Ultrasound and Regional Block Demonstrations

Speaker 1So, we wanna welcome everyone. Thank you for uh joining us in this uh virtual um portion of our symposium. Everyone who received the glasses. Hopefully, everything was OK in terms of how you, uh, received the glasses. My name is Alok Sharonan. This is Doctor Michael Bullock, who you know, we've been seeing from the lectures today.

Speaker 1Um, the goal of this portion of the lecture, of this part of the course is to teach everyone how to perform these Ultrasound guided blocks. And the way we're going to do it is that we have, uh, two simulators, one over here. Let me see, is this camera, it's uh

Speaker 1The bottom left is this one, right?

Speaker 1I think the camera on the right. I think this is a good picture. If there's any, any problems, let us know. But we have over here the, one of the Spine stimulators, and this is gonna be a sim simmi, yeah, perfect. This is a simulator that we have that helps go over how to do Ultrasound in general.

Speaker 1So the first part of this program is going to be how to do Ultrasound. Dr. Bullock is going to teach us the basics of using Ultrasound and how to target Ultrasound. The next, we're going to move to the Other Spine simulator, which is actually created to teach everyone how to do the TL block. So,

Speaker 1Dr.

Speaker 2Bullock, sounds good. Thank you.

Speaker 2So in figuring out how to use Ultrasound, you need to realize that uh there are many different types of Ultrasound, and we're gonna use um B-mode Ultrasound. Um, and the choice of probe is uh is paramount to getting the correct um image. So for superficial structures, a standard linear probe is, um, adequate. Um, this one goes, uh, in a wide variety of, um, uh, frequencies so that you can get better resolution or deeper penetration.

Speaker 2Um, for the Spine blocks, what I found more successful is the curvilinear probe, and the curvilinear probe is more of a deep penetration probe, uh, with lower frequencies and, and, um, and better resolution and, and deeper structures. Um, but it's, it's also allows your needle to come in at a steeper angle.

Speaker 2So we're gonna do the practice on the um trainer with uh the linear probe at this point, so I can show you the movements of Ultrasound um and show you how to align your needle.

Speaker 2The Other component that's necessary is uh a medium to transmit, and we're gonna use gel.

Speaker 2So, um, putting gel on the Ultrasound probe, you want to assure that

Speaker 2On your screen, you see the laterality. So, I'm checking with my finger, and I can say that this is the left side of the screen is gonna be to my left. I like to orient the side of the screen to my side as well. It helps me visualize my needle.

Speaker 2With any sort of Ultrasound guidance, you wouldn't have a starting point and ending point. The starting point for any sort of uh Spine Ultrasound is gonna be midline, and we'll get to that in a second. Um, but essentially, you want to put your probe on perpendicular in all planes, OK? So this is what I'm doing here. And what we see is this uh trainer here.

Speaker 2With my probon, um, perpendicular and all planes. So, there's different movements that you can do with this. I suggest holding this almost like you hold a pencil. I hold down at the flanges with my thumbs, uh, and my, my middle finger kind of pushing down a little bit. So,

Speaker 2Being able to compress the image brings out better resolution, um, lightening up on the pressure is also going to give you um a more of a view of any sort of venous structures that might be present, um, but compression and, um,

Speaker 2And relaxation are, are, are very basic movements for the Ultrasound.

Speaker 2The Other movements are going to be scanning, so that's keeping the probe in a perpendicular and all planes uh orientation, or even if you were to tilt it, it's keeping it in that same sort of orientation, just moving the probe, um, either, uh, forward and backwards or side to side.

Speaker 2For a variety of different ways. This is called scanning. So we have pressure, we have scanning.

Speaker 2And we can also have rotation. So if your needle is not directly under your probe, if it's coming at an angle, if you were to rotate your probe slightly, you will get a better view of your needle, OK?

Speaker 2So rotation is another key component to Ultrasound movements.

Speaker 2So we have pressure, we have scanning, we have rotation, and the last one is fanning or anisotropy. So what this is meant to do is it's meant to get the image in the best access that you can get it, more of a short axis.

Speaker 2So if you were to see um a structure, and typically when we scan for uh any sort of ankle blocks, we're looking at the, the popliteal fossa, looking at the sciatic nerve at that uh area.

Speaker 2Uh, we find it helpful to do a little bit of a caudal tilt, so that caudal tilt actually gets those nerves.

Speaker 2That may have been uh aligned.

Speaker 2Um, like this, it gets them in more of a perpendicular position so that you get your best image. That's where you're going to see your most hyper-echoic image and get the best view that you can.

