Blocchi TAP e della guaina rettale guidati da ultrasuoni in ERAS

- My name is Chris Pennell. I'll be moderating today's webinar. I'd like to welcome everybody to SonoSite behind the scan webinar titled RAs Utilizing Ultrasound Guided Tap and Rectus Sheath Blocks. Before we begin, I have just a couple of things to cover. For one, all attendees are muted and we'll be conducting a q and a session at the end of the presentation. And we are currently broadcasting this webinar on multiple platforms. And in order to ask questions, you must be on the main Zoom webinar stream. Now, if you're on the main zoom stream, you can type your questions into the q and a box in the toolbar located at the bottom or the side of your screen, and you can feel free to enter them throughout the presentation and we'll get to them once the main presentation is over. This webinar will be recorded and archived for future reference on our webinars page. And here with us today, we have Robert Fall. Robert Fall is a certified anesthesiologist assistant. Robert has been part of the Ohio Anesthesiology group, Southwest Division at Southwest General Hospital for the past 24 years, where he is the chief anesthetist. He's also the clinical coordinator at Southwest for the Cleveland case, Western Reserve University, CAA program in 2016. Robert created PNB school, which focuses on expanding the use of ultrasound guided regional anesthetic techniques. He's taught at numerous anesthesia training programs around the country and given talks to industry leaders around the United States. Robert, thanks so much for being here, and I'll go ahead and turn it on over to you. Thanks, - Chris. Thanks for having me. Happy to be here. My name's Robert Dahl, as you said, from PNB School. I'm an anesthetist southwest of Cleveland, Ohio at Southwest General, and I'm excited to be here because I get to speak on some of the procedures that we use on a, on a sometimes daily basis, definitely weekly. And I, I get to share what we do at Southwest and how we've tweaked our procedures and, and blocks and for, for abdominal surgery. So today we're gonna speak on ERA a s utilizing ultrasound guided tap and rectus sheath blocks. And this should be a good one. So some of the basic points here is some, are some of the summary summary benefits from ERA a s from abdominal surgery. Some of the goals that we have, it should all be goal oriented. So I think many of us know these goals by now. But definitely one of the biggest is shorted length to stay in the hospital, and that's a measurable outcome for sure. Decreased overall complication rates, decreased infection, DVT, et cetera, decreased 90 day readmittance rates, which is important because of the global fees. Now, decreased pain scores, which is important. Again, most of what we do is driven by Press Ganey scores, feedback from patients. So if they don't have pain, those, those scores usually go up. And of course, decrease nausea and vomiting overall is the, the goal is increased patient satisfaction. So if you summarize all of that, patients get home faster, they have less complications, decreased pain and nausea, vomiting, overall patient satisfaction is gonna be increased. So then it's the how, how do we, how do we accomplish these goals? And really the key is early ambulation, again, no secret, it's been written about in numerous papers, but you know, then it's how do we get, how do we get these patients to ambulate a little bit earlier, better pain control for sure. That's, that's probably top two with nausea and vomiting. So decreased nausea and vomiting, increase your, your, you know, better, your pain control one way or another. And then return of normal gut function is, is just as important. It goes hand in hand for with nausea, vomiting as well. And so how do we do that? We, we usually think about limiting opiates in some way. We found out that opiates are very useful. We know that for a long time, but how we use them has changed over the years. And definitely in my practice, how I use them, I try to limit it and, and give just what I need to give to get patients through surgery comfortably into the postoperative period. And then of course, with regional anesthesia, combine those two to decrease the opiates and your, and your gut function gets back to normal and you have a decreased rate of nausea, vomiting. Other keys to early postoperative patient ambulation. The biggest one that, that I think gets left out and, and, and I tell everyone at our hospital how important it is at least every other week, is you need to establish patient expectations. So you need to establish, you know, the, the ground rules for what, what their part in all of this is going to be. And, and there's a, a really good summary here in this image of how to get that done. So at every point of contact for the patient, you wanna reinforce what the expectations are. If they're having a, a, a bowery section, robotic, laparoscopic, or open or otherwise, you have to tell them what their, what their expectations are. So when they go to the surgeon's office, we wanna tell them, Hey, you're gonna have surgery. We're gonna tell 'em all about the surgery and and postoperative care they're gonna get. And once they hit that floor, we're gonna, we're gonna tell them what their expectations are and we, we can, we can define those any way we want. So it could be sitting at bedside within a couple