1
|
Joseph N, Sun VH, Som A, Di Capua J, Elsamaloty L, Huang J, Vazquez R. Evaluation of paravertebral blocks in improving post-procedural pain and decreasing hospital admission after microwave ablation of liver tumors. Sci Rep 2023; 13:13854. [PMID: 37620391 PMCID: PMC10449898 DOI: 10.1038/s41598-023-36607-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/07/2023] [Indexed: 08/26/2023] Open
Abstract
Although ablations are performed with conscious sedation or general anesthesia, microwave ablations can be painful post procedure. Newer analgesic modalities, including regional blocks, have promoted the proliferation of less invasive anesthesia care for ablative procedures. This study evaluates whether bilateral paravertebral blocks reduce the need for additional analgesics in comparison to unilateral blocks in microwave ablations. In this retrospective study, individuals undergoing microwave ablation who underwent unilateral versus bilateral nerve blocks at a single institution from 2017 to 2019 were compared. Categorical variables were analyzed using Pearson's chi-squared tests. Comparisons of means were completed using multiple T-tests corrected using the Holm-Sidak method with α = 0.05. Regression modeling was used to identify factors related to increased MME (milligram morphine equivalent) usage and post-procedure admission rates. A total of 106 patients undergoing 112 liver MWA procedures were included in this analysis, with patients receiving either a bilateral or unilateral block. Pre-procedural characteristics demonstrated no significant differences in age or gender. Bilateral blocks were associated with decreased usage of gabapentin (14% vs. 0%, p = 0.01) and a lower rate of post-procedure admissions (OR 0.23, p = 0.003). Therefore, when using paravertebral blocks, bilateral blocks are superior to unilateral blocks, as demonstrated by decreased rates of hospital admission and reduced use of systemic neuropathic pain medication. Additionally, reducing post-procedural MME may reduce the rate of admission to the hospital.
Collapse
Affiliation(s)
- Nicholos Joseph
- Harvard Medical School, Massachusetts General Hospital, Boston, USA
| | - Virginia H Sun
- Harvard Medical School, Massachusetts General Hospital, Boston, USA
| | - Avik Som
- Division of Vascular and Interventional Radiology, Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - John Di Capua
- Division of Vascular and Interventional Radiology, Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Lina Elsamaloty
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Pennsylvania, Philadelphia, USA
| | - Junjian Huang
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Alabama at Birmingham, Birmingham, USA
| | - Rafael Vazquez
- Department of Anesthesiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.
| |
Collapse
|
2
|
Liu DM, Hadjivassiliou A, Valenti D, Ho SG, Klass D, Chung JB, Kim PT, Boucher LM. Optimized nerve block techniques while performing percutaneous hepatic ablation: Literature review and practical use. J Interv Med 2020; 3:161-166. [PMID: 34557322 PMCID: PMC7420394 DOI: 10.1016/j.jimed.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/19/2020] [Indexed: 01/11/2023] Open
Abstract
Percutaneous image guided thermal ablation has become a cornerstone of therapy for patients with oligometastatic disease and primary liver malignancies. Evolving from percutaneous ethanol injection (PEI), thermal ablation utilizing radiofrequency ablation (RFA) and microwave ablation (MWA) have become the standard approach in the treatment of isolated lesions that fit within the size criteria for curative intent therapy (typically 3-4cm). With the evolution of more intense thermal ablation, such as MWA, the dramatic increase in both the size of ablation zone and intensity of heat generation have extended the limits of this technique. As a result of these innovations, intra-procedural and post-procedural pain have also significantly increased, requiring either higher levels of intravenous sedation or, in some institutions, general anesthesia. In addition to the increase in therapeutic intensity, the use of intravenous sedation during aggressive ablation procedures carries the risk of over-sedation when the noxious insult (i.e. the ablation) is removed, adding further difficulty to post-procedural recovery and management. Furthermore, high subdiaphragmatic lesions become challenging in this setting due to issues relating to sedation and compliance with breath hold/breathing instructions. Although general anesthesia may mitigate these complications, the added resources associated with providing general anesthesia during ablation is not cost effective and may result in substantial delays in treatment. The reduction of Aerosol Generating Medical Procedures (AGMP), such as intubation due to the COVID-19 Pandemic, must also be taken into consideration. Due to the potential increased risk of infection transmission, alternatives to general anesthesia should be considered when safe and possible. Upper abdominal regional nerve block techniques have been used to manage pain related to trauma, surgery, and cancer; however, blocks of this nature are not well described in the interventional radiology literature. The McGill University group has developed experience in using such blocks as splanchnic, celiac and hepatic hilar nerve blocks to provide peri-procedural pain control [1]. Since incorporating these techniques (along with hydrodissection with tumescent anesthesia), we have also observed in our high volume ablation center a dramatic decrease in the amount of sedatives administered during the procedure, a decrease in patient discomfort during localization and ablation, as well as decreased pain post-procedure. Faster time to discharge and overall reduction in room procedural time serve as added benefits. The purpose of this publication is to outline and illustrate the practical application and use of nerve block/regional anesthesia techniques with respect to percutaneous hepatic thermal ablation.