Speaker 2Cause remember, we want to see your needle.

Speaker 2Um, parallel underneath, or if you're coming out of plane for whatever reason, you want to see your structures, um.

Speaker 2In in the best orientation that you can.

Speaker 2So I brought up a couple terms that are important. One is inplane, the Other is out of plane. What in-plane does.

Speaker 2It allows you to see your needle.

Speaker 2So, I know now that

Speaker 2The left side of the screen, the needle will be coming in from the right side of the screen.

Speaker 2And I looked down at my hands first. I insert my needle.

Speaker 2And then I look up at the screen.

Speaker 2Look back down at my hands until I see my needle. Look up at the screen.

Speaker 2No, I'm doing just a little bit of scanning back and forth to ensure that we can see what we need to see.

Speaker 2So you can see my needle right there. OK? So I found my needle, I can continue to advance it.

Speaker 2As you see, as I'm advancing it,

Speaker 2Then goes out.

Speaker 2I continue to advance that I can't see the tip. So what do I do? What's, what are the troubleshooting steps at this point? Well, I can see the shaft, and I want to make sure that I know where my tip is, and I know my tip is farther than that.

Speaker 2So I can do a little bit of scanning and see if I can identify my tip.

Speaker 2I don't necessarily see it very well with this needle.

Speaker 2Do a little bit of rotation and see if I can find it better. Again, still seeing the shaft.

Speaker 2If I'm not sure, I can always come out. Now.

Speaker 2I'm actually gonna switch needles to get a more hyper-echoic needle.

Speaker 2That's for better visualization with uh this type of Ultrasound. So similarly,

Speaker 2Again, from the right side of the screen.

Speaker 2And insert a needle, look down at the hands.

Speaker 2And watch the needle come in on screen. Now I can see that tip better. As I continue to advance.

Speaker 2I can see that tip. Continue to advance, and I can see that tip. Now, I'm coming in obliquely on purpose, and the reason that I'm doing that is because I want you to see that as I come in obliquely, I want to find my tip.

Speaker 2And I can rotate to find the entire shaft.

Speaker 2OK. So small little movements, just microscopic movements.

Speaker 2To be able to really get your needle in, in, in a good plane, OK? Cause it's paramount that you need that you see your tip, OK?

Speaker 2Now, we talked about another technique which is called out of plane technique. So, this is an in-plane technique, meaning that your needle and your probe, the probe beam are aligned. The out of plane technique means that the probe plane and the needle are in different orientations.

Speaker 2So the needle will be coming in.

Speaker 2From the middle of the screen.

Speaker 2You won't see it until about mid-screen.

Speaker 2You see that tissue deflection there?

Speaker 2Now, this is more of an advanced technique, and it's not necessary for the blocks that we're presenting today, but it is a part of uh Ultrasound and um

Speaker 2Regional anesthesia.

Speaker 2So, I'm not going to spend too much time on that.

Speaker 3When would you use

Speaker 3in-plane versus out?

Speaker 2Uh, I use out of plane for a pair of vertebral blocks for deeper structures, um, and structures that are going to be difficult to, um, to get to unless you use an out of plane technique, so limited Windows to get there.

Speaker 2Pavertebral blocks, sometimes, um, anterior sciatic blocks, things like that. So with our Spine Surgery, regional anesthesia, I think in-plane technique is the best way to do it because you can visualize your needle, needle the entire way. OK, um, and it's gonna give you a lot more information. The Windows aren't so tight. Got it. OK.

Speaker 2OK.

Speaker 2So that's it for the general basics of Ultrasound. Does anybody have any questions?

Speaker 1Um, I actually, I had a question also. So when you're putting the Ultrasound probe on, where do you recommend, uh, entering in? How far away from the probe should the needle be? Do you want to go close to it? Cause you'll be, you'll be going through the gel then. So do you want to be away from it? How do you, what do you recommend?

Speaker 2Couple things. Uh, I'm a big proponent of being as parallel as you can. So if I were to come in on this model,

Speaker 2See if I can find this here. That's a previous track.

Speaker 2If I can come in on this model as parallel as I can to the probe, and you're gonna be able to see the needle better. And so you see the needle here. There's the needle tip. Mhm.

Speaker 2Right there, OK? And you get a reverberation artifact, and it, it actually shows needle upon needle upon needle as it moves down. So I actually think that that's the best way to visualize your needle. So the farther away that is possible, the best. I don't like coming in too close with a linear probe. OK. With the curvilinear probe, it's not as big a deal. With the curvilinear probe, you can come in fairly close, uh, because you are using it for deeper structures and tend to need that, that depth.