hours. It could be walking within an hour, taking 10 steps, 20 steps, traveling 30 feet, whatever we decide. Then in pre-admission testing, they're gonna hear the same thing. And pre-op before the surgery, the nurses are gonna tell 'em the same thing. The surgical team, of course, and anesthesia are gonna tell them the exact same expectations and by the time they get this surgery done and get to, to, to pack you and then up to the floor, they've already heard it seven times. And you'd be amazed just by reinforcing that what happens when they get to the floor is they follow those rules and, and the expectations are met. They're sitting at bedside, they're walking within hours and everyone's on board. So to summarize, avoid postoperative nausea and vomiting. We include proper volume replacement. I had to mention that because we don't wanna overload the patient with fluids, but we don't wanna make them, make them hypovolemic as well. So euvolemic usually if it's a bowel case, a little bit less. So multiple anti-emetics, pre-op intraop and postoperatively. And then treat any, any other emesis postoperatively with rescue antiemetics now that we have. And, and again, decrease postoperative nausea and vomiting. How maybe limit opiates we need. We need to limit opiates in some way and just use an appropriate amount if we're gonna use them and get that gut function back as fast as we can. So how do we do that? Adequate postoperative analgesia is one of the ways. And how do we do that? We, we use multimodal approach for analgesia on these cases, and we can define this however we want. There's not one way to write an ERAS protocol, and your surgeons are gonna have input, your nursing staffs gonna have input. Everyone in the anesthesia group's gonna have input at some point. So we use combinations of the drugs here, NSAIDs, ketamine, ddo, magnesium, local by the surgeon on top of the blocks, hemodynamic modulators. You know, beta blockers have been shown to affect substance p, gabapentin, and propofol with an asterisk, because I understand the slide says analgesia and we've been taught propofol as an anesthetic, but are there are ways to use propofol to, to blunt responses to stimuli? And we know it's very short acting. And so if we can get patients through periods that we know are gonna be stimulating with propofol, it's a huge benefit because it goes away so quickly. And so that's probably information for a, a whole nother talk. So we'll, we'll try to stay on task here. And of course, how do we limit or avoid opiates? One of the best ways we control analgesia that, that we've seen over the last probably 20 years is ultrasound guided regional anesthesia. So that's when I got involved in this, and that's been one of the best ways that we can, we can control pain for abdominal surgeries. So we wanna talk about tap and rectus blocks and, and I'm just gonna speak on our approach, the southwest general approach. We almost always, for abdominal surgery performed bilateral subcostal ultrasound guided tap and rectus sheath blocks that excludes open umbilical and inguinal hernia repairs. Because for those we would just do rectus sheath or a one-sided tap block. But whenever we're speaking on robotic or laparoscopic or even large extended exploratory laparotomies, usually we will use bilateral subcostal tap and rectus sheath blocks to help with perioperatively with pain. So, and there is, I always get this question, so why tap and rectus first ql? 'cause there are some, some big QL believers and they use it every during these surgeries as well. So why tap and rectus versus QS is a good question. And for us, it came down to a few things. And number one was consistency. So tap and rectus blocks are very reliable. We know they do not provide visceral pain relief, but they provide very consistent and reliable somatic relief QL ones. Anecdotally for me, I did maybe 50 QL ones before I decided that it wasn't the block for us because two oh ones were hit or miss, I could put the medicine in the, the exact same spot every time, and I just did not get the consistent results that I needed to be able to tell patients and surgeons that they were gonna have really good pain relief postoperatively. The other reason is that, that tap and rectus blocks are technically easier, in my opinion. QL ones are easy, but QL twos and threes are technically difficult, meaning for all of our anesthesia providers, they weren't going to perform those at a higher rate of, of success. So all of our anesthesia staff is comfortable performing tap and rectus blocks, even even on, on morbidly obese patients. They're just simpler. So it's, it's all on for our, for our group, it's all hands on deck, all anesthesia providers perform blocks, and so whoever's available, if you're available to come and help be a third person even that's even better. So it's all hands on deck. We train everybody to perform the blocks that we normally need to do on a daily basis. So all hands on deck and our protocol, I'm not going to get too specific, but Multimodals begin preop, continue preoperatively. You can decide what multimodals are best for you, your patients, and, and you know, you know, your surgeons the best tap and rectus blocks performed before incision. And that's important because you get ahead, you know, you're gonna blunt that response to incision, so you're gonna decrease the amount of opiate you need. And these blocks aren't surgically analgesic. We know that. We, we just feel it's important to, to block these patients before incision. And that's, that's an argument against surgeon performing. And I put in quote, tap blocks, I've seen them describe peritoneum injections with local, like a, a, a block as a tap block, which isn't truly a tap block, but it works, it can work pretty well if they're good at it and, and very specific with their injection. But it's also after incision. So we're al we're already gonna have to treat the pain with opiates from incision, and then the blocks will come later at a later time. So we like to get out ahead of it, put the tap and rectus blocks in before incision and, and again, they're not, they're not surgically analgesic. So a small amount of opiate given an induction goes a long way. And we try to time our opiate really well to minimize how much we need to give timing's everything, especially to our surgeons. So the next slide will show, you know, the timing, the workflow of the tap and rectus box. When are you gonna perform these blocks? Are you gonna perform 'em in pre-op? Are we gonna perform them in the or? You need to have an efficiency in mind to get everything done and not delay surgical cases, especially at our hospital, that would never fly. So you wanna have everything together, get your supplies together, assign anesthesia role. So if it's a, an anesthetist and a physician, or if the physician needs to call someone in as well, extra or two physicians just to sign who's doing what. One does airway one does blocks and the procedure begins, you know, just after induction for us. So what we'll do is we'll induce the patient and then we'll utilize the OR team to prep and drape for the block immediately after the patient's asleep. So I know in anesthesia we're taught, you know, the airway first, but we can definitely work in parallel. They don't have to disturb us, you know, they're not moving the patient dramatically. So we can, we can prep and drape for the block just after we've gone to sleep. And usually we utilize our OR team for that. The PA or SA will do that, the resident, whoever, whoever's in the room at that time. And then we've already dedicated one person to, to perform the block. So they're pushing the, the ultrasound over while we're, while we're intubating, getting everything ready. And they'll do the block as we're taping the tube, getting other things done, getting the anesthetics set, the vent settings. And really at this time, you have to think, especially if you have somebody new at these, you wanna limit the time you allocate to complete the blocks. It's not a race you don't wanna rush, but it shouldn't take you 20 minutes to do these blocks. These are pretty simple and straightforward. So if it takes longer than you deem acceptable, just aboard it or, or give it to somebody else and, and see if they can't get it done faster. But there should be a time limit to, to these blocks so that you don't delay the surgeons. If you do three of these cases in a day and you add, you know, 10 minutes per case, that's probably, probably a little bit too long. Five minutes would be much better. But again, it's all hands on deck. Everybody's helping everybody's in on what we're doing and they actually, what we've seen is our staff take great pride in helping us. I mean, they started gloving the anesthesia provider on the way around the bed to do the blocks. They're prepping, they're asking to prep, they're all over it. So it's been fun to watch. The idea here is to work in parallel two groups working at the same time, performing different tasks so that we cut down on time. It's just trying to be efficient and, and just using common sense to, to get the day done a little bit quicker. So the tab block, just a quick review here. I think this is a common block used. The target is the lower six thoracic and there's T seven to T 12 and L one. We're gonna talk about that a little bit. I, I think, I think the target there is a little more T nine-ish for taps, and that's maybe why we're gonna be talking about rectus sheath blocks as well. But we'll, we'll go over that. There's some, some great images on that in a little bit. The target for the local anesthetic, we want want to inject the, the local superficial to the transverse abdominus muscle and deep to the fascia above the muscle. That's important. You need to go deep to the fascist, you need to enter the fascia, pop through it and stop above the muscle. Again, provides somatic analgesia to the abdominal. No visceral pain really. And we'll kind of try to break this down the best, the best I could do here with this image. So we have the external oblique and as we peel layers away, hopefully you kind of get an idea. There's the internal oblique, and then one more down will be the transverse, the dominus muscle. And you can see the little thoracic nerves run, run through this plane that's highlighted here. Deep to that is the peritoneum. We obviously wanna avoid that and we wanna just try to get the local, where these little nerves are, are innervating the abdominal wall. This image shows exactly where we should inject. If the needle is the yellow arrow, we're, we're gonna pop through that fascia layer above the transverse abdominus muscle and inject just above the muscle. And sometimes people are a little confused, they think maybe we're within the