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Topics: Anesthesiology, Cardiology, OR (Shared System), Pain Mgmt, and Surgery
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https://www.youtube.com/watch?v=62WxSa3kJ0c
Transcript

- Our webinar today is called Ultrasound Guided Regional

Anesthesia for Cardiac Surgery,

and 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 the 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 a genuine interest

and 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, Dr.

Teams is coming to us from Conne from Texas today

where they are thawing out from the tundra

that hit that state recently.

I'm sure you've all heard of that. So really appreciate Dr.

Teams taking the effort to, to be with us today.

And with that, I'll turn it over to you.

- Awesome. Well, thank you so much for that.

I'm, I'm happy to be here.

And yes, we thought out down here in Texas and,

and we were able to, to do this,

so we're really excited about it.

So we're gonna go over some really cool things today,

particularly blocks for cardiac anesthesia.

Now, I, I do cardiac anesthesia

and so I'm gonna talk to you a little bit about the,

the things that I do in my own clinical practice and,

and what's worked for me.

We've done a little bit of experimenting when it comes

to some of these blocks

and I'll kinda explain to you what, what's worked

and what we currently do in clinical practice.

And so without further ado,

let's go into a couple things here.

So I'm gonna jump to my slides.

So for cardiac anesthesia,

there's really a few options we have

for pain management, right?

So we could do PO IV pain medications.

That's kind of been the mainstay for a long time.

Th thoracic epidurals really is not an option

for cur cardiac anesthesia.

And we should all pretty much know why we don't wanna

massively heparinized our patients

and then give them a thoracic epidural

and a, you know, an epidural hematoma that's usually not,

that's usually frowned upon in more recent literature.

There's ESP blocks

and I run into a lot of colleagues throughout the country

who do a lot of ESP blocks with great success for

cardiac anesthesia.

And that's actually gonna be one of the blocks we're

gonna scan today.

And we're gonna talk about quite a bit in length.

And that's gonna be the first block we're gonna talk

about today.

The second one is doing what I call the modified PEX block.

And for those of you who are familiar with doing X blocks

for, say, breast surgeries or mastectomies or implants

or that sort of thing, it's a, it's a takeoff of that.

And I'll explain some of the nuances

for doing this modified PEX block

and why it's, it's worked for us.

It's one of the blocks that we currently do.

So going to thoracic epidurals,

has anybody ever felt like this where, you know,

has anybody really wanted to do a thoracic epidural anymore?

I mean, you know, a lot of people like doing 'em.

I used to do 'em a lot when I was ear early on in my career

until we started using some of these other nerve blocks.

But you know, sometimes it's trying to find that roadmap

for doing a thoracic epidural.

And every once in a while I felt like I was gonna do this.

You know, that's generally frowned upon.

You don't want to do the through

and through technique when you're doing a thoracic epidural,

but sometimes I've felt like that, you know,

but luckily there's a lot of better,

I don't wanna say better, but there's a lot

of really great analgesic modalities

for nerve blocks out there, particularly these ones ESP.

So we're gonna talk about ESP first.

So here's kind of the anatomy for it.

So obviously the rector spine muscles are just, you know,

go are on the side of the, of the thoracic

and lumbar spine there.

And there's a couple muscles that overly them.

So one of them

that's viewed there in the middle is gonna be the rhomboid.

And then on top of that you have the, the trapezius muscle.

A lot of people kind of want to focus in on those muscles,

but really the crux

of this block is identifying properly the

transverse process.

The erector spinal muscles just live right on top of it.

Now depending on where you are, where, whether you're

below the the scapula, you may

or may not see the rhomboid muscle,

but it doesn't really matter, right?

It is just kind of a landmark to know where you're at.

I like using the tip of the scapula to kind of know

where I'm at for, for this block,

because it's very dependent on which dermatomes that you're,

that you're in now.

This kinda shows a little bit of what the spread of

that local anesthetic and how it really works, where

that local anesthetic kind of spreads around and is, and

and goes kind of in the paravertebral space

and gets those spinal nerve roots as they come out

and traverse the, you know, around the ribs.

So one, one aspect of the rector spine

that comes up quite a bit is what about the spread of it?

And there was actually a really great study

that was done here by, oh, I can't pronounce his last name,

a Aki I think is how you say it.

But in all these, they used, they used 20 mls

and they did two different types.

One was a retro laminar block, which is pretty,

is very similar to rector spining block.

And then there's rector spining block

and this shows them putting it at T five.

And that's what I would recommend doing

for any thoracic case

because if you see it on the blue lines there,

the very first one, the big box there on the left,

you'll see what the spread is.

And it pretty much covers all the dermatomes

that we're concerned about

with when we're talking about cardiac anesthesia.

So the main dermatomes

for cardiac anesthesia are gonna be obviously your

sternotomy, which is gonna be from T two all the way down

to T six and maybe chest tubes that are subxiphoid,

which might be T seven, T eight, maybe T nine.

But generally T seven

and T eight are, are, are really where it's gonna be.

And then on the, these other ones to the side is

where the spread, the spread of this local anesthetic is.

And they used a cadet, these were cadaveric studies

where they could look and see that

some spread into the epidural space,

some spread into the neuro foramen,

and then obviously spreading more laterally into

the intercostal space.

Whereas with this retro laminar block it, it,

it pretty much is fixated there.

It doesn't, the retro laminar block stays was

inside a fascia plan that doesn't like to spread laterally.

And then there's actually some pretty cool studies.

These are just kind of highlighting three of them

that talk specifically about CAR ESP

for cardiac cases.

And all these studies which have done more

pretty recently have all demonstrated that yes,

erector spining block is actually pretty good.