Collapse
Affiliation(s)
- D M Liu
- Associate Professor, Faculty of Medicine, University of British Columbia, Canada.,Voluntary Professor, Miller School of Medicine, University of Miami, USA.,Department of Radiology - Division of Interventional Radiology, Vancouver General Hospital, Canada.,Associate Professor, Faculty of Applied Science, University of British Columbia, Canada
| | - A Hadjivassiliou
- Department of Radiology - Division of Interventional Radiology, Vancouver General Hospital, Canada
| | - D Valenti
- Assistant Professor, Faculty of Medicine, McGill University, Department of Radiology, Division of Interventional Radiology, McGill University Health Centre, Montreal, Canada
| | - S G Ho
- Department of Radiology - Division of Interventional Radiology, Vancouver General Hospital, Canada.,Clinical Professor, Faculty of Medicine, University of British Columbia, Canada
| | - D Klass
- Department of Radiology - Division of Interventional Radiology, Vancouver General Hospital, Canada.,Clinical Associate Professor, Faculty of Medicine, University of British Columbia, Canada
| | - J B Chung
- Department of Radiology, Vancouver General Hospital, Canada.,Associate Professor, Faculty of Applied Science, University of British Columbia, Canada
| | - P T Kim
- Department of Surgery Division of Hepatopancraticobiliary Surgery/Liver Transplantation, Vancouver General Hospital, Vancouver, Canada.,Clinical Associate Professor, Faculty of Medicine, University of British Columbia, Canada
| | - L M Boucher
- Assistant Professor, Faculty of Medicine, McGill University, Department of Radiology, Division of Interventional Radiology, McGill University Health Centre, Montreal, Canada
| |
Collapse
|
3
|
Kalava A, Clendenen S, McKinney JM, Bojaxhi E, Greengrass RA. Bilateral thoracic paravertebral nerve blocks for placement of percutaneous radiologic gastrostomy in patients with amyotrophic lateral sclerosis: a case series. Rom J Anaesth Intensive Care 2017; 23:149-153. [PMID: 28913488 DOI: 10.21454/rjaic.7518/232.scl] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND AIMS To assess the efficacy of bilateral thoracic paravertebral nerve blocks (PVB) in providing procedural anesthesia and post-procedural analgesia for placement of percutaneous radiologic gastrostomy tubes (PRG) in patients with amyotrophic lateral sclerosis (ALS). METHODS We prospectively observed 10 patients with ALS scheduled for PRG placement that had bilateral thoracic PVBs at thoracic 7, 8, and 9 levels with administration of a mixture of 3 mL of 1% ropivacaine, 0.5 mg/mL dexamethasone, and 5 μg/mL epinephrine at each level. The success of the block was assessed after 10 minutes. PRG placement was done in the interventional radiology suite without sedation. All patients were followed up via phone 24 hours after the procedure. RESULTS All 10 patients had successful placement of PRG with PVBs as the primary anesthetic. Segmental anesthesia over the surgical site in all cases was successful with first attempt of the blocks. Three patients had significant hypotension after the block, requiring boluses of vasopressors and intravenous fluids. All patients reported high levels of satisfaction and sleep quality on the night of the procedure. CONCLUSIONS Bilateral thoracic PVBs provided satisfactory procedural anesthesia and post-procedural analgesia, and thus, seem promising as a safe alternative to sedation in ALS patients having PRG placement.