fascia, but if you pop through the fascia inject, you actually compress the transverse dominance muscle deep, okay? It compresses against both layers of fascia above and below and the local. And so it kind of forms a line on top of it. And then the line above the local, and you'll see that in a video here, the line above the local will be the fascia still. So you'll see two lines, but it's you, you inject deep to the fascia. I wanna mention it's important to consider pro placement while performing the block because this is a volume block. But if we're doing four blocks and all the volume may not be as high as you would really like, so depending on your pro placement and where you perform this block, it might dictate a little bit what kind of coverage you get. So pro placement's very important and I mean anterior posterior and cranial cosal. So again, i I I said before, we always perform these blocks just subcostal and you'll see why in some images here. But when we combine it with the rectus sheath, we're gonna try to get as much purchase as we can with all of these blocks. So we perform a subcostal at the anterior aary line for optimal coverage for us. I never know where the surgeons are gonna put the ports. Okay, I could, I could stare at them every single case I do, and I can never figure out, there's always one that I, I would've never guessed. And so I want to get as much purchase on the abdominal wall as possible so that if I have one robotic port or a drain site that's not covered by my blocks, I don't feel horrible afterwards because really we haven't done any, any justice for the patient at that point. So just a reminder of some of the anatomical lines here, mid axillary line, anterior axillary lines, costal margin, T 10 level, I know pretty basic stuff, but our goal for the tap block is really this anterior axillary line for how, how we we do these. And you'll see an image of how the local spreads at that level. Most people think the T 10 level is where you put your pro for all taps when they first start this. Okay? I've always argued that just stay subcostal and you'll get better coverage overall. You can follow the costal margin with your probe. You don't have to be transverse across the abdomen, just just use that costal margin as as one of your landmarks. So here you can see where, why probe placement is so important. As we, as we move the probe anterior and posterior kind of shifts the coverage are of our abdominal block. Now we're gonna have local spread in all planes, but you can help yourself out by, by placing that probe at the mid axillary, anterior axillary line there. The blue circle is, is where our target is. Usually you can get a little bit more anterior coverage by using the orange line a little bit more anteriorly there. But remember we're also doing rec to sheath blocks, so that's gonna cover more midline as well. It's really comes down to the volume that you're using. You need higher volume to get better coverage. So this will show you kind of how, how, we'll we'll just track that, that costal margin with the probe and wind up at the anterior axillary line. And then bring our, me our, our needle in medial to lateral in plain. Okay, these, these blocks were all done with the in plain approach and right at the anterior axillary line, just, just that looks about right, right there. And then our needle will come from the medial side and we'll be in plain. And you can see how our, our volume kind of spreads there. We'll, we'll inject, and this isn't medical advice any of this, but, but what we do is we inject about 20 mils there with our other block. So 20 mils on each side for the tap block and 10 mils each side for the the rectus sheet. We get really good coverage. We cover mostly abdominal wall with that. So subcostal, anterior AOR lines, the volume block, fascial plane block, this video show proper local placement after the initial improper local placement. So you saw, you see the needle come in there from the medial side and it's going to enter what I thought was the fascia above the tap plane. And it's not correct. I could see the fascia in intact below and now you could just see it pop through that fascia plane and inject again. And it pushes the muscle down a little bit. I could feel the pop better. And so we just readjusted a little bit. I love this video for that fact because it's, it, nothing's ever perfect. You just have to keep adjusting until you get what you like. And then once the local's injected, I always move into that space and, and, and then continue the injection, make sure I'm in that plane and you'll see the local spread nicely kind of people talk about the unzipping effect, but definitely open up that space all along that plane. So the tab block coverage, again, this shows where that anterior and axillary line, that injection at that at that level. And you can see we get T 10, we're not gonna get T seven with that tap block. And so this is why we add the rec de sheath block again, just subcostal. And you can see the kind of coverage that we're after with the rectus sheath block as well. So with the tab block filling up where we inject it, getting as much purchase as we can with that block. And then adding the rectus sheath block adds a whole nother level of coverage for the abdominal wall rectus sheath block. Re quick review here, again, very simple block targets. The anterior cutaneous branches, the