In fact, I believe that first one is, let's see,

make sure that's the one.

Yeah. So that first one is actually comparing erector

spining block to thoracic epidural,

which we know thoracic epidural is the gold standard.

And it, it says, ESP is a promising alternative

to a thoracic epidural in optimal perioperative pain

management and cardiac surgery.

And in that study it goes in

and says that there really wasn't a lot

of difference from a pain management opioid utilization

between the two modalities.

Clearly the, the benefits of not having

to worry about the coagulation, the epidural hematomas

and that sort of thing for ESP are gonna be a lot better

than for your thoracic epidurals

and the complications that can go along with that.

So let's get into a little bit about

how we actually scan this block.

I'm gonna show you two different techniques,

but the one that's widely used is this one

where you start on that right at the spinous process.

So that's gonna be that blue box in the bottom left hand

corner and, and then you just slowly scan laterally.

Now as you slowly scan laterally,

what you'll see is first the lamina.

And I don't see, let's see if we can see my, my arrow here.

I don't know if you can see my arrow on this.

No, you can't see my arrow. That's okay.

Actually, you know what you will here in just a second.

Let me, I'm gonna do a little laser pointer.

Okay, so here's the spinous process here

and then this is gonna be the lamina.

And the lamina almost looks like a saw tooth pattern.

And I'll show you that when I, when I scan today.

But it's, it's usually pretty deep

'cause the lamina kind of comes deeper

and then the transverse processes are a little bit more

superficial, which is gonna be this red line here.

And then as you go more lateral to that,

you're gonna be on, on the ribs.

Now there's some characteristic little features

that are on ultrasound for these differences.

One is the transverse processes typically look a little bit

more boxy and you can kind of appreciate

that a little bit here where they're pretty flat.

So transverse processes are generally pretty flat,

whereas the ribs are round,

they generally have a more roundish appearance to them.

The other aspect is,

is when you're scanning transverse process,

there will be the absence of the lungs.

Obviously we don't wanna see the lungs here.

You can see the pleura down here.

Sometimes you can see a little bit of pleura,

but generally I don't see it a whole lot.

You see it very more prominently when you're scanning

and you're over the ribs.

Also, I'll show you, there's a way you can see

that transition point between transfer process and ribs.

As you slowly scan laterally, there's a shifting

that goes on between transverse process and ribs.

The second way I'll show you how to scan is,

is not doing your probe longitudinally this way,

but you actually go the other way.

You go sagittal, okay?

And that way you can actually see both the transfers process

and the spinous process and the rib all in one view.

And I'll show you what that looks like.

Characteristically on the ultrasound when we, when we go

to scanning, there's several different

positions that we can use.

This is the typical standard position we use that, you know,

just for the patient sitting, doing it with them awake.

Obviously if you're doing it before surgery, this is ideal.

You want, you can do it right

before, you know, in the OR if you want to, right

before you, you lay 'em down to induce 'em for anesthesia

and you can go in there

and inject your 20 ccs of low anesthesia.

Some people like to put catheters in there,

other people like to put long acting local anesthetics such

as liposomal vacating in there, all which you can do

and we've done in the past.

The other way you can do it is you can have 'em laying down.

As you can see in this image on the right,

they're in this view, they're kind

of going over the patient.

I kinda like to, if they're lateral, I, I kinda like

to stand on the side that,

that they are rather than reaching over it.

Or some people like

to do this when they're completely prone.

So that's also a way of doing that.

So here is ultrasound image of that.

So you can see the needle goes down

and you can see this nice boxy shape

of the transverse process and the needle will go down there

and tap the transverse process.

And the key is, is you want the local anesthetic to go

underneath the muscle, not into the muscle.

And sometimes that fascia layer that's covering the top

of the transverse process can be a little

challenging to pop through.

Even when you feel you're on bone,

sometimes you're actually pushing the fascia onto the

bone and you're not through the fascia.

So sometimes I'll show you a video here in a minute of

what I mean, but sometimes I have

to go a little bit over the rib or maybe,

or treasure process rather,

or maybe come at it at this angle.

So I pierce through that fascia before I go in there.

Now let me, let me show you a video of that.

Now, in this video you'll actually see them

with their first injection.

They'll actually inject

intramuscularly and I'll show you what that looks like.

So here, this is actually rhomboid right here.

Trapezius is above there.

And this is this spinous erector spiny muscles

here, transverse process.

So see that local anesthetic there,

that was actually intramuscularly.

So they, they're kind of go taking an approach

where they're going above the, there you go.

That's, that's really good there.

They're going above the transverse process.

And then see how it just kinda lifts off.

There's kind of that black line right

there of local anesthetic.

And then when they stop injecting, it will compress down.

And if you see that happening when you're doing your,

your block, you know you're in the right spot.

If you're intramuscularly, it doesn't collapse,

it will just stay there.

And so that's kind of a telltale sign

to know if you're in the right spot is if you see it kind

of expanding.

And then when you stop injecting it, it contracts again.

Okay, that's, that's one way that we can tell about that.

So what we're gonna do is, I'm actually gonna go what we're,

I'll go over PEX block real quick

and then we'll, we'll go to scanning.

So, so the modified PEX block, I'm,

I'm just gonna show you slides of how to get to a regular

classic PEX block and then I'll kind

of explain some of the differences here.

This is a lot of verbiage kind of explaining how I do it,

but I talk a lot about home base.

When I, when I talk about my blocks, like

last month we talked about the quadras and born block

and that home base was doing a tap block well, so

that you don't get lost

and you can count the ribs appropriately.

