AJA Asian Journal of Anesthesiology

Advancing, Capability, Improving lives

Short communication
Volume 55, Issue 1, Pages 24-25
T. Fujii 1 , Y. Shibata 2 , Y. Ban 3 , A. Shitaokoshi 3 , K. Nishiwaki 4
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Abstract

Thoracic paravertebral block (TPVB) is an efficient alternative to epidural anesthesia. The location of a catheter within the thoracic paravertebral space (TPVS) has been examined in the human cadaver studies, but it is unclear how it goes into the TPVS during catheterization. In this report, thoracoscopy was used to observe the thoracic cavity in real-time during a parasagittal in-plane approach of ultrasound-guided TPVB. During thoracoscopy, we observed whether a paravertebral catheter could be advanced caudally beyond the ribs into the neighboring TPVS. Our result demonstrated that the catheter was difficult to be advanced beyond the ribs and confined within the same level of TPVS as where it was inserted. In the previous thoracoscopic observation of the paravertebral spread, we assumed that the local anesthetic acts most strongly at the intercostal level of the injection. Therefore, we recommend to insert the catheter for TPVB at the level corresponding to the incision site of thoracotomy.

Keywords

Thoracic paravertebral block; Catheterization; Paravertebral catheter; Thoracoscopy;


1. Introduction

Thoracic paravertebral block (TPVB) is an efficient alternative to epidural anesthesia for perioperative analgesia in thoracic surgery. In our institution, we perform ultrasound-guided TPVB and insert a catheter into the thoracic paravertebral space (TPVS) for the management of post-thoracotomy pain. The location of a catheter within the TPVS has been examined in human cadaver studies,1–3 but it is unclear how it goes into the TPVS during catheterization and whether a paravertebral catheter could be advanced in the craniocaudal direction beyond the ribs into the neighboring TPVS.

2. Methods

Thoracoscopy was used to observe the thoracic cavity during parasagittal in-plane TPVB. At the end of video-assisted thoracoscopic surgery (VATS), we observed whether a paravertebral catheter could be advanced caudally beyond the ribs into the neighboring TPVS. In this technique, the 15–6 MHz ultrasonic linear array transducer of a portable ultrasound machine (S-Nerve, FUJIFILM SonoSite, Bothell, WA, USA) was positioned about 2.5 cm lateral to the midline between two adjacent transverse processes (Fig. 1). An 18-gauge Tuohy needle (Perican, B. Braun Melsungen AG, Melsungen, Germany) was inserted in-plane and in the cranial-to-caudal direction under ultrasonographic guidance, making an angle of 75°–90° with the skin until it came in contact with the lateral edge of the transverse process. Once the needle met the transverse process, it was withdrawn partially and redirected caudally to walk-off the lateral edge of the transverse process. The needle was advanced about 10–15 mm past the point of contact with the lateral edge of the transverse process until its tip entered the TPVS. After ruling out the possibility of intravascular tip placement, ventral displacement of the parietal pleura by 10 mL of saline injection was observed ultrasonographically. (Ultrasound image, Video 1). An epidural catheter (Perifix ONE, B. Braun Melsungen AG, Melsungen, Germany) was inserted to a depth of 5 cm into the TPVS through the Tuohy needle.

Fig. 1
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Fig. 1. The patient is positioned in a lateral decubitus position with the side to be blocked uppermost. An ultrasonic linear array transducer is placed about 2.5 cm lateral to the midline between the two adjacent transverse processes. An 18-guage Tuohy needle is inserted in-plane in the cranial-to-caudal direction under ultrasonographic guidance.

The following is the supplementary data related to this article:

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Video 1. Catheterization in an ultrasound-guided thoracic paravertebral block using thoracoscopy (Parasagittal in-plane approach).

The first case was a 20-year-old man (weight, 58 kg; height, 171 cm) who underwent VATS for recurrent pneumothorax. TPVB was performed at the end of VATS using a parasagittal in-plane approach. In the case presented in the second video, the patient was a 71-year-old woman (weight, 49 kg; height, 147 cm) who underwent VATS because of a diagnosis of interstitial pneumonia. TPVB was performed using the same technique at the same timing as the first case.

3. Results

The catheter was confined within the same level of TPVS as where it was inserted. Even though the catheter was inserted forcibly, it was difficult to advance it beyond the ribs (Thoracoscopic view, Video 1). In one case, the catheter penetrated the parietal pleura and was displaced into the thoracic cavity (Thoracoscopic view, Video 1).

4. Discussion

Based on the present report, we found that it was difficult to advance a paravertebral catheter in the craniocaudal direction beyond the ribs. We recently reported the spread of local anesthetic injected into the TPVS under thoracoscopy.4 In this previous report, we described the lateral expansion of the local anesthetic along the intercostal space on thoracoscopy, which resulted in the local anesthetic pressing down the parietal pleura ventrally on ultrasonography. Therefore, we assumed that the parietal pleura adhere more firmly to the ribs than to the intercostal spaces, and that the local anesthetic acts most strongly at the intercostal level of the injection. Thus, we suggest that catheterization for TPVB should be performed at the same thoracic level as that for intercostal thoracotomy.

There are limitations associated with our findings. First, our observations were made in the thoracic cavity on the non-ventilated side. The change in interpleural pressure during one-lung ventilation may affect the catheterization. Second, the catheter was inserted 5 cm into the TPVS. However, the ideal length into the TPVS has not been clarified. Future studies are needed to investigate the optimal length and insertion technique regarding ultrasound-guided TPVB.

Conflicts of interest

The authors declare that they have no competing interests.

Ackowledgements

The authors would like to appreciate Editage (http://www.editage.jp/) for providing professional editing services.


References

1
C. Luyet, U. Eichenberger, R. Greif, A. Vogt, Z. Szücs Farkas, B. Moriggl
Ultrasound-guided paravertebral puncture and placement of catheters in human cadavers: an imaging study
Br J Anaesth, 102 (2009), pp. 534-539
2
C. Luyet, G. Herrmann, S. Ross, et al.
Ultrasound-guided thoracic paravertebral puncture and placement of catheters in human cadavers: where do catheters go?
Br J Anaesth, 106 (2011), pp. 246-254
3
B. Cowie, D. McGlade, J. Ivanusic, M.J. Barrington
Ultrasound-guided thoracic paravertebral blockade: a cadaveric study
Anesth Analg, 110 (2010), pp. 1735-1739
4
T. Fujii, Y. Shibata, K. Nishiwaki
Observation of an ultrasound-guided thoracic paravertebral block using thoracoscopy
Acta Anaesth Taiwanica, 54 (2016), pp. 101-102

References

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