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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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.

Esophagectomy

The case is booked as an Ivor-Lewis esophagectomy.  Let’s learn a couple of things here from what the surgery will be, to the type of anesthesia, to post-op pain management.

What’s an Ivor-Lewis esophagectomy?

Esophagectomy

Anesthetic monitors:

  • Central line (Cordis for volume in emergency)
  • Vigileo/FloTrac – SVI, SVV, SVR, CO great markers for fluid management
  • BIS
  • UOP

Anesthetic technique:

  • Induction: lidocaine, Propofol, rocuronium/sux (dependent upon if blockage from tumor necessitating RSI or not)
  • Maintenance: sevoflurane
  • Extubation: attempt in OR
  • Fluid management
    • Colloid vs. crystalloid
    • CVP vs. Esophageal doppler vs. pulse pressure vs. stroke volume variation
      • Keep SVI >35 mL/m2 to decrease risk of AKI
  • OLV
    • To reduce lung damage and ARDS
    • 4-6 cc/kg ventilation strategy (lung-protective)
    • Pressure-controlled
    • Optimization of PEEP
    • PIPs <35mmHg, Plateau pressure <25mmHg
  • Pain Management
    • Pre-op adjuvant pain meds:
      • Oxycodone XR 20mg PO if <70y/o or 10mg if >70yo
      • Celecoxib 400mg PO if <70y/o or 200mg if >70yo
      • Pregabalin 150mg PO if <70y/o or 75mg if >70yo
    • Thoracic Epidural: Improved blood flow to anastomotic site, earlier extubation times, reduced pneumonia rates.
  • Vasopressors: phenylephrine. Consider norepinephrine (improved CO), vasopressin if needed.

Case:

40-something year old female who was newly diagnosed with squamous cell cancer of her distal esophagus about 2 months prior.  Presented to ED with N/V, epigastric pain, malnourishment.  Had underone chemo and radiation.  PMH achalasia, endometriosis.  NKDA. Scheduled for Ivor-Lewis esophagectomy.  Pt appeared cachectic, on TPN, 45kg, 5’5″.  L chest port-a-cath in place.

In OR, pt received T7 epidural.  RSI w cricoid pressure throughout.  37Fr L DLT placed gently without resistance.  31cm at teeth noted after fiberoptic bronch check.  20g L radial a-line placed.  Surgeon stated no cervical approach needed, therefore, I placed a R IJ cordis and CVP.  FloTrac for SVI, SVR, SVV, CO.

Albumin for IVF.  Goal SVI >35, CVP 5-10. Phenylephrine for SBP >90.  OGT (resistance met prior to first dark marking on tube that was expected with 6 cm tumor).  BIS goal 40-60.  Epidural initially dosed with 5ml 2% lido with epi.  Another dose given roughly 30 minutes later.  Remaining dosing throughout case with 4ml 0.25% bupi.  Acetaminophen IV 1000mg prior to incision.  Fentanyl IV for abdominal laparoscopy.

Abdominal laparoscopy –> tumor unable to be freed/resected via laparoscopy.  Converted to laparotomy.  Tumor adhered to pericardium.

R thoracotomy: OLV at 200ml TV, RR 21 (volume-restrictive ventilation strategy 4-6ml/kg).  Good lung isolation.  Good anastamosis of tissues.  Two lung ventilation according to surgeon.  Recruit lungs to decrease atelectasis.

Emergence: + Pressure support through DLT.  Extubate in OR.

Lessons learned:

  1. Early communication with surgeon(s).
  2. Lung-protective strategies
  3. Volume restriction for IVF
  4. Appropriate pressor choice
  5. Pain control: thoracic epidural (0.125% bupiv + hydromorphone 10mg/ml), IV low dose ketamine (0.1-1mg/kg/hr), precedex if tolerated, if PO then preop pain meds above.  If not PO, then IV acetaminophen RTC, IV ketorolac RTC (if ok with surgeon).  Continue baseline pain regimen if patient is a chronic pain patient.
  6. Setup is key.  Discuss which side for the cervical approach (if doing) prior to doing neck lines so not in the surgical field.

Resources: