🩻 Looking Beyond Pain Scores 📚 Pilot RCT comparing ESP catheter, intravenous lidocaine infusion, and multimodal analgesia for rib fractures: ✔ Similar pain scores ✔ Similar opioid use ✔ Less delirium with ESP 🔗 doi.org/10.1136/rapm-2026-10… #RegionalAnesthesia #ESPBlock #RAPM

🚨 Publication Highlight – Indian Journal of Anaesthesia (IJA) 🚨 Sacral erector spinae plane block for chronic pain: Fascial plane block or more? 🔗Read here: PubMed Link - pubmed.ncbi.nlm.nih.gov/4016… 💡This correspondence in the Indian Journal of Anaesthesia explores the role of sacral erector spinae plane (ESP) block in managing chronic pain. Traditionally recognised as a fascial plane block, ESP at the sacral level is increasingly being considered for its potential broader mechanisms and clinical impact. 🔑 Key Clinical Insights ✔️ESP block at the sacral level may extend analgesia beyond classic dermatomal distribution. ✔️Possible mechanisms: local anaesthetic spread, involvement of dorsal rami, and neuromodulatory effects. ✔️Expands the clinical utility of ESP block from acute postoperative pain to chronic pain syndromes. ✔️Offers a promising interventional option for patients with refractory sacral or pelvic pain. 🌟 Why it matters: With the rising need for opioid-sparing strategies, ESP blocks at unconventional sites like the sacral region may emerge as valuable tools for comprehensive chronic pain management. 📚Published in Indian Journal of Anaesthesia (March 2025 | Vol 69 | Issue 3) ✍️ Prof Rakesh Garg Editor-in-Chief, Indian Journal of Anaesthesia Professor, Onco-Anaesthesia & Palliative Medicine, AIIMS New Delhi 📧drrgarg@hotmail.com #Anaesthesia #PainMedicine #ChronicPain #RegionalAnaesthesia #ESPBlock #FascialPlaneBlock #IJA #Indian_J_Anaesth

🔍 Debunking the ESP Block Myth: It’s Not About the Bloodstream! 💉❌ “ESP block works via systemic absorption” - Sounds clever, but let’s break it down with science and logic. #ESPBlock #RegionalAnesthesia #PainManagement #LocalAnesthetics #SpineSurgery #TipOfTheDay #MyRATips Tip of the Day: 🔸 🧠 Local Action, Not Global Confusion 🎯 Local anesthetics (LAs) block voltage-gated sodium channels at nerve membranes, halting nociceptive transmission. This requires proximity to nerves, not floating around in the bloodstream. 🔸 🧪 Systemic Absorption ≠ Mechanism of Action All LAs are absorbed systemically over time - it’s their natural metabolic fate. 💡 But their analgesic effect is local, right where they’re injected. No different for ESP. 🔸 ⚡ Systemic = Non-Selective = Toxicity Sodium channels are everywhere: brain 🧠, heart ❤️, GI tract 🌀. ⚠️ Systemic LA can’t “choose” to act only on pain pathways - it may cause side effects, not targeted pain relief. 🔸 📍 ESP Block Mechanism: Fascial Magic Injected deep to the erector spinae muscle, LA spreads in the interfascial plane. 🧬 It reaches dorsal rami, ventral rami, and sometimes even the paravertebral space ➡️ segmental analgesia from behind. 🌀 The block is multi-dermatomal and longitudinally extensive, ideal for posterior thoraco-lumbar coverage. 🔸 🎯 Why It's Perfect for Spine Surgeries Dorsal rami (DR) innervate: Skin and muscles of the back Facet joints Posterior elements of the vertebrae 💪 ESP block, by consistently involving DR, provides excellent posterior analgesia - making it highly useful in: Lumbar decompressions Posterior fusions Laminectomies Minimally invasive spine surgeries 🔸 🧪 The IV Lignocaine Fallacy If systemic LA were truly effective for ESP-like analgesia, IV lignocaine would deliver the same effect. ⚡🧠 It doesn't. Why? Because location matters. Proximity is power. ✅ Bottom Line 📌 ESP block works locally by targeting dorsal and ventral rami through interfacial spread - not systemically via bloodstream circulation. 📌 It's anatomically sound, clinically effective, and perfectly suited for back surgeries. 🔒 It’s not about the blood - it’s about the block.