intercostal nerves and literature says T seven to T 12, pretty accurate. T seven with volume to T 12 for sure, with 10 mils that we give, we, we get pretty good coverage. So local anesthetic is deposited deep to the rectus muscle, superficial, the posterior rectus sheath. So just posterior to the, to the muscle, just deep to the muscle, okay? And, and just anterior to the, to the rectus sheath, just superficial rectus sheath provides, again, somatic analgesia. So no visceral coverage. Again, a straightforward block. And here it's a little bit hard to peel some of these layers with the program I use here, but you'll get an idea. There's the anterior rectus sheath fascia there, and then of course the rectus muscle. Yeah, it's okay. And then, and then the posterior rectus sheath, there'll be other images to show that as well. So in fact there's a, there's a labeled image of that. So here, here's the image right here. So the, the needle's coming from the medial side, we can see there's the, the rectus muscle, the belly, so medially, the linear elbow would be medial off this screen between the rec eye. And you can always start your, your exam there and then just move lateral to either side. That's a good way of finding the rectus muscle, especially on a, on obese patients. Important here is the transverse salus fascia, which is that orange is yellow line. And then the peritoneum, which is the green line, forms two lines beneath deep to the rectus muscle. Many people often think when they're alerting this, that you inject between the two lines. And that's, that's not the case. You want to, you're gonna feel the, the transverses fascia with your needle. It's gonna be a blunt tip needle, hopefully. And you're gonna inject at that point, and it's going to, you're gonna see another, you know, an un zippering effect there. It's gonna push the muscle anteriorly and then the local will spread along that transverses fascia. And you'll get really good coverage with, with a small volume here. So again, subcostal block, it's also a volume block. Anytime we talk about fascial planes, usually it's a volume type block, better coverage with higher volume. And you can start your, your exam midline and then move lateral. So you'll see linear elbow, you'll see both rec eye and just move, move lateral so that you center one of the, the rectus muscles in, in your ultrasound image. And then for us, I always teach medial collateral in plain approach. I think that's, there's some blood vessels you can get into there laterally. So to avoid that, a medial to lateral approaches a little bit better, notice how the probe is angled to mirror the, the costal margin. It's not transverse across the belly. And, and that's done on purpose here. So you can just mirror the costal margin and, and use that as one of your landmarks. Video here again, rectus sheath. A block is pretty straightforward. Rectus muscle. The posterior rectus sheath, same image that was labeled that you'll see the needle approach medial to lateral. And there's that unzipping really straightforward. You're gonna feel that transverse satisfaction with the needle. You can stop, you can inject the mill, open up the space and then continue injection once you, once you're sure where you are. So the rectus sheath block, again, immediate immediately subcostal, the goal is to get a little more cephalic coverage than the tap lock I believe provides. So T seven is pretty consistent and it's gonna be more anterior medial wall coverage. Again, combined with the tap lock, you're gonna get great coverage of the abdominal wall. Interestingly enough, cadaver die studies, there's one just kind of done, when you inject the rock die at that level, it will, the local anesthetic will spread along that sheath will spread coddly. So you'll get great coverage depending on the amount of volume that you inject. And they've done dye studies to prove that. And we see it in our incisional coverage every time we do these blocks. So even if a laparoscopic procedure is converted to open, we'll get really good coverage of that midline incision. So I'm very confident, you know, an anecdotally that, that these blocks work really well for perioperative pain relief. So again, and this, this needle comes in from the lateral side only 'cause I thought I would run outta room on the, on the, if it came from the medial side, but you can see a single injection bilaterally, this will spread along the sheath and this is where we get great coverage from the rectus block, even even for midline incisions. So to summarize this, again, this is our tap block in incision. We combine it with our rectus block because we don't feel it gets cephalic coverage enough. It doesn't get to the TC you know, it's T seven level as consistently as we would like. Even an anterior injection wouldn't, wouldn't get there. So we add the rectus block bilaterally and we get great coverage of the, of the abdominal wall from both of these blocks. So we'll do tap and rectus blocks bilaterally. And you know, it usually takes us about, people laugh at this, but maybe three or four minutes on, on average to get these blocks in. So it's not a race, but it's challenge. We like a challenge for sure, add your multimodal analgesics. We know the tap and rectus blocks aren't surgically analgesic, but we know what to expect with them. We know they're consistent and we can really apply our multimodal