Speaker 2Um, you spoke about the gel. Um, we use sterile gel packets, so even if you were to get a little bit of gel, it's sterile, it's, uh, biodegradable, OK, uh, and not really that big of an issue.

Speaker 1And so in terms of sequence, um, I know if you just walk me through the sequence, do you, you put the Ultrasound probebo, and we're going to go through this in the in the model in a second, but you put the Ultrasound probon, do you put the needle in first and then try to find the needle? Yes, or does the needle try to find the Ultrasound probe? So

Speaker 2a little

Speaker 2bit of both. Um, one thing that I did skip over, and I wanna address is once we put the probe on, we want to get the correct depth, and we want to get, uh, the correct settings. I said we use B mode, which is, uh, essentially.

Speaker 2For brightness. So if we use our gain, we can increase gain and make the, uh, the image more, uh, hyperchoic, or we can decrease gain to hopefully uh get better contrast. And that's gonna be different on different ultrasounds Ultrasound machines. This one has a, a 2D, OK, um, if you're looking for vessels, there's also a, uh, a Doppler function that you can see vessels and it sees movement. Um, so you can use this if you're worried that you're near an arterial structure being a structure that is of importance.

Speaker 2Uh, lastly, you want to make sure that you're at the correct depth and the correct

Speaker 2Uh, focus. Most of the new Ultrasound machines have a, uh, focus, uh.

Speaker 2Um

Speaker 2A knob that you can alter to to get kind of the the best image at that level and you can actually see, especially with the Samsung, which I love, um, that really brings out the image.

Speaker 1Yeah, 11 of the challenges I always find is that that mix of between uh depth and focus and basically trying to get that sweet spot because you lose a little bit.

Speaker 1Uh, depth, and then, you know, you gain a little bit of double here. So I find that to be really challenging, especially with people, patients who are

Speaker 1overweight,

Speaker 2especially with patients that are overweight. Most Ultrasound machines, if they don't have that focus function, have, um, kind of rudimentary functions where it says frequency where you can have a resolution frequency.

Speaker 2This one's not gonna do it. You can have resolution frequency or penetration frequency. So the resolution frequency on these probes, since it has a variety of frequencies, the resolution is going to be the higher frequencies and less penetration. Got it. So if you have an obese patient, that's not a great modality to have, you want to go to the penetration function, which gives you a lot more penetration but less resolution. However, that helps you to see your structures more, more deep, right.

Speaker 1No, I know, I know we didn't really bring many Other machines, but do you see a big difference between the different Ultrasound machines that are out there? I, I,

Speaker 2I do. They all have similar features. Um, some of them are controlled by a screen, some are controlled by knobs, um, some of them are dual, like this one is here.

Speaker 2Um, I, I do see a difference with, with them. Um, like I said, I'm partial to the Samsung. I also like the Konica Minolta, which we're using, and, uh, Sonosite all provide really good ones. I know Phillips and GE have fantastic machines as well.

Speaker 1And butterfly, of course, is all over the internet nowadays. Butterflies

Speaker 2all over the place, and I, I hear that they are coming out with a new Ultrasound that's gonna even be

Speaker 2better.

Speaker 1So, OK, great. And do you think that for Spine procedures, the type of Ultrasound you need is any more unique than what is already in hospitals?

Speaker 2Um.

Speaker 2I don't think so. I think, you know, you can achieve the goals, especially for these types of blocks with any sort of Ultrasound machine. OK. So, I think the better resolution you have, obviously is gonna give you better results, but uh, you can, these can be done with standard ultrasounds.

Speaker 1OK, that's great. Are there any questions from the audience?

Speaker 1Sometimes it's hard for everyone at the VR headsets,

Speaker 3just a reminder on the left hand side you should see your attendee list all the way at the top of that if you click that microphone button, you'll unmute yourself and

Speaker 3you can speak with everyone.

Speaker 1Can you turn this a little bit? I just wanna be able to see. Can you turn the cart?

Speaker 1OK, so now, why don't we go ahead and so that was great, um, simulator training. So here in the lab, we're gonna have everyone go through the simulator training, but now we're gonna go and look at the actual uh TLlip block itself.

Speaker 1So this is a similar that basically will help us uh see the anatomy that's relevant to the TLleb block and then also relevant to the ESP block.

