You Might Also Like

• Ultrasound-Guided Serratus Anterior Plane Block Can Help Avoid Opioid Use for Patients with Rib Fractures
• How to Perform an Adductor Canal Nerve Block
• How To Perform an Ultrasound-Guided TAP Block for Appendicitis Pain

Explore This Issue

ACEP Now: Vol 40 – No 09 – September 2021

(click to enlarge)
2A) The transverse view of the thoracic spine demonstrates the relationship of the erector spinae muscle, transverse process (TP), and ribs. Note the intercostal spinal nerve as it exits the spinal canal and gives off the ventral ramus, dorsal ramus, and sympathetic ganglion. The white arrow indicates the direction of the injection for an erector spinae plane block.
2B) The goal of the block is to place anesthetic between the erector spinae muscle and the transverse process (TP). Anesthetic is thought to flow into the paravertebral space (orange dashed circle).
Credit: Arun Nagdev

Supplies

1. High-frequency linear transducer (13–6 MHz) or low-frequency curvilinear transducer (5–1 MHz), depending on the depth of transverse process.
2. Anesthetic: 15–30 mL bupivacaine 0.5% (5 mg/mL; maximum 2 mg/kg). In large-volume plane blocks such as the ESPB, always refer to a reputable weight-based local anesthetic dosing chart.¹¹
3. Normal saline flushes 10–20 mL. This can be mixed into the same syringe as the local anesthetic or injected separately to initially open the fascial plane (hydrodissection).
4. 100-mm 21-g blunt-tip block needle or 20–22-g Quincke spinal needle. Needle visualization for deep target blocks is significantly easier when using echogenic block needles.
5. 91-cm or 36-inch tubing.
6. Chlorhexidine skin prep.
7. Transparent dressing (Tegaderm) for the transducer and sterile gel packets.
8. 25–30-g needle for local skin wheal.

Procedure

1. Pre-block

The patient should be placed on continuous cardiac monitoring and pulse oximetry whenever performing a high-volume ultrasound-guided nerve block. Additionally, the clinician should be knowledgeable of the signs, symptoms, and treatment of local anesthetic systemic toxicity (LAST) and have 20% lipid emulsion therapy readily available for this rare but potentially serious complication. (See www.lipidrescue.org for more information.)

2. Positioning

The ESPB may be performed with the patient either prone, sitting upright, or in lateral decubitus; the latter we find the most difficult to achieve optimal needle visualization. Needle entry is typically performed cranial to caudal in direction, and the ultrasound machine should be placed in direct line of vision for the operator (see Figure 3 for basic positioning with ultrasound system).

(click to enlarge)
The erector spinae plane block can be performed with the patient supine, upright, or in decubitus.
Credit: Arun Nagdev

3. Survey Scan

Level of block: This large-volume planar block will spread craniocaudally, providing multiple levels of analgesia with a single injection. To provide analgesia for rib fractures, choose the spinal level of the middle fracture as a target (eg, T6 for fourth to eighth rib fractures). T7 has been described as an effective target for pain associated with pancreatitis, T8 for renal colic, and L1 for appendicitis.^8–10