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Ultrasound guided thoracic paravertebral block in breast surgery

2009; Wiley; Volume: 64; Issue: 2 Linguagem: Inglês

10.1111/j.1365-2044.2008.05843.x

1365-2044

K. Hara, Shinichi Sakura, Takeshi Nomura, Yoji Saito,

Intraoperative Neuromonitoring and Anesthetic Effects

AnaesthesiaVolume 64, Issue 2 p. 223-225 Free Access Ultrasound guided thoracic paravertebral block in breast surgery K. Hara, K. Hara Shimane University School of Medicine, Izumo City, JapanE-mail: khara@med.shimane-u.ac.jpSearch for more papers by this authorS. Sakura, S. Sakura Shimane University School of Medicine, Izumo City, JapanE-mail: khara@med.shimane-u.ac.jpSearch for more papers by this authorT. Nomura, T. Nomura Shimane University School of Medicine, Izumo City, JapanE-mail: khara@med.shimane-u.ac.jpSearch for more papers by this authorY. Saito, Y. Saito Shimane University School of Medicine, Izumo City, JapanE-mail: khara@med.shimane-u.ac.jpSearch for more papers by this author K. Hara, K. Hara Shimane University School of Medicine, Izumo City, JapanE-mail: khara@med.shimane-u.ac.jpSearch for more papers by this authorS. Sakura, S. Sakura Shimane University School of Medicine, Izumo City, JapanE-mail: khara@med.shimane-u.ac.jpSearch for more papers by this authorT. Nomura, T. Nomura Shimane University School of Medicine, Izumo City, JapanE-mail: khara@med.shimane-u.ac.jpSearch for more papers by this authorY. Saito, Y. Saito Shimane University School of Medicine, Izumo City, JapanE-mail: khara@med.shimane-u.ac.jpSearch for more papers by this author First published: 12 January 2009 https://doi.org/10.1111/j.1365-2044.2008.05843.xCitations: 74 A response to a previously published article or letter can be submitted to the Online Correspondence section at http://www.anaesthesiacorrespondence.com. A selection of this correspondence is published several times a year in Anaesthesia.All correspondence intended for publication in Anaesthesia should be addressed to Dr David Bogod, Editor-in-Chief, and submitted as an e-mail attachment to anaesthesia@nottingham.ac.uk. For multi-author letters, a covering letter signed by all authors must be submitted either by post, fax (44 (0) 115 823 1908) or by e-mail as a scanned document before correspondence can be published. Alternatively, letters may be submitted typewritten on one side of paper, double spaced with wide margins to Anaesthesia, 1st Floor, Maternity Unit, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK. All paper submissions must include a signed covering letter, a disc or CD-ROM with a Word for Windows or .rtf version of the letter and an email address for the corresponding author.Copy should be prepared in the usual style of the Correspondence section. Authors must follow the advice about references and other matters contained in the Author Guidelines at http://www.blackwellpublishing.com/journals/ana/submiss.htm. Correspondence presented in any other style or format will be returned to the author for revision. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Thoracic paravertebral block has usually been performed using a loss of resistance technique [1, 2] with the transverse process is an important landmark. However, since the transverse process is neither visible nor palpable, its location is unknown until the block needle encounters the bone. If it is not encountered, the needle tip might advance further causing pleural puncture. Pusch et al. showed that ultrasound scanning of the transverse process and parietal pleura gave an accurate reading of the depth to the paravertebral space [3], but only made the measurements before, not during paravertebral block at T4. Breast surgery is often performed with axillary dissection making additional thoracic paravertebral blocks necessary at several vertebrae. We sought to determine whether visualisation of anatomical landmarks, needle advancement and the spread of local anaesthetic in the paravertebral space as well as knowledge of the distance from the skin to those landmarks using ultrasound imaging could help perform the block at both T1 and T4. With Institutional Review Board approval and written informed consent, 25 healthy patients undergoing unilateral breast surgery received thoracic paravertebral block combined with general anaesthesia. They were placed in the lateral decubitus position with the side to be blocked uppermost. A 3–11 MHz linear array probe (Philips SONOS 5500; Philips Medical Systems, Andover, MA, USA) was applied longitudinally to the paravertebral area. An 18G Tuohy needle was inserted perpendicularly at T4 to hit the transverse process via an out-of-plane approach. This was then directed over the top of the bony structure. The deviation of the needle from the perpendicular line was kept at 15°. The paravertebral space was identified using loss of resistance to normal saline injection without ultrasound. After negative aspiration, 15 ml of 0.5% ropivacaine was administered incrementally under ultrasound guidance. Thoracic paravertebral block at T1 was performed using the same technique with 5 ml of solution. Sensory block was assessed by loss of cold sensation 10 min later. All patients received the block at T4 and 22 at T1. Both parietal pleura and transverse process were successfully visualised at T4 (Fig. 3a) in all patients, while only transverse process visualisation was possible at T1. The distances measured using ultrasound and needle depth are in Table 1. Distances measured using ultrasound correlated well with needle depth. Injection of local anaesthetic was visualised as turbulence at T4 in all patients. Downward movement of pleura was observed at T4 in four patients during injection (Fig. 3b). No accidental pleural puncture occurred. All patients had loss of cold sensation at least between T2 and T4. Ultrasound imaging not only helped determine needle insertion sites, but also provides information on the depth to the paravertebral space. Ultrasound imaging may make thoracic paravertebral block easier to perform and help avoid inadvertent pleural puncture. Figure 3Open in figure viewerPowerPoint (a) Measurements of the distances from the skin to the transverse process and pleura on ultrasound longitudinal image at T4. TP = transverse process, PP = parietal pleura, LIG = intertransverse and superior costotransverse ligaments. , distance from the skin to TP; , distance from the skin to PP. (b) Visualisation of local anaesthetic and the downward shift of PP on ultrasound longitudinal image. (A) Before injection, (B) After injection. TP = transverse process, PP = parietal pleura, LA = local anaesthetic. Table 1. Distances from the skin to anatomical landmarks by ultrasound and needle depth. Values are mean (range) in cm. Anatomical landmark T1 T4 Skin to transverse process (ultrasound) 2.7 (1.8–4.1) 2.0 (1.2–2.8) Skin to transverse process (needle) 3.2 (2.0–4.5) 2.3 (1.5–3.0) Skin to pleura (ultrasound) – 3.1 (2.3–4.1) Skin to loss of resistance (needle) 4.6 (2.8–6.0) 3.6 (2.5–4.5) References 1 Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001; 95: 771– 80. CrossrefCASPubMedWeb of Science®Google Scholar 2 Kairaluoma PM, Bachmann MS, Korpinen AK, Rosenberg PH, Pere PJ. Single-injection paravertebral block before general anesthesia enhances analgesia after breast cancer surgery with and without associated lymph node biopsy. Anesthesia and Analgesia 2004; 99: 1837– 43. CrossrefPubMedWeb of Science®Google Scholar 3 Pusch F, Wildling E, Klimscha W, Weinstabl C. Sonographic measurement of needle insertion depth in paravertebral blocks in women. British Journal of Anaesthesia 2000; 85: 841– 3. CrossrefCASPubMedWeb of Science®Google Scholar Citing Literature Volume64, Issue2February 2009Pages 223-225 FiguresReferencesRelatedInformation