🔥🫁 "Pain at the Core: On-Arrival Blocks for Chest and Abdomen" 🧍‍♂️🛡️ #PainAtTheCore #OnArrivalBlock #TruncalAnalgesia #ChestWallBlock #AbdominalBlock #RegionalAnesthesia #ESPBlock #TAPBlock #SAPBlock #UltrasoundGuidedRA #PointOfCareBlocks #OnArrivalRA #TipoftheDay #MyRATips Tip of the Day: 🟦 Why FOCUS on Truncal Pain Early? 🫁 Chest and abdominal injuries often compromise vital functions - especially breathing, coughing, and cooperation. 🔥 Pain in these regions is often deep, diffuse, and distressing, and opioids alone may not suffice or may cause respiratory depression. 🛠️ Regional blocks offer site-specific, opioid-sparing relief that improves immediate care and downstream outcomes. 🟨 CLINICAL GOALS of Truncal On-Arrival Blocks 🫁 Restore respiratory efficiency (chest trauma, rib fractures) 🚑 Facilitate imaging, positioning, and transport 🧘 Relax abdominal guarding (peritonitis, pancreatitis) 📉 Reduce sympathetic overdrive in trauma 🫱 Enhance cooperation for procedures or airway planning 🟫 COMMON INDICATIONS 🟦 Chest Wall: Rib fractures (especially multiple) Flail chest Post-thoracostomy or chest tube placement Chest wall contusions in blunt trauma 🟨 Upper Abdomen: Blunt abdominal trauma Acute pancreatitis Upper GI perforation or distension Postoperative laparotomy or laparoscopy pain 🟧 Lower Abdomen: Inguinal hernia (painful or strangulated) Appendicitis with guarding Abdominal wall hematomas or incisional pain 🟪 BEST CHOICES 🫁 For Chest Wall Injuries: ESPB, SAPB, or ICNB. Provide broad dermatomal coverage. Safe to perform away from critical structures like the pleura. Ideal for rib fractures, flail chest, and chest tube insertion pain. 🧼 For Upper Abdominal Pain: ESPB at T6–T9 levels or TAP Block. Relieve guarding and improve respiratory effort in conditions like pancreatitis or blunt abdominal trauma. 🧩 For Lower Abdominal Conditions: TAP Block, RSB, IIN/IHN Block. Provide localized anterior abdominal wall analgesia. Suitable for inguinal hernia, appendicitis, or post-incisional pain. 🟥 ESPB: CHAMPION? ✅ Superficial and safe (away from pleura/major vessels) ✅ Wide craniocaudal spread ✅ Suitable for non-sterile or semi-sterile environments ✅ Excellent for rib fractures and abdominal wall pain ✅ Can be done quickly with or without USG 🟧 KEY PEARLS 🧼 Basic aseptic precautions suffice in emergency use 🩻 USG is ideal but can be landmark-based if skilled 🧾 Document block site, volume, drug, and response ⏱️ Reassess for conversion to longer-acting block or catheter if needed 🟫 CHEST WALL BLOCKS: RULE “Hit the Rib, Deposit the Drug” 🔹Deep SAP Block – Needle hits the rib, inject deep to serratus 🔹External Oblique Intercostal Plane Block – Target rib at anterior/mid-axillary line, inject above EO 🔹Parasternal Block – Identify rib near sternum, inject in intercostal plane 🎯A safe, reproducible approach - perfect for emergency or limited-resource settings. 🟨 ABDOMINAL WALL BLOCKS: RULE “Follow the Muscle, Find the Plane” 🔹TAP Block – Feel or visualize the abdominal wall → insert between internal oblique & transversus abdominis 🔹Rectus Sheath Block – Palpate the rectus muscle → inject posterior to it, above posterior sheath 🔹Ilioinguinal/Iliohypogastric Block – Palpate ASIS → inject in plane between internal oblique and transversus abdominis near the iliac crest 🎯Key Tip: Identify the muscle → follow its plane → deposit where spread flows freely. ✅Reliable, reproducible, and effective for anterior abdominal wall analgesia. "When pain impairs breathing or masks diagnosis, a timely On-Arrival Block for the trunk may be your best intervention - not just for comfort, but for survival."