Speaker 2So with this, when I was demonstrating with the linear probe, um, I said that applications for Spine are going to be better served by using the uh curvilinear probe. So I'm switching the probe over.

Speaker 2In a similar

Speaker 2Need some gel, of course.

Speaker 2In a similar way, I wanna know where my laterality is. So I'm gonna touch with my left hand. I see that the left side is, um, is on the left side of the screen. Now, the way that I like to start scanning for Spine is to start, uh, at the sacrum, which I think would be here.

Speaker 2Uh, and start scanning midline. And what we're able to see is once we get midline, we're, we're able to see what, what looks like sacrum there. And as we start to scan more cephalide, we see, uh, L5, L4, L3, the spinous spinous processes of those. And the spinous processes are great, um, a great landmark to start, a great sonographic landline, uh, landmark to start. And then we can turn it, um, I just, again, the rotation, I just rotated it 90 degrees, and we can see our spinous process there in the middle.

Speaker 2Uh, and then actually with this, we can see.

Speaker 2Spinous process, you can see the lamina, and you can see the transverse process. Got it.

Speaker 2This is a great view for the T-lip block right here at the spinous process because what you see is the next muscle immediately adjacent is uh multifious uh and then uh longestimus, uh, right beside it. So, in order to achieve this block, you're gonna come in from a lateral to medial direction, and with this one you can actually insert a little bit closer to the probe because of the footprint. And so as I'm advancing, you see I'm

Speaker 2Looking down and making sure before I advance that I see my needle. And I click into that plane there. Once I click into that plane there, I'll be able to inject local anesthetic. Um, and actually, I'll tell you what, I, I would say hydrolocate with saline first and, and make sure that you're in the correct plane because if you're using a medication such as liposomal bupivacaine, you don't want to waste that medication.

Speaker 2Once you get into that plane, hydrolocate with saline, and then once you're happy with your result, uh, you can inject, uh, the local anesthetic and switch over. Again, similarly, if you want to advance further, continue to do that. Keep your needle in view, click in there.

Speaker 2It's beautiful. And as you see, I'm moving slowly. This is not something that you need to rush with, uh, especially, uh, being this close to the Spine and to, um, neural structures. Um, you wanna make sure that you could take a little bit of time to do this. Then as we come out, we withdraw.

Speaker 2And we can flatten and do the cutaneous Injection here. So flattening, you wanna come back to almost the skin, flatten your needle, and you can advance forward.

Speaker 2Once you get to your maximum point, inject local anesthetic, and then you can withdraw as you inject.

Speaker 1Yeah

Speaker 1So that's obviously beautiful and you're obviously very skilled at all this. So you were able to see the needle on fast the whole way. But uh having gone through the Learning curve, it doesn't usually work out that easily for me.

Speaker 1Sometimes you see the front of the needle, the back of the needle. So what do you suggest? Do you suggest going in a little bit, a couple of centimeters with the needle, trying to find it with, with the Ultrasound, and then advance, or do you find, do you, do you say go in for about 2 inches in

Speaker 1advance?

Speaker 2What I'd like to do is I'd like to at least get the tip of the needle under the Ultrasound. And so it just depends where your entry point is. Uh, I'd like to see at least 1 centimeter of needle under the Ultrasound. So, as I come in, I'm gonna come in, uh, off on purpose.

Speaker 2I've inserted, well, there we go. I've inserted 2 centimeters in, but 1 centimeter should be at uh at where the probe is. Now, what I do, and the way that I teach residents to do this is I, I say, look down at your hands. You can't find your needle. I know your needle is in. Look down at your hands and tell me where your needle is. If you can see my hands here, you can't really see from up top.

Speaker 2The Needle

Speaker 2Can you focus on my hands here?

Speaker 2Is there a way to do that? Yep. Let me see if I can turn it just a little bit.

Speaker 2There we go. OK. So my needle is, is out of the Ultrasound beam. You can see that very clearly. So what I have my residents do is I have them look down at the needle, look down at their probe, and put the probe right over the needle, OK? And many times that'll find your needle, and I can see on the screen, there's the needle. Um, once they do that, once they find it, then they can start advancing, OK? Now, I'm gonna rotate it on purpose so that we just see part of the needle.

Speaker 2As we come in, we can see, OK, well,

Speaker 2There's part of the needle. Um, I'm not really too sure which is, there's the shaft, is that the tip? I'm not entirely sure. Well, is that the tip? Maybe? I don't know. Again, look down at your hands, see that there's a rotational component, and turn back, just rotate back, and then you can scan and find your needle. Now I can see my needle with a lot more clarity. I can see the tip.

