Transcript
- Before we begin, please be advised all
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We will conduct a q and a session at the end
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The webinar will be recorded and archived for future use.
Welcome to our webinar titled Multimodal Analgesia,
analgesia, and the Lateral Quadratus Lumbo Block.
With us today we have Audra Upton, director
of Clinical Applications here at Sono site
and Kim Warren,
clinical application specialist for Sono Site.
Audra and Kim will be assisting
with the live demo portion of the webinar.
Our presenter today is Dr. Richard Teams.
Dr Teams is a dedicated anesthesiologist
with a unique background in nursing who excels in working
with trauma and critical care patients.
He trained at the busiest trauma center in the US
and has exceptional regional skills
and ultrasound technique in multiple nerve block modalities.
He is currently the director
of regional anesthesia at John Peter Smith Hospital, as well
as National Clinical Director of Regional Anesthesia
for Envision Physician Services.
Dr. Teams is an officer in the United States Army
Reserve Medical Corps.
His clinical interests include acute pain management,
regional anesthesia, advanced airway techniques,
and cardiovascular anesthesia.
He has genuine interest in enthusiasm for teaching clinical
and acute pain regional anesthesia,
and is a bilingual English Spanish patient advocate.
Thank you so much for being here today, DR. Teams.
And with that I will turn it over to you.
- Awesome. Thank you so much. I really appreciate it.
I am going to share my screen here.
Let me make sure you guys see all this. Ready?
Okay. Do you see that okay, Laura?
- That looks perfect. - Awesome. Well, great.
Well, I'm really excited to be here with you all today.
I'm excited to talk
to you a little bit about multimodal analgesia
and also about the QL block.
I know that's kind of been a,
a really great topic in the realm
of regional anesthesia over the last couple years,
and it's something certainly I've used quite a bit in my
clinical practice over the last couple years
with a great success.
It's been a really fantastic tool to help combat pain
for a lot of our patients with, with big belly surgeries.
So what I wanted to do first is kind
of talk a little bit about multimodal analgesia.
I'll, I'll talk about that briefly
and kind of what, what I did at at
at my hospital in Fort Worth, which is kind of cool.
I'm, I'm coming to you from, from Fort Worth, that's
where I practice at John Peter Smith Hospital,
which is a level one trauma center.
And, and we did a lot of really great things
to help combat the opioid epidemic.
I know the opioid epidemic has kind of taken a little bit
of a bat backseat to COVID,
but it's still important nonetheless.
And here are actually some really staggering statistics
related to the opioid epidemic.
Just look at the top number there.
Which opioids in 2017 beat out breast cancer firearms
and automobile accidents, which is pretty crazy.
There is a reason why we have an opioid epidemic
and all the prescribing habits that kind of went along
with it, but there's a better way to do that.
And one of the things I wanna talk about is kind of what,
what the conventional treatment for treatment
treating pain has been in the past.
And I was an ER nurse before I went to medical school
and it was pretty staggering when PA patients
from the ER would come in.
If you had mild to moderate pain,
you just got a weak opioid,
maybe we would give you two milligrams of morphine
'cause that was considered weak.
And then if you had moderate to severe pain,
then you get a more potent opioid,
we'd give you maybe four milligrams of morphine
or maybe 0.5 milligrams of Dilaudid.
And then if you had breakthrough pain
or still had pain, then guess what?
We gave you more opioids.
And the, the travesty in all this really I think is the fact
that this is still kind of perpetuating today.
In fact, I just got off the phone with my, my mother-in-law
who had a lap coli yesterday.
And guess what they prescribed her?
They just prescribed her opioids. That was it.
They did not prescribe her any multimodal stuff.
So I put her on a multimodal regimen, the one that I kind
of implemented at my hospital.
And she has yet to take an opioid, they do really well
for pain management.
So what we did at our hospital was we rolled out a
multimodal order set.
And so now for mild to moderate pain, we would give a slew
of these types of medications, all of which are non-opioids.
And the key here is to schedule them as opposed
to making them PRN.
So for moderate to severe pain, we would use,
we use ketamine pretty ubiquitously throughout our hospital.
And we can also do nerve blocks.
And then for breakthrough pain, that's where in the cog
of the will of pain management, you know,
opioids do have a role
and that's where they should belong is is there.
And then briefly, I just will go over this slide real quick.
This is actually a slide from what we, what we implemented
and rolled out at our hospital related
to multimodal analgesia.
So we have our first line that includes Tylenol and Celebrex
or naproxen, one of the two which are all scheduled.
And then the adjuvants,
which are also considered first line medications,
which includes your gabapentin or or
or pre or Lyrica.
We have muscle relaxants in there.
And then we also have ketamine, which is
a medication we would give to our patients
for moderate pain if they're a medicine patient,
or we would schedule it if they're a surgery trauma patient.
And then for our second line breakthrough pain is, is
where we put our, our opioids.
And we rolled this out at the end of 2018.
And right now we've lowered our opioids
by over 50% from, from the time
before we had this, this order set.
And I really think the key is is to scheduling non-opioids.
And, and, and,
and this is actually for everybody in the hospital.
This isn't just for surgery patients.
This in fact this,
this is a snippet from the medicine order set.
So this is our medicine patients.
This is what they would get if
clearly if they needed it, right?
You know, I mean, you don't need someone who, you know,
just has, you know, a diabetic, you know,
going into ketoacidosis, you don't need this.
But if someone has acute pancreatitis,
which ironically we also use lidocaine for,
which is a really great medication,
all these non-opioids we've been able to utilize for that.
But I wanted to go, that's just a little blurb I wanna talk
about for multimodal analgesia.
Clearly for our surgical patients,
we can offer them more than just the medications in the form
of pills.
And for belly pain
and belly surgeries, the biggest one would be doing these
plane blocks, these abdominal wall plane blocks.
Now historically, this, this is what we would normally do
for, for belly cases.
And you know, it's been well utilized in, in throughout,
you know, the last couple decades,
which is the classic tap block.