Collapse
Affiliation(s)
- Arun Kalava
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA.,Department of Anesthesiology, Tampa General Hospital, Tampa, FL, USA
| | - Steven Clendenen
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA
| | - J Mark McKinney
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA
| | - Elird Bojaxhi
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA
| | - Roy A Greengrass
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA
| |
Collapse
|
4
|
Continuous right thoracic paravertebral block following bolus initiation reduced postoperative pain after right-lobe hepatectomy: a randomized, double-blind, placebo-controlled trial. Reg Anesth Pain Med 2016; 39:506-12. [PMID: 25304475 PMCID: PMC4218764 DOI: 10.1097/aap.0000000000000167] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background and Objectives We hypothesized that continuous right thoracic paravertebral block, following bolus initiation, decreases opioid consumption after right-lobe hepatectomy in patients receiving patient-controlled intravenous analgesia with sufentanil. Methods Patients undergoing right-lobe hepatectomy with a right thoracic paravertebral catheter placed at T7 30 minutes before surgery were randomly assigned to receive through this catheter either a 10-mL bolus of 0.2% ropivacaine before emergence, followed by a continuous infusion of 6 mL/h for 24 hours (PVB group), or saline at the same scheme of administration (control group). All patients were started on patient-controlled intravenous analgesia with sufentanil in the postanesthesia care unit. The primary outcome measure was total sufentanil consumption during the first 24 postoperative hours. P = 0.05 was considered as significant. For the multiple comparisons of data at 5 different time points, the P value for the 0.05 level of significance was adjusted to 0.01. Results Sixty-six patients were assessed for eligibility, and a PVB catheter was successfully placed for 48 patients. Data were analyzed on 22 patients in group PVB and 22 patients in the control group. The cumulative sufentanil consumption in the PVB group (54.3 ± 12.1 μg) at 24 postoperative hours was more than 20% less than that of the control group (68.1 ± 9.9 μg) (P < 0.001). There was also a significant difference in pain scores (numerical rating scale) between groups, where the PVB group had lower scores than did the control group at rest and with coughing for the first 24 hours (P < 0.001). Conclusions Continuous right thoracic paravertebral block, following bolus initiation, has an opioid-sparing effect on sufentanil patient-controlled intravenous analgesia for right-lobe hepatectomy patients and reduces numerical rating scale pain scores at rest and with coughing in the first 24 postoperative hours.
Collapse
|
5
|
Abstract
Malignancy resulting in impaired biliary drainage includes a number of diagnoses familiar to the interventional radiologist. Adequate drainage of such a system can significantly improve patient quality of life, and can facilitate the further treatment options and care of such patients. In the setting of prior instrumentation, cholangitis can present as an urgent indication for drainage. Current initial interventional management of malignant biliary duct obstruction frequently includes endoscopic or percutaneous intervention, with local practices and preprocedural imaging guiding interventional approaches and subsequent management. This article addresses the indications for percutaneous drainage, technical considerations in performing such drainage, and specific techniques useful in attempting to achieve clinical end points in patients with malignant biliary duct obstruction.
Collapse
Affiliation(s)
| | - Robert K Ryu
- Department of Radiology, University of Colorado, Aurora, CO.
