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.
After speaking to a colleague of mine regarding regional anesthesia for thoracotomy and mastectomy, I am reading up on Erector Spinae Plane (ESP) block.
I’ve been hearing more and more about PEC 2 block for mastectomy. What’s wonderful about this block is that it seems that the risk of pneumothorax is lower than for a paravertebral block.
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).
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