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 ¤ Introduction
 ¤ Case Report
 ¤ Discussion
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UNUSUAL CASE
Year : 2021  |  Volume : 17  |  Issue : 4  |  Page : 562-565
 

Ultrasound-guided thoracal paravertebral block for awake thoracoscopic lobectomy in a high-risk patient: The first reported case


1 Department of Anesthesiology and Reanimation, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
2 Department of Thoracic Surgery, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey

Date of Submission23-Mar-2021
Date of Decision07-May-2021
Date of Acceptance22-Jul-2021
Date of Web Publication17-Sep-2021

Correspondence Address:
Volkan Ozen
Darülaceze Cad., No: 27, Sisli, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_106_21

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 ¤ Abstract 

One-lung ventilation provided by double-lumen tube intubation under general anaesthesia has conventionally been considered necessary for thoracoscopic major pulmonary resections. Recently, regional anaesthesia techniques have been used to avoid complications of tracheal intubation and general anaesthesia. Although paravertebral block (PVB) comes to the fore as a safe and useful regional anaesthesia technique for intra-operative and post-operative analgesia for a wide variety of surgeries involving the thoracic and lumbar regions, it is sometimes used for anaesthesia. Here, we aimed to demonstrate that biportal video-assisted thoracoscopic surgery can be performed in a right upper lobectomy while maintaining spontaneous ventilation in a 55-year-old, awake patient who was not intubated under ultrasound-guided PVB.


Keywords: Awake, lobectomy, paravertebral block, video-assisted thoracoscopic surgery


How to cite this article:
Ozen V, Derdiyok O, Karacalar S. Ultrasound-guided thoracal paravertebral block for awake thoracoscopic lobectomy in a high-risk patient: The first reported case. J Min Access Surg 2021;17:562-5

How to cite this URL:
Ozen V, Derdiyok O, Karacalar S. Ultrasound-guided thoracal paravertebral block for awake thoracoscopic lobectomy in a high-risk patient: The first reported case. J Min Access Surg [serial online] 2021 [cited 2021 Dec 8];17:562-5. Available from: https://www.journalofmas.com/text.asp?2021/17/4/562/326101





 ¤ Introduction Top


Video-assisted thoracoscopic surgery (VATS) has been widely used in recent years for many thoracic surgical procedures, including lobectomy which stands out as a less invasive method, significantly reduces post-operative pain and morbidity compared to classical open thoracotomy.[1] This method, which is usually performed under general anaesthesia by providing single-lung ventilation with a double-lumen endotracheal tube or bronchial blocker, can be used to prevent some complications related to general anaesthesia (vocal cord, tracheal injury, barotrauma).[2] Thoracic epidural anaesthesia (TEA) and thoracic paravertebral block (PVB) are the two most common regional anaesthesia techniques used in non-intubated thoracoscopic surgical procedures while preserving spontaneous ventilation. However, TEA has rare but serious complications such as dural puncture, epidural abscess, epidural haematoma and nerve damage.[3] Thoracic PVB, is easily performed with ultrasound (US) guidance and provides effective analgesia and anaesthesia with ipsilateral somatosensory and sympathetic nerve blockage without most of the side effects observed with TEA.[4]

In the literature, VATS procedure with thoracic PVB without intubation appears to be applied to patients under deep sedation.[2] In our case, due to the existing comorbidities, right lobectomy was performed awakely under thoracic PVB under US-guided thoracic PVB without applying any anaesthetic agent to the patient.


 ¤ Case Report Top


A 55-year-old male patient was admitted to our clinic with complaints of shortness of breath. He has a 30-year smoking history and 10-year chronic obstructive pulmonary disease (COPD). A mass of approximately 4 cm in the right upper lobe was detected in the computerised tormus tomography taken due to the pre-diagnosis of COVID-19 [Figure 1]. There was no endobronchial lesion in his bronchoscopic examination. No pathology was found in the bronchial lavage material, either. In positron emission tomography, a 39 mm × 16 mm right upper lobe mass (SUDmax 7.7) was detected in the upper lobe of the right lung, although transthoracic fine-needle aspiration was performed, no pathology was found. No evidence of malignancy was detected in the aspiration and brush samples taken. No acid-fast bacilli were seen. Lung function tests were within normal limits (forced expiratory volume in 1 second: 2.6lt 93% forced vital capacity 2.8lt). There were no signs of pre-operative hypoxaemia. Pre-operative arterial blood gase values of the patient: pH: 7.39, pCO2: 50 mmHg, pO2: 76 mmHg Lactate: 1.4 mmol/L, HCO3: 28 mmol/L. However, the patient, who continued to smoke despite the absence of any other co-morbidities, was hospitalised three times in the last 6 months due to severe COPD exacerbation. In addition, the diffusing capacity of the lung for carbon monoxide (DLCO) test, which is one of the important determinants of post-operative mortality and morbidity in thoracic surgery, was found to be 59%. Due to the frequent occurrence of severe COPD exacerbations in the past 6 months and the DLCO test being <60%, it was decided to perform an awake VATS lobectomy in order not to irritate the airways, reduce post-operative morbidity, prevent complications due to intubation and lung damage caused by the ventilator.
Figure 1: Computed tomography of the torso has a mass approximately 4 cm in the right upper lobe

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After the patient was premedicated with 4.5 mg (0.07 mg/kg) intramuscular midazolam, he was taken to the operation room.[5] In the operating room, standard monitorisation was started. Electrocardiography (ECG), non-invasive blood pressure (BP) monitoring and pulse oximetry monitoring were performed. Baseline values were SpO2: % 94 (on room air), heart rate 74 beats/min, BP 122/77 mmHg. SpO2, ECG and BP values of the patient were continuously monitored and recorded in anaesthesia follow-up record every 5 min. Written consent was taken from the patient.

Paravertebral blockage

The patient was placed in the left lateral position. After the skin and probe were prepared aseptically, a linear 5–10 MHz frequency range US probe was placed longitudinally in the patient's midline at the level of the T3 vertebral spinous process, with the medial edge of the probe in contact with the spinous process. The probe was then moved caudally into the intercostal space between adjacent ribs. The inferior part of transverse process was visualised as a hyperechoic convex line with posterior acoustic shadowing. The apex of thoracic paravertebral space was visualised as a wedge-shaped hypoechoic space surrounded by the hyperechoic line of the pleura below and the superior costotransverse ligament above. After the subcutaneous tissue was anesthetised with 2 ml of lidocaine, a 22 gauge, 100 mm insulated facet-type needle (BBraun Sonoplex, Melsungen, Germany) was advanced from the outer part of the probe with the in-plane technique from lateral to medial to the costotransverse ligament. When the needle tip was seen to be in the paravertebral area, 10 ml 0.5% bupivacaine was injected after being aspirated to control the presence of blood and/or air. Depression of the pleura was observed with the diffusion of local anaesthetic.

The patient was placed in the left lateral position. After disinfection with an antiseptic solution, 2 ml of lidocaine 1% was administered for local anaesthesia in the skin and the subcutaneous area. A linear 5–10 MHz frequency range US probe was oriented longitudinally on the patient's midline at the T3 level. The probe was then moved laterally (3 cm from the midline) until an appropriate view of adjacent transverse processes, corresponding paravertebral space and pleura. An 22G, 100 mm, insulated facet type needle (BBraun Sonoplex, Melsungen, Germany) was inserted via an in-plane technique and pierced superior costotransverse ligament into the paravertebral space. After negative aspiration, 10 ml of 0.5% bupivacaine was injected.

