ESP block - future direction and remaining questions

@amit_pawa
ESP Block
Future Direction &
Remaining Questions

Disclosures
GE Healthcare
Sintetica Ltd
B Braun Medical Ltd
@amit_pawa
Butterfly Network, Inc
Pacira
Complete Anatomy App 3D4 Medical

@amit_pawa
I’ll Cover
What We Know About ESP
Questions We Need To Answer
What The Future Holds For ESP
What We Don’t Know About ESP

ESP
Evolution
GA Spinal Epidural TAP Block
@amit_pawa

What Do We Know About ESP?
@amit_pawa

Much Enthusiasm & Many Indications!
@amit_pawa

We Love ESP
We Don’t Love
ESP
@amit_pawa

Fear Of
Change
Too Novel
Lack of
Evidence
Unsure of
Role
Inconsistency
Lack of
Experience
Fear of
Failure
Prefer
Alternatives
Variable
Sensory Loss
@amit_pawa

Cutaneous Sensory Loss
@amit_pawa

2020
12 volunteers
20mL 0.5% Ropi
Posterior Thorax Only
Sitting Position
@amit_pawa

2020
6 volunteers
30mL 0.375% Ropi
Post/Lateral Thorax
Sitting Position
1 Pt had ?MTP injection
@amit_pawa

Blockade of Dorsal
Ramus IS Likely
@amit_pawa

If I was to Consider
Blocks…
@amit_pawa

EFFECTIVE
SAFE
SIMPLE
@amit_pawa

SIMPLE
SAFE
EFFECTIVE
@amit_pawa
(We Think)

What DO We Know?
Sometimes ESP Blocks Work Well
Sometimes ESP Blocks Don’t Work Well
Sometimes ESP Blocks Work Just Enough
Dermatomal Loss of Sensation Varies
Dense Neural Blockade is Rare
Evidence is Inconsistent
Dorsal Ramus Block is Likely
@amit_pawa

What We Don’t Know About ESP
@amit_pawa

What We Don’t Know?
How Does It Work? - PVB by Proxy?
Does it Matter if Sensory Loss Varies?
What is Optimal Volume?
Does ESP Have a Role In Modern RA?
Does It Provide Effective Analgesia?
Is it Really Safe with Anticoagulation?
@amit_pawa

Mechanism of Action
@amit_pawa

Mechanism of Action?
LA action on:
Nerves in the injected Plane
Nerves in adjacent Planes/tissue
Nerves in distant Planes/tissue
(Systemic Absorption)
Mechanisms of Action Of Fascial Plane Blocks - Jinn KJ, Lirk P, Hollmann M, Schwarz S - Ahead of Print RAPM 2021
@amit_pawa

mixture comprising 10 mL of an iodinated
hexol (Omnipaque 300; GE Healthcare,
), diluted in 85 mL of 0.9% sodium chloride
collimation, 1.2 mm. Images were reconstructed using a soft
tissue algorithm at 3 mm slice thickness at 3-mm intervals. All
images were reviewed by a consultant radiologist. Spread of
nsional CT reconstruction of injectate spread (darker area) after injection at the T5 level deep to erector spinae muscle.
caudal spread from T1 to T8. The solid arrows indicate the penetration of dye beyond the costotransverse junction
intertransverse spaces.
d Pain Medicine • Volume 41, Number 5, September-October 2016 ESP Block in Thoracic Pain
Twenty milliliters of a mixture comprising 10 mL of an iodinated
contrast material, iohexol (Omnipaque 300; GE Healthcare,
Princeton, New Jersey), diluted in 85 mL of 0.9% sodium chloride
with 5 mL of methylene blue dye was injected. Within 20 minutes
of completing the injections, cadaver 2 was transferred to a 128-slice
multidetector CT scanner (Siemens Flash CT; Siemens Healthcare)
where abdominal and thoracic imaging was performed to radio-
graphically assess the distribution of injectate. Images were
acquired using routine clinical imaging protocols with the follow-
ing parameters: kilovolt (peak), 120; effective milliampere-
second, 210; rotation time, 0.5 seconds; pitch, 0.8; and detector
collimation, 1.2 mm. Images were recon
tissue algorithm at 3 mm slice thickness
images were reviewed by a consultant r
injectate was assessed primarily upon rev
set supplemented with multiplanar images
caudal spread of injectate from C7 to T8
T8 on the left, occurring in a paraspinous
transverse processes anteriorly and the erec
teriorly (Fig. 5). Lateral spread extended t
verse processes at all levels, and slightly bey
junctions at levels T3 to T6 on the right an
FIGURE 6. Dissection of the right side of cadaver 2 after an ultrasound-guided ESP block and dye injection deep to e
Trapezius and rhomboid muscles have been removed. The longissimus thoracis portion of the erector spinae muscle
cranially and dense staining of its anterior (deep) surface is visible. The external intercostal muscle, internal intercosta
surrounding tissues are also heavily stained. Dye has penetrated deep to these layers and through the costotransvers
The Erector Spinae Plane Block
A Novel Analgesic Technique in Thoracic Neuropathic Pain
Mauricio Forero, MD, FIPP
,* Sanjib D. Adhikary, MD,† Hector Lopez, MD,‡
Calvin Tsui, BMSc,§ and Ki Jinn Chin, MBBS (Hons), MMed, FRCPC||
oracic neuropathic pain is a debilitating condition that is
sponsive to oral and topical pharmacotherapy. The benefit
al nerve block procedures is unclear due to a paucity of ev-
invasiveness of the described techniques. In this report, we
el interfascial plane block, the erector spinae plane (ESP)
uccessful application in 2 cases of severe neuropathic pain
ng from metastatic disease of the ribs, and the second from
ultiple rib fractures). In both cases, the ESP block also pro-
sive multidermatomal sensory block. Anatomical and radio-
ation in fresh cadavers indicates that its likely site of action
and ventral rami of the thoracic spinal nerves. The ESP
omise as a simple and safe technique for thoracic analgesia
neuropathic pain as well as acute postsurgical or posttrau-
in Med 2016;41: 00–00)
hic pain is a common chronic pain condition with
tiologies, including surgery, trauma, and diseases
s zoster, diabetes, and cancer.1
It is notoriously diffi-
Case 1
A 67-year-old man, weight 116 kg and height 188 cm [body
mass index (BMI), 32.8 kg/m2
] with a history of heavy smoking
and paroxysmal supraventricular tachycardia controlled on ateno-
lol, was referred to the chronic pain clinic with a 4-month history
of severe left-sided chest pain. A magnetic resonance imaging
scan of his thorax at initial presentation had been reported as nor-
mal, and the working diagnosis at the time of referral was post-
herpetic neuralgia. He reported constant burning and stabbing
neuropathic pain of 10/10 severity on the numerical rating score
(NRS), radiating from his spine into the anterior chest wall, mainly
at T5 and extending several dermatomes inferiorly. There was sig-
nificant sleep disturbance and impairment of quality of life. Phys-
ical examination revealed allodynia and hyperesthesia over the
affected dermatomes with a primary trigger point over the T5 der-
matome 3 to 4 cm lateral to the neuraxial midline. Pain manage-
ment up to that point had included pregabalin (600 mg daily at
the time of consultation), nonsteroidal anti-inflammatory drugs,
baclofen, fluoxetine, and marijuana with no improvement. Several
different opioids had been tried but all had to be stopped due to
Within several minutes, the patient reporte
diminished significantly, and a full assessment
sensory block was performed 2 hours later. By
tient had obtained complete relief of pain, with
There was an area of diminished sensation to p
Hospital, McL 2-405, 399 Bathurst St, Toronto, Ontario, Canada M5T 2S8
(e‐mail: gasgenie@gmail.com).
The authors declare no conflict of interest.
Copyright © 2016 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000451
Regional Anesthesia and Pain Medicine • Volume 41, Number 5, September-October 2016
Copyright © 2016 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this a
Spread “In the Vicinity” of Dorsal/Ventral Rami
@amit_pawa

