Continuous paravertebral block using a thoracoscopic catheter-insertion technique for postoperative pain after thoracotomy: a retrospective case-control study. Journal of Cardiothoracic Surgery volume 12, Article number: 5 (2017)
To place the PV catheter at the T4-5 level, the authors used an in-plane transverse technique under ultrasound guidance, with the probe in a transverse orientation. After identifying the anatomic landmarks on ultrasound, a 17-gauge Tuohy needle was advanced in a lateral to medial direction, until the tip was beneath the transverse process. For all recipients in the study, the authors further confirmed correct PV catheter placement with real-time infusion of a local anesthetic (1-3 mL of 1.5% lidocaine with epinephrine 1:200,000); they were able to visualize on ultrasound the spread from the tip of the catheter.
Once it was confirmed that the tip remained in position, the PV catheter was secured with skin glue (Dermabond®, Ethicon, Inc.; Somerville, NJ). Next, at the PV catheter insertion site, the authors placed an occlusive dressing on a chlorhexidine-impregnated sponge (BioPatch®, Johnson & Johnson Wound Management, a division of Ethicon, Inc.; Somerville, NJ). The PV catheter was connected to an elastomeric pump (ON-Q®, Halyard Health, Alpharetta, GA), an infusion of 0.2% ropivacaine was started at a rate of 0.2 to 0.25 mL/kg/h; the maximum dose was 7 mL/h per side in bilateral lung transplant recipients and 14 mL/h in unilateral single-lung transplant recipients.
Under sterile conditions and while patients still were in the lateral position with the diseased side up, a linear ultrasound transducer (10-12 MHz) was placed in a sagittal plane over the midclavicular region of the thoracic cage. Then the ribs were counted down until the fifth rib was identified in the midaxillary line (Fig 1).18 The following muscles were identified overlying the fifth rib: the latissimus dorsi (superficial and posterior), teres major (superior), and serratus muscles (deep and inferior). The needle (a 22-gauge, 50-mm Touhy needle) was introduced in plane with respect to the ultrasound probe, targeting the plane superficial to the serratus anterior muscle (Fig 2). Under continuous ultrasound guidance, 30 mL of 0.25% levobupivacaine was injected, and then a catheter was threaded. A continuous infusion of 5 mL/hour of 0.125% levobupivacaine then was started through the catheter.
Effect of Continuous Paravertebral Dexmedetomidine Administration on Intraoperative Anesthetic Drug Requirement and Post-Thoracotomy Pain Syndrome After Thoracotomy: A Randomized Controlled Trial. JCVA February 2017. Volume 31, Issue 1, Pages 159–165.
After speaking to a colleague of mine regarding regional anesthesia for thoracotomy and mastectomy, I am reading up on Erector Spinae Plane (ESP) block.
- Rib fractures
- Continuous Erector Spinae Plane Block for Rescue Analgesia in Thoracotomy After Epidural Failure: A Case Report. A & A Case Reports. 8(10):254–256, MAY 2017.
- The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Regional Anesthesia and Pain Medicine. Volume 41, Number 5, September-October 2016.
- The Ultrasound-Guided Continuous Erector Spinae Plane Block for Postoperative Analgesia in Video-Assisted Thoracoscopic Lobectomy. Regional Anesthesia and Pain Medicine: July/August 2017 – Volume 42 – Issue 4 – p 537.
Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane. Indian J Anaesth. 2018 Jan; 62(1): 75–78.
- Mastectomy/Breast reconstruction
- Abdominal surgery
- Continuous Erector Spinae Plane (ESP) Analgesia In Different Open Abdominal Surgical Procedures: A Case Series. Journal of Anesthesia and Surgery. https://doi.org/10.15436/2377-1364.18.1853.