This is kind of the dermatome spread
that you would get if you do a tap block.
Usually it will cover up to TT nine, which you can see,
hopefully you can see my pointer here,
just a little above theus.
And we'll go down to L one.
That's usually what you would get if you,
if you did a classic tap block.
Now this green one here is a subcostal tap.
So that's basically going under the costal margin here
and it will cover this area.
Okay? Now rectus sheath is the other one
where you can go right under the rectus muscle and
and infiltrate some local anesthetic
and it will get everything
that encompasses the linear semilunar.
So all the borders of the rectus muscle,
you'll get analgesia.
So big stem to stern, you know, xiphoid to pubis incisions.
This is a, a pretty good block for that because it will,
because it will cover all that.
And then you can do your four point tap,
which basically you're doing four different injections,
which can get everything
that's in the subcostal region up here.
And then also what your classic tap is.
Now, that's historically what we've been using
for most belly cases and and pain.
And certainly that's been the case at our hospital.
But then back in 2000, early 2018,
we started implementing the QL block for most
of our belly cases to now
where QL block is the mainstay at our hospital.
In fact, I don't do tap blocks anymore.
In fact, the only tap block I do now is actually a
Subcostal tap.
And I'll usually do those if they have a really high
incision up here, which let me click to this next one.
So this purple line represents
what typically you'll see as far as analgesia,
analgesic spread of the belly.
So it can go almost all the way up to maybe T seven,
maybe TT some interest says T four.
I don't agree with that.
I think T seven is pretty reasonable.
But you know, you can clearly see up here,
you'd be missing some analgesia
if they have a really high incision.
So sometimes I'll do a subcostal tap.
I also do subcostal taps for our cardiac cases
to get the chest tubes that are going subxiphoid.
But really that's it. If I'm gonna do a,
what I normally would've in historically done a tap block,
now I do a QL block and there's a couple reasons for that.
So you can do these blocks for all types of incisions,
but the big one here is this.
So the biggest difference between a QL block
and a tap, actually I'm gonna go back here, aside from
how much more spread you get
because you do get more cephalad spread with a QL blog.
But here's the, here's the big one is you may get some
visceral nce, some visceral pain coverage
because of where, where it spreads,
it will spread depending on where you put it.
We'll talk a little bit about that
to the paravertebral space,
which can get those visceral arons,
which innervate the organs, which is usually what causes
that visceral pain, that dull achy crampy pain
that you get from your bowel resections, your hernia
surgeries, even your C-sections.
Whereas a tap subcostal tap rectus sheath,
classic tap, those will not get those visceral aaryn,
it will only get somatosensory.
So it's basically only getting those, the incisional pain
that you get from from the surgery.
So a lot of times we're doing a lot of robotic cases
and laparoscopic cases, which, you know, you don't get a lot
of somatosensory pain from that
because they're such small incisions
and it's such a small localized area in your belly where,
where the trocars are going into.
But these patients do get a lot of visceral pain
because those robotic arms
and that laparoscopic procedure is going in there
and it's messing with the bowels or whatever organs inside.
And so they will get visceral pain.
QO blocks can help with that.
And I put in there may because not all the time you do it.
And there, there's a couple pitfalls that can happen,
which we'll we'll talk about here, why a,
a QL block may not work,
but if you do it right most
of the time it works really well.
Before I move on, there's a really good study that kind
of highlights this difference here.
There was a study for post C-section patients
where they compared a classic tap to a QL
block post C-section.
And what they noticed was is the amount
of pain medications postoperatively was about the same
between the two groups,
but that the vast pain scores was statistically
significantly less in the QL block group.
And that is most likely owing to the fact that you get more
of this visceral pain coverage with a QL block.
And certainly that is what we have seen in,
in my clinical practice,
there has been a big difference in the efficacy
of blocks when I do a QL block versus historically when I do
a a a tap block.
So how I start the scanning for this,
'cause there's a lot of, I mean, you can go on YouTube
and find pretty much anything out there, right?
You can, you can find all the conspiracy theories in the
world on YouTube and certainly there's plenty about QL block
and you know, I've seen some pretty outrageous
things about how to do it.
The way I te teach it is I always teach blocks
that there's a home base.
So if I'm, for example, doing an inner scaling,
I always teach people to do a supra clave, look
for the subclavian artery, and then find the nerves
and then track the nerves up.
Well, that's home base QL block is no different.
I think going to sono anatomy that everybody is used
to and, and is comfortable with, I think is a really great,
great starting point.
So in this case,
the starting point is basically putting your probe right at
the level of the umbilicus, just lateral to it,
tracking laterally from the rectus muscle until you see
what I call the boat sign.
This is, this is the boat sign.
So it looks like the bowel of a boat.
Well, this actually here is the
transversal abdominis muscle.
Okay? So once you go lateral to that, this,
this big one here, this is the internal oblique,
this one is the external oblique,
and then the deepest layer here is your transverse
salus abdom muscle.
I like doing it this way
because it, it, it, it alleviates any confusion
that one may have as to which muscle
and which fascial plane to look for.
A lot of times I see people put the probe immediately right
in the inner mid axillary line, right on the side and,
and they're like, oh, we're just gonna count the
layers from the bottom up.
I'm gonna, I'm gonna kind of show you that sometimes
that's not always, you're not always gonna be correct
by doing it this way.
You look for the boat sign, you'll never, you'll,
you'll never go wrong.
You'll always know that this is the correct plane.
So this is the transverse abdominis plane
and this is a transverse abdominis muscle.
So I take this
and then basically all I'm doing is I'm scanning
posteriorly, just lateral right at the level
of the umbilicus.
And once you get to the, the end,
what happens medially, I'm gonna go back here.
What happens medially is you have this little peak here,
I call it the boat sign.
But the similar thing happens posterior medially, which
what I call the tip of the tap,
that's gonna be the word of the day today.
I'm gonna use that terminology a lot. The tip of the tap.
So the tip of the tap is all, is the transverse abdom
muscle terminating and coming to a, a tip, if you will.