ESP Mechanism?
PVB spread by Proxy?
jected dyes into the back muscles after retrolaminar (RL, right) and ESP block (ESP, left).
columbar fascia covering the erector spinae muscle was revealed. (b) The muscle ﬁbre
The spread pattern of the dyes in the vertebral laminae was seen after removal of all bac
ocostalis; Lo, longissimus thoracis).
(b)
(c)
Anaesthesia 2018, 73, 1244–1250
Original Article
Comparison of injectate spread and nerve involvement
between retrolaminar and erector spinae plane blocks in
the thoracic region: a cadaveric study
H.-M. Yang,1
Y. J. Choi,2
H.-J. Kwon,3
J. O,3
T. H. Cho3
and S. H. Kim4
1 Assistant Professor, 2 Instructor, 3 Research Assistant, Department of Anatomy, 4 Associate Professor, Department of
Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine,
Seoul, Korea
Summary
Although different injection locations for retrolaminar and erector spinae plane blocks have been described,
the two procedures have a similar anatomical basis. In this cadaveric study we compared anatomical spread of
dye in the thoracic region following these two procedures. Following randomisation, 10 retrolaminar blocks
and 10 erector spinae plane blocks were performed on the left or right sides of 10 unembalmed cadavers. For
each block, 20 ml of dye solution was injected at the T5 level. The back regions were dissected and the
involvement of the thoracic spinal nerve was also investigated. Twenty blocks were successfully completed. A
consistent vertical spread, with deep staining between the posterior surface of the vertebral laminae and the
overlaying transversospinalis muscle was observed in all retrolaminar blocks. Moreover, most retrolaminar
blocks were predominantly associated with fascial spreading in the intrinsic back muscles. With an erector
spinae plane block, dye spread in a more lateral pattern than with retrolaminar block, and fascial spreading in
the back muscles was also observed. The number of stained thoracic spinal nerves was greater with erector
spinae plane blocks than with retrolaminar blocks; median 2.0 and 3.5, respectively. Regardless of technique,
the main route of dye spread was through the superior costotransverse ligament to the ipsilateral paravertebral
space. Although erector spinae plane blocks were associated with a slightly larger number of stained thoracic
spinal nerves than retrolaminar blocks, both techniques were consistently associated with posterior spread of
Anaesthesia 2018 doi:10.1111/anae.14408
Original Article
Comparison of injectate spread and ner
between retrolaminar and erector spina
H.-M. Yang,1
Y. J. Choi,2
H.-J. Kwon,3
J. O,3
T. H. Cho3
and S. H
Anaesthesia 2018, 73, 1244–1250
@amit_pawa

ESP Mechanism?
PVB spread by Proxy?
jected dyes into the back muscles after retrolaminar (RL, right) and ESP block (ESP, left).
columbar fascia covering the erector spinae muscle was revealed. (b) The muscle ﬁbre
The spread pattern of the dyes in the vertebral laminae was seen after removal of all bac
ocostalis; Lo, longissimus thoracis).
(b)
(c)
Anaesthesia 2018, 73, 1244–1250
Original Article
Comparison of injectate spread and nerve involvement
between retrolaminar and erector spinae plane blocks in
H.-M. Yang,1
Y. J. Choi,2
H.-J. Kwon,3
J. O,3
T. H. Cho3
and S. H. Kim4
1 Assistant Professor, 2 Instructor, 3 Research Assistant, Department of Anatomy, 4 Associate Professor, Department of
Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine,
Seoul, Korea
Summary
Although different injection locations for retrolaminar and erector spinae plane blocks have been described,
the two procedures have a similar anatomical basis. In this cadaveric study we compared anatomical spread of
dye in the thoracic region following these two procedures. Following randomisation, 10 retrolaminar blocks
and 10 erector spinae plane blocks were performed on the left or right sides of 10 unembalmed cadavers. For
each block, 20 ml of dye solution was injected at the T5 level. The back regions were dissected and the
involvement of the thoracic spinal nerve was also investigated. Twenty blocks were successfully completed. A
consistent vertical spread, with deep staining between the posterior surface of the vertebral laminae and the
overlaying transversospinalis muscle was observed in all retrolaminar blocks. Moreover, most retrolaminar
blocks were predominantly associated with fascial spreading in the intrinsic back muscles. With an erector
spinae plane block, dye spread in a more lateral pattern than with retrolaminar block, and fascial spreading in
the back muscles was also observed. The number of stained thoracic spinal nerves was greater with erector
spinae plane blocks than with retrolaminar blocks; median 2.0 and 3.5, respectively. Regardless of technique,
the main route of dye spread was through the superior costotransverse ligament to the ipsilateral paravertebral
space. Although erector spinae plane blocks were associated with a slightly larger number of stained thoracic
spinal nerves than retrolaminar blocks, both techniques were consistently associated with posterior spread of
Anaesthesia 2018 doi:10.1111/anae.14408
Original Article
Comparison of injectate spread and ner
between retrolaminar and erector spina
H.-M. Yang,1
Y. J. Choi,2
H.-J. Kwon,3
J. O,3
T. H. Cho3
and S. H
Anaesthesia 2018, 73, 1244–1250
“the amount of dye within the paravertebral space following both
retrolaminar and ESP injections seemed to be too small to allow for upward
or downward flow.”
@amit_pawa