I always call home base for PEX block,

looking at the intra clavicular block,

finding the arteries just underneath the clavicle

'cause it's really easy to find the second rib from that,

from that location.

And then it just becomes a counting game.

Then you can just count the second

rib, third rib, fourth rib.

If you need to go down to the fourth rib.

And I'll show you some techniques.

You can kind of angle your probe a little medially,

like you're kind of angling it towards the, the,

the sternum a little bit

that usually can help make the ribs look a little,

a little nicer.

Now for cardiac, what I do is

when you're in the midclavicular line, you'll actually see,

let me go to this next image.

When you're at Midclavicular line, you'll see the pec minor

underneath the pec major here.

Okay? Now this is my Spanish version of this.

You have pectoral meor and pectoral meor.

So this is and serrato, that's all Spanish,

but you know, just know those, those are these,

these are the right muscles here, okay?

So underneath the pec major muscle is the pec minor muscle

when you're in midclavicular line.

Now what I use for cardiac is I just go

medial to

where I don't see the pec minor muscle anymore.

And that's kind of where I start or do my injection.

So I've done this several different ways.

I've done this where I've done a classic PEX block,

I've done this where I've done a para sternal block

and then we've found that doing it this way has,

has done several things for us.

So what are the pitfalls of doing the other ones?

So let's talk about regular PEX block for cardiac.

So for cardiac, obviously we're doing a sternotomy,

which is coming all the way down from here all

the way down to the xiphoid.

Okay? The manubrium all the way down to the xiphoid.

Well, I found that if I'm a little lateral, some

of the times I don't get all the spread that I need to

around the, the sternum.

And so, and, and I've missed it.

So we, we did probably 10 cases.

We were just doing classic PEX blocks

and probably about 30 to 40% of them, they,

they had some pretty good sternal chest pain despite doing a

really good pex one of pex two block.

Well then we moved to doing this per sternal technique

where we injected just per sternly,

just right at the lit ribs and,

and just, just lateral sternum.

Well, we didn't get very far

because most of our blocks will do when,

when we're right after induction.

And there was a couple instances, we,

we had two instances in a row actually where the surgeon,

after making the sternotomy,

he actually saw the local anesthetic in the field.

And so it wasn't very effective at that point

because he sucked it all out when he did his sternotomy.

So I said, well, what's a really good way that we can,

you know, not have that problem.

And, and a good sono anatomy

landmark is the border

of the PEC minor and going right there.

So you're a little bit more medial than a classic PEX block,

but your lateral than a, than a per sternal block.

And then in addition, what I do is I'll inject

both at the third rib, which is here

and the fourth rib, which is here to get pretty good spread.

And that has kind of been the winning number

for getting good reliable

sternal analgesia.

And, and we've done a lot of experimenting with this.

We've done it where we've just gone to the third rib,

we've injected 20 ccs there, we've done 30 ccs, we've,

we've done it all at fourth rib.

But I've found that reliably getting the whole

sternotomy doing the third

and the fourth rib has been very effective.

And most of these patients do extremely well.

So well in fact that the largest decrease in opioid

utilization has been the cardiac patients at our hospital.

So they now average one tramadol a

day and that's the average.

So that means a lot of these patients don't take any

narcotics, they don't take anything

because they simply don't need it.

So that's been kind of the biggest win

for our hospital has been this, this block specifically.

In addition, I'm not gonna go into this right now,

but what we found is just doing this wasn't enough

because a lot of these patients were having a lot

of pain subxiphoid from the chest tube.

So right here, subxiphoid

or subcostal,

these patients were having pain from the chest tubes

that were sticking out underneath them.

So we would combine this with a subcostal block,

just doing a small amount of local anesthetic there

would help help out tremendously for that.

So the volumes I use are 10 ccs on, on each of these ribs.

So 10 ccs, a local anesthetic on the third rib,

10 ccs on the fourth rib

and then I'll do 10 ccs on each side for a, for a subcostal

or yeah subcostal tap block.

That's how I would do it. Now the classic tap block looks

similar to this where you, you a P two block is right on top

of the rib or depending on if you're lateral enough,

you can actually see the serus anterior muscle,

which you can actually appreciate here.

You have to be pretty lateral

to appreciate the radus anterior muscle

where they're putting it in between there.

If you're at the midclavicular line

or slightly lateral to that,

generally you will not appreciate the radus anterior muscle.

And if that's the case, what you would do is you just go

down and tap the rib

and put your local anesthetic there instead of on top

of a muscle such as the radus anterior

muscle 'cause it's not gonna be there.

And then, and then you slowly back out

and then put local anesthetic between the PEC MA minor

and peck major, which is APEC one block, which is this one,

which is putting local anesthetic right there.

So this is kinda what it looks like when you're

doing home base.

This is an infraclavicular block.

So you look, you're about mid clavicular line here,

you can see the arteries, you can see the pic, minor pic,

major muscles right there.

Now if you do a little medial tilt with this probe,

basically you're tilting it towards kind of the sternum.

All of a sudden you'll see the second rib kind of pop up.

And then from there you can scan down.

So from here you can scan down.

This is clearly a little bit more lateral

because I can see a little bit

of serus anterior muscle here.

And then here is the PEC minor muscle

and here's the pec major muscle on top of that.

Here's another image of that

where you can see this is just a very, very small amount

of satu anterior muscle here.

Okay, okay, here's our rib right there.

And then you can see PIC minor and pic major.

Now remember when we're doing this for cardiac, I'll get

to this view initially,

but then I'll just, my probe medially

until this muscle disappears and kind of goes away.

Okay? So I'm gonna leave you with this thought just

to keep calm and do a regional anesthetic

because it is the wave of the future.

