block. 

Right. It's a blunt instrument for if you're gonna use local anesthetic, you can you can use it for a block. Okay. Then Hold on. But before before you can you remember where you're gonna go with that? 

Because I just wanna pick up on something. So I for what it's worth, I agree with you, and I I have never knowingly well, no. I haven't used intravenous lidocaine as an infusion perioperatively. I have given it a single bolus of, say, a hundred milligrams as part of a multimodal thing. But I spoke to an American abdominal surgeon at abdominal wall meeting I attended a few years ago, and he told me that he You go to abdominal wall meetings? 

I was invited to talk in abdominal wall meeting as a whole host of plastic surgeons and general surgeons. It was called in fact, it was called AWRE, abdominal wall reconstruction Europe. That's a niche, man. Check out my Insta feed. Yeah. 

I mean, anyway, this got this, this surgeon told me that he has two types of people anesthetizing for him. He has a physician. I'm not don't this is not trying to get political, but he had a physician anesthesiologist, and he had a CRNA. And all of his patients would go to, high dependency units or, you know, a critical care type setting postoperatively, and he'd review them the next day. Now the anesthesiologist would do a thoracic epidural for his major abdominal surgery cases, these abdominal wall reconstructions, and the CRNA would use IV lidocaine perioperatively and in the postoperative period. 

But what I was struck by, which is really interesting, is he told me when he visited the patients the next day, he couldn't tell the difference between those that had had thoracic epidural or those that had or on an intravenous lidocaine infusion. He said they looked equally as comfortable. Now I I can't believe it, but he told me it, so I have to nothing to do but but to believe him. But I don't feel comfortable doing this, but this is so that's kind of why I just I just wanted to post that out there. There are some people that have a great deal of success with this technique, but the whole idea of sending someone on the floor or to you know, even to critical care on an IV lidocaine infusion makes me gives me the heebie jeebies. 

So I just wanted to sorry sorry to interrupt your flow. I just wanted to raise that there. Yeah. No. I I I believe that too. 

I mean, lidocaine is an analgesic. If you have enough of a plasma level, you will feel better. Putting them in a high dependency unit or ICU is one thing where they can be monitored properly, but the cases that I was talking about where there was very bad outcomes were not that. And so I we're seeing a shift away from it at our hospital. It used to be a real big thing six, seven, eight years ago, but Uh-huh. 

I think we've we've we have done a better job in terms of putting local anesthetic in a different place to end effecting good outcomes. So so I I interrupted you as you're about to launch full flow into whether you think it has a role. And and so then what do you what do you think? So and this is exactly why I think ESP does have a role because the QL block, as much as I do like it, is not for the faint of heart. It's and it's not for a beginner. 

So if you want a technique to succeed, it has to be relatively simple, so it's scalable, has to be safe, you're not gonna hurt anybody with that or cause a complication like quads weakness, and it has to actually do something. So there there has to be some kind of effect, and ESP hits all three of those. It it is a technique that you can teach beginners because, hey, see that bone there? Go and hit the bone on the on the corner. If you have any kind of skill with needling and and ultrasound, that's an easy task and it's safe. 

You're not gonna I'm sure someone's caused a pneumothorax with an ESP block. I think they have. Yeah. Yeah. But assuming that you're hitting the right target, I think it's a much safer thing than a paravertebral in a beginner's hands. 

And even though you and I both agree paravertebral is the king of blocks, but it's it's for me, it's all about the scalability. Mhmm. It gives you a good result that can be done by many, many people. Okay. Whilst I am a a a proponent of the ESP in the right indication for the right practitioner in in those you've you've laid out some of those, some of those situations, I find it harder to see a role for ESP in abdominal surgery because that that fascia is pretty thick, and you gotta make sure and, again, if you inject between the erector spinae muscle complex there, and the fascia, that thick fascia down on that lumbar area, I just don't see how it's gonna cross insignificant amount in order to get meaningful abdominal analgesia. 

And, basically, if we're doing it up in the thoracic area, say for thoracic abdominal surgery, you're probably gonna do it, what, seven? Maybe a bit lower than that. I think if you're doing it in the t seven region, I just I don't know. I haven't had that experience with it working as well as I have when I have used it in in in the breast. I've been speaking to Maurizio Ferrero, who you'll know is I'm sure you know well, and he is one of the the the the founders, in fact, the founder of the ESP book. 

He's been showing me some really fabulous footage about his patients in clinic who've got anterior chest issues, say, for example, postherpetic neuralgia. And he's done these, you know, standard erector spinae plane blocks. And within twenty minutes, thirty minutes or so, you know, with a catheter in the sit shoe, he's shown them. They've shown absolute resolution of the anterior chest wall analgesia. So he is con he just doesn't understand why people are not getting the same results, as he is, and he's saying people are not doing the ESP properly. 

But as we go lower down the thoracic spine, I think it gets slightly more difficult to do it. So I don't know what what if you're gonna do it for abdominal analgesia, where are you gonna do your bilateral ESP blocks? What level are you headed for? We typically do them at t 10. And Okay. 

With the hope that, I mean it's, so it's still a thoracic procedure, so you still have the same landmark. So I start with the ribs and I slide medially until I see the TPs and then go there. Granted the muscle's a little bit thicker than it is at say T five, but it's still it's still the same technique. And that that is another reason why I think it's useful and scalable because the same thing that I'm teaching people to do for thoracic cases or breast cases, I'll say, hey, just do the same thing. Just instead of t five, do a t 10. 