Dorsal Rami Spread only?
ESP Mechanism?
A Cadaveric Study Investigating the Mechanism of Action
of Erector Spinae Blockade
Jason Ivanusic, PhD,* Yasutaka Konishi, MD,†‡ and Michael J. Barrington, PhD, MBBS, FANZCA†§
Background and Objectives: Erector spinae block is an ultrasound-
guided interfascial plane block first described in 2016. The objectives of
this cadaveric dye injection and dissection study were to simulate an erector
spinae block to determine if dye would spread anteriorly to the involve or-
igins of the ventral and dorsal branches of the spinal nerves.
Methods: In 10 unembalmed human cadavers, 20 mL of 0.25% methy-
lene blue dye was injected bilaterally into the plane between the fifth thoracic
transverse process and erector spinae muscle. An in-plane ultrasound-guided
technique with the transducer orientated longitudinally was used. During
dissection, superficial and deep muscles were identified, and extent of
dye spread was documented in cephalocaudal and lateral directions. The
ventral and dorsal rami of spinal nerves and dorsal root ganglion at each
level were examined to determine if they were stained by dye.
Results: There was extensive cephalocaudad and lateral spread of dye
deep and superficial to the erector spinae muscles. Except for 1 injection
(from 20), the ventral rami were not stained by the dye. In only 2 injections
did the dye track posteriorly through the costotransverse foramen to the
dorsal root ganglion. In all other cases, the dorsal root ganglia were not in-
volved in the dye injection. The dye stained the dorsal rami posterior to the
costotransverse foramen.
Conclusions: There was no spread of dye anteriorly to the paravertebral
space to involve origins of the ventral and dorsal branches of the thoracic spinal
nerves. Dorsal ramus involvement was posterior to the costotransverse foramen.
(Reg Anesth Pain Med 2018;43: 567–571)
In clinical reports, ESB resulted in extensive cutaneous sen-
sory block indicating both ventral and dorsal spinal rami involve-
ment.1
Furthermore, a cadaveric dye injection and dissection in 1
cadaver reported spread of dye in the vicinity of the origins of the
ventral and dorsal rami of the spinal nerves.1
Hence, ESB has
been described as a technically simpler alternative to ultrasound-
guided paravertebral block with a similar mechanism of action.
In addition, ESB is likely to be safer than paravertebral blockade
because the injection is in a plane remote from critical structures
such as the pleura, and thus there has been significant clinical in-
terest in this block. Therefore, the objective of this current cadav-
eric experiment was to simulate an ESB to determine if dye would
spread anteriorly to the paravertebral space to involve the origins
of the ventral and dorsal branches of the thoracic spinal nerves.
The extents of craniocaudal and medial-to-lateral spread of the
dye were also documented.
METHODS
This project was approved by the Human Research Ethics
Committee, University of Melbourne (Project within Program
Ethics ID 1441811.3). Ten unembalmed human cadavers were ob-
tained through the body donor program of the Department of
Anatomy and Neuroscience. None of the specimens were frozen
before the interventions were performed. Before commencement
REGIONAL ANESTHESIA AND ACUTE PAIN
ORIGINAL ARTICLE
tion. A skin incision was made along the midlin
processes from above C7 to the lower lumbar ver
reflected laterally to expose the posterior thoracic
Superficial muscles (trapezius, latissimus dorsi
were individually identified and reflected. T
muscles were identified and removed at their
the extent of dye spread deep and superficial t
explored and documented. The extent of cepha
(e‐mail: Michael.Barrington@svha.org.au).
Funding was from departmental resources only. Support was provided by the
Imaging and Posters Unit at the Department of Anatomy and Neuroscience,
University of Melbourne, and Anastasia Arsenoulis from FUJIFILM
SonoSite, Inc, which provided an ultrasound machine.
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000789
Regional Anesthesia and Pain Medicine • Volume 43, Number 6, August 2018
@amit_pawa