So with that, what I'm gonna do is I'm gonna move over

to draw our live model here

and we're gonna do some scanning.

So I'm gonna scan for erector spiny first,

I'm gonna kinda show you how, how I do that,

these different views and, and angles that we do for that.

And then, and then I'll, we'll scan the peck mark as well.

Okay, so for cardiac it's pretty simple

because here I can just use the base of the scapula

as my landmark.

And really all I wanna do is inject either T four or T five.

So I can just use the base of the scapula

and just go just slightly above that.

Okay? So let's see here, I'm gonna go.

So just so you know which superior and inferior.

So the, the left

of the screen is gonna be cephalad and,

and the right of the screen is gonna be caught at, okay,

so I'm just gonna kind of go right here in the

middle of the screen.

And then this is, that's actually my

spinous process right there.

Sometimes it's pretty hard to see

because it's a very narrow structure looking this way.

And as I go lateral, this down here at the bottom,

I'm gonna move this arrow here,

this down here at the bottom, this is the lamina

of the, of the spine.

And you see it's almost one continuous white line.

It almost looks kinda like a sawtooth pattern.

As I go a little bit more, it looks even a little bit more

sawtooth, the kinda looks like the sawtooth pattern.

Now as I go more lateral, see these structures kind

of starting to jet up.

That is the transverse process

and it's pretty flat on the top here,

although it kinda looks a little round.

But when I go even more lateral

look, see how they disappear.

And then this other structure appears here.

So this is actually rib, I'm a little bit more lateral here.

Now I'm gonna go back medial and notice what happens.

I'm gonna go medial medial, medial, medial

and then see that shift and then boom,

this comes back up here again.

I can see a little bit of pleura down here.

I told you earlier, you can't see it,

but usually, you know, if you have a thicker patient,

usually it's, it's really deep like this.

But when I go more lateral to the rib, look

how much more superficial the pleura is here.

So this is, this is rib here

and it's looks a lot more round,

it's a little bit more rounded of a structure.

I'm gonna go medial again

and boom, that is the transverse process.

It's a little bit more flat on top.

Now it's really important

that you hit the transverse process.

Now I have inadvertently on many occasions,

well I don't wanna say many occasions on, on,

on certain occasions I've accidentally hit the rib.

Now what happens if you do that?

What happens if you hit the rib

and you miss the transverse process?

Well, there's a little ligament here

and I'm actually gonna show you that

by doing the other technique to help find this.

So sometimes people have a, a hard time appreciating this

or appreciating which one is which.

So one of the things you can do is you can do a

sagittal approach.

And I'll show you this here in a second. So here's sagittal.

And so if you look at my probe,

I just rotated at 90 degrees.

Now this right here, this structure right here,

that is my spinous process.

This is my lamina.

I'm just gonna kind of scan up and down a little bit.

Now this, this is perfect right here.

So this is the lamina right here.

And then this little bulb that's coming up here,

that's my transverse process.

Now see there's a little nick right

here, almost looks like a little nick.

And then this goes up, this is the rib.

I'm gonna go scan a little bit lateral here.

So here on the left side

of the screen you can appreciate this is transverse

or spinous process kind of comes down here into the lamina,

comes up to the transverse process.

And then there's this little nick here

as the rib comes up out from

underneath the transverse process.

Now what I was

explaining earlier is if you hit the rib

and not get on the transverse process,

the local anesthetic is trapped there.

It will only spread laterally around the rib. Okay?

Versus if I'm on the transverse process,

the local anesthetic will come medially

and down into the paravertebral space.

So what that means is your block just won't be as effective.

Alright? Part of the efficacy of this block is the fact

that you are very close to the paravertebral space.

If you get too lateral, this local anesthetic will hang out

and just get the terminal branches of the, of the,

the, of the, of the causal nerves.

And it won't get around the paravertebral space.

'cause it's pretty much will stop right here at this nick

where this ligament is.

Okay? So with this view, if you get lost,

it's really easy to identify.

Now I can say, okay, this here is my transverse process.

So if you have a ultrasound machine that has a center line,

I can, I can put a little center line there

and then I can just use my probe.

I can just rotate it again, one 90 degrees,

just keeping that in the center.

And now I know that that is my transverse process.

And then I can still go with my needle cef lad to coda.

And actually I have a chopstick I can kind of show you.

So this is kind of the way I would go

with my needle is I'd just go cef lad

to coda with my needle.

Now if I go a little bit more lateral again, you see

that transition point as you see the,

the rib pop up into view.

Oops, let me go back here. Okay, good.

So just last time I'm gonna kind of show you this.

I'm gonna scan this one more time.

So this is, this is doing a longitudinal view.

So I'm starting right at the midline.

So this is gonna be my spinous process.

As I scan lateral,

you can start seeing this nice white continuous structure,

which is the lamina.

And then more superficially, you'll start seeing rise up.

You'll see these, the transverse process. Okay?

Now as you see the transverse process, if you go too lateral

and you go too fast, then all of a sudden you'll be in rib.

Okay? And you'll see a lot of pleura right here. Okay?

And look how much more rounded this looks.

If I go back medial, you see

that transition point a lot more flat.

Very difficult to see pleura weigh down here.

I can still see it because I'm, I'm scanning that deep.

But, but a little bit more difficult.

It's kind of one of the telltales

for it being in the transverse processes.

Again, it's harder to see the pleura than

when you're at the rib.

And again, a little bit more boxy. Okay?

So again, I'm just gonna go phyla to codad with my needle,

and I'm gonna go down and tap the top

of the transverse process right here.

And the key is I want to be underneath the fascia.