Speaker 1Yeah, and I think that's another interesting point is that um you, we may get fooled to think that you're seeing the tip of the needle, but you don't, but you're actually seeing a bit, a middle of the portion. So what, how do you know that you're actually seeing the tip?

Speaker 2So most of these um needles are, are sharp needles have a very echogenic tip. I put the bevel up. When you put the bevel up, what you tend to find is that you get a nice, um, kind of triangular image at the front.

Speaker 2You may get slightly fooled.

Speaker 2By the shaft, but the shaft is gonna get you a different type of view. It's not gonna be that triangular bevel up view. OK. And the way that the bevel is up actually helps you see the tip better. If you were to turn it, you don't see the tip quite as well, and you can get fooled to thinking that that's part of the shaft as well. Got it. So I always inject the bevel side up, and it gives you a good marker as to, uh, where your needle tip is, now.

Speaker 2I'm gonna go ahead and inject or insert just a little bit more again to show that shaft issue, because here we see the shaft, but we don't see kind of that triangular tip at the beginning, we just see a linear structure.

Speaker 2When I come back and actually get it in view, we can now see the tip there. Now,

Speaker 2It also helps sometimes if you just lightly jiggle the needle, because if you jiggle the shaft, it's gonna stay in place. Do you see how it's kind of staying in place? It's moving a little bit, but it's not really moving, uh, lateral to medial, right.

Speaker 2When you do that with the tip, when you get the tip in view, you do that, you see that the tip is actually moving lateral to medial in between those muscles there. So I'm gonna pull back a little bit, but you see that the tip is actually moving lateral to medial. Yes. So just that slight little agitation,

Speaker 1yep,

Speaker 2helps identify the tip as well.

Speaker 1That's

Speaker 1beautiful.

Speaker 1That's beautiful. So just to repeat then, so you, you put the Ultrasound probe on at the sacrum.

Speaker 1And you hold it, uh, in plane. You're holding it, yep, so you're holding it basically parallel to the spine's process, correct? And then once you find the sacrum, you're gonna roll it up and then for the blocks, do you prefer to do them at L5, L4,

Speaker 2L3, L3, L4.

Speaker 2Either one of those works fine. You get, uh, for the ESP blocks, you get about a 4 level spread, so it's gonna be appropriate if you do it at L3. I think that's fantastic. OK, um, and for the T-lip block, I, I believe it's similar. It's a 3 to 4 level spread

Speaker 1typically. OK. So then let's say you roll the probe up to the, say the 3rd or 4th. So Spine process.

Speaker 2So again, we can count at this point, um, we can count that's sacrum 543.

Speaker 2And then from here, I just rotate.

Speaker 1So then at that point you turn the probe and then now the spinus

Speaker 2process. So here I've lost my spinous process, but I can always scan down and find the, the spinous process. Got it

Speaker 2there,

Speaker 1right.

Speaker 1And so when you do the, when you do the, I guess the tele block, um, do you like to see the spinal process on fos in full view, or do you'd like to go in between the spinous

Speaker 2processes? I like to go in full view. OK. I, I think for a couple of reasons, but I also think that it gives you kind of a nice backstop, OK, uh, if your needle were to go too far, too far, OK, yep. So say that you were insert your needle, uh, you can run into the spinous process here as a safety margin, yeah, uh, as opposed to.

Speaker 2Say here there where it's just gonna keep going through. Yeah,

Speaker 1it's interesting

Speaker 1because a lot of people when they first start learning the blocks are scared about hitting the canal and so having the spinus process as a backstop is a nice block for you, right? And go ahead. So then, so then you find your spinus process and you're gonna get into the actual right plane. But in this particular situation, you say bevel up, go 2 centimeters, and once you're in 2 centimeters, try to find the needle, try to find the needle on the Ultrasound,

Speaker 2on the Ultrasound.

Speaker 2And the more superficial you can have your needle, the more, uh, the farther away it is from important structures, the better, until you find your needle, and then you can advance.

Speaker 2To the structures that you need. Again, that's coming out of plane. Now I'm readjusting. I can see my tip there.

Speaker 2I, I made a little track there. I'm gonna go down to that. And

Speaker 1do you have an assistant hold the Ultrasound probe for you or do you always hold

Speaker 1it yourself?

Speaker 2I do it myself, and that way I can make the small micro movements that are necessary to get your, your tip in view. So again bevel up.

Speaker 2I can see my tip.