Dorsal Rami Spread only?
ESP Mechanism?
A Cadaveric Study Investigating the Mechanism of Action
of Erector Spinae Blockade
Jason Ivanusic, PhD,* Yasutaka Konishi, MD,†‡ and Michael J. Barrington, PhD, MBBS, FANZCA†§
Background and Objectives: Erector spinae block is an ultrasound-
guided interfascial plane block first described in 2016. The objectives of
this cadaveric dye injection and dissection study were to simulate an erector
spinae block to determine if dye would spread anteriorly to the involve or-
igins of the ventral and dorsal branches of the spinal nerves.
Methods: In 10 unembalmed human cadavers, 20 mL of 0.25% methy-
lene blue dye was injected bilaterally into the plane between the fifth thoracic
transverse process and erector spinae muscle. An in-plane ultrasound-guided
technique with the transducer orientated longitudinally was used. During
dissection, superficial and deep muscles were identified, and extent of
dye spread was documented in cephalocaudal and lateral directions. The
ventral and dorsal rami of spinal nerves and dorsal root ganglion at each
level were examined to determine if they were stained by dye.
Results: There was extensive cephalocaudad and lateral spread of dye
deep and superficial to the erector spinae muscles. Except for 1 injection
(from 20), the ventral rami were not stained by the dye. In only 2 injections
did the dye track posteriorly through the costotransverse foramen to the
dorsal root ganglion. In all other cases, the dorsal root ganglia were not in-
volved in the dye injection. The dye stained the dorsal rami posterior to the
costotransverse foramen.
Conclusions: There was no spread of dye anteriorly to the paravertebral
space to involve origins of the ventral and dorsal branches of the thoracic spinal
nerves. Dorsal ramus involvement was posterior to the costotransverse foramen.
(Reg Anesth Pain Med 2018;43: 567–571)
In clinical reports, ESB resulted in extensive cutaneous sen-
sory block indicating both ventral and dorsal spinal rami involve-
ment.1
Furthermore, a cadaveric dye injection and dissection in 1
cadaver reported spread of dye in the vicinity of the origins of the
ventral and dorsal rami of the spinal nerves.1
Hence, ESB has
been described as a technically simpler alternative to ultrasound-
guided paravertebral block with a similar mechanism of action.
In addition, ESB is likely to be safer than paravertebral blockade
because the injection is in a plane remote from critical structures
such as the pleura, and thus there has been significant clinical in-
terest in this block. Therefore, the objective of this current cadav-
eric experiment was to simulate an ESB to determine if dye would
spread anteriorly to the paravertebral space to involve the origins
of the ventral and dorsal branches of the thoracic spinal nerves.
The extents of craniocaudal and medial-to-lateral spread of the
dye were also documented.
METHODS
This project was approved by the Human Research Ethics
Committee, University of Melbourne (Project within Program
Ethics ID 1441811.3). Ten unembalmed human cadavers were ob-
tained through the body donor program of the Department of
Anatomy and Neuroscience. None of the specimens were frozen
before the interventions were performed. Before commencement
REGIONAL ANESTHESIA AND ACUTE PAIN
ORIGINAL ARTICLE
tion. A skin incision was made along the midlin
processes from above C7 to the lower lumbar ver
reflected laterally to expose the posterior thoracic
Superficial muscles (trapezius, latissimus dorsi
were individually identified and reflected. T
muscles were identified and removed at their
the extent of dye spread deep and superficial t
explored and documented. The extent of cepha
(e‐mail: Michael.Barrington@svha.org.au).
Funding was from departmental resources only. Support was provided by the
Imaging and Posters Unit at the Department of Anatomy and Neuroscience,
University of Melbourne, and Anastasia Arsenoulis from FUJIFILM
SonoSite, Inc, which provided an ultrasound machine.
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000789
Regional Anesthesia and Pain Medicine • Volume 43, Number 6, August 2018
nusic et al Regional Anesthesia and Pain Medicine • Volume 43, Number 6, August 2018
@amit_pawa

