Novel Blocks Evidence Based Or

Flights Of Fancy
Abdominal Wall Blocks
Stuart Grant
Professor of Anesthesiology Duke University Medical Center
stuartgrant1@me.com
@galusweegie
 Faculty Disclosure
Nothing to disclose
X Yes, as follows:
Honoraria/Expenses
Consulting/Advisory Board BBraun Medical
Speakers Bureau
Funded Research (Individual)
Funded Research (Institution) SPR Therapeutics
Royalties/Patent Oxford University Press
Stock Options
Ownership/Equity Position
Employee
Other
Off-Label Product Use
Will you be presenting or referencing off-label or investigational use of a therapeutic product?
X No
Yes, as follows:
 The suspects
• Erector Spine Plane Block
• Quadratus Lumborum of many flavors
• Anterior
• Posterior
• Lateral
• Transversalis Fascia Plane Block
• Transversus Adominus Plane Block
• Posterior
• Subcostal
• Rectus Sheath Block
 Honorable Mention

• MTP
 What are we trying to achieve?

• Abdominal Wall Analgesia why?

• Improved function- early ambulation

• Reduced side effects- reduced pulmonary complications, nausea etc…

• We measure pain score, and opioid requirements but we want above.

 What Stu Wants To Know

• What is the easiest with the highest success rate?

 Erector Spinae Plane Block

• Will Review Publications for abdominal surgery only

• I will not cover mechanism or chest wall applications

• Prospective Randomized Controlled Trial

• Cohorts and Case Series

Erector Spine Plane Block In Pub Med
• Prospective Randomized Controlled Trial

• Only 30 patients total

• ESP versus control in Lap Chole

• Primary End Point Pain

• 24h Tramadol 130mg vs 200mg in control

• More patients required rescue fentanyl in control group

 Pain At Rest Pain On Movement

40
MIN
#3 HOURS
• Prospective randomized trial

• Subcostal TAP versus ESP

• Primary outcome Tramadol Consumption @ 24h

• All Subcostal TAO and ESP successful

• 57 patients analyzed ages 1-7

• ESP vs Anterior QLB

• FLACC Scores through first 6h recorded (Faces Legs Activity Cry

Consolability)

• No difference between groups

• Prospective Randomized Controlled Trial Spine Surgery

• Lower Tramadol Use with ESP compared to control

• Pain scores better up to 24h but……

• More Fentanyl Use In Control Group

• More Nausea In Control Group

Quadratus Lumborum Blocks
 Anterior Quadratus Lumborum

• Publications for abdominal surgery only

• Prospective Randomized Controlled Trial

• Cohorts and Case Series

Round of applause for the art!
• Not congruous. Placed in lumbar for thoracic block.
• Lumbar weakness assured.
• And a Pneumothorax in 1 of 6 cadavers (never mind a moving diaphragm)
• Potentially a renal biopsy
All this because paravertebral block is potentially dangerous??
 Posterior Quadratus Lumborum

• Publications for abdominal surgery only

• Prospective Randomized Controlled Trial

• Cohorts and Case Series

• Randomized 74 patients with block done under GA and blinded assessor

• Primary end point was pain

• There was a difference in pain from 3 through 24h after surgery

 Lateral Quadratus Lumborum

• Publications for abdominal surgery only

• Prospective Randomized Controlled Trial

• Cohorts and Case Series

• 76 Patients undergoing C-Section randomized to TAP or Posterior QL

• Primary outcome was a difference in morphine.

• Positive study for primary outcome but no difference in pain scores using
AUC as assessment.
• 60 subjects in total

• Intrathecal 12.5MG Hyperbaric bupivacaine with fentanyl 20mcg

• Randomized to Lateral QL 20ml 0.375 Ropiv. or no QL.

• Patients not blinded. Post op Assessor was blinded

 Transversalis Fascia Plane Block

• Publications for abdominal surgery only

• Prospective Randomized Controlled Trial

• Cohorts and Case Series

Transversalis Fascia Retrospective
Reported Quadriceps Weakness
Lateral 1%
Posterior 19%
Anterior 90%
Intramuscular 0%
 Summary

• Data is limited for some of these blocks

• Lots of case reports and cadaveric studies

• A lot of these not matured yet

• Question remains what is easy quick and safe to perform?

• Usually a decade for a block to mature………