Apologies- it seems the audio didn’t upload! Here is a new link! @ANZRA_X #RegionalAnaesthesia #RegionalAnesthesia #ESPblock youtu.be/uPvt_aSv1KA?si=k_QQ…

I like to have patients lateral for an ESP if possible as they don't need anyone to help them to stay in position, and they often drift off once the local starts to work. This doesn't work if fractures are very near the transverse process. #rauk25 #rauk #espblock @amit_pawa

"Don’t Be Fooled: Why ESP Block Isn’t a Spine Surgery Soloist" #ESPBlock #AnesthesiaTips #SpineSurgery #RegionalAnesthesia #PainManagement #PatientSafety #MinimallyInvasive #MyRATips Tip of the day The Erector Spinae Plane (ESP) Block may look like a magic trick—but here's why it's not your one-stop solution for spine surgeries: 🎯 Targets dorsal rami only consistently – covers skin & deep muscles 🚫 Misses anterior rami – which supply superficial/intermediate muscles & thoracolumbar fascia ⚠️ Medial branch spread? – too unpredictable to trust 🔥 Fascial pain generators – often go untouched 🔒 Airway security in prone – GA is a must for patient safety, isn't it? So, when does ESPB shine? ✅ Great for minimally invasive procedures (e.g., vertebroplasty, endoscopic discectomy) ❌ Not enough for open or major spine surgeries Use ESPB smartly—but don’t fly solo when the stakes are high!

If you only can learn one truncal analgesia block then I would recommend this. It is easy, generally safe, effective, and can be done anywhere from cervical to sacral spine. Learn more: youtu.be/18mjNxAsav8 #ESPblock #RegionalAnalgesia #chronicpain #acutepain #painphysician

" THORACIC WALL BLOCKS: An Art of Looking Between the Lines" #Thoracicwallblocks #Chestwallblocks #Parasternalblocks #PECSblocks #SAPblocks #PVB #ESPblock #RISSblock #ITPblock My 10 points between 6 LINES: ANTERIOR CHEST WALL BLOCKS: (A) Medial to the Midclavicular line: PMM covers ribs & ICMs in the parasternal region. External ICM becomes the Anterior Intercostal Membrane anteriorly (Posterior Intercostal Membrane is formed by Internal ICM posteriorly). 1. Parasternal blocks: Probe placed sagitally over the parasternal region. LA deposition- Between PMM and ICM for Superficial parasternal block OR between internal ICM and transversus thoracic muscle for Deep parasternal (Transversus Thoracic Plane) block. Coverage- Anterior cutaneous nerve T2-T6. Vascular landmark- Internal mammary A. in TTP block. (B) Between Midclavicular - Anterior axillary lines: Muscles from superficial to deep include PMM, PMnM, and SAM above ribs & ICMs. 2. PEC ZERO (Modified Clavipectoral Fascial Plane) block:* Probe placed vertically between the clavicle (proximally) and 2nd Rib (distally). LA deposition- Above and below PMnM. Vascular landmark- Acromial branch of TAA. 3. PEC 1 (InterPectoral plane) block: Probe over 2nd Rib. LA deposition- Between PMM and PMnM. Vascular landmark- Pectoral branch of TAA. Coverage- LPN & MPN. 4. PEC 2 (Pecto-Serattus Plane) Block: Probe over 3rd Rib. LA depostion (2 injections)- Between PMM-PMnM & PMnM-SAM. Coverage- LPN & MPN, ICNs T2-T6. (C) Between Anterior - Posterior Axillary lines: Muscles include SAM (anterior to midaxillary line). LDM & SAM (posterior to midaxillary line) above the ribs. 5. BRILMA (on 4/5th ribs) and modified BRILMA (on 7/8th ribs): Probe placed at midaxillary. LA depostion- Between SAM and Ribs. Coverage- Lateral cutaneous nerves T2-T7 (BRILMA) and T5-T12 (modified BRILMA). 6. SAP 1 (superficial SAP): Probe between Midaxillary- Posterior axillary lines. LA deposition- Between SAP muscle and LDM at 4/5 th ribs level. Coverage-Intercostobrachial N., T3-T9, LTN, and TDN. SAP 2 (Deep SAP): LA deposition below SAM at 4/5 th ribs level. Vascular landmark- Thoracodoral A above SAM. Coverage- Intercostobrachial N. and T3-T9. POSTERIOR CHEST WALL BLOCKS: (D) Probe kept parasagittal 2.5 cm lateral to the midline: 7. Thoracic PVB: LA deposition above pleura by piercing superior costotransverse ligament. 8. Inter Transverse Process (ITP) Block: LA deposition anterior to C-T ligament in the retro CT space. (E) Probe kept parasagittal 4 cm lateral to the midline: 9. Thoracic ESP Block: LA deposition below ESPM by hitting the tip of the TP. (F) Probe between TP and Scapula: 10. RISS (Rhomboids Intercostal Sub-Serratus plane) Block: LA deposition between RHM-ICM along the Medial border and below SAM at the inferior angle of the Scapula. Coverage- T2-T11 dermatomes.

A balanced discussion of #ESPblock?? Is it possible? Maybe... 🆓🔗rdcu.be/dq1A5 @Ropivacaine @DalAnesthesia @CJA_Journal Currently, there are four proposed mechanisms of action of the ESP block:

What Wut? #ESPBlock covers what?! 😂😉 @jeffgadsden @BlockIt_Hot_Pod #AC2023

#SAP block and #ESPblock for thoracotomy. #RCT in Feb 2022 issue. Read here: bit.ly/3so8Sqb @AoraIndia @ESRA_Society @RegionalAnaesUK @CJA_Journal @AFSRA10 @aosra_pm

A pilot RCT comparing ESP block and Thoracic Epidural for traumatic rib fractures in July 2023 issue of #IJA Read here: bit.ly/3QjaATA @STS_CTsurgery @NM_Lung @ThoracicAGuys @CritCareReviews @SOCCA_CritCare @UCL_RCCA @WOSCCT @CCRG_Research #espblock #thoracicepidural

Check out the new BJA #miniflipbook with all of the FREE content from the May issue. Articles on: #ESPblock #hypotension #cognitivedysfunction #sepsis #paediatrics #EEG #cancerpain #fatigue #FONA bja130-5.elsevierdigitaledit…

Check out the new BJA #miniflipbook with all of the FREE content from the May issue. Articles on: #ESPblock #hypotension #cognitivedysfunction #sepsis #paediatrics #EEG #cancerpain #fatigue #FONA bja130-5.elsevierdigitaledit…

Check out the new BJA #miniflipbook with all of the FREE content from the May issue. Articles on: #ESPblock #hypotension #cognitivedysfunction #sepsis #paediatrics #EEG #cancerpain #fatigue #FONA bja130-5.elsevierdigitaledit…

Check out the new BJA #miniflipbook with all of the FREE content from the May issue. Articles on: #ESPblock #hypotension #cognitivedysfunction #sepsis #paediatrics #EEG #cancerpain #fatigue #FONA bja130-5.elsevierdigitaledit…

Check out the new BJA #miniflipbook with all of the FREE content from the May issue. Articles on: #ESPblock #hypotension #cognitivedysfunction #sepsis #paediatrics #EEG #cancerpain #fatigue #FONA bja130-5.elsevierdigitaledit…

Its a good day in ED when my patient says that his chest pain is completely gone after my #ESPblock. Regional anaesthesia is a must have skill for ED physicians

Conversation: Phenol spread in erector spinae plane block for cancer Article: bit.ly/3p6CyGN Letter: bit.ly/3LxuuGe Letter: bit.ly/3LBsJZ0 #regionalanesthesia #pain #ESPblock @gdossantos_md @AndresR00916584 @dr_rajgupta @ESchwenkMD @ASRA_Society