And, and usually it points right at,
and that fascia continues on as the thoraco lumbar fascia.
Well, right where that tip of the tap is,
that is your QL one.
Now in the literature there is a description
of actually four different types of quadras lumbar blocks.
There's a QL one, a QL two, a QL three,
and not a QL four, but it's called an intra quadratus block.
Basically what they're doing is,
is they're injecting local anesthetic
inside the quadratus lumbo muscle itself.
The QL three block is also known
as the trans quadratus block.
I'll just talk briefly about a QL three.
I typically don't do it.
Usually the patients have to be completely lateral.
It's a lot, it's a deeper block.
And basically, in essence, what it is,
is a slightly lateral lumbar plexus block.
That's really what it is.
And so it, it, it, it can be a little bit more challenging
to do, but a QL one block is right here,
right at the tip of the tap.
If I just go a little bit more lateral along this thoraco
lumbar fascia, this is actually called the combined
thoraco lumbar fascia.
When I go underneath that fascia, just a lateral to to
that right on top
of the quadras lumbo muscle, that's a QL two.
Now, in this image, it shows the tip
of the internal oblique.
I don't look for that as a sign.
A lot of people are like, well, where is the QL two?
And I'm gonna, when we do our, our live scanning, I'm gonna,
I'm gonna talk at nausea about this.
'cause when I teach live, I get lots of questions.
Well, where's QL two? Well, where should I put my needle?
Where should I, where's a QL one? Where's all this?
This I don't necessarily use the internal bleak
and where it terminates as the spot
where my QL two is really,
I can put my local anesthetic anywhere
underneath this fascia.
Okay? Now, one of the other aspects that I like
to talk about is the exact location
to put your local anesthetic.
If I asked a hundred of you, how many
of you have had a failed tap block?
I would get a hundred hands raised
because, you know, someone says, you know this, you know,
my, my patient didn't, didn't, I didn't get any effect.
I didn't feel like it worked at all.
There's a couple reasons for that.
One, we already elucidated to, one
of the reasons why people think tap blocks fail is really
because they're not getting visceral aary,
which we already discussed.
The second reason is, is
because a lot of times these,
the local anesthetic inadvertently or,
or intentionally, is not put in the proper location.
I'm actually gonna go back to this image here.
If we look at this image, this is actually really great.
You can almost see train tracks here.
You can see two fascia layers. And that's actually true.
That's actually what happens here, right where the arrow is,
it just looks like one thick fascia layer,
but in essence it's two, one fascia is covering the top
of the transverses ab salus muscle.
And then the other fascia is covering the underbelly
of the internal oblique.
So the question is, where do I put my local anesthetic?
Do I put it on underneath the internal oblique muscle,
but on top of the fascia?
Or B, do I put it in between this, right?
C where you see the train tracks, do I try
to put it in between there?
Or C do I put it underneath the fascia covering the top
of the transverses ADOS muscle,
but on top of the transverses ados muscle?
So there's three choices there.
And a lot of times people will put it in one of three cho,
one of those three locations.
Well, which location is the best?
Which is the, which is the plane
that the nerves actually run in?
Well, the answer is actually C,
the nerves run on top of muscle.
They run on top of the transverses abdom muscle,
but underneath the fascia that covers it.
So what you want to do is you wanna go through both
of these lines.
If you were doing a classic tap
and put your local anesthetic on top of the muscle,
I've done a lot of cadaver studies.
In fact, I did one in Tampa about a month ago,
and we actually shot dye in there
and try to stain this for doing tap muscles.
Really great experience.
But anytime I do a cadaver dissection, it's fun to try
to pull off and peel away the fascia very carefully
and see if you can see the nerves.
And a lot of times you can and,
and you see exactly where those nerves are.
And those nerves are right on top of the muscle,
but underneath the fascia.
So if I put my local anesthetic in between here,
will my block work?
And the answer is yes, it will,
but it just won't be as effective
because now that local anesthetic has to diffuse
through an entire fascial layer to get
to where the nerves are.
So if you put it in the right spot to begin with,
usually your blocks are gonna
be a little bit more effective.
So there's two reasons why tap may or may not work.
One is you're not getting visceral
pain like we talked about.
And number two is maybe you're putting it in
between the fascia layers
or in the wrong fascia plane to begin with.
Okay? But the,
but the, that holds true also for QL block.
So where should I put my local anesthetic and a QL block?
Well, I wanna put it
underneath the fascia on top of the muscle.
And, and if I'm doing a QL two,
what I wanna do is penetrate the fascia that covers the top
of the quadratus lumbar muscle
and infiltrate my local anesthetic underneath that fascia.
And that fascia layer is called the thoraco lumbar fascia.
So let's talk a little bit about this from an anatomy
standpoint here.
So this actually highlights a little bit why I discourage
people to just put their probe laterally right in the mid
axillary line immediately and try
and find their fascial planes.
And the reason is, is actually
because of this, this fat pad here is called the perren fat.
And sometimes when you scan,
it can inadvertently look like
the transverse abdo muscle.
I have some really great images that came from my hospital
of needles going through the transverse abdo muscle.
And they're basically numbing the perineal fat.
So they're, they're not doing anything in the way
of helping with analgesia.
They're just that perren flat.
Just didn't know what hit 'em though,
because now they're numb,
but it's not gonna be effective at con at controlling,
visceral or somatic pain at all.
And so this is actually what you need to look out for.
We'll talk a little bit more about peroneal fat in the,
in the sense of QL blocks
and what it looks like under sono anatomy.
But here you can see the tip of the tap,
which is right here, right underneath this fascia.
See that little band right there? See this,
this band right here, this is the thoracolumbar fascia
and it covers right over the top of the Quadra lumbo,
the Quadra lumbo muscle, which is this one.
This is the, this is the Quadra lumbo muscle right here.
So right at the tip of the tap underneath it, right
underneath that fascia, that is
where my QL one is QL two is actually
I, let me, let me show that.
So here's QL one right there, right at the tip of the tap.
And sometimes this is what it looks like in real life.