analgesics in a timely manner to to, to help the patients be pain-free, perioperatively antiemetics as appropriate, pre-op, intraop post-op, and then rescue. So have 'em all lined up, have some sort of protocol so that you can track it, you know, your, your outcomes, and then you can tweak it as, as needed. Minimize overall opiate and, and maximize a small amount of opiate with optimally timed dose. So timing of opiates is really important. It can really decrease the amount of opiate you use if you time it well. So you can blunt the response to intubation with a little opiate. You can blunt the response to incision with a little opiate and then everything else, the, the multimodals and, and the blocks should carry you through the rest of the procedure. And if it doesn't, you have the right to give more. But less is more about the timing of the opiates are really important to us. I teach that to, to everyone I work with as much as I can be efficient with the blocks to gain surgeon, buy-in, be ready, have everybody on board, utilize the team. Usually the assistants are kind of standing by while someone's helping with anesthesia. So you can put them to work or ask them to work or, or talk to administration and see if you can't get something together. But we, we definitely, I love seeing it. They take part in it as a team. It's great for everyone in the program. They take pride in what we do. So it's, again, it's not a race, but when we, when we perform these blocks in about three or four minutes and, and everything goes as is planned, everyone takes pride in that. And so it's good for the team as well as the patient, the number one contributor to great success with these blocks or even our, our total joints. And those blocks set patient expectations early, get 'em ambulating and that takes the, the whole, the whole perioperative team all the way up to the floor nurses. They need to be on board about what we're trying to do. And, and, and you have to educate, you have to educate everyone, tell 'em what the goals are, define everyone's role, and work together and then, you know, get their feedback, you know, make sure that they're involved in the system. So setting patient expectations early, very, very important. That's it. Thanks for having me Jody Sauna site, love speaking on some of these procedures and, and era A protocols and the things we do at Southwest and sharing 'em with everyone. I know everyone does things a little bit different. I love to learn from everyone. So to be able to speak on something like this that we get to use daily or weekly is a lot of fun for me. So thank you again and hopefully - Everyone gets to use out of this. Thank you so much Robert for, for that excellent presentation. We got quite a few questions that came in. So let's see, the first one is, any use of goal directed volume replacement with flow track - Monitors? Boy, that's a great question and the quick and simple answer is no, and we don't have the equipment and I don't, it's not anything that anyone's pushed for or asked for to my knowledge either. It's, it's been, it's, it takes a, as you all know, probably it takes a lot of work to get a protocol and a system in place. And so for us it's been baby steps and, and we've gone two steps forward, one step back, but we keep going forward. So sur I mentioned surgeon buy-in there at the, at the end and it's important and especially at our hospital being a private practice hospital. So these private practice general surgeons especially can really move and we're giving 'em two, if not sometimes three rooms and three teams believe it or not. And so just to not slow him down sometimes is a lot of work. So no, unfortunately I don't have much experience with that at all. His surgeries are pretty quick and our other general surgeons are pretty quick. So as far as volume replacement, we're we, we keep it pretty simple. - All right, and the next question is, what about low thoracic epidurals for laparotomies? Are those used at all? - Yeah, not at our hospital. Not for years. We used to use thoracic epidurals for all kinds of surgeries. Nephrectomies other open large laparotomies, and they're really the gold standard as far as I'm concerned, as far as analgesia goes, you know, there's a whole nother risk profile. And also most of the time our goal is to get our patients walking really fast postoperatively. So we've kind of gone to this ultrasound guided, you know, peripheral nerve block technique and this era eras protocol and, and, and managed patients that way. So over the years, that's kind of fallen by the wayside. But definitely within my career we were, we were, we were utilizing thoracic epidurals and e and even low thoracic epidurals for, for laparotomies as well. And, and like I say, they, they worked great. I mean, if you want someone to have less pain, that's the way to go. They're, they're excellent. So good question. - Nice. And a follow up to that, are these all day surgeries that you're working on? - Our, our hospital, I would say the longest surgery would be six to seven hours would be like a, a very complicated colon resection with maybe some adhesions. So that's probably the longest surgeries we're performing. And we get, you know, we get probably 20, 20 hours out of our tap and rectus blocks, I would say. So, yeah, pretty long, but not all. I wouldn't call 'em all day surgeries. - Gotcha. All right, next up we have in laparotomies and abdominal surgery, what data compares UGRA tap and rectus block EFF efficiency or efficacy versus x parel or other catheters directly by surgeons to directly visible tissue planes? - I, I don't have the study right off the top of my head, but that's a very direct question and there's, I'm trying to think. There's probably data there, but I, I just can't quote it at this time. - Gotcha. And then after volume blocks, what volume of local do you advise surgeons who want to add at the end? - So after, so it depends on the length of the surgery, obviously. And like I said, in in the presentation we're doing 20, I'll dilute the local just for this reason. So I will use 0.375% ropivacaine and so I will dilute the half percent a little bit and I will use 20 for each tap, 20 mil mills and I'll use 10 for each rectus block. And if as long as the surgery in most of these abdominal surgeries are longer, I'm comfortable with them using, you know, 20 mils a quarter percent. We usually don't get that question even asked. It's been so long to inject and the patients do fine. - Excellent. Good question. Next question is, what are you using for your la - Yeah, so I just kind of answered that, but row pivoting 0.375% will, will dilute it a little bit just to give us a little more wiggle room at the end when the surgeons wanna inject the ports or even in the beginning if they have a little epinephrine in their local and they want to utilize that to stop some, some of the ports from bleeding. So we'll, we'll just dute it a little bit and, and I've had luck and I think for other reasons I've diluted sometimes to quarter percent and, and it seems to work close if not as well as the 0.375. So it's semantics there. I think as far as the, you know, how much, how much energy you actually give, it's, it's tough to tell sometimes. - Gotcha. This is a follow up to the previous question about the all day surgeries. You said what, what I mean is do the patients go home that same day? - So both. So some patients go home same day and, and one of the interesting things we found, and probably one of the reasons why this presentation came up with CYTE is through COVI, we were, they were, the hospital administration were advising us to cancel any admissions, any surgeries that needed admissions that weren't emergent. This was just at our hospital. I'm sure some of you experienced that and you know, all of this worried us, the volume decreasing and what we were gonna do with staffing. And one of the things we offered that I offered immediately was because I didn't un, I didn't know if all the surgeons understood that, you know, they weren't sending all of their hysterectomies home in the same day. And I think with what we had done with our blocks and our ERAS protocols, I think it was time to, to kind of have that conversation with some of these physicians who just weren't comfortable for one reason or another, sending their hysterectomies home the same day. And, and that was a real positive that came out of this, is that they understood that they could do that. Excuse me. So yeah, so a certain percentage, you know, their hysterectomies go home the same day. Now even our o our GYN surgeons have requested, we do these blocks for everybody, for everything, even if it's a tubal ligation depending on where they're putting their ports. So some, you know, some of the patients stay, some of the patients go home. - Excellent. Next question is, what percentage of peritoneal puncture do we advise patients for rectus sheath blocks? - I don't, I don't quote a number. I I say very low risk to, to insert the needle in, into your abdomen and, and cause trauma. And to the, to my knowledge, I still haven't heard of, of a, a poor outcome from the happening. And, and some of the other experts that I speak with around the country really haven't had any issues with it as well. So I'm not quoting a number there, I'm just going over generalized risk and that explaining that that is a risk and it's always a risk. So no numbers on that one. - Okay, next one is, our surgeons can be in the abdomen within five to 15 minutes of induction. Since large volume locals are likely lower concentration, slower onset. How long do we need to ask surgeons to wait before incision for preemptive analgesic benefit - Can only speak from my experience, and I've never waited and never had a problem. And these blocks work very, very consistently. So I don't know that there's, that there's been a study on this either. So just from my knowledge and from what you know, I've done at least over a thousand of these, if not more. I, I don't keep track, but there's never been a problem with, with the surgeons being too fast and entering the abdomen and the local just kind of leaking out and having no effect. Yeah. - All right. What's your routine antiemetic therapy? - So as far as this protocol for me it's, it's two types of surgeries. One is a bowel resection, one is one is anything abdominal that's not a bowel resection. So for our bowel resections, we're, we're withholding Decadron for everything else I'm giving, I'm giving four milligrams a Decadron, I'm giving Zofran and, and now we're using Erol again. And then I'll also a rescue Antiemetic. Bohemus, we use that as well, but there's others for sure. That's pretty much it. Okay. - Okay. Next question. Is X perel or adding adjuncts to local? - Yeah, so I