Anaesthesia, 2010, 65, pages 1221–1224 doi:10.1111/j.1365-2044.2010.06420.x .....................................................................................................................................................................................................................
CASE REPORT
Thoracic paravertebral anaesthesia for awake video-assisted thoracoscopic surgery daily F. Piccioni,1 M. Langer,2,3 L. Fumagalli,1 E. Haeusler,1 B. Conti4 and P. Previtali5 1 Staff Anaesthetist, 2 Director, Department of Anaesthesiology, Intensive Care and Palliative Care, 4 Staff Surgeon, Department of Thoracic Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy 3 Professor of Anaesthesia and Intensive Care, 5 Resident Anaesthetist, Universita` degli Studi, Milan, Italy Summary
Thoracic paravertebral blockade has been described as an effective alternative to epidural blockade for the management of postoperative pain after thoracic surgery. Here we present what we believe is the first description of the use of thoracic paravertebral block as the sole anaesthetic for video-assisted thoracoscopy. Two oncology patients with severe respiratory disease presented for video-assisted thoracoscopic surgery. Thoracic paravertebral block provided excellent surgical conditions and postoperative pain relief for these patients and allowed an optimal assessment of the anaesthetic impact on respiratory function. . ......................................................................................................
Correspondence to: Dr F. Piccioni Email:
[email protected] Accepted: 12 May 2010
Paravertebral block has been described as an effective alternative to epidural block for the management of postoperative pain after thoracic surgery [1–3]. It is usually combined with general anaesthesia. We could not find any reports of its use as the sole anaesthetic for thoracoscopic surgery. In these two case reports we describe the successful use of the thoracic paravertebral block as the sole anaesthetic for video-assisted thoracoscopy. Case 1 A 65-year-old woman (weight 65 kg, height 160 cm) presented for video-assisted thoracoscopy, parietal pleural biopsy and talc pleurodesis. She suffered from chronic obstructive lung disease and four years previously had undergone a total thyroidectomy for papillary carcinoma associated with the presence of bilateral pulmonary metastases, for which she had postoperative radiotherapy and chemotherapy. A year later she underwent right video-assisted thoracoscopy and talc pleurodesis for recurrent effusions. Two months later diagnostic imaging revealed cervical, pretracheal, retroclavicular, mediastinal and bilateral pulmonary metastases. She subsequently presented with severe dyspnoea and a chest X-ray showing a large left pleural effusion, requiring insertion of a chest 2010 The Authors Journal compilation 2010 The Association of Anaesthetists of Great Britain and Ireland
drain, and signs of right pulmonary atelectasis. Arterial blood gas analysis (breathing air) showed hypoxaemia and respiratory alkalosis: SaO2 = 88%; PaO2 = 6.39 kPa; PaCO2 = 4.39 kPa; pH = 7.51. Pulmonary function tests revealed her forced vital capacity (FVC) was 26% of predicted and forced expiratory volume in 1 s (FEV1) 30% of predicted with a FEV1 ⁄ FVC ratio of 0.96. Her forced expiratory flow from 25% to 75% (FEF 25–75%) was 53% and peak expiratory flow (PEF) 52% of predicted values. She also had a history of hypertension and recurrent episodes of atrial flutter treated with percutaneous ablation. On admission, her ECG revealed normal sinus rhythm with a rate of 95 bpm and echocardiography revealed mild aortic stenosis. Her medications included metoprolol (25 mg twice daily), acetylsalicylic acid (100 mg once daily) and candesartan (16 mg once daily) for hypertension. She consented to a regional anaesthesia technique and conversion to general anaesthesia if necessary. The patient took only metoprolol on the morning of surgery. After applying non-invasive monitoring, we performed thoracic paravertebral blocks without sedation, with the patient in the sitting position [4]. The superior aspects of spinous processes of T3–T6 were marked and needle insertions performed 2.5 cm laterally 1221
Æ
F. Piccioni et al. Thoracic paravertebral anaesthesia for awake video-assisted thoracoscopy Anaesthesia, 2010, 65, pages 1221–1224 . ....................................................................................................................................................................................................................