The space between the tip of the tap
and the quadras lumborum muscle.
It sometimes there's actually a, a gap there,
I'd say in about 40% of patients.
But I'm gonna show you some images
where it's actually the QL muscle is really
close to the tip of the tap.
I'll show you that here in a minute.
But a QL two block is here just on top
of the quadras lumborum, but underneath the fascia.
Okay? And a QL three is way over here.
This is the SOAs muscle. And look at this.
This is the transverse process.
And if I was gonna do a lumbar plexus block, this is
where I'd go, well look,
it's just like a centimeter lateral, not,
maybe not even a centimeter lateral to that.
That's a QL three. It's a lot deeper.
Generally you need to use a curvy linear
probe to get down there.
And it is a little bit more effective
'cause it's right there next to the paravertebral space.
But let's show how the local anesthetics can flow.
So for a QL one, if I injected it here, this is kind of
what the flow of the local anesthetic is, okay?
Some of it will go over here.
The reason I like to do a QL two block typically
is because of this.
Here's a QL two
and this is the spread notice
where the green terminates here, this is
where you're getting that visceral afferent analgesia is
when the local anesthetic spread spreads posterior medially
and encompasses around the paravertebral space.
And indeed, when you do cadaver studies, you'll see,
you know, we shoot dye in there
and that dye, you dissect the cadaver,
you inject it way over here,
but that dye is hanging out right here,
right in the pair of vertebral space.
Now QL three is right here, obviously it's right there next
to the paravertebral space.
So it's going, it's gonna get those
visceral arons really well.
Some questions I always get related to this is, well,
are you gonna get some weakness or numbness in the quads?
And the answer is yes, you can.
Now, if I do a QL two block, again, when we're doing taps,
usually volume is gonna be a more
of a dilute local anesthetic.
So you could use, you know, quarter percent bupivacaine
or quarter percent ropivacaine or 0.2% roca.
But a lot of volume, well
that lower concentration usually doesn't cause a lot of
motor weakness.
Now I think in the, you know, thousands
of QL blocks I've done over the last, you know,
several years, I, I think I have had one, maybe two patients
that had some mild non clinically
significant quad weakness.
But QL three,
that's actually been a little bit more prevalent
even in the literature.
In fact, a lot of people are doing QL three blocks
for hip fractures because it's getting more of those.
And it's, it's a little bit denser block
'cause you're it closer to it.
But usually when I do a QL two block,
because I'm using a dilute local anesthetic, it is not
clinically significant to cause quad weakness.
So here's a, here's a great image of that.
So notice where this one, the QL one is right here,
right at the tip of the tap.
And notice this is the image I wanted to explain to you.
So here is the lateral border
of the quadras lumborum muscle, okay?
And, and look how close
or adjacent it is to the, the, to the tip of the tap.
It's very close. So you'll see this in probably 60%
of patients where the tip of the tap and the,
and the lateral border of the QL muscle are really close
together versus it being spread out,
which can happen some of the time.
So this is actually a video that was shot by SonoSite and,
and I'm, I'm gonna play it real
quick and I'm gonna kind of talk.
So this over here on the right, this is actually medial.
So actually the boat sign is way over here.
It's kind of, I'm gonna pause real quick.
It is kind of funny. If you look, I'll play it again.
But you can see the whole transverse abdominal muscle in
one plane.
So this is obviously from a, of, from a skinny person,
but actually right here, this is lateral.
Notice this, this right here is the tip of the tap
and here's the quadras lumbar
muscle and it kind of comes up.
If I were to do a QL two block, I'd put my needle right here
underneath this tho lumbar fascia.
Now the thoraco lumbar fascia is a very, very,
very thick fascia.
In fact, a lot of times when you're going through it,
it kind of, it feels hard and hard to, to, to go through.
And that's 'cause it's, it's just that it's very thick.
But also because it's thick, if you have a thicker patient,
a lot of the Sonos, the, the, the ultrasound
raise will be absorbed by that fascia.
And so a lot of times you won't really appreciate how
that muscle looks.
So here, this looks really pretty.
I mean this is a really great looking image.
You can really appreciate the, the muscle.
It's not usually like this.
Usually it looks kinda like schmutz you,
you can't really tell what's underneath there.
And a lot of it is because of the thickness
of the thoracolumbar fashion, it's kind of sucking up a lot
of those sonar rays.
But here you can see just a little bit of the perren fat.
This is actually, yeah, this is a little bit
of the perineal fat, which is right here.
But if I was gonna do a QL one, I'd come in here
and pop right, right here.
And that will infiltrate underneath this.
Oh, this is a, this is a QL one,
QL two would be anywhere along this area.
So a lot of people are like, well where
exactly do I put my needle?
I mean, you could put it here, you could put it here,
you could put it here, here, here, here, here.
Anywhere along that plane considered is considered a QL two.
So the other question I get is,
is well why should I do a QL two versus a
QL one versus a tap?
Well, we already kind of talked a little bit,
elucidated a little bit if you will, about why we,
we would do a QL versus a tap is
because we'll get the visceral A efforts.
So there's a good better best.
So good is doing a tap
better is doing a QL one best is doing a QL two.
So if you can get to and can do a QL two, then do it.
Go for it. You don't need to come back and do a QL one, two.
I get that question a lot too.
Should I do a QL two and a QL one?
No, you would just do one or the other.
But sometimes, and this has happened to me, I just,
I mean I can't get there.
My needle doesn't get there.
It's, you know, it's a really big patient.
We call 'em Texas small patients in Texas, you know,
they're really challenging to get to
and you know, if I can only get to a QL one, I get
to a QL one, well that's better than a tap.
All right? And if I can't get to any of it,
but I can do a tap, then do a tap.
Or sometimes people get lost, they're learning how
to do this for the first time, you know,
it's taking 'em a little bit longer than they'd like to.
Well, I mean fine, you know, cut your losses,
come back another day and do it, try it again
and maybe just do a tap at that point.
But, but the, but finding the anatomy is actually pretty
easy and we'll do it when we do the live scanning.