This procedure was repeated at T5 level with 10 ml of 0.5% bupivacaine, respectively. When pleural displacement was observed at all two levels, PVB was seen to be successful [Figure 2].
Figure 2: Pleural displacement was observed at all two levels, paravertebral block was seen to be. TP: Transvers process, LA: Lokal anaesthetic, PVS: Paravertebral space

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Sensory block was evaluated with the pinprick test over the T1-T7 dermatomes. The surgery commenced 15 min later, and no deterioration was observed in the haemodynamic parameters in the 5 min sequential measurements of the vital signs. During the procedure, patients breathed O2 through a ventimask as required to keep oxygen saturation >90%. Intrathoracic vagal block with 3 mL of 2% lidocaine was used to prevent coughing during thoracoscopy.[6]

An iatrogenic pneumothorax originated from thoracoscopic incisions, causing the gradual collapse of the ipsilateral lung. Mediastinal lymph node was first sampled because of the diagnosis of mediastinal lymphadenopathy. Pathology of 4R and 7 lymph nodes was evaluated as normal. VATS wedge was performed. Frozen was reported as non-small cell lung cancer. The right upper lobectomy decision was made. Right upper lobectomy with VATS was performed using a two-port technique. In the fifth intercostal space in the anterior axillary line, in the seventh intercostal space in the posterior axillary line, a 3 cm operation port and a 1.5 cm observation port were made, respectively.

The surgery was completed in 22 min without the need for sedation or further analgesia administration. There was no complication such as Horner's syndrome, hypotension, or total spinal anaesthesia. However, all necessary equipment was readily available should a complication was encountered. The patient was taken to the recovery room and monitored for 40 min with vital signs. The patient did not need post-operative supplemental oxygen therapy in post-anaesthesia care unit. The vital signs of the patient during transfer to the surgical department were: visual analogue scale 0/10, SpO2 91% (on room air), BP 131/80 mmHg and heart rate 76/min. During the first 12 post-operative hours, he did not require any analgesics. The patient was mobilised for 2 h postoperatively. Tube thoracostomy was terminated in one post-operative day. He was discharged in 3 post-operative days.


 ¤ Discussion Top


This presented case is the first case in the literature who underwent VATS lobectomy with US-guided thoracic PVB while awake. This method provided effective intra-operative and post-operative anaesthesia and analgesia without leading to complications in a patient with limited pulmonary function.

Applying the advantages of lobectomy performed with VATS over open thoracotomy together with an appropriate regional anaesthesia technique increases post-operative outcome. TEA is an effective and widely used regional anaesthesia method in VATS lobectomies. In previous studies at the literature, it was reported that TEA performed surgical procedures with VATS for various thoracic pathologies in awake patients that will increase the post-operative morbidity and prolong the hospital stay.[2],[7]

PVB has been shown to be a technique that provides analgesia as effective as TEA in various clinical studies.[7] When 0.36 ml/kg dose of local anaesthetic (LA) is administered, it has been reported that there is at least four segments in the vertical plane when it is applied. However, the anatomical differences of the patient and reasons such as the level at which the block is applied may prevent the LA drug from spreading evenly in this plane. However, when PVB is applied with US, real-time visualisation of the block needle can be easily directed into the paravertebral area without creating pleural perforation.[8]

Although PVB is seen less frequently than TEA in the literature, short-term side effects such as hypotension, bradycardia, urinary retention are observed. The reason for this may be that it is associated with less hypotension and urinary retention since PVB is applied as a unilateral technique, thus preserving respiratory and sympathetic function on the opposite side.[9] In addition, dural puncture and intrathecal injection can rarely be seen in needle-related complications such as nerve damage, intercostal artery injury, haematoma, pleural puncture and pneumothorax in PVB. However, it is stated in the literature that when this block is applied with US, it can reduce the complications associated with the needle.[9],[10],[11],[12] In our case, no needle-related complications were observed. The reason for this can be thought to be because the area to be blocked is performed by the US-guided in-plane technique in real time after scanning the vascular structures with US Doppler.

