American Society of Regional Anesthesia and Pain Medicine February 2018 - 18

Figure 3: If the transducer is too lateral, the ribs will be visualized
instead. (A)These are recognizable as rounded acoustic shadows with an
intervening hyperechoic pleural line. If the transducer is too medial, the
thoracic laminae (flat hyperechoic lines) will be visualized (B).

Figure 4: After correct transverse process (TP) identification, an
18-gauge echogenic needle is inserted using an in-plane, cranial-to-caudad
approach to contact the bony shadow of the TP with the tip deep to the
fascial plane of the erector spinae muscle.

sheath. Correct catheter location is confirmed by bolusing 2-3 cc
of normal saline 0.9%. Following confirmation of correct catheter
tip location, 20 cc of ropivacaine 0.5% is injected and cranial and
caudal spread of local anesthetic can be visualized.

is confirmed by injecting 0.5-1 cc of normal saline 0.9% and
observing linear fluid spread lifting the erector spinae muscle off
the tip of the TP (Figure 5). Once the fascial plane is recognized, the
needle is removed and the catheter is inserted through the needle

18

ESP Catheter Management and Follow-Up. The APMS team
assesses patients daily, focusing on pain scores, incentive spirometry
outcomes, ambulation status, 24-hour opioid requirements, mental
status, and the integrity of the catheter insertion site. The anesthesia
on-call team gets a thorough sign-out and manages any issues
overnight, these may include infusion pump malfunction, inadequate
analgesia, and inadvertent catheter removal.
Breakthrough pain is managed with small doses of intravenous
opioids. We have observed fewer instances of inadequate analgesia

American Society of Regional Anesthesia and Pain Medicine
2018



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