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Regional Anesthesia Workshop Lumbar Neuraxial, Thoracic Paravertebral & ESP Block
Javier Webar, MD | McGill University
•
Identify the midline and depth of the posterior complex.
•
Accurately identify intervertebral spaces.
•
Evidence of improved efficacy of epidural placement in parturients:
•
-
Less epidural failure rate.
-
Increase first pass success and fewer needle passes.
-
Lower rate of incomplete analgesia.
Some evidence (mainly cases reports) of increased success in patients with anticipated difficult neuraxial blockade secondary to obesity, spinal deformity and previous surgery.
BJA Educ. 2015;16(7):213-220
BJA Educ. 2015;16(7):213-220
Anesthesiology 2011; 114:1459–85
BJA Educ. 2015;16(7):213-220
BJA Educ. 2015;16(7):213-220
BJA Educ. 2015;16(7):213-220
Anesthesiology 2011; 114:1459–85
Anesthesiology 2015; 123:459-74
•
Alternative to thoracic epidural analgesia with equivalent analgesia.
•
Can be placed in awake, sedated or GA patient.
•
Advantages of unilateral block, lower incidence of hypotension and urinary retention.
•
Risk of pneumothorax (~ 0.5%) and bleeding complications. -
•
Must follow similar guidelines regarding anticoagulation therapy/prophylaxis.
Ultrasound vs Landmark Technique (Patnaik et al. RAPM, 2018) -
Increase success with US (94 vs 72%).
-
More dermatomes blocked with US (1–2).
2–5 MHz
1
Begin scanning in parasagittal plane ~ 5 cm off the midline
2
Arrange intercostal space in the middle of image
3
Slowly move probe medially to locate transverse process
4
In–plane approach from caudal to cranial
5
Inject under costotransverse ligament, watch pleura descend
20–25 mL of LA (single shot) or 5 mL per intertransverse space
Depression of the Pleura
•
Injection between erector spinae muscles and posterior surface of the transverse process.
•
Works by LA spread to the paravertebral space.
•
1 single injection at T5 can produce extensive analgesia of the ipsilateral thoracic wall.
•
Main advantages are simplicity and safety.
•
Single Shot >>> Catheter
•
No efficacy/dose finding RCTs available.
Anechoic “band” between ESM and TV (ESP)
T5 = 20–25 mL of LA (single shot)
Javier Webar, MD | McGill University
•
Identify the midline and depth of the posterior complex.
•
Accurately identify intervertebral spaces.
•
Evidence of improved efficacy of epidural placement in parturients:
•
-
Less epidural failure rate.
-
Increase first pass success and fewer needle passes.
-
Lower rate of incomplete analgesia.
Some evidence (mainly cases reports) of increased success in patients with anticipated difficult neuraxial blockade secondary to obesity, spinal deformity and previous surgery.
BJA Educ. 2015;16(7):213-220
BJA Educ. 2015;16(7):213-220
Anesthesiology 2011; 114:1459–85
BJA Educ. 2015;16(7):213-220
BJA Educ. 2015;16(7):213-220
BJA Educ. 2015;16(7):213-220
Anesthesiology 2011; 114:1459–85
Anesthesiology 2015; 123:459-74
•
Alternative to thoracic epidural analgesia with equivalent analgesia.
•
Can be placed in awake, sedated or GA patient.
•
Advantages of unilateral block, lower incidence of hypotension and urinary retention.
•
Risk of pneumothorax (~ 0.5%) and bleeding complications. -
•
Must follow similar guidelines regarding anticoagulation therapy/prophylaxis.
Ultrasound vs Landmark Technique (Patnaik et al. RAPM, 2018) -
Increase success with US (94 vs 72%).
-
More dermatomes blocked with US (1–2).
2–5 MHz
1
Begin scanning in parasagittal plane ~ 5 cm off the midline
2
Arrange intercostal space in the middle of image
3
Slowly move probe medially to locate transverse process
4
In–plane approach from caudal to cranial
5
Inject under costotransverse ligament, watch pleura descend
20–25 mL of LA (single shot) or 5 mL per intertransverse space
Depression of the Pleura
•
Injection between erector spinae muscles and posterior surface of the transverse process.
•
Works by LA spread to the paravertebral space.
•
1 single injection at T5 can produce extensive analgesia of the ipsilateral thoracic wall.
•
Main advantages are simplicity and safety.
•
Single Shot >>> Catheter
•
No efficacy/dose finding RCTs available.
Anechoic “band” between ESM and TV (ESP)
T5 = 20–25 mL of LA (single shot)
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