In VATS surgeries performed with non-intubated TEA, it has been reported that satisfactory results have been obtained in terms of patients and surgery due to both early mobilisation and oral intake, and the low need for additional analgesic drugs.[8],[13]

In our case, results that increased patient comfort were obtained by being mobilised after the 2nd h postoperatively, starting oral intake and not needing any analgesic medication for the 1st 12 h postoperatively. This is due to the successful US-guided PVB application without using any neuromuscular medication.


 ¤ Conclusion Top


This case has shown that US-guided PVB is feasible and safe in awake thoracoscopic surgery without intubation. However, such interventions require surgeons experienced in VATS and competent anaesthetists. In the treatment of lung tumours in selected patients, it is recommended to be preferred because it is an attractive and less invasive method.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Kim DH, Oh YJ, Lee JG, Ha D, Chang YJ, Kwak HJ. Efficacy of ultrasound-guided serratus plane block on postoperative quality of recovery and analgesia after video-assisted thoracic surgery: A randomized, triple-blind, placebo-controlled study. Anesth Analg 2018;126:1353-61.  Back to cited text no. 1
    
2.
Li H, Huang D, Qiao K, Wang Z, Xu S. Feasibility of non-intubated anesthesia and regional block for thoracoscopic surgery under spontaneous respiration: A prospective cohort study. Braz J Med Biol Res 2020;53:e8645.  Back to cited text no. 2
    
3.
Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy – A systematic review and meta-analysis of randomized trials. Br J Anaesth 2006;96:418-26.  Back to cited text no. 3
    
4.
Fentie DY, Gebremedhn EG, Denu ZA, Gebreegzi AH. Efficacy of single-injection unilateral thoracic paravertebral block for post open cholecystectomy pain relief: A prospective randomized study at Gondar University Hospital. Local Reg Anesth 2017;10:67-74.  Back to cited text no. 4
    
5.
Ozen V, Orhan ME. Review of the effects of anesthetic agents used as premedication for patients undergoing electroconvulsive therapy with diagnoses of bipolar disorder or major depression on convulsion, recovery period, and hemodynamic parameters. J Mind Med Sci 2019;6:271-7.  Back to cited text no. 5
    
6.
Hung MH, Hsu HH, Chen KC, Chan KC, Cheng YJ, Chen JS. Nonintubated thoracoscopic anatomical segmentectomy for lung tumors. Ann Thorac Surg 2013;96:1209-15.  Back to cited text no. 6
    
7.
Komatsu T, Kino A, Inoue M, Sowa T, Takahashi K, Fujinaga T. Paravertebral block for video-assisted thoracoscopic surgery: Analgesic effectiveness and role in fast-track surgery. Int J Surg 2014;12:936-9.  Back to cited text no. 7
    
8.
Chu L, Zhang X, Lu Y, Xie G, Song S, Fang X, et al. Improved analgesic effect of paravertebral blocks before and after video-assisted thoracic surgery: A prospective, double-blinded, randomized controlled trial. Pain Res Manag 2019;2019:9158653.  Back to cited text no. 8
    
9.
Yeung JH, Gates S, Naidu BV, Wilson MJ, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016;2:CD009121.  Back to cited text no. 9
    
10.
Pace MM, Sharma B, Anderson-Dam J, Fleischmann K, Warren L, Stefanovich P. Ultrasound-guided thoracic paravertebral blockade: a retrospective study of the ıncidence of complications. Anesth Analg 2016;122:1186-91.  Back to cited text no. 10
    
11.
Song L, Zhou Y, Huang D. Inadvertent posterior intercostal artery puncture and haemorrhage after ultrasound-guided thoracic paravertebral block: A case report. BMC Anesthesiol 2018;18:196.  Back to cited text no. 11
    
12.
Fujii T, Shibata Y, Nishiwaki K. Breakage and retention of thoracic paravertebral catheter: A case report. JA Clin Rep 2017;3:4.  Back to cited text no. 12
    
13.
Kuş A, Gürkan Y, Arslan Zİ, Akgül AG, Aksu C, Toker K, et al. Our ultrasound-guided paravertebral block experiences in thoracic surgery. Agri 2015;27:139-42.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]



 

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