And when I do my local anesthetic infiltration,

I'm just gonna see the local anesthetic, the hypo ity

of the local anesthetic raise up the muscle.

And usually again, when I stop my injection,

then it will kind of collapse again.

Okay? Now again, I see a lot

of people doing this technique throughout the country

with great success.

And it's been, and it's a great block.

It does, it does a good job for, for treating pain,

parasternal pain,

and even the subxiphoid pain from chest tubes.

The, the only pitfall I have found

with it is just in my clinical practice is

workflow issues.

So workflow has been, you know, I have

to have the patient awake, I have

to have 'em sitting up like this,

and then I do the, do the injection and then I lay 'em down

and then I induce 'em.

And, and that can be, that's a workflow issue for, for,

for us now we have a anesthetic team, an acute pain service

that will do the blocks for us.

And so we can parallel process a lot when we're doing our

blocks where while the cardiac team is inducing the

patient, the acute pain service team can be doing PEX blocks

or these modified pex blocks.

So that's why we, we like to do these modified pex blocks

more than these ESP blocks.

It's not because they are, they are

better, it's just the workflow has been better.

And there was a question, so let's see what it is.

What, what was the question? What local do you use?

Okay, so concentration we use, we use liposomal bupivocaine

because we found that it's lasted longer for us.

And so I mix a concentration of 20 ccs

of liposomal bupivocaine,

and I mix that with 40 ccs of quarter percent bupivocaine.

So that makes a total of 60.

And then it's three, three and three.

So third rib, fourth rib subcostal.

So it's pretty much 30 ccs on each side.

And that's been the concentration we've used

and it's worked really well for us

because of the, the

how, how long it lasts.

Okay, so I just saw that question.

So again, if you have questions on these, you can type,

type them in and, and I'll, I'll get to 'em

and I'll ask them or answer 'em.

Okay? And we're actually gonna have a good amount of time

to go over questions at the end.

I'm gonna save 15 minutes at the end

to go over any questions you guys have.

Alright? So with that,

what we're gonna do is we're gonna move to PEX blocks here,

and I'll kinda show you

that I'm gonna change my settings here just a little bit.

Great. Okay. So I'll show you kinda what I do for home base.

And let's see here.

So, all right, so the left

of your screen is gonna be cephalad

and the right of your screen is gonna be caught at,

so if I am at the midclavicular line,

okay, right under the clavicle, boom right there,

you can see.

Let's see here. Okay, you can see my vessels here.

Here's my, here's my vessels right here. Okay.

And then this is gonna be your pec major right here.

And this is your PEC minor.

Now she's, she's really skinny

and so I don't really have to do a lot of adjustment,

but this is actually my second rib right here.

Usually if you do a slight medial tilt,

now if you look at my camera, if I do a slight medial tilt,

a lot of times you can actually appreciate it a

little bit more superficially.

So there, there's the medial tilt.

There's without it, see, without it, it, it kind

of hides way down here.

A lot of times people can appreciate it,

but if you do a medial tilt like that,

you'll really appreciate that second rib.

Okay? And then it's just a counting game.

So there's second rib and then you go down to third rib.

Okay? Oops, you can go down to third rib right there.

Now this is, this is really great.

So if you're, you're doing like a mastectomy or, or,

or implant or whatever, this is where you could go,

you go down to third rib, tap the top, tap the top

of the third rib, which is gonna be your PEX two block.

And then back up slightly here to see, to get in

between the peck major muscle here

and the peck minor muscle here.

So this is where I would go

for a PEX one block for PEX two block.

I wanna go here. Now notice I don't really appreciate

any serus and tear muscle.

Maybe this right here, very small amount

of fascia is most likely the connective

tissue of the S stratus interior.

And if I go a little bit more lateral, yeah,

now I can really appreciate it.

So this actually right here is actually serratus very thin,

very small amount of Serra tissue.

But that's again, more lateral.

Now notice what else happens when you go more lateral,

the more lateral you go,

the thicker your pec minor muscle is.

Okay? Now when the more medial you go, look how thin it is.

Now I've only gone probably traversed about a

centimeter and a half.

It is not a huge amount of distance. Okay?

So for the sake of argument, this is gonna be,

I go medial here knows what I don't see now,

now I don't see the PEC minor at all.

All I see here is my pec major on top of the rib.

So this is gonna be my fourth rib right here.

And this is my third rib right here.

So when I do this block, this modified pec block

for cardiac, what I, what I'm gonna do now, let me,

I'm gonna try something here.

Freeze, okay? I'm gonna freeze this here

and I'm gonna see if I can still use my arrow.

Oh I can. Great. Oh this is, this is awesome.

Alright, so, so I'm gonna kind of explain this a little bit.

This is the ideal view you wanna have when you're doing

a modified PEX block.

I wanna try to see both the fourth rib

and the third rib in the same

plane in the same view here.

And when I come in

and do it, I try to put my needle a little bit more cephalad

about by about two centimeters than where the probe is.

Okay? And then I'll come down

and I'll usually come to the fourth rib first.

Try doing the fourth rib first

because you,

your needle trajectory will be a lot more, a lot straighter.

Okay, so imagine I'm here right in front of the camera.

Oh, there we go. So if I go down to the third rib,

I'm gonna take a sharper angle to go down to it

because it's gonna be a lot more proximal.

Okay? My fourth rib is gonna be over here.

So I can take a, a slightly more less

of an acute angle.

And it's usually harder to do when you get

to the fourth rib at, to do that angle that's really flat.

So if you back up from your probe about two centimeters

and you go in, you'll find it,

it's gonna be a lot easier to do.