Speaker 2Advance.

Speaker 2There we go. Advance, advance. I'm in that plane between multifitous and long distance, and I can continue to advance. Oh, lost my needle. Gotta find it. There we go. There it is again. Again, I can do that little jiggle, find that that is the tip, and continue to advance as you need to, as you need to into this plane.

Speaker 1And so when you get into the plane, you typically get about 1 or 2 cc's to sort of do like a hydro dissection of the plane and that opens up. So, OK, that's perfect, yep.

Speaker 1So great. So then basically, so that we just learned how to do the tele block. We start from the sacrum, um, find the spinous process of L5, L4, L3.

Speaker 1We turn the probe once we get to L3, 90 degrees, 90 degrees. Make sure we can see the spinus process on FOs. When we do, then we can introduce the needle. Typically, the needle is introduced about a couple centimeters lateral to the probe. The bevels up.

Speaker 1We advance 2 centimeters. Uh, once we have advanced 2 centimeters, make sure we can see the needle on loss and then get into the plane that we need to.

Speaker 2Agreed, agreed. You know, one thing that I didn't mention is say that you need to make a correction. I'm coming in really deep with this needle, OK? What do I do? Do I just bend the needle and try and go? No, you want to come back up almost to skin, redirect your needle. You want to hold your needle from the hub, and you want to direct from the hub. If you need to come back and make a direction, you come back to skin.

Speaker 2And make that correction.

Speaker 1That's a great point.

Speaker 1Yeah, I find that to be challenging. OK, wonderful. That's great. So that's the, that's the telip block. That's

Speaker 2the te lip block,

Speaker 1and that's basically the telip block plus the superficial aspect of it, right. So let's talk about the ESP

Speaker 2block. So the ESP block, I scan for ESP in a similar fashion.

Speaker 1Do you want some more gel? Uh,

Speaker 2no, I think I'm OK.

Speaker 2Similar fashion, so find sacrum.

Speaker 2Scan of L5, L4, L3, and from L3 now.

Speaker 2At the L3 spinous process here. The ESP block is obviously a bilateral block, as is the T-lip block. Um, what I do at this point at L3 is I come and find a transverse process, and we can see our transverse process here. So all I'm doing is I'm from the spinous process is scanning laterally to find the transverse process. So, I see L3 transverse process right there in the middle of the screen.

Speaker 2In a cephalo to cauda direction, similarly about 2 centimeters out, I, I placed my needle.

Speaker 2And I've changed orientation on you guys, but it's coming in the left side of the screen. OK, so I see my needle, and my needle is not really lining up. So what I want to do is come back.

Speaker 2Get my view back and reinsert my needle so that it's coming in.

Speaker 2That looks better. As I advance.

Speaker 2I'm coming down on the transverse process. Now,

Speaker 2Sometimes with these models, it's a little bit more difficult to see, but you can see there when I jiggle it, that my tip is uh slightly above the transverse process, and I continue to advance, it's actually contacting transverse process there.

Speaker 2There's my needle tip. Got it. OK. And so from here we do the same thing, hydro dissect or hydrolocate, as I'd like to say, uh, and then inject local anesthetic once you know you're in the correct plane. Got it. And if you need to redirect, again, you want to get your, your best view. I'm doing this in kind of, uh, are

Speaker 1you, are you holding, are you holding the probe directly on fast? Are you tilting it? What,

Speaker 2yeah, let me, let me show you, and I'll show you how, uh, say that this is a patient that is.

Speaker 2Sitting, OK. This is how I would typically do it. Um,

Speaker 2I would hold my Ultrasound probe here, find sacrum 543 here, and then once I get to 3, I can scan to the side, find the transverse process. So there's transverse process.

Speaker 2OK, now what I would do is looking down at my hands, insert the needle.

Speaker 2It's gonna come in from the left.

Speaker 2I see that my needle tip is high, OK, but my view is good.

Speaker 2So I'm gonna come back in and steep in.

Speaker 2Steven?

Speaker 2Now I'm contacting transverse process there.

Speaker 2OK. OK.

Speaker 2That's still a good view, and I can still contact transverse process. Now, the, the nice part about this is because you are aiming at transverse process, it's another backstop, right? Uh, and you're not gonna get any, any vital structures, uh, in the abdomen along the way. Yeah, and if you're, and if you're doing this in a thoracic view as well, you're not gonna get into the long lunk.

Speaker 1And how long does it take you to to do these blocks?

Speaker 2Uh, these blocks, it takes from needle in to needle out, um, about 25 seconds.