am off the adjuncts to local train. I, I don't add anything. I would use X perel if I had it and they, I don't have access to it. I, I, I haven't used it. I have limited, limited experience with expel because we, we are unable to get it at our facility and, and our pharmacy is, has been very clear about that. So we've tried multiple times and we've tried for multiple reasons and, and I know a lot of people are using it and I would, I would love to use it and try it and, and have my own opinions on it. I see the studies, but, but again, I, I would love to to use it myself and, and see I wish I could tell you more. Yeah. But I know a lot of people are using it for sure. - Alright, I'm not sure if you answered this already. What is your local anesthetic cocktail preference? - Yeah, so for these tap and rectus blocks, it's just, it's still 0.375% ropivacaine and, and then, you know, doublechecking in the volume, if you have a tiny patient you definitely have to have to watch but usually fall well within the, the max dose of, of ropivacaine. - Gotcha. Any use of liposomal bupivacaine for these blocks for longer duration of action? - Yeah, so I kind of answered that. It's just naming it a little bit different, but I wish, I wish and I wish I had that experience and I, I wish I could talk about it more because I had the experience and I know some out there are using it and I maybe in the future we'll come back and and update this a little bit. - Gotcha. And for multimodal analgesia, do most people get magnesium and DMin and ketamine routinely? If yes, what doses? - They're pretty good there Chris. Thanks Dex Meine. Yeah, so I will use DM meine for our surgeons are pretty quick even in the longer cases and our, a lot of our patients are no opiate naive. They're, they're just, they don't take a lot of opiates. So I will bolus my dexa medo up up to about 25 mics for the case. Non bowel resections I'll definitely use, I can use a pain dose of Decadron sometimes as well. Ketamine, I'll definitely use magnesium. I stay away from only because of our relationship with our surgeons. I think they have asked us to stay away from it. I've offered it and, and no one's really taken me up on that and that, and that's okay. So ke definitely ketamine, DMed and then if, if the patients are hyperdynamic still after insufflation, then I'll look to use some beta blocker, you know, to kind of, to kind of top things off. And then some well-placed opiate for sure. I'm, I'm not opposed to that. I can do many of these cases without opiate, but excuse me, definitely 50 mics of fentanyl upfront goes a long way and that's kind of the message I was trying to get that that I'm not a big huge opiate free guy. I think a little bit of opiate goes a long way. So as long as we're using that upfront and, and judicially, I think, I think that makes sense. - Alright, next question is how do we cover the higher T six dermatomes of subcostal incisions? Yeah, - It's tough. You can add some local up towards the top of the incision and, and I think that's probably the best way to do it with what we're trying to accomplish. So if they're really pushing the superior portion of that, that incision, I just think injecting local anesthetic right at the top might, might just cover that it won't last as long, but it might get 'em walking a little bit quicker. And that's all we've really tried. So if that, if they're really pushing that incision superior, then, then it's, it's, they're probably just gonna have a little pain. You may just deal with that little, with a little opiate as well, to be honest. - Okay. How did these blocks compare with ESB? - So I have used ESB for thoracic. I, I haven't really used ESB for abdominal because we wrote this tap and rectus protocol to compare the two. You would've to, you know, this would, this is a study worthy subject, right? So the bottom line is for me is perform the blocks that it's twofold are most consistent for the patient so that you can, you can tell these patients exactly what to expect when they wake up and that. And then number two, can you perform these routinely and quickly? So abdominal, you know, ESPs, when are you gonna perform? Those are, they're, they're gonna be performed in pre-op, which might even be better if you have to perform 'em in, in, in the or, it's probably gonna be a little cumbersome. And then can everybody perform ESPs? Because at our, at our place, it really didn't take off so far, so I never want to jump down that rabbit hole where only one or two people are doing ESPs and maybe a surgeon views those as being better and, and so it gets a little murky there. So yeah, no, I would love to, I would love to read that data and, but we do extremely well with our tap and rectus blocks. They're, they're pretty straightforward and everyone's in on it. So that's where we are now. - All right, fantastic. Great questions. Yeah, doesn't look like we have any more questions left. So Robert, thank you so much for being here and delivering just an amazing presentation and sticking around for the q and a. Super helpful for everybody. Next time, you know, check out our behind the scan webinars page on sonosite.com to see what's coming up next. And for everybody else, this recording will also be available there as well. So thank you again, Robert, for coming by and thank you everybody else for coming. - Thanks for having me. Thank you. , plain_text