| |
Collapse
|
6
|
Piccioni F, Fumagalli L, Garbagnati F, Di Tolla G, Mazzaferro V, Langer M. Thoracic paravertebral anesthesia for percutaneous radiofrequency ablation of hepatic tumors. J Clin Anesth 2014; 26:271-5. [PMID: 24856797 DOI: 10.1016/j.jclinane.2013.11.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 11/25/2013] [Accepted: 11/27/2013] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE To present our preliminary experience using a thoracic paravertebral block (TPVB) as the sole anesthetic in percutaneous hepatic radiofrequency ablation (RFA). DESIGN Retrospective case series of 12 ASA physical status 1, 2, and 3 patients of average risk scheduled for RFA. SETTING University medical center. MEASUREMENTS The first 12 procedures performed using TPVB were analyzed to evaluate the efficacy and safety of this anesthetic technique. Data collected included patients' characteristics, procedure, pain referred during paravertebral punctures, and RFA (verbal numerical scale; VNS). Anesthesia and medical records also were reviewed for any major complications that occurred during or after the RFA. MAIN RESULTS Ten of the 12 patients presented for hepatocellular carcinoma; the other two patients had melanoma metastasis. Nine patients were ASA physical status 1 or 2; the other three patients were ASA physical status 3. Nine had liver cirrhosis. All patients had normal coagulation profiles. The TPVBs were performed in a median time of 6.5 (4-15) minutes. Onset of sensory loss to pinprick test occurred approximately 15 to 20 minutes after the injections. No evidence of bilateral blockade was seen in any patient. In most cases, the extent of anesthesia ranged from T6 to T11 or T12. In one patient (no. 2), the stimulating needle elicited no sensory or motor response at the T7 level; the local anesthetic was then injected one cm beyond the transverse process. All patients were very pleased with their anesthetic care; all were discharged from the hospital with no procedure-related complications. CONCLUSION The use of thoracic paravertebral block as the sole anesthetic for RFA of liver produced satisfactory unilateral anesthesia and minor adverse events.
Collapse
Affiliation(s)
- Federico Piccioni
- Department of Anesthesia, Intensive Care and Palliative Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan 20133, Italy.
| | - Luca Fumagalli
- Department of Anesthesia, Intensive Care and Palliative Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan 20133, Italy
| | - Francesco Garbagnati
- Department of Radiology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan 20133, Italy
| | - Giuseppe Di Tolla
- Department of Radiology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan 20133, Italy
| | - Vincenzo Mazzaferro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan 20133, Italy
| | - Martin Langer
- Department of Anesthesia, Intensive Care and Palliative Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan 20133, Italy; Department of Pathophysiology and Transplantation, University of Milan School of Medicine, Milan 20122, Italy
| |
Collapse
|
7
|
Gazzera C, Fonio P, Faletti R, Dotto MC, Gobbi F, Donadio P, Gandini G. Role of paravertebral block anaesthesia during percutaneous transhepatic thermoablation. Radiol Med 2014; 119:549-57. [DOI: 10.1007/s11547-013-0372-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 05/28/2013] [Indexed: 12/26/2022]
|
8
|
Spiček-Macan J, Stančić-Rokotov D, Hodoba N, Kolarić N, Cesarec V, Pavlović L. Thoracic paravertebral nerve block as the sole anesthetic for an open biopsy of a large anterior mediastinal mass. J Cardiothorac Vasc Anesth 2013; 28:1032-9. [PMID: 24035063 DOI: 10.1053/j.jvca.2013.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Jasna Spiček-Macan
- Department of Anesthesiology, Reanimatology, and Intensive Care, University Hospital Centre Zagreb, Jordanovac 104, Zagreb, Croatia.
| | - Dinko Stančić-Rokotov
- Department of Thoracic Surgery, University Hospital Centre Zagreb, Jordanovac 104, Zagreb, Croatia
| | - Nevenka Hodoba
- Department of Anesthesiology, Reanimatology, and Intensive Care, University Hospital Centre Zagreb, Jordanovac 104, Zagreb, Croatia
| | - Nevenka Kolarić
- Department of Anesthesiology, Reanimatology, and Intensive Care, University Hospital Centre Zagreb, Jordanovac 104, Zagreb, Croatia
| | - Vedran Cesarec
- Department of Thoracic Surgery, University Hospital Centre Zagreb, Jordanovac 104, Zagreb, Croatia
| | - Ladislav Pavlović
- Department of Pulmonology, University Hospital Centre Zagreb, Jordanovac 104, Zagreb, Croatia
| |
Collapse
|
9
|
Abstract
Paravertebral blocks have been demonstrated to represent an interesting alternative to epidural, especially for the management of perioperative and trauma pain. Initially performed mostly as single-shot blocks for breast surgery, thoracotomy, and hernia repairs in adults and children, presently these blocks are also used for placement of a paravertebral catheter, either unilateral or bilateral. Although complications associated with the performance of these blocks are infrequent, the use of ultrasound-guided approaches, which allow performing the block under direct vision, is becoming the standard in most groups performing these blocks routinely.