Speaker 1OK, but starting out, what, how long do

Speaker 1you

Speaker 2think? I would say give it, uh, 2 minutes or so. OK, yeah,

Speaker 1so they're pretty fast.

Speaker 2They're pretty fast overall, yeah,

Speaker 1you can do both the telip as well as

Speaker 1the ESP, yeah.

Speaker 2And then, so similarly now we know that this is, um, transverse process on the right side. We can move over the left side just by scanning over to the left side and see similar structure again.

Speaker 2Same sort of thing. See needle, redirect.

Speaker 2There's some tip, redirect touch us there.

Speaker 1And what Medicine do you typically give for the ESP versus the tele block?

Speaker 2It, it depends on your goals of care. Um, I typically tend to use, uh, bupvocaine and liposomal buppivocaine, so 0.5%, um.

Speaker 2Marking, um, bupivacaine along with the, with the Experel. Got it. I mix it to 50 mLs and I'll use 25%. 0 wow, 25, and that gives you, that gives you a, it'll give you a surgical block as well. OK. I mean, if you're using it for Postoperative analgesia, you can mix it with a 0.25% buppivacaine, yeah, and higher volumes to get more spread, but that's typically not needed. OK, um, if you don't want to or if you can't, if your Expel is not on formulary or if you have some Other.

Speaker 2Um, um, contraindication or displeasure, um, you can use catheters, and catheters get threaded in, and I would use ropivacaine for that 0.2% ropivacaine, um.

Speaker 2For surgical block 0.5% ropivacaine, for the Postoperative Pain control, 0.2% ropivacaine.

Speaker 2You can also make mixtures with bupivacaine and dexamethasone along with epinephrine, um, if you're not using liposomal, yeah, uh, and that'll give you about 20 to 24 hours' worth got it of a

Speaker 1block. Wow, that's beautiful. So you have the patient sitting up when you're doing it, not prone.

Speaker 2I have the patient sitting up almost in an epidural spinal position, yeah, and I find it very easy to switch from this to a spinal. Yeah, exactly. It's very efficient, but the, but the patient, um,

Speaker 2You know, with their, with their chin down to their chest, um, kind of expanding their, um, uh, their spinus processes, right, which helps out with visualization to get into the space.

Speaker 2That's beautiful.

Speaker 2Thank you. Yeah. Anything else?

Speaker 2Um, nothing else. I think I'm gonna throw out a plug again for the, uh, the Duke, uh, website to teach you about the ESPs and about, um, we'll get TLlip on there for the next one, the next go round. Um, so if you guys have that chance, it's on YouTube, Duke Rap.

Speaker 1Is there a question? yep.

Speaker 1Yeah, that's

Speaker 3a fabulous, uh, hi, hi demonstration.

Speaker 2Thank you, thank you.

Speaker 3They, so you're only doing a single block at L3, and that'll get you to levels above and

Speaker 2below? Yes.

Speaker 2It's pretty consistent that it gets 4 levels in the lumbar area.

Speaker 3How often do you have to go up higher to maybe L2, L1?

Speaker 2Um, it's very rare. I mean, maybe it's some morbidly obese patients that, uh, are, it's just difficult to visualize the L3.

Speaker 2Um, I think L2 to L4 is gonna be, gonna be pretty sufficient to get what you need, especially coming from

Speaker 2Uh, cephaliticotid.

Speaker 2Uh, but I generally, like I said, I tend to aim for L3. Um, going up to L1, I've never really had to do that so much. I've usually stayed 234.

Speaker 2I've had good success with it.

Speaker 3And more commonly if we're doing uh L5-S1 uh T lift is doing uh L5 sufficient.

Speaker 2Yeah, L5 that would be fine.

Speaker 2That's gonna get you an appropriate spread.

Speaker 2Fabulous.

Speaker 3Thank you. Of

Speaker 2course, this is great.

Speaker 2What Other questions?

Speaker 1Rob, uh, Doctor Wang, just a question for you. How, how do you like the picture that you're seeing right now? I apologize, we're, we're learning from you as much as you're learning from us, but how's the picture? Were you able to see everything properly?

Speaker 3Yeah, the picture is, uh, very clear. I'm able to actually magnify. I don't know if you see my screen set up,

Speaker 3but I

Speaker 3actually, uh, instead of having it 3.

Speaker 3vertically, I expanded out the screens maximally and have it basically like a 3 monitor horizontal so I can see you guys on the model and then the model side by side and the Ultrasound is actually right above you. So this is awesome. virtual

Speaker 3is fabulous.