Bilateral Continuous Erector Spinae Plane Block Contributes to Effective Postoperative Analgesia After Major Open Abdominal Surgery: A Case Report. A&A Practice: December 1, 2017 – Volume 9 – Issue 11 – p 319–321
Ultrasound-Guided Erector Spinae Plane Block in Patients Undergoing Open Epigastric Hernia Repair: A Prospective Randomized Controlled Study. Anesthesia & Analgesia: July 2019 – Volume 129 – Issue 1 – p 235-240
- Cardiac surgery
- Continuous Erector Spinae Plane (ESP) Block for Postoperative Analgesia after Minimally Invasive Mitral Valve Surgery. October 2018Volume 32, Issue 5, Pages 2271–2274.
- Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Ann Card Anaesth 2018;21:323-7.
Continuous ESP block catheter (my current regimen and what I’m able to get at my institution):
- Braun Periflex catheter through 17g epidural needle
- Cranial-to-caudal approach @ T5 (mastectomy, vats, rib fractures)
- 20ml 0.25% bupi + epi prior to catheter
- Catheter 5cm in space
- 5 ml 0.25% bupi + epi after catheter placed
- Mix: 0.125% bupi + fentanyl @ 10 ml/hr
- If PCEA available, bolus 15ml every 3 hours; continuous as mix above.
- U/S guidance: probe position similar to infraclavicular block. Find 3rd, 4th rib.
- Pt position: Head away from side of block. Ipsilateral arm abducted.
- PEC 2: Inject 20 ml 0.25% bupi between pec minor and serratus.
- PEC 1: Inject 10 ml 0.25% bupi between pec major and pec minor.
- Serratus: 5th rib, mid-axillary line. Inject 30 ml 0.125% bupi along top (superficial) and bottom (deep) of serratus muscle (which is just deep to the latissmus dorsi).
Update: Oct 24, 2018
PECs blocks in Cardiac Surgery
- BJA 2010 – Efficacy and Safety of Paravertebral Blocks in Breast Surgery: a meta-analysis of randomized clinical trials
- BJA 2010 – Effect of Anesthetic Technique and Other Perioperative Factors on Cancer Reccurence
- Anesthesiology 2006 – Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis?
- BJA 2012 – Can anesthetic and analgesic techniques affect cancer recurrence and risk?
- ASA: Paravertebral Block Ups Breast Cancer Surgery Outcomes
- Anesthesiology News – Paravertebral Blocks: The Evolution of a Standard of Care
- YouTube Ultrasound-Guided Paravertebral Block
- NYSORA – Paravertebral Block: Landmark Technique
- Paravertebral Block Landmark Technique
- NYSORA – Paravetebral Block: Ultrasound-Guided Technique
But wait… what about the potential side effects/adverse events from a paravertebral block?
Why not do a TIVA with propofol and dexmetetomedine and local anesthesia via surgeon? Where’s that study to compare?
Prolonging blockade with adjuvants:
- IOSR J of Dental and Medical Sci; Dec 2015. Comparative study of bupiv with dexamethasone and bupi with clonidine through single space PVB for post op analgesia in thoracic and abdominal surgeries.
- 0.125% Bupiv + clonidine (1mcg/kg) vs 0.125% bupiv + dexamethasone (4mg): greater duration of analgesia in the dexamethasone group.
Today, we had a guest speaker Christian Spies from Queen’s Hospital in Hawaii who spoke on his experience with his TAVR team and conscious sedation vs. general anesthesia for these patients. More specifically, we are speaking of the transfemoral route.
- Patient selection is key (consider for COPD; bad for OSA)
- Short surgical time for monitored anesthesia care (MAC)
- Decrease invasive monitoring (no PA catheter,+/-CVP)
- No difference in hospital LOS or 1 year mortality rate
- Move from TEE to TTE if MAC
- Be prepared to convert MAC to GA (can be difficult in already tenuous patient in a crowded space under the drapes)
- MAC agents: dexmetetomidine, propofol, ofirimev
- Decrease pressor use
- Develop an algorithm for MAC vs. GA and patient selection
For my own lit search:
- Anaesthesia Nov 2011: Sedation vs general anaesthesia for the ‘high-risk’ patient – what can TAVI teach us?