So what I do is I'll go down, tap the fourth rib,

do my local infiltration there, and then I'll back up

and then I'll go dive down and hit the top of the third rib.

So just in the, like in this view here.

So let's go back to this view here.

So in this view here, I'll come down here,

I usually tap the top of the fourth rib.

And one of the key things you wanna find

or see when you're doing your injection is you wanna see the

local anesthetic going over the top of the rib and trying

and going and going caught at, okay,

same thing when you're doing the third rib,

you wanna see the local kind of going a coad.

Now when you do the injection, it looks very similar

to the injection we did on the ESP block

where the, the muscle will just kinda raise up from

the, from the rib

and as soon as you stop injecting, boom,

it will collapse down again.

That's very typical for doing this modified pex block.

So that's again, another key feature you can look for

to show that you're not intramuscular.

Because if you're intramuscular

then it's just gonna stay there.

It's gonna hang out there.

Now I always say to go down

and tap the rib, that's very important to do,

but just know that you just need to tap it.

I had a colleague once

who I was teaching 'em how to do this.

They were really excited about it.

They went down and they tapped the rib

and I started injecting, but I wasn't able to inject.

And I said, well, you're probably on the fascia back up a

little bit, back up a little bit.

Still couldn't inject. Still couldn't inject.

He backed up all the way out of the, out of the skin

and we looked and there was a little piece

of bone sticking out of the tip of the needle.

So he had caused a, he, he'd done a bone biopsy basically.

So, so just go down and tap the rib.

Especially these older individuals, they're, they, they,

they're a little bit more frail and cartilaginous.

I think we have another question. Yes.

- The question on the chat portal,

have you used continuous catheter tech for erector spine,

a block for cardiac surgery?

When would you use modified peck versus erector spine A

for cardiac surgery?

- Yeah, so, so the question

for this was have I used catheter techniques for,

for cardiac surgery doing erector spining

and when would I use that versus doing a modified peg walk?

So the answer to the question is, yes,

I have used catheter technique

for cardiac surgery and they work great.

You can get good longevity with them.

Obviously with a catheter they can stand in there for three,

four or five days if they need to.

But again, you're doing both sides.

You're doing two different catheters,

which you, which you can do.

But we don't typically do them at our hospital

because of, as I mentioned, workflow.

So some people are really comfortable doing erector spiny

blocks and if that's the case, great, just keep doing 'em

because they do work as we show that they, they they show

that they work and they're very efficacious.

I don't know

that there's a study out there comparing PEX block

to rector spiny block specifically for cardiac surgery

and which one is better

because the, I mean they're both, they're both great.

They both work really well.

Some one might work better

for you from a workflow standpoint.

You know, there's also doing the modified peck block

technique with a catheter, which we've actually done

before as well.

Now we have to do that at the end of the procedure before,

before we take them up to the ICU or, or, or

or emerge them from anesthesia.

But you know, you can also do that as well.

You can also do a catheter technique for that as well. Okay.

I'm trying to remember. There was one other thing I was

gonna say about PEX blocks.

So yeah, if you get lost with a PEX block, just go back

to home base, go back

and find the infraclavicular spot right in the midclavicular

line and then you can just do a little medial tilt

with the pro, you can see that, that rib pop right up.

Okay. That's always gonna be your second rib.

From there it's just a counting game.

Then you just go down to the third rib, fourth rib

and then you can just scan a little bit medially

until you see, or you, until you don't see the pi miner.

When the pi miner kind of dives away or goes away.

That's a really good landmark to know, okay,

I've gone medial enough to do it,

but not too medial to

where my local anesthetic is now gonna go into

the surgical field.

'cause if it goes into the surgical field

and the surgeon's like, wait, what is all this?

You know, suck it, you know, they suction it out

and then it's not very effective.

And then they're like, well don't do these blocks anymore.

You know, because I don't want, I don't want you

to mess up my surgical field.

You know, we all know the arguments that the surgeons make,

but, but yeah, so that, that's, that's the technique

that we currently do at our hospital.

But again, we have used erector spiny

techniques, which are great.

So for us it's not a, this one is better than this one.

It's just for us, the workflow is better for us

to do a modified PEX block technique.

But you can do catheter techniques

for ESP and they work well as well.

Also. Now I think we had some more questions.

Do we have any more questions? I don't have any.

No other questions? Okay.

Well if you guys have any other questions we can certainly

entertain them right now talking about,

we have four more minutes.

We have, we have a couple more minutes to go

to go over any questions you guys might have related

to these, these different types of blocks.

So wanna thank our live model? She was awesome.

Thank you very much. This was, this was really fun.

And then yeah, if you have questions, one

of the things you can do, you can always submit them to, to

SonoSite Fujifilm and they can send 'em to us.

Yeah. And I think we had a question. Go ahead.

- Are you concerned about heparin

for erector spin aid block at emergence?

- At emergence or at at emergence. Oh, okay.

That's actually a great question,

which we didn't talk about.

We kind of lightly talked about

for obviously thoracic epidurals.

So obviously there's reasons why we don't wanna do thoracic

epidurals in highly heparinized patients.

But interestingly enough for ESP blocks,

the 2018 ARA guidelines really helped highlight a

lot of the coagulopathy

concerns that we should have for different blocks.

And the biggest one is, can we put pressure on it?

And if we, and is it gonna cause

if a hematoma does develop, is

that gonna cause a major problem?

So if we look at ESP block in those regards,

now can we put pressure on it?

Yeah, sure. But usually you're,

the patient's already putting pressure on it if they do get

a hematoma anyway because they're laying

on their back, right?

The other one is, is if a hematoma does develop,

is it really gonna be a problem?