Speaker 2It's great to hear. Very encouraging.

Speaker 3The only, uh, the only thing is if they have, uh, if you guys have a virtual transducer that I can practice on.

Speaker 2Yeah, there we go. That's the next step.

Speaker 3One question I had, um, when you're doing that ESP block, does it matter how close you get to the lamina, or just as long as you're

Speaker 3in that space?

Speaker 2Yeah, you really want to be on the transverse process, so even a little bit more lateral, um, you wanna be right on.

Speaker 2There's

Speaker 2There's a tissue plane that runs right over the transverse process in between um.

Speaker 2underneath the erector spinal group and uh the uh the muscles in between um the uh transverse processes. There's a nice little fascial plane that you need to get into. And so, coming down and touching the uh transverse process either um a little bit more cephalite or a little bit more caught out is important to get into that, um, that space.

Speaker 2So if you come down and just touch the transverse process on top with the needle, you're not gonna get a, a very good block, and you're probably gonna get an intramuscular block. So coming down either a little bit before or a little bit after is gonna be beneficial. I recommend a little bit before because then you can still use that transverse process as a backstop. Did that answer your question?

Speaker 2Yeah, no, that's great. I appreciate it yeah.

Speaker 3ESP is also level.

Speaker 1I'm

Speaker 3sorry.

Speaker 3I'm sorry, is the, uh, the ESP also two level above two level,

Speaker 2or is it just at that level? The, the TLlip, is that what you're

Speaker 2No, the ESP. The ESP is gonna be 4 levels, so it'll get you about 2 above and 2 below. Mhm.

Speaker 4Thank you.

Speaker 4Have you noticed like any difference between catheter-based treatment and single shot or just straight Injection?

Speaker 2Yeah, so that's a great question. I think with uh if you're using a single shot with just plain uh local anesthetic, you're, you're gonna be time-limited, you know, ropipicane is gonna get you 12 to 13 hours and buppifecaine probably about 14 to 16 hours. If you place a catheter, um, you can run the catheter with a system like, like Nimbus, like, uh, Doctor Braxton did.

Speaker 2Uh, which is a great system, and you can prolong for, you know, days' worth, especially using the, uh, intermittent bolus function, which opens up those fascial planes again.

Speaker 2Um, I'd say you probably get about 4 or 5 days' worth out of that. Um, using liposomal buppipicaine, we're seeing about 3 to 4 days.

Speaker 4And and with the catheter, do you not have to be as accurate as opposed to single shot? I've had some times in single shot, maybe you're not in the plane that you think you are, and they get um extra and then not so much, but.

Speaker 4My experience limited with catheter, they get more medication can flood the

Speaker 4plane.

Speaker 2Yeah, yeah, yeah. So the, the liposomal bupivocaine when it's placed in, it's, it's actually essentially fixed once it's in. The liposomes don't tend to move, whereas plain local anesthetic really does, uh, is differential. It, it varies with uh your position or patient position. Um, the catheter still should be placed, uh, in that plane. I've, I've seen a lot of failures for fascial plane blocks, um, where the

Speaker 2The initial single shot is good, and then the catheter is not placed correctly, or vice versa. Um, it's generally rare to have a, a good placement of catheter if you're not in the right spot. So, the catheter does need to be in the right spot, um, and I think it's actually even more important for a block like this to have the catheter in the right spot.

Speaker 2Um, the single shot, you know, you're gonna get some sort of efficacy. I don't know what the efficacy would be if you're in the wrong spot, uh, but the catheter does need to be in that fascia plane in order to allow that local anesthetic, once it's injected again through the catheter to reopen that plane.

Speaker 2Thank you. Course.

Speaker 3Do you ever use uh the Grouppivacaine with epi or it's just all plain?

Speaker 2If I use liposomal buppivacaine, it, it's mixed, admixed with plain buppivacaine. If I'm using just regular buppivacaine without liposomal, then I use epinephrine.

Speaker 2Similarly with ropivacaine, if I use ropivacaine, um, I'm gonna use epinephrine.

Speaker 2100,000 1 to 400,000, uh-huh, 1 to 400,000 epinephrine, yeah.

Speaker 1Uh, that you wouldn't use epinephrine,

Speaker 2um, if I'm using liposomal because it's not indicated in any contraindications. Oh, no, no contraindications of the patient, no.

Speaker 2No, it's actually a fantastic vascular marker.

Speaker 2Huh, it's interesting.