- JACC May 2012: The Minimalist Approach for Transcatheter Aortic Valve Replacement in High-Risk Patients
- Cardiac Interventions Today May 2012: Rouen Experience Supports Safety of TAVR Using Local Anesthesia
- MedPage Today July 2012: TAVI: No Need for Patients to ‘Go Under’
- Amer J Card Jan 2013: Effect of Local Anesthetic Management With Conscious Sedation in Patients Undergoing Transcatheter Aortic Valve Implantation
- SCA 2013: PBL — Anesthesia for TAVR
- Indian Heart J March 2014: Transcatheter aortic valve implantation under conscious sedation – the first Indian experience
- TCTMD Mar 2015:As TAVR Evolves, Local Anesthesia Could Be an Option for Lower-Risk Patients
***Update May 1, 2018***
We at Scripps Memorial Hospital in La Jolla do most of our transfemoral TAVRs via conscious sedation assuming appropriate patient selection. These patients still tend to be the inoperable patients not cleared for open heart AVR (aortic valve replacement). My techniques and choices for setup have changed over time as I’ve had a chance to fine-tune my plan based on prior experiences with TAVR. Patients typically come to the hybrid room with a 20g PIV placed by the pre-op RN.
- 4 channel Alaris pump:
- dexmedetomidine @ 0.7 mcg/kg/hr until incision –> 0.4 mcg/kg/hr until valve deployment –> off
- norepinephrine @ 2 mcg/min (titrating on/off, up/down as vitals suggest)
- Isolyte (IV carrier fluid) @ 200ml/hr until valve deployment –> 50ml/hr
- Cordis neck line
- Initially, I would have the interventional cardiologist setup a femoral venous line since they’re getting access to the groin. However, the cardiologist would use that femoral line for emergent ECMO cannulation and I would lose my venous access and have to depend on a measly 20g PIV. Nowadays, I try for a short 14g or 16g PIV. If I can’t get one, the patient gets an awake right IJ cordis for large venous access.
- Hot line fluid warmer with blood-Y tubing: this is for hookup to a large PIV or cordis line
- Right radial arterial line
- I started only placing right radial arterial lines because there was a case of a dissection and I immediately lost my left radial arterial line and couldn’t do pressure monitoring. I insist on only using the RIGHT radial for my arterial monitoring. Do not let the cardiologist only give you arterial monitoring based on their femoral arterial access. It will only give you intermittent monitoring and there are critical points leading up to the deployment where you need CONTINUOUS arterial monitoring. Therefore, I’ve found the right RADIAL arterial line best for continuous monitoring.
- Facemask for continuous oxygen at 10L/mim with ETCO2 monitoring
- For trans-subclavian/axillary approach vs. transfemoral approach TAVR, I’ll put in a supraclavicular block right after Cordis/large-bore PIV venous access for patient comfort while still utilizing conscious sedation/MAC.
- When the patient gets to the room, transfer patient to OR table. Start IV fluids @ 200ml/hr. Cases that go well are about 2 hours from start to end.
- Facemask O2 at 10L/min.
- Start sedation: precedex/dexmedetomidine @ 0.7 mcg/kg/hr. Some patients may receive 1-2mg midazolam x 1 and 25-50mcg fentanyl for radial art line placement.
- Place right radial art line with lidocaine for skin numbing. Place PIV with lidocaine. If unable to get access for PIV, prep neck –> sterile gown/glove/drapes for U/S guided Cordis placement with lidocaine.
- OR staff preps patient. Antibiotics prior to incision.
- At incision –> precedex to 0.4 mcg/kg/hr. 25-50mcg fentanyl PRN discomfort. 10-20mg propofol push for discomfort if needed while large sheath placed for valve deployment.
- Crossing valve –> BP changes. Manage with volume or levophed.
- Don’t treat over-drive pacing too aggressively when the valve is deployed. Typically, once the new valve is in, a little volume will help normalize the BP.
- Once valve is deployed, turn precedex off. No other sedation or BP meds needed. Change IVF rate to 50ml/hr.
- Patient heads to PACU awake, interactive, and comfortable.
What techniques do you like to do? Any suggestions on a different approach?