And for ESP block, it's probably not because,

because that hematoma is gonna develop

between the transverse process

and the erector spining muscles versus

in the epidural space,

which is very tight enclosed bony structure space

that can cause obviously a lot of problems.

That's why we don't like to do thoracic epidurals

for that very reason.

But for ESP, no.

And so we have done ESP blocks a lot

for heparinized patients.

Also patients on Plavix, Eliquis, all the people

who are on Coumadin, you can do ESP blocks for them

based on those new ASRA guidelines.

It's really helped highlight this as a, as a safety issue.

So, so no, I'm not concerned at all for doing them

for heparinized patients.

That was a excellent question. I'm glad you brought that up.

Was there another, was there another one?

- Yeah, DR teams, we have one more.

Yeah, it's actually a multi-question question. Oh, those are

- My, those are the best kind I hope, I hope there's,

I hope there's betting going on.

Just like the last video. Oh yeah, that's, there's,

there was a bet that was going on.

I want, let's okay, go ahead.

- Okay. Any tips for starting out doing ESP blocks,

rib block, both those questions

and then also, where exactly do you place the block

subxiphoid for the chest tube?

- Okay, so,

so the first question was just starting out doing ESPA

good, good way to do it.

Yeah. So yeah, so if you're just starting out doing ESP,

I mean the best way to get good at something is to do it.

And it is, it, it's, it's not a challenging block, right?

So what we're really focusing on

for ESP is we're looking at the bony structures.

And so starting at the spinous process,

which you may not see,

but as you move off the spinous process, you see

that nice white structure of the laminate

and they keep going lateral, just go real slow.

What I see a lot of people doing is they're like, okay,

there's this, and they, they literally move

their probe this fast.

You don't, you shouldn't do that.

If you're starting off, you

and I even do this, I don't, I don't go that fast.

I start here at the, at the midline,

right at the spinous process

and I'm literally going at a snells pace.

And then when I'm, when I think I'm there, I go back

and I scan and then I go more lateral

to verify, yeah, that's the rib.

And if I still have questions about it.

'cause sometimes if you get these bigger patients, I'm like,

gosh, I don't know, is that rib is that transverse process?

Then what I'll do is I'll do the sagittal approach

where I'll go this way

and I'll be like, okay, yeah, I see that nick

between the transverse process and the rib

and now I know that's transverse process.

So I'll take it, I'll move it right over

to the transverse process and then I'll rotate 90 degrees

and then I'm like, okay, I like it there.

And then the other key, the other thing

that's helped me out, especially

with educating other people is get a marking pen.

And when you get that level, mark it, mark the skin,

mark the outline of the probe

because how many times have we found the perfect image

that we wanna block and then we look away to grab our needle

or we grab something else

or you know, tell the surgeon to shut up, don't bother me,

I'm doing a block, whatever.

And then we come back and then we can't

and we can't find our, our block, it's gone.

Right? But if you mark it out, then you're like,

okay, bam, there it is again.

So that's been tremendously helpful for people learning how

to do these so that, so they get it

and they can be a little bit more facile with it.

Now the, the other question was, oh, for,

for subxiphoid, well I can show you real quick.

I can scan it real quick. We have time. We have time, right?

Yes, we have time. Yeah, we have all kinds of time.

It'd just be your belly. Yeah.

So for, so what we would do here, let me unfreeze this.

Okay, so what we would do here, oh this is perfect.

So I just go subxiphoid, okay.

And as I just move a tiny bit lateral, what I'm looking

for is I'm looking for the rectus muscle

and the transverse salus abdominus muscle.

Okay? So where those are is right here.

So this all up here is the rectus muscle

and this little wedge right here is the transverse salus

abdominus muscle.

Okay. So the cool thing about this block is I can, where my,

I need my, my pointing one.

So this is my needle expel almost. All right?

So I can either go, I can either go from medial to lateral

or yeah, or lateral to medial

or I can go medial to lateral, it doesn't matter.

So when I do this block, I usually stand on one side

of the patient and I do it here

and then I go over to the other side

and then I can do it here.

This is another great image here.

You can see the rectus muscle on top.

And then down below you can see the transverses

abdominus muscle here.

So where I'm going is right in between,

I'm just putting my local anesthetic right in

between the transverse abdo muscle and the rectus muscle.

Now notice how my, how my probe is oriented.

My probe is oriented where I'm abutting the costal margin

and the costal margin is at an angle.

Okay? It's not, it's not completely sagittal like this,

it's at an angle.

And another thing you can do is you can do what I sometimes,

depending on your patient's body habitus,

it may be a little bit more challenging

to see the transverse abdominus muscle.

So you can do what I call the costal peak.

And a costal peak is basically I rotate my, my probe

and I'm like trying to peak underneath the ribs

and look what happened there when I did that,

the transverse abdominus muscle, which is right here

where my arrow is, is a lot bigger.

If I'm straight up

and down, look how small it gets, it almost disappears.

So you kind of need to do a slight,

what I call costal peak in order to really visualize that.

So here I can really see, I can see

that transverse sali abdom muscle

and again, I can just go me a medial to lateral

with my needle just like this and, and go down there

and inject my local anesthetic there.

And that will get the dermatomes that are right there

where those chest tubes come out subxiphoid

and it pretty much gets everything subxiphoid all the way

down to about T eight T nine area.

But usually you don't even need to go that far down.

Did that answer your questions?

Hopefully that, hopefully that did what,

was there any other, was there any other questions about

that or follow up questions to that?

I know that's, that was kind of a quick one.

I didn't have slides about that,

but that's, that's a really great question for getting those

that dermatome where the costal margin is.

