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He WJ, Xu WX, Zhang XD, Chen Y, He SY, Wei XQ, Huang XL. Midpoint transverse process to pleura block for postoperative analgesia following laparoscopic renal cyst decortication: Two case reports. World J Clin Cases 2024; 12:3629-3635. [PMID: 38983401 PMCID: PMC11229905 DOI: 10.12998/wjcc.v12.i18.3629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/21/2024] [Accepted: 05/11/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND The midpoint transverse process to pleura (MTP) block, a novel technique for thoracic paravertebral block (TPVB), was first employed in laparoscopic renal cyst decortication. CASE SUMMARY Thoracic paravertebral nerve block is frequently employed for perioperative analgesia during laparoscopic cyst decortication. To address safety concerns associated with TPVBs, we administered MTP blocks in two patients prior to administering general anesthesia for laparoscopic cyst decortication. The MTP block was performed at the T9 level under ultrasound guidance, with 20 mL of 0.5% ropivacaine injected. Reduced sensation to cold and pinprick was observed from the T8 to T11 dermatome levels. Immediately postoperative Numeric Pain Rating Scale scores were 0/10 at rest and on movement, with none exceeding a mean 24 h numeric rating scale > 3. CONCLUSION MTP block was effective technique for providing postoperative analgesia for patients undergoing laparoscopic renal cyst decortication.
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Affiliation(s)
- Wei-Jie He
- Department of Anesthesiology, Liuzhou People's Hospital affiliated to Guangxi Medical University, Liuzhou 545000, Guangxi Zhuang Autonomous Region, China
| | - Wen-Xing Xu
- Department of Anesthesiology, Liuzhou People's Hospital affiliated to Guangxi Medical University, Liuzhou 545000, Guangxi Zhuang Autonomous Region, China
| | - Xu-Dong Zhang
- Department of Anesthesiology, Liuzhou People's Hospital affiliated to Guangxi Medical University, Liuzhou 545000, Guangxi Zhuang Autonomous Region, China
| | - Yue Chen
- Department of Anesthesiology, Liuzhou People's Hospital affiliated to Guangxi Medical University, Liuzhou 545000, Guangxi Zhuang Autonomous Region, China
| | - Shu-Ying He
- Department of Anesthesiology, Liuzhou People's Hospital affiliated to Guangxi Medical University, Liuzhou 545000, Guangxi Zhuang Autonomous Region, China
| | - Xian-Qin Wei
- Department of Anesthesiology, Liuzhou People's Hospital affiliated to Guangxi Medical University, Liuzhou 545000, Guangxi Zhuang Autonomous Region, China
| | - Xiao-Lan Huang
- Department of Ultrasound Medicine, Liuzhou People's Hospital affiliated to Guangxi Medical University, Liuzhou 545000, Guangxi Zhuang Autonomous Region, China
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Jones A, Le-Wendling L, Ihnatsenka B, Smith C, Baker E, Boezaart A. Empirical guide to a safe thoracic paravertebral block based on dimensions of paravertebral space when ultrasound visualization is challenging. Reg Anesth Pain Med 2024; 49:133-138. [PMID: 37429621 DOI: 10.1136/rapm-2022-104181] [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: 11/14/2022] [Accepted: 03/27/2023] [Indexed: 07/12/2023]
Abstract
Although ultrasound (US) guidance is the mainstay technique for performing thoracic paravertebral blocks, situations arise when US imaging is limited due to subcutaneous emphysema or extremely deep structures. A detailed understanding of the anatomical structures of the paravertebral space can be strategic to safely and accurately perform a landmark-based or US-assisted approach. As such, we aimed to provide an anatomic roadmap to assist physicians. We examined 50 chest CT scans, measuring the distances of the bony structures and soft-tissue surrounding the thoracic paravertebral block at the 2nd/3rd (upper), 5th/6th (middle), and 9th/10th (lower) thoracic vertebral levels. This review of radiology records controlled for individual differences in body mass index, gender, and thoracic level. Midline to the lateral aspect of the transverse process (TP), the anterior-to-posterior distance of TP to pleura, and rib thickness range widely based on gender and thoracic level. The mean thickness of the TP is 0.9±0.1 cm in women and 1.1±0.2 cm in men. The best target for initial needle insertion from the midline (mean length of TP minus 2 SDs) distance would be 2.5 cm (upper thoracic)/2.2 cm (middle thoracic)/1.8 cm (lower thoracic) for females and 2.7 cm (upper)/2.5 cm (middle)/2.0 cm (lower thoracic) for males, with consideration that the lower thoracic region allows for a lower margin of error in the lateral dimension because of shorter TP. There are different dimensions for the key bony landmarks of a thoracic paravertebral block between males and females, which have not been previously described. These differences warrant adjustment of landmark-based or US-assisted approach to thoracic paravertebral space block for male and female patients.
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Affiliation(s)
- Anastasia Jones
- Anesthesiology, University of Florida, Gainesville, Florida, USA
- Anesthesiology, Moffitt Cancer Center, Tampa, Florida, USA
| | | | - Barys Ihnatsenka
- Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Cameron Smith
- Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Erik Baker
- Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Andre Boezaart
- Anesthesiology, University of Florida, Gainesville, Florida, USA
- Lumina Health, Surrey, UK
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Wilson AA, Schmid AM, Pestaña P, Tubog TD. Erector Spinae Plane Block on Postoperative Pain and Opioid Consumption After Lumbar Spine Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Perianesth Nurs 2024; 39:122-131. [PMID: 37747377 DOI: 10.1016/j.jopan.2023.06.003] [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: 10/25/2022] [Revised: 02/21/2023] [Accepted: 06/02/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE Evaluate the effectiveness of the erector spinae plane (ESP) block in lumbar spine surgeries. DESIGN Systematic review with meta-analysis. METHODS PubMed, Cochrane Library, CINAHL, Google Scholar, and other gray literature were searched for eligible studies. Risk ratio (RR), mean difference (MD), and standardized mean difference were used to estimate outcomes with suitable effect models. The quality of evidence was assessed using the Risk of Bias algorithm and the grades of recommendation, assessment, development, and evaluation (GRADE) approach. FINDINGS Twenty-two randomized controlled trials involving 1,327 patients were included. The erector spinae plane (ESP) block demonstrated a lower cumulative pain score within the first 48 hours at rest (MD, -1.03; 95% CI, -1.19 to -0.87; P < .00001) and during activity (MD, -1.16; 95% CI, -1.24 to -1.08; P < .00001). In addition, ESP block decreased opioid consumption (MD, -6.25; 95% CI, -8.33 to -4.17; P < .00001) and prolonged the time to first analgesic rescue (MD, 5.66; 95% CI, 3.11-8.20; P < .0001) resulting in fewer patients requesting rescue analgesic (RR, 0.33; 95% CI, 0.13-0.83; P = .02), lower incidence of postoperative nausea and vomiting (RR, 0.29; 95% CI, 0.10-0.79; P = .02) with improved patient satisfaction score (standardized mean difference, 2.17; 95% CI, 1.40-2.94; P < .00001). CONCLUSIONS ESP block can provide effective postoperative pain control for lumbar spine surgery, improve patient satisfaction, and reduce the amount of postoperative opioid use.
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Affiliation(s)
- Alyssa A Wilson