Collapse
Affiliation(s)
- Jacques E Chelly
- Division of Acute Interventional Perioperative Pain and Regional Anesthesia, Department of Anesthesiology, University of Pittsburgh Medical Center, Presbyterian-Shadyside Hospital, PA 15232, USA.
| |
Collapse
|
10
|
Culp WC, Culp WC. Practical Application of Local Anesthetics. J Vasc Interv Radiol 2011; 22:111-8; quiz 119. [DOI: 10.1016/j.jvir.2010.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 09/24/2010] [Accepted: 10/11/2010] [Indexed: 11/29/2022] Open
|
11
|
|
12
|
Tsai T, Rodriguez-Diaz C, Deschner B, Thomas K, Wasnick JD. Thoracic paravertebral block for implantable cardioverter-defibrillator and laser lead extraction. J Clin Anesth 2008; 20:379-382. [DOI: 10.1016/j.jclinane.2008.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Revised: 01/12/2008] [Accepted: 01/15/2008] [Indexed: 11/30/2022]
|
13
|
Culp WC, Payne MN, Montgomery ML. Thoracic paravertebral block for analgesia following liver mass radiofrequency ablation. Br J Radiol 2008; 81:e23-5. [DOI: 10.1259/bjr/61546726] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
14
|
Baumgarten RK. Re: Thoracic paravertebral block for percutaneous transhepatic biliary drainage. J Vasc Interv Radiol 2006; 17:1855; author reply 1855-6. [PMID: 17142719 DOI: 10.1097/01.rvi.0000242168.70424.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
15
|
Re: Thoracic Paravertebral Block for Percutaneous Transhepatic Biliary Drainage—Reply. J Vasc Interv Radiol 2006. [DOI: 10.1097/01.rvi.0000242211.76863.c0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
16
|
Culp WC, McCowan TC, DeValdenebro M, Wright LB, Workman JL, Culp WC. Paravertebral Block: An Improved Method of Pain Control in Percutaneous Transhepatic Biliary Drainage. Cardiovasc Intervent Radiol 2006; 29:1015-21. [PMID: 16988878 DOI: 10.1007/s00270-005-0273-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE Percutaneous transhepatic biliary drainage remains a painful procedure in many cases despite the routine use of large amounts of intravenous sedation. We present a feasibility study of thoracic paravertebral blocks in an effort to reduce pain during and following the procedure and reduce requirements for intravenous sedation. METHODS Ten consecutive patients undergoing biliary drainage procedures received fluoroscopically guided paravertebral blocks and then had supplemental intravenous sedation as required to maintain patient comfort. Levels T8-T9 and T9-T10 on the right were targeted with 10-20 ml of 0.5% bupivacaine. Sedation requirements and pain levels were recorded. RESULTS Ten biliary drainage procedures in 8 patients were performed for malignancy in 8 cases and for stones in 2. The mean midazolam use was 1.13 mg i.v., and the mean fentanyl requirement was 60.0 microg i.v. in the block patients. Two episodes of hypotension, which responded promptly to volume replacement, may have been related to the block. No serious complications were encountered. The mean pain score when traversing the chest wall, liver capsule, and upon entering the bile ducts was 0.1 on a scale of 0 to 10, with 1 patient reporting a pain level of 1 and 9 reporting 0. The mean peak pain score, encountered when manipulating at the common bile duct level or when addressing stones there, was 5.4 and ranged from 0 to 10. CONCLUSIONS Thoracic paravertebral block with intravenous sedation supplementation appears to be a feasible method of pain control during biliary interventions.
Collapse
Affiliation(s)
- William C Culp
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205-7199, USA.
| | | | | | | | | | | |
Collapse
|