Thoracic surgery: PVB, SAPB, TEpi, ESP block, Precedex

Paravertebral Catheter Use for Postoperative Pain Control in Patients After Lung Transplant Surgery: A Prospective Observational Study.  JCVA February 2017. Volume 31, Issue 1, Pages 142–146.

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.

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From NYSORA

Ultrasound-Guided Serratus Anterior Plane Block Versus Thoracic Epidural Analgesia for Thoracotomy Pain. JCVA February 2017. Volume 31, Issue 1, Pages 152–158.

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.

Figure-17-Nagdev-2017-ACEP-Now-Ultrasound-Guided-Serratus-Anterior-Plane-Block-Can-Help-Avoid-Opioid-Use-for-Patients-with-Rib-Fractures-
From http://painandpsa.org/rnb/

Erector Spinae Plane Block


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.

Adjuvants to prolong regional anesthesia

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ERAS for Cardiac Surgery

ERAS for cardiac surgery. #eras #pain #multimodal #opioids #surgery #cardiac #perfusion #perfusionist

I have been utilizing ERAS in general surgery, OB, and ortho cases.  Diving into one of my more tricky populations, I opted to see what ERAS practices are out there for cardiac surgery.  Careful what you look for my friends.  There’s actually a good amount of information out there!

ACCRAC podcast: ERAS for Cardiac Surgery

ERAS Cardiac Consensus Abstract – April 2018

Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: a randomized clinical trial. European Journal of Cardio-Thoracic Surgery, Volume 54, Issue 3, 1 September 2018, Pages 491–497, https://doi.org/10.1093/ejcts/ezy100

** Audio PPT ** American Association for Thoracic Surgery: Enhanced Recovery After Cardiac Surgery. April 2018

The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer.  The Journal of Thoracic and Cardiovascular Surgery. April 2018Volume 155, Issue 4, Pages 1843–1852. 

Enhanced Recovery for Cardiac Surgery. J Cardiothorac Vasc Anesth. 2018 Jan 31. pii: S1053-0770(18)30049-1. DOI: https://doi.org/10.1053/j.jvca.2018.01.045

ERAS
From Journal of Anesthesiology

Enhanced Recovery After Cardiac Surgery Society

My blog posts:

Key Points

  • Level 1 (Class of recommendation=Strong Benefit):
    • Tranexamic acid or epsilon aminocaproic acid should be administered for on-pump cardiac surgical procedures to reduce blood loss.
    • Perioperative glycemic control is recommended (BS 70-180; [110-150]).
    • A care bundle of best practices should be performed to reduce surgical site infection.
    • Goal-directed therapy should be performed to reduce postoperative complications.
    • A multimodal, opioid-sparing, pain management plan is recommended postoperatively
    • Persistent hypothermia (T<35o C) after CPB should be avoided in the early postoperative period. Additionally, hyperthermia (T>38oC) should be avoided in the early postoperative period.
    • Active maintenance of chest tube patency is effective at preventing retained blood syndrome.
    • Post-operative systematic delirium screening is recommended at least once per nursing shift.
    • An ICU liberation bundle should be implemented including delirium screening, appropriate sedation and early mobilization.
    • Screening and treatment for excessive alcohol and cigarette smoking should be performed preoperatively when feasible.
  • Level IIa (Class of recommendation=Moderate Benefit)
    • Biomarkers can be beneficial in identifying patients at risk for acute kidney injury.
    • Rigid sternal fixation can be useful to reduce mediastinal wound complications.
    • Prehabilitation is beneficial for patients undergoing elective cardiac surgery with multiple comorbidities or significant deconditioning.
    • Insulin infusion is reasonable to be performed to treat hyperglycemia in all patients in the perioperative period.
    • Early extubation strategies after surgery are reasonable to be employed.
    • Patient engagement through online or application-based systems to promote education, compliance, and patient reported outcomes can be useful.
    • Chemical thromboprophylaxis can be beneficial following cardiac surgery.
    • Preoperative assessment of hemoglobin A1c and albumin is reasonable to be performed.
    • Correction of nutritional deficiency, when feasible, can be beneficial.
  • Level IIb (Class of recommendation=Weak Benefit)
    • A clear liquid diet may be considered to be continued up until 4 hours before general anesthesia.
    • Carbohydrate loading may be considered before surgery.

 

ERAS for cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia

Erector Spinae Plane Block

After speaking to a colleague of mine regarding regional anesthesia for thoracotomy and mastectomy, I am reading up on Erector Spinae Plane (ESP) block.

 

Indications:

 

 

Other regional blocks

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.

Double lung transplant

The pt was relatively young and rather cachectic, weighing at most 40kg.  Primary reason for the dlt was primary pulm htn. PA pressures were quite high in the 60s-80s. RV showed pressure overload.  However, the procedure went well.