But I wanna point out to listeners, and you can go back to our ESP episode, I was doing it wrong. I was hitting the top of the transits process and getting an intramuscular injection, and they were not working well for me until we started to get, you know, pepper pot the fascia as as Amit says and get get truly deep to the ES muscle. That's interesting. I think John Bailey, would he he commented on this, and he was hearing and talking about the pepper potting. He's like, well, why don't you just do an ITP block, an intertransverse process plane block? 

So do you think there's a role for doing that, in the low thoracic area? So, you know, rather than doing an ESP block, just go between, for example, t ten and t eleven in the intertransverse process area into that tissue complex and just popping a needle in there and doing, volume of injectate because then at least you know you're a bit closer to the para virtual space. What do you think? Is there a role for that? I because I'm I'm just again, even though I'm supporting the ESP where I think it's indicated, I don't know where my love affair with ESP is going. 

And for abdominal surgery, I'm less convinced. Now I will agree with you. It's not my first choice, right? So I have to get down to plan D before I'm choosing ESP for abdominal surgery. I'm doing a rectus or a TAP or a QL, But, again, it it it's a good option. 

It's better than nothing and better than a failed epidural and better than IV lidocaine and and easy to do. Okay. I think I think that helps me to stratify it. That that makes so we're it's almost fitting that we're finishing up talking about this technique because we're not saying it's one of the most key or one of the most valuable techniques, but it's something else to have in your toolkit like with everything else. When you're starting off with regional anesthesia, you gotta kind of amass a set of techniques that you can use, moving forward. 

And ESP role, where it may have a role in thoracic surgery and it does have a role in abdominal surgery, neither of us are saying it's high up on our it's not top on our priorities. Because I've heard other people talking about, certainly with laparoscopic surgery, surgically sighted tap blocks because then the surgeon can see under direct vision what they're doing. And I think that may have more value than an ESP block. But listen, I take it. If you're gonna do something pre operatively or you're looking for a postoperative rescue technique, maybe it's worthwhile having a stab. 

Pardon the pun. Yeah. I I think the places that we use it are, like, the robotic case when they've got trocars in different quadrants. And and so, like, I I may or may not have worked with a gynecologic surgeon that does a quote, unquote, minimally invasive procedure with fifteen different ports in the belly. And I'm just like, how is this minimally invasive? 

Yes. I do remember you mentioning this surgeon before. Yeah. That's an, I think, opportunity where, you know, thoracic epidural is overkill because this patient's meant to go home and a TAP block is just gonna cover half of the half of it. A QL block would be great, but not everyone's comfortable doing that. 

And so that's a good opportunity for I think someone who's who's less of a regional enthusiast like Yeah. Like you or I might be to to do a good job for that patient. Okay. Okay. I I I kind of feel I know where that is. 

So, Jeff, we're we're we're gonna wrap up this, this three part series on abdominal wall blocks. Is there anything you wanna say to to close it down, to shut it down? How how do you wanna win this? What do we want people to kind of take away as their take home message from this? There's certainly potential for a lot of confusion about what block to choose for abdominal stuff. 

And I'll just I'll just reiterate my algorithm in terms of abdominal blocks, sort of like in the plan, you know, the plan a block structure. So if I get called to the room and they say, hey, surgeon's open. We wanna do a block for this patient afterwards. My first question always is, is it midline? Midline, rectus sheath. 

Wins every time. And then if not, if it's out to the side and below the umbilicus, that's a tap. Easy. And then for anything else, if it's me personally, I'll probably do a QL. Yeah. 

But I I can see that ESP also taking a role in that third category if someone's not comfortable with any with a QL. I think that's really nice and that that kind of that's easy for me to to understand. Hopefully, something for our listeners to take away. But in the in the correct circumstances, you would still perform a thoracic epidural. Right? 

So where you felt there was a role, you would still perform a thoracic epidural, but perhaps less so than you would do maybe in the past. That's right. Yeah. I think if it's gonna be, you know, a clearly defined three, four, five day inpatient stay and a lot of surgical trauma, we still do thoracic epidurals. And actually, in my hands, I think rather than meeting thoracic epidurals, I still think I'd be doing an intrathecal injections of a spinal with big dose dimorphins. 

That's where our practice kind of diverges. That's that's really interesting. Listen. I have loved going on this journey into the abdomen with you, Jeff. I hope you've enjoyed it as much as I have. 

I've certainly learned a lot from you as always. Likewise. Yeah. Thanks, man. Well, listen. 

I I, you know, I would always like to end on a high note. So, I'd like to to end on a on a couple of jokes. What did the pirate say when he turned 80? Don't know. I may be. 

I may be. I may be. Hey. You're just try you're just trying to win the joke off now by putting extra jokes in. So much better in my head. 

Okay. One one one other one for you. K? My niece calls me ankle. I call her my knees. 

Oh, okay. I like the pirate one. Okay. Okay. Listen. 

I'm I'm done on that. Have you got anything before for me before we wrap up? No. I think you've done a good job on the jokes there. I've worked hard to get to get votes here. 

Well, listeners, please remember to like and subscribe to our podcast from your usual podcast provider and leave us a rating. That really helps. And where can they follow us? Yep. Please leave us a rating. 

They can follow us at x or Twitter at at block it underscore hot underscore pod, at YouTube at block it like it's hot. And we got one more, Jeff. Where where where is the other place? Oh, the Insta. Yeah. 

It's block underscore it underscore like underscore it underscore hot. Exactly. And don't forget our hashtag. Block it like it's hot or b I l I h. Exactly. 

Until the next time. We hope you all block it like it's hot.