Up until 2020…
@amit_pawa
PVS VR DR

Up until 2020…
There is Limited Evidence of “By-Proxy” Spread
Variation Exists in Cadaver Studies too!
Cadaver Results May Not Relate to “Real Life”
(Mechanical Ventilation/Movement)
@amit_pawa

2021
2 Cadavers - Bilat ESP at T5 - 20mL black dye
Microscopic Histological Examination
Dorsal Spread T2/3 - T10/11 PLUS 10cm Laterally
Macroscopic Anatomical Dissection
Ventral Spread T2/3 - T9/10 (Paravertebral)
@amit_pawa

2021
Dye Diffused into Intercostal Space
Followed Blood Vessels
Associated with Dorsal Ramus
Via CostoTransverse Foramen
@amit_pawa

11 Embalmed Cadavers
Micro CT of Th PVS
2021
May 2021
@amit_pawa

Communicates with PVS via Medial/Lateral Slits
Retro SCTL space:
SCTL incompletely formed Posterior wall of Th PVS
Communicates with ES Plane & Intervertebral Foramen
Contains Dorsal Ramus & Proximal Ventral Ramus
May 2021

Possible Route
ESP = PVB by Proxy?
May 2021

In Cadavers
If Injectate can access the
Retro-SCTL space, it can access
the Paravertebral Space
What About Live Subjects?
@amit_pawa

Imaging Studies In the Living!
@amit_pawa

30mL LA & Contrast
Intervertebral foramina
Paravertebral
Epidural
Intercostal
2018
@amit_pawa

Intervertebral Foramina
13mL Contrast & Phenol
Paravertebral Space
2019
2019
@amit_pawa

25mL LA
Retrolaminar
Paravertebral
Epidural
13mL Contrast & Phenol
Paravertebral Space
2019
2019
@amit_pawa

In Living Subjects
There Is Evidence of Ventral Spread towards:
Paravertebral Space
Epidural Space
@amit_pawa

In Living Subjects
There Is Evidence of Ventral Spread towards:
Paravertebral Space
Epidural Space
Does this Explain the Analgesic Effect?
@amit_pawa

Volume of Injectate
@amit_pawa

3 Cadavers - ESP vs RLB on each
20mL of Radio Contrast at T5
ESP - Epidural Spread - 2-5 levels
MRI then Dissection
ESP Additionally 5-9 intercostal spaces
ESP - “Paravertebral” Spread - 2-3 Spinal Levels
2018
@amit_pawa

10mL 30mL
7 Cadavers - Bilateral ESPs
10mL vs 30mL
Endoscopy plus Dissection
10mL injections - NO Paravertebral Spread
30mL injections - ALL Paravertebral Spread
3 Spinal Levels (Median)
2019
@amit_pawa

10mL 30mL
30mL 30mL
10mL 10mL
10mL vs 30mL
More PosteroLateral Spread
2019
@amit_pawa

10mL 30mL
30mL 30mL
10mL 10mL
10mL vs 30mL
More PosteroLateral Spread
Is it Worth Increasing Volume
from 20 to 30mL?
2019
@amit_pawa

2 Cadavers - USG ESP at L3 - 10mL + 10mL + 10mL Contrast/dye
Realtime Fluoroscopy & Dissection
10mL
20mL
30mL
2 min post-injection
10mL - 2 Levels - L2-3
20mL- 3 Levels - L1-3
30mL - 4 Levels - L1-4
No Spread to PVS/Ventral Rami
@amit_pawa

Volume
Ideal Volume between 20-30mL?
Same for Thoracic vs Lumbar?
@amit_pawa

Is it Safe in Anticoagulation?
@amit_pawa

What about Bleeding Risk?
@amit_pawa
ASRA/ESRA
Assoc. of Anaesthetists
Excellent, but
No Specific
Block Guidance
)
Canadian Practice Advisory
Bleeding Risks
Block Consensus Grades
ESP Low Risk IV-C
PVB High Risk* III-B

2018
Left Ventricular Assist Device Insertion
Systemic Heparinisation
4 cases rescue ESP catheters
1 case pre-operative ESP catheter
Good Analgesia
No Complications with Catheter Insertion/removal
@amit_pawa

Post-op Lung Transplant
Severe Pain Post Extubation
Atrial Fibrillation requiring Systemic Anticoagulation
@amit_pawa

Post-op Lung Transplant
Severe Pain Post Extubation
Atrial Fibrillation requiring Systemic Anticoagulation
Continuous ESP for 4 Days
No interruption to Heparinisation
ESP Catheter
Oxygen Sats
Pain Score
@amit_pawa

Anticoagulation & ESP
Appears To Be Safe
As Always - Risk vs Benefit Discussion
@amit_pawa

Sensory Loss
Does Absence/Variability Matter?
@amit_pawa

Has A Block Failed If
No Loss of Sensation But…
Analgesia & Opioid Reduction Still Evident?
Pt Derives Benefit (Pain Scores & Opioids)?
Improvement in PROM & QoR?
@amit_pawa
Is Sensory Loss A Marker of Success with ESP?

Why Inconsistent Sensory Loss?
Complexity of Cutaneous Innervation
Overlapping Innervation Crossing Midline
Interindividual Variation
Low Concentration of LA at Target
Due To A Differential block - (C >A-delta fibres) ?
Accuracy of Injection & Variability of Spread
@amit_pawa

Modern Regional Anaesthesia
Starring…
Erector Spine Plane Block?
@amit_pawa

Increasing Access to RA
Regional Anaesthesia - Daunting to Uninitiated
Concept of ESP is Simple
Safe & Superficial Block
Entry Level Block For ALL Including ED/ICU
Can Use as a “Stepping Stone” @amit_pawa

ESP
PVB
MTP
Skill Progression
@amit_pawa
Inspired by Ki Jinn Chin

ESP
PVB
MTP
Skill Progression
ESP
@amit_pawa

ESP
PVB
MTP
Skill Progression
ESP
MTP
@amit_pawa

ESP
PVB
MTP
Skill Progression
ESP
MTP
PVB
Risk Difficulty
@amit_pawa

We Need Alternatives to PVB/TEA
@amit_pawa

@amit_pawa

Coagulation/Sepsis/Certain Specialties (Cardiac/Tx)
Hypotension (Sympathectomy)/Side Effects
Rescue Technique (Failed Epidural/PVB)
Inability To Perform Epidural/PVB
- Patient Positioning
- Lack of Skilled Practitioner/Post-Op Monitoring
@amit_pawa

Where May ESP Blocks
Have a Role?

2019
2020
2021
ESP & Spines Seem
Like a
Good Fit!

RCTs Against MMA & Active Comparators
Does ESP Provide Effective Analgesia?
Use of PROM like QoR - look at MCID
@amit_pawa
Identify “Best Fit Surgery”
If is not Perfect, is it Good Enough?

How to Improve Success Rate
How to Maintain Consistency
Determine Ideal Endpoint
Determine Optimal Volume
Determine Optimal Needle Direction
@amit_pawa

Parasagittal Out-of-Plane?
Transverse In-Plane/Out-of-Plane?
Determine Optimal MASS of LA
Ensure Retro-SCTL Endpoint with MTP?
Optimal Catheter Regimen
@amit_pawa

“We need to spend LESS EFFORT on celebrating
UNIQUE APPLICATIONS, and instead FOCUS on
rigorously CLARIFYING HOW THIS BLOCK actually
WORKS through careful and patient investigation
SO that WE CAN APPLY IT more CONSISTENTLY in
our practice “
@amit_pawa

The Erector Spinae Plane Block :
Is Here to Stay
Is Not Perfect
Probably Works in Number of Ways
May Be “Good Enough”
Doesn’t Need Any More Case Reports
Needs More RCTs
@amit_pawa

“What We Don’t Know
Is Much More Than
What We Know”
- Albert Einstein -
ESP Block:

@amit_pawa
amit.pawa@gstt.nhs.uk

ESP block - future direction and remaining questions

ESP block - future direction and remaining questions

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ESP block - future direction and remaining questions