Just remember, just remember you need to, you need

to be up a right at the costal margin.

Lemme make sure I can, I can see it right.

You need to be right at the costal margin

and you're need, you need to be at an angle, okay?

You're not gonna be completely sagal,

you're gonna be at an angle.

'cause the costal margin is at an angle like this.

So you need to be, you need to be kind

of at an angle right up, right up

to the costal margin when you do it.

And then again, you can go medial to lateral

or you can go lateral to medial with your needle.

It doesn't matter. The, the what matters is the location

of the local and anesthetic and the tissue plane,

which should be between the rectus muscle

and the transversal ado muscle.

Okay? So that was a really great question.

- Yes. And they said that you answered it beautifully.

Thank you. Oh good. Do you have another question?

How long do you see the modified pex blocks using last,

using your combo of lipisol

and regular bupivocaine? Sorry,

- I know it's kind of a mouthful.

Yeah, so, so I'll see about two to two

and a half days of good analgesia.

And we, we actually have really good data about

that at our hospital because every patient

who does get liposomal bupivacaine,

we do follow them for two days.

Okay? If we just gave them plain ropivacaine,

then we only follow them for one day.

And, and, and that's pretty consistent, right?

So if I use just plain row pca, you know,

generally I'll get maybe 18,

maybe 24 hours at the max with it.

Usually between 12

and 24 hours is kind of the tail end of that.

But with liposomal bupivacaine for this modified technique,

I get a between two, two

and a half days out of it

with an average probably being about two days analgesia.

And so, and that's, that's usually plenty enough

to get the patients obviously extubated,

which is the most important aspect, you know, post

cabbage or heart taste or whatever is getting 'em extubated.

And then also facilitating pain for the,

for eventual chest tube removal.

Because once the chest tubes are removed,

usually they don't have as much pain after that.

So, so that's kind of been, that's kind of been really great

for us as far as the, the, the duration of it.

So, very good question.

- Okay. And one last question.

How much local anesthetic for this block,

- For the modified peck or for the ESP?

- Well, they didn't say, so I'm,

I'm assuming for the modified pecks,

- Well, I, I'll just answer for both.

So for ESP I'll do 20

to 30 ccs on each side.

So you know, for ESP you need to do both sides.

Same thing for, for modified peck, you gotta do both sides.

And so I'll do a total of 30 ccs

of local anesthetic per side.

So what that is is 10 ccs for the third rib, 10 ccs

for the fourth rib, and then 10 ccs for that subcostal.

Alright. If I am using liposomal bupivacaine,

I will, I, I won't inject it immediately.

Just right off the bat I always have 10 ccs

of saline loaded onto it

because it can look just like your tissue planes.

And so I want to use that, that saline, the hypo

ity of saline to verify that I'm in the right tissue plane.

'cause again, remember sometimes it, just

because I'm on the bone doesn't mean I'm under the fascia.

And so I wanna make sure I'm under the fascia

and I don't want it to be disturbed with the, the

how lip, the, the lipid of liposomal bupivacaine.

I don't want that to interfere with my view.

So I'll, I'll load it with the 10 ccs of saline.

So, and I'll just give, you know, three, four

or five sometimes I've had to give 10 ccs of saline,

which isn't a problem, just to make sure

that I am in the right tissue plane.

I see it lifting up

and then I'll add the liposomal bupivacaine after that.

So again, 30 ccs each side.

So a total of 60 ccs of local anesthetic.

And how that's broken down is 20 ccs of

liposomal bupivacaine

and 40 ccs of quarter percent bupivacaine.

That's how it's broken down. So 20 and 40. Okay.

And then that gives me a total of 60

and then I can do 30 on each side.

Now if I was doing it for ESP, you know,

if I'm doing a catheter then I'd probably do 20 ccs

of ropivacaine and then put my catheter in.

If I'm doing it with liposomal bpi,

I'd probably do 30 ccs on each side as well.

So that'd be a total of 60 ccs as well

for the one, for the one location.

- Great. That is all of our questions

and we are actually at time,

but I, I really appreciate such a detailed webinar.

You did fantastic. That was, that was really incredible.

- Thank you. - So thank you everyone for joining us today

and if you wanna see any of our other webinars,

they will be posted on our website.

Daniel, can you go to that last slide by any chance?

- Oh, I can do it. Here we go. - One more slide

- Was thinking about it. Sorry.

- There we go, we go. Okay.

So this website right here shows it'll be,

there'll be a recording of this presentation

and also all of our past webinars and future webinars.

So feel free to check out future topics

and if you wanna see a recording of this webinar,

it will be posted there in about a day or two.

I thank you all for joining us today.

This was a great webinar and we'll see you again soon.

Thanks.

Learn techniques and indications for successful ultrasound-guided regional anesthesia for chest wall surgeries, including Modified PECS, Subcostal TAP, and an Erector Spinae block. Dr. Teames will discuss the types of chest wall procedures that may benefit from the use of ultrasound-guided regional anesthesia, and share his personal tips for success.

What You'll Learn

  • Identify the proper muscles and tissue planes required to perform Modified PECS, Subcostal TAP, and an Erector Spinae Blocks
  • Discover how these blocks can help with postoperative analgesia for cardiac and chest wall procedures
  • Review the dermatomes and areas covered by the blocks
  • Increase your ease and success with proper needle placement techniques
Richard Teames
Presenter: Richard S. Teames, M.D.
Position: Director of Regional Anesthesia John Peter Smith Hospital, Fort Worth, TX | National Clinical Director of Regional Anesthesia Envision Physician Services | MAJ, 94th CSH, MC, USAR

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.

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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.