So lemme go back to this video real quick.
So this is scanning lateral. So obviously this is the,
this is the Quadra limb bore muscle.
Again, that fascia right on top is the,
is the Thor lumbar fascia.
And that's where you want to go to.
So here, this is actually the internal bleak,
this is external bleak way over here is gonna be the
rec, the rectus muscle.
This is what I would typically call the boat sign,
although it doesn't typically look like a boat here.
And then as they're scanning laterally, this is
where I do a classic tap.
There you can see the tip of the tap muscle right there.
And then the quadra lumbar muscle.
Okay, so what we're gonna do, this is gonna be kind of cool,
never been done before.
So I, like I said, am in Fort Worth, we are gonna jump over
to Minnesota to Kimberly
and to Audra who are going to be the ones scanning.
So they're the models and the scanners.
So this is actually gonna be kind of cool
and I'm gonna walk 'em through this.
So we've actually, we kind of did a,
just a brief walkthrough,
but we're gonna see how good of a teacher I am,
if I can walk them through this
and explain this to you from Minnesota.
So this is gonna, this is gonna be kind of cool.
So actually this is them.
So, so Audra, is this you scanning?
Oh, well you can, you can, yes, it is this. Okay, awesome.
So, so Kim is our model.
So you can see in the left corner here, this is,
you can see herb scanning.
And then as far as the, what you wanna look for is the, the,
the probe is just lateral to the umbilicus
and right in between the costal margin
and the top of the iliac crest.
So right here you can see the rectus muscle.
So the rectus muscle is, is what you're seeing.
And she's just lateral to the umbilicus.
Now as she scans a little bit more lateral,
just go a little tiny bit more lateral
and she, I'll, I'll have her put an
arrow in here in just a little bit.
Oh, there you go. Okay. Okay, right there.
So right here is what's called the line stem lunars.
This is your, basically your border of your six pack.
Now if she goes a little bit co at,
just slide your probe a little coad notice,
she slides her probe a little co at,
usually it looks more like an hourglass sign.
So if you move your arrow up a up
and into the right, just a tiny bit up
into the right a little bit.
Yeah, right in that area.
Yeah, not so much in this case,
but a lot of times it does, it looks more
like an hourglass sign.
But now go a little bit lateral
and we're gonna start seeing the, the boat sign.
Okay. And that's it right there.
So there is the tap muscle coming into view.
So that's actually her tap right there coming into view.
So it's the boat sign
and then she's gonna scan a little bit more lateral.
So all we're gonna do now is we're gonna spy the, the, the,
the transverse south abdominal plane.
Now, actually stop right there.
So if you look on the left side, see
how those planes are kind of curling?
They're curling down. It's like they're falling off a cliff.
So you'll, if, if your probe isn't flat to the patient,
you'll start seeing that curling.
So what she's gonna do is she's gonna take her probe
and she's gonna kinda rotate it around the belly.
And when she does that, look what happens.
See how it makes the planes nice and flat.
That's one of the biggest pitfalls I see when,
when people are scanning is they're not,
they're not taking the, the probe
and cur curving it around the roundness, if you will,
of, of the belly.
So that's what, that's what you wanna do.
So now she's gonna go a little bit more lateral
and we're gonna see if we can see the tip of the tap.
And there we go.
So that's actually the tip of the tap right there.
And that hypo coke structure on the left, I don't know,
is that one of your rib?
That might be a rib. Are you just caught?
Yeah, go a little bit. Caught at just poke a little bit.
Caught at. So sometimes you can inadvertently look at
and see your false ribs.
You could see the, the, the 11th and 10th rib,
but which that may be one right there.
Okay, good. So, so, okay, here you go. Perfect.
So there's the tip of the tap right there.
You can see the tip of the tap.
There's kind of a little void there.
And then to the, to the left,
you can see the thor lumbar fascia
going all the way around there.
And then go a little bit more lateral and curl around
and aim the probe a little bit up towards the umbilicus.
Perfect. So that's actually the quadra
lumbo muscle right there.
That big, yeah, there you go.
Big hyper hypoechoic structure.
That's her quadra lumbo muscle.
And look how it's closely abutting the tip of the tap.
It's not, it's not far away at all.
And then so go to the tip of the tap, which is right there.
So if I popped underneath that fascia, right where
that arrow is, that's where I'd do a QL one.
Well, if I wanna do a QL two,
I would just go a little bit more posterior medial, right
where that arrow is anywhere along that.
But I wanna go underneath the fascia.
You wanna pop through the fascia
and go on top on top of the muscle.
Okay? Now if you look at the image of her scanning, notice
how she's holding the probe.
So her probe, she's kinda, she's kinda holding it
with her knuckles on the bed
and she's angling the probe kind
of up towards the umbilicus.
That's, that's the way I do it.
The beauty about doing it this way is you can do a QL
block with almost any patient, even a large patient
with them completely supine.
That's the awesome thing about this block.
A lot of people I know they wanna, they wanna rotate 'em,
they wanna put 'em on their,
they wanna put 'em on their side and that's fine too.
That will expose the area just a little bit better.
But probably 95% of the time, this is exactly how I do it.
Now, there's occasional
where I might have a patient has large panties
or they have, you know, they're a little bit larger
of a patient and you may wanna put a hip roll under him.
So where you would wanna put it is right where you see her,
her, her pants kind of terminating.
There is, you wanna put it right there? Yep.
They're doing it perfectly. That's exactly what you want,
what you wanna do and just maybe just do a little bit
of a roll and put it under there.
What you don't wanna do is you don't wanna put
that roll cephalad upward.
Yep, exactly. You don't wanna put it there
because now that roll is gonna be in the way
of your ultrasound probe
and you're not gonna be able to get a good image.
So I see that a lot too.
When I'm teaching and training people, I will,
I'll see them put a roll and they'll just shove it
all the way underneath there.
I'm like, well no, you need to put it just under their hip
bone exactly how they're doing it.