after skin anaesthesia with a total of 7 ml lidocaine 1%. We used a 70-mm, 22-G insulated stimulating needle (Polymedic; Temena SARL, Bondy, France) and peripheral nerve stimulator (Polystim II; Temena SARL). The needle was directed perpendicular to the skin until the transverse process was contacted. The needle was then ‘walked’ cranially off the transverse process and advanced 1.5–2 cm with the nerve stimulator current set at 2.5 mA (0.3 ms duration and 1 Hz) until an appropriate intercostal muscle response was seen. Then the stimulating needle was cautiously advanced until the muscle or sensitive response could still be achieved by a stimulating current of 0.5 mA. After careful aspiration, 5 ml ropivacaine 1% per segment was administered at four segments. The blocks took us 10 min to perform. The onset of sensory loss to pinprick occurred approximately 15 min after the injections. There was no evidence of bilateral blockade. The patient was transferred to the operating room and placed in the right lateral position for surgery. Supplemental oxygen was administered at 10 l.min)1. The patient remained haemodynamically stable throughout surgery and tolerated the pneumothorax well with no coughing. She remained comfortable and able to talk throughout her surgery. No supplemental analgesia was required during the 30-min surgical procedure. At the end of surgery, acetaminophen 1 g was given intravenously and the patient was transferred to the recovery room. Forty-five minutes later, arterial blood gas analysis results were: SaO2 = 97%; PaO2 = 10.39 kPa; PaCO2 = 5.06 kPa; pH = 7.47. At this point the patient was transferred to the thoracic surgery unit. She developed atrial fibrillation that night which was successfully treated with amiodarone. On questioning the following day, she was extremely pleased with her anaesthetic. Case 2 A 61-year-old man (weight 74 kg, height 170 cm) presented for video-assisted thoracoscopy for parietal pleural biopsy and talc pleurodesis. He had a one-year history of right inferior lobe carcinoma associated with right paratracheal and hilar lymphatic metastases. Three weeks later, diagnostic imaging revealed multiple sternal and vertebral metastases. He subsequently underwent radiotherapy and chemotherapy. Later that year he presented with severe dyspnoea (with SpO2 of 85% breathing air). His chest X-ray showed a large right pleural effusion. A thoracic drain was immediately inserted into the right pleural cavity. Arterial blood gas analysis (breathing air) showed hypoxaemia and respiratory alkalosis: SaO2 = 93%; PaO2 = 8.26 kPa; PaCO2 = 4.93 kPa; pH = 7.46. Pulmonary function tests 1222
revealed a FVC of 46% of predicted value, FEV1 46% of predicted value, with a FEV1 ⁄ FVC ratio of 0.76. The FEF 25–75% was 29% and PEF 55% of predicted values. He also had a history of right femoropopliteal venous thrombosis associated with asymptomatic pulmonary thromboembolism. His admission ECG revealed normal sinus rhythm with a frequency of 92 bpm. His medications included subcutaneous nadroparin (15200 IU once daily) and oxycodone (10 mg once daily). The patient consented to have regional anaesthesia and conversion to general anaesthesia if necessary. He was premedicated with 1 mg oral lorazepam. Following application of non-invasive monitoring, thoracic paravertebral blockade was performed with the patient in the sitting position, as described above. Four millitres ropivacaine 0.75% was administered at six levels. We took 15 min to perform the blocks. Onset of sensory loss to pinprick occurred about 15 min after injection. There was no evidence of bilateral blockade. The patient was transferred to the operating room and placed in the left lateral position for surgery. Supplemental oxygen was administered at 10 l.min)1. Again, the patient remained haemodynamically stable throughout surgery and tolerated the pneumothorax well with no coughing. He was comfortable and talking throughout surgery and did not require supplemental analgesia during the 25-min procedure. Forty-five minutes after entering the recovery room, he was transferred to the thoracic surgery unit. Two hours after the end of procedure, arterial blood gas analysis results were: SaO2 = 95%; PaO2 = 9.06 kPa; PaCO2 = 4.39 kPa; pH = 7.46 (breathing air). On questioning the following day, he was extremely pleased with his anaesthetic care. Both surgical procedures were performed with the patients in a full lateral position. Skin incisions were lateral in the fifth, sixth or seventh intercostal spaces, followed by blunt dissection to the parietal pleural surface, insertion of a 10.5-mm diameter trocar and passage of the thoracoscope. Parietal pleural biopsies were taken and 8 g hydrated magnesium silicate (Steritalc; Novatech, La Ciotat, France) insufflated through the thoracoscopic trocar while the lung was still deflated. At the end of the intervention, two chest tubes were placed and 15 cmH2O suction applied. The patients were transferred to the thoracic surgery unit once a routine postoperative chest X-ray had excluded the presence of residual pneumothorax. Discussion
Thoracic paravertebral blockade allowed us to avoid general anaesthesia and the potential necessity for a period of postoperative ventilation following video-assisted tho 2010 The Authors Journal compilation 2010 The Association of Anaesthetists of Great Britain and Ireland
Æ
Anaesthesia, 2010, 65, pages 1221–1224 F. Piccioni et al. Thoracic paravertebral anaesthesia for awake video-assisted thoracoscopy . ....................................................................................................................................................................................................................
racoscopy in our two patients with respiratory insufficiency. Regional anaesthesia techniques may provide better haemodynamic stability, superior postoperative analgesia, decreased surgical stress response and fewer side effects, such as nausea and vomiting, when compared to general anaesthesia. Several studies have demonstrated that thoracic paravertebral blockade is adequate as the sole anaesthetic for breast surgery [5–8]. Thoracic surgery has been successfully carried out under epidural blockade [9–11]. No previous studies have reported video-assisted thoracoscopy performed solely under thoracic paravertebral blockade. According to a recent meta-analysis, thoracic paravertebral blockade and epidural analgesia provide comparable pain relief after thoracic surgery [2], but paravertebral block has a better side-effect profile and is associated with a reduction in pulmonary complications. Epidural anaesthesia may be contraindicated or technically challenging in sepsis, coagulation disorders, pre-existing neurological disorders and difficult thoracic vertebral anatomy. Complications associated with epidural anaesthesia include dural puncture, neurological injury and paraplegia. Paravertebral blockade offers an attractive and effective alternative with fewer contra-indications. There are no large randomised trials comparing paravertebral blockade with epidural blockade; however, paravertebral blockade seems to be associated with improvements in respiratory function, maintenance of haemodynamic stability and fewer complications [2]. By administering local anaesthetic near the somatic nerve roots, thoracic paravertebral blockade provides unilateral anaesthesia without producing bilateral sympathectomy. A well-known potential complication of thoracic paravertebral blockade is pneumothorax. However, the incidence is low at 0.5% [12, 13], and less of a problem if thoracoscopy or thoracotomy is planned. Paravertebral blockade is relatively easy to learn; it can be performed using the commonly practiced loss of resistance technique [14], with the assistance of ultrasound [15] or using a nerve simulator [4]. In addition, stellate ganglion block or administration of nebulised local anaesthetic can be performed to suppress coughing related to surgical manipulation during thoracic surgery [16]. During video-assisted thoracoscopy, spontaneous breathing may become difficult due to the open pneumothorax created to perform the procedure, resulting in mediastinal shift and compression of the dependent lung. However, maintenance of diaphragmatic tone will tend to reduce the respiratory compromise. We needed to be prepared to convert to general anaesthesia during both procedures and would not attempt a regional technique in patients with a suspected difficult airway. 2010 The Authors Journal compilation 2010 The Association of Anaesthetists of Great Britain and Ireland
At our institution, we use thoracic paravertebral block to achieve surgical anaesthesia for breast cancer surgery in high-risk patients and for postoperative pain control after thoracic procedures. We prefer nerve stimulator guidance to advance the needle close to the paravertebral nerves, because we think this results in a better vertical spread of local anaesthetic [17]. The small volume (5 ml) used at each paravertebral level reduces the risk of epidural spread. In conclusion, the use of thoracic paravertebral block as the sole anaesthetic for video-assisted thoracoscopy resulted in adequate unilateral anaesthesia, stable hemodynamics and a high level of patient satisfaction in our two patients. We believe this is the first case report in which thoracic paravertebral block has been successfully used as the sole anaesthetic for video-assisted thoracoscopy. More clinical experience is required to determine the future role of thoracic paravertebral blockade as the sole anaesthetic for thoracic surgery. Acknowledgement
Published with the patients’ written consent. The first case described in this manuscript was presented as a poster at the SMART Congress, Milan, Italy, 2008. No external funding and no competing interests declared. References 1 Vogt A, Stieger DS, Theurillat C, Curatolo M. Singleinjection thoracic paravertebral block for postoperative pain treatment after thoracoscopic surgery. British Journal of Anaesthesia 2005; 95: 816–21. 2 Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy – a systematic review and metaanalysis of randomized trials. British Journal of Anaesthesia 2006; 96: 418–26. 3 Joshl GP, Bonnet F, Shah R, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesthesia and Analgesia 2008; 107: 1026–40. 4 Naja MZ, El Hassan MJ, Oweidat M, Zbibo R, Ziade MF, Lo¨nnqvist PA. Paravertebral blockade vs general anaesthesia or spinal anaesthesia for inguinal hernia repair. Middle East Journal of Anesthesiology 2001; 16: 201–10. 5 Weltz CR, Greengrass RA, Lyerly HK. Ambulatory surgical management of breast carcinoma using paravertebral block. Annals of Surgery 1995; 222: 19–26. 6 Greengrass R, O’Brien F, Lyerly K, et al. Paravertebral block for breast cancer surgery. Canadian Journal of Anesthesia 1996; 43: 858–61. 7 Cooter RD, Rudkin GE, Gardiner SE. Day case breast augmentation under paravertebral blockade: a prospective study of 100 consecutive patients. Aesthetic Plastic Surgery 2007; 31: 666–73.
1223
Æ
F. Piccioni et al. Thoracic paravertebral anaesthesia for awake video-assisted thoracoscopy Anaesthesia, 2010, 65, pages 1221–1224 . ....................................................................................................................................................................................................................
8 Naja MZ, Ziade MF, Lo¨nnqvist PA. Nerve-stimulator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial. European Journal of Anaesthesiology 2003; 20: 897–903. 9 Pompeo E, Mineo D, Rogliani P, Sabato AF, Mineo TC. Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules. The Annals of Thoracic Surgery 2004; 78: 1761–8. 10 Mineo TC, Pompeo E, Mineo D, Tacconi F, Marino M, Sabato AF. Awake nonresectional lung volume reduction surgery. Annals of Surgery 2006; 243: 131–6. 11 Al-Abdullatief M, Wahood A, Al-Shirawi N, et al. Awake anaesthesia for major thoracic surgical procedures: an observational study. European Journal of Cardiothoracic Surgery 2007; 32: 346–50. 12 Lo¨nnqvist Pa, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade. Failure rate and complications. Anaesthesia 1995; 50: 813–5.
1224
13 Naja Z, Lo¨nnqvist PA. Somatic paravertebral nerve blockade incidence of failed block and complications. Anaesthesia 2001; 56: 1181–201. 14 Eason MJ, Wyatt R. Paravertebral thoracic block: a reappraisal. Anaesthesia 1979; 34: 638–42. 15 Pusch F, Wildling E, Klimscha W, Weinstable C. Sonographic measurement of needle insertion depth in paravertebral blocks in women. British Journal of Anaesthesia 2000; 85: 841–3. 16 Guarracino F, Gemignani R, Pratesi G, Melfi F, Ambrosino N. Awake Palliative thoracic surgery in a high-risk patient: one-lung, non-invasive ventilation combined with epidural blockade. Anaesthesia 2008; 63: 761–3. 17 Naja MZ, Ziade MF, El Rajab M, El Tayara K, Lo¨nnqvist PA. Varying anatomical injection points within the thoracic paravertebral space: effect on spread of solution and nerve blockade. Anaesthesia 2004; 59: 459–63.
2010 The Authors Journal compilation 2010 The Association of Anaesthetists of Great Britain and Ireland