And then that will just kinda lift it up a little bit
so you can rotate around.
So let's do this one more time.
Let's do this exercise again. So let's start at home base.
So home base is just lateral to the umbilicus.
Usually that muscle you're gonna see there is gonna be
the rectus muscle.
And then, yep, that's all the rectus muscle right there.
And you can actually, oh actually stop right there.
This is, this is kind of cool.
So you see the train tracks there.
So the top one is the fascia covering the bottom
of the rectus muscle.
And then the bottom one is the peritoneum.
So that's the peritoneum. So one reason I don't like doing
rectus sheath blocks is because of that reason,
because the peritoneum is right there.
You know, we have a thing called peritoneal dialysis, right?
And how we use peritoneal dialysis is we put dialate in the
peritoneum and it gets absorbed.
Well, if you do local anesthetic in the close
to the peritoneum, then it's
gonna get absorbed very quickly.
So rectus sheath blocks are effective for, like I said,
somatic sensory paint, but they just don't last very long.
And the reason they don't last very long is
because of the high absorption rates there.
All right, so let's just go a slightly co ad.
So where I like my probe
to be when I do this is just about a centimeter
or two co A to the umbilicus.
And then I go a little bit lateral.
So now we can start seeing the,
there you go, there's the boat sign.
So you can see the, the, the transverse abdominis muscle.
And we're just gonna go a little bit lateral
and I'm just gonna spy the plane above it, the top the plane
above the, the,
the transoral abdel plane, which is above it.
And I'm just gonna rotate around.
Yep, that's, that's the plane. Exactly right.
So I'm just gonna rotate around, just keep rotating around,
look at how she's put her hand position.
And then I'm gonna push in
and right there, look at the tip of the tap.
So there's the tip of the tap, which is right there,
and then to the lateral
and inferior to that is the quadra lumbo muscle.
Now this is, this is kind of cool.
One of the things that you can do to help facilitate you if,
especially if you have a big patient, is pressure,
you wanna push in as much.
Now if she pushes in a little bit,
it's gonna make it a little bit more superficial.
Look at that. Her, her QL two block is right at two
and a half centimeters, almost two centimeters.
I mean, that's nothing. In fact, the QL block is
a little bit more superficial than a classic tap.
And that's, that's pretty typical.
You, you, you'll usually see
that a QL two is a little bit more superficial
than a classic tap.
So right where that arrow is is where I would do a QL two,
but again, underneath the fascia.
And then if I go medial with the arrow, arrow
is a QL one.
Oh, right there. Yep.
Now look at all that movement to the right
underneath the tap muscle.
Yeah, come a little bit. Yeah, right there.
So what that is, that's actually,
that's actually peroneal fat actually that's moving
and it's moving because she's breathing.
So I, I get a lot of people who kind of freak out.
They're like, oh my goodness, you know, the diaphragm's
right there, I'm gonna puncture it.
And no you're not.
That's actually the diaphragm moving and it's,
and it's moving the fat.
So that's why you'll see a lot of that,
that translated movement.
That's what you're seeing there is the translated movement.
Another pitfall,
or not pitfall a complaint or I should say,
or a reason why people say they don't want do a QL block is
'cause they think it's a, it's a little bit more
of a dangerous of a block.
And that's actually not true.
In fact, I think it's a safer block. And here's why.
So if I do a classic tap, so move your probe a little bit,
right In mid ary line, move a little bit more medial like
where we do a classic tap, classic tap would be right there.
Okay? That's your classic tap. Okay?
So if I go in and I do my classic tap
and I just pop in there,
but if say for example, I don't see my needle all the way,
okay, and then I see it
after I've gone through the tap transoral abdominal muscle.
Alright? How, how many times does that happen?
Well, that happens every once in a while, right?
You're in the peritoneal cavity, right?
You're, you're in there getting ready to hit big hit, big,
big stinky, right?
We don't, we don't wanna do that.
We don't want our surgeons to have to repair a bowel injury
because we inadvertently went in
there and, and, and popped it.
Okay? Now think of what your trajectory
of your needle is gonna go to.
So it's gonna go from the top right
of your screen all the way down to do your classic tap.
If you go too far, you're in the middle,
you're in the peritoneal cavity now versus doing a QL block.
So let's scan posterior medially back
to the quadras lumborum area.
So right there, so there's our QL block right there. Bam.
So I can see the tip of my tap right there on the right side
and right in the middle of your screen I can see my
quadras lumbo muscle.
I'd even go a little bit more lateral, just kind
of moving the up right there.
That's exactly what I like to see.
I like to see a little bit of the tip of my tap.
So if I inadvertently go too deep, again,
my needle is gonna be coming from the top right
of my screen, right where that zero is in the top right
of my screen and it's gonna be coming down.
Yep, it's gonna be coming right from there
and it's gonna be coming right down that way.
Now, if I go too deep, where am I? I'm just in more muscle.
I'm not in the peritoneal.
In fact, it's kind of skying away from,
from the peritoneal cavity.
So you're less likely to get into the peritoneal cavity,
do cavity doing a QL block than you are doing a,
doing a, a tap block.
Now if you do get into the QL block, well guess what?
There's medical literature to support you in the fact
that in, in the, in the vein
of doing an intra quadratus block, right?
So there's, there's medical, medical literature saying
that you can put your local anesthetic inside the QL muscle.
I personally wouldn't do it,
but you know, there's, there's that to support you if you,
if that accident accidentally inadvertently happened.
Now, what does happen some of the times is
as my needle does go in
and I pierce the thoraco lumbar fascia,
maybe my needle is just a little bit inside muscle.
I usually do one or two ccs of local anesthetic just
to make sure I'm underneath the tho lumbar fascia.
And if I do see that it is, then great, I'll,
I'll dump the rest of my local anesthetic there.
But if I don't, you know,
you can always pull back a little bit.
Sometimes on your really big patients it's hard
to see your needle.
Maybe you felt a distinct pop
and you're, you're there, maybe you're
only seeing part of your needle.
These are, these are ultrasound guided nerve block pitfalls
that happen to everybody.
And certainly they happen to me.
One little trick that I've learned
is if I feel like I'm there, that I'm in the QL space,
but I just can't see the tip of my needle,
what I'll do is I'll have my injector inject a couple
ccs of air.
And a lot of times you do that, you'll see a nice puff
of air and sometimes I won't see my needle,
but I'll see this puff of air
underneath the thoraco lumbar fascia
and I'm like, great, I'm right where I need to go
and then I'll dump the rest of my local anesthetic there.
That, that may happen every once in a while to you.
And that's just a a, a cool little way to,
to verify that your needle is in the spot
that you think it is because you've gone through
that thoraco lumbar fascia.
Last thing and then I wanna go to get to questions is your,
your angle of attack.
So I'm gonna have Audra kind of point
with her left hand kind of where to put her needle.
So where I want her, the needle
to go would be just a little bit up about a centimeter up
from where the, the probe is.
What I found is, is if you're too far away from the probe,
trying to find your needle is gonna be really hard.
So in this case, you probably want
to put your needle pretty close to the probe
and notice the tissue translation, she's pushing right up by
that zero fact that half centimeter mark.
You can actually see where that needle's gonna enter from.
Some people wanna bring their needle straight down
and so they, they put the needle like 3, 4, 5 centimeters up
from the probe way up there.
You can do that if you're like super amazing, you know,
the god of regional anesthesia
and you have no problem finding your, your needle.
You know, that is once, once you are that far away trying
to go through that amount of tissue
and finding your needle, I find people,
they find their needle but then their image sucks.
They can't see what what we are currently now seeing.
So if you just put your needle right there close
to the probe, your angle
of attack is gonna be a little bit steeper
and it's gonna be about a 45 degree angle.
So a lot of people want to go down kind of
what she's doing kind of straight down.
You don't wanna do that 'cause then you're going into the
ultrasound probe,
you wanna do a 45 degree angle into the patient.
Okay? And you'll be surprised you'll do that
and you're like, Ooh, I feel like I'm going right
into her intestines.
But you're not. It's going right along that muscle
and that fashion, it will pop right in there.
So go in at about a 45 degree angle. Okay?
Those are some pitfalls I see when I teach people
and when I, when I watch people do blocks is people usually
take too shallow of an angle
and they're almost going in to the ultrasound probe
or they're starting their needle
and their angle of attack too far away
from the ultrasound probe.
So with that, so I think it's, it's 3 45 central time.
I wanted to leave enough time for for questions
and to go over, you know, if people had questions
and Laura, I don't know if anybody had any questions.
- Yeah, just a reminder, feel free
to put some questions in the q and a box.
And we do have one question, Dr.
Teams, you mentioned the good, better
and best how tap is good.
QL one is better, QL two is best.
Well what about the QL three block?
- Yeah, so QL three block, I mean it,
it's a, it's a great block.
The, the shortcomings I find are
that it is a little bit more challenging.
You have to have a Kirby linear probe, not everybody does.
And so, so a lot of people feel like the,
the QL three, it's not, it's not
as beneficial from the, the hassle of it if you will
because I have to have my patient lateral, you know,
and a lot of who, who wants
to turn a patient lateral and, and do that.
I can get to the paravertebral space just as easily
by doing a good QL two block as I could with a QL three.
Now the benefit of QL three is you may have a more dense
block, so it may have a little bit more
better analgesia I think.
But, but you also may, that also may come
and translate with some quad weakness,
which is a little bit, I don't wanna say a lot,
but a tiny bit more prevalent in a QL three block
versus a QL two block.
So, so those are some of the reasons why it's a lot easier.
I can, you know, I like doing a QL two block
'cause I like my patient supine, they're asleep,
I put 'em under anesthesia, excuse me,
and I can just pop in there.
I don't have to move them. It's a lot easier
and I get good pain relief with it.
- Right, that makes sense.
Are there any vessels that may be on the way
that you would wanna avoid when doing QL blocks?
- So not really. Every once in a while.
In fact, actually we didn't point it out in, in in Kim,
but in the, in the area I noticed
where you do the, on her, if I were
to do a classic tap block,
there's some what's called infra epigastric vessels.
There's usually small 99%
of the patients you don't notice them,
but around the quadras lymph borum, no, there's,
I've never noticed any vessels that are there.
Usually the infra epigastric vessels run in
that tissue plane in between the, the internal
and internal oblique
and the transverse transverses aus muscle.
And that's usually a lot more medial.
And I actually did see him in, in Kim interestingly enough.
But you know, that's why you always want
to use your same technique regardless what block you do,
which is you always want to aspirate before you inject.
And if you get blood back,
then you know, don't inject there.
That's, that's it.
But typically there's not some giant, you know,
aorta sticking out that you can hit.
Right. Which is great.
So again, that's a another safety aspect of the block.
- So another question,
how long do you see your patients getting
post-op pain control?
- That is a great question. So it, it depends.
So it depends on your local anesthetic really.
So historically we used to use 0.2%
of ropivacaine
and if I did ropivacaine that may last, you know, 12
to 18 hours, you know,
they'll get some analgesia outta that.
We switched to liposomal bupivacaine for all
of our fascial plane blocks, including the QL blocks
and we actually kind of did a little study about that
and followed our patients for two days
and kind of comparing the two
and we don't notice a remarkable difference in, in duration.
So for liposomal bupivacaine we see an average of about
two to two and a half days of some semblance of analgesia.
So some patients have had up to three days,
some have had a little bit more,
but most of our open belly cases actually the biggest
telling one was doing that
and our length of stay for open belly cases, our length
of stay for open belly cases at my hospital since making
that switch to QL blocks
and using liposomal bupivacaine went from 5.5 days
to 3.2 days.
And that was the only change we did.
We had already done multimodal analgesia on them
before that, that was the only change we did.
So, so there's actually something to using, you know,
the type of local anesthetic.
So it just depends on where you're at.
Now if you put it in the wrong tissue plane, you know,
that's where I see these blocks only lasting for four hours.
So if you put your, your local anesthetic in the wrong
tissue plane doing a tap, you know, it may work
for four hours because it's, you know, it's not,
it's not right on the nerves that you're, you're looking to
to, to to block.
- Right, right. Okay.
Can you talk about the lift lumbar interfacial triangle
as a potential target area for analgesia?
- So wait, sorry, sorry, say that one more time.
- Can you talk about the lift lumbar interfacial triangle
as a potential target area for analgesia?
- Yeah, so, so lift,
so I can talk about it,
but the, the, the thing about doing that,
I mean it's, it's similar to a, a QL one block, right?
'cause you're basically going under the same fascia
and it's the lumbar fascial plane, which is the,
the thoracolumbar fascial plane,
which is the same one we're talking about here.
But it's typically, it's just basically a QL one block.
Again, I like to go a little bit more posterior medial to
that and try to get on top of QL muscle to get that
because that spread is gonna get closer
to the paravertebral space than a lift block
or a QL one block is gonna get, get you.
The other thing about the triangle is,
is it's really hard
to appreciate all the time on your patients, right?
I can reliably, it doesn't matter how big
or small you are, I can reliably teach someone
and show someone to look for the tip of the tap.
And that is a very reliable sodo anatomy marker to identify
where my QL one spot is a hundred percent of the time.
In fact, I can't even think of the last time I,
I haven't been able to find the tip of the tap on a patient.
It's a lot easier to do than defining a, a triangle,
which is, which is hard to appreciate on various patients,
depending on their body habit, right?
But it's in essence it's, it's like a QL one block.
I don't know if that answered your question.
If you, if you wanted to clarify more on that, I'm,
I'm happy to go over that more with you.
- I will follow up with that attendee in just a moment.
And while I do that, one more question so far,
do you have any experience with continuous catheters
in QL blocks?
- So I did kind of experiment with them.
They, I have done them. Yes.
They they do, they do work. I mean you can continue them on.
So where I've done this is been
with patients who've had actually a open belly, right?
So we've done, you know,
you know I work at a level one trauma center.
So you know, we have our number of patients
who have open bellies
and so sometimes, you know, they're gonna have an open belly
for four or five, six days, right?
Hopefully not. But sometimes that's the case.
Well if I use liposome will bepi, that may only last for two
or three days and I don't necessarily wanna go back in
and block 'em every time.
I certainly can. So you can put catheters in here
and you just basically put the catheter down right
where the QL two space is.
And the cool thing is, is it will just ride over the top
of the quadras lumbo muscle
and it's going towards the paravertebral space
and you just leave it there and it's, and they
and they just sit there and they're, and they're,
and they work, they work fine.
I just noticed a lot of people don't like doing 'em.
'cause a lot of people don't want to, the hassle
of doing them for a for a QL block,
but they do work really well.
- Okay, great. And I followed up with
that attendee about the lift
and she said that was a perfect explanation
and they were having an argument about it
and you just won her $5.
So,
- Hey, alright.
Okay. I want a drink. I like Dr. Pepper. Okay.
- Okay. - You can get me, you know what?
You, you can take your your $3
and get yourself a drink and you can buy me a Dr.
Pepper at a restaurant. Yeah.
So, so yeah, I just, so I, I hear that.
So here, the thing about regional anesthesia is it's
amazing, it's awesome,
and people always wanna find this new
little thing, right?
That can be a little janky. Right.
So Lyft, I think is, is one of those things, unfortunately.
And so I, I like to keep things simple and, and,
and, and reliable simplicity and reliability
and regional anesthesia are key.
And so that's why I teach QL the way I do is
because it's, I think it's simpler and,
and it's very reliable.
And, and being able to identify and knowing where you're at
and not getting lost, so, right.
So, yeah. Well, congratulations.
You know, I'm glad I could make somebody some money.
- Right. And I, I'm, that's all for questions.
I'm gonna share this one last picture here
and just for everyone on the call,
we will be posting some future webinars.
Dr. Teams has agreed
to do another webinar in probably February.
So check out this website here.
- Oh yeah, that, that one actually was gonna be kind of cool
because we want to talk about blocks for cardiac surgery.
And so, one, I kinda elucidated to this just a little bit,
but one of the types of blocks we do
for cardiac surgery is modified pex blocks.
So I think I'll be talking about a modified PEX block
approach and also erector spiny blocks for cardiac surgery.
- Perfect. It's gonna be very good. I'm excited.
So yeah, I'll go to this website
to check out our future webinar schedule.
That one will be posted very soon.
And we thank everyone for joining us today.
Thank you so much, Dr. Dr.
Teams, for your presentation
and walking us through that demo.
And thank you to Audra and Kim for, for learning
and moving along with that demo.
That was, that was really exciting.
Thank you all so much for joining us.
- Thank you. This was awesome. I really appreciate it.
Learn the technique and indications for performing a lateral Quadratus Lumborum 1 and 2 block.
What You'll Learn
- Identify the proper muscles and tissue planes required to successfully perform a Quadratus Lumborum 1 and 2 block
- Discuss proper needle placement technique including tips and tricks to help increase ease and success of performing Quadratus Lumborum blocks
- Review the dermatomes and areas covered by the block
- Discuss the types of procedures the Quadratus Lumborum block could most benefit
Dr. Richard Teames is a dedicated anesthesiologist with a unique background in nursing who excels in working with trauma and critical care patients. He trained at the busiest trauma center in the U.S. and has exceptional regional skills and ultrasound technique in multiple nerve block modalities.
He is currently the Director of Regional Anesthesia at John Peter Smith hospital as well as the National Clinical Director of Regional Anesthesia for Envision Physician Services. Dr. Teames is an Officer in the United States Army Reserve Medical Corp. His clinical interests include acute pain management, regional anesthesia, advance airway techniques, and cardiovascular anesthesia. He has a genuine interest and enthusiasm for teaching clinical and acute pain/regional anesthesia and is a bilingual (English/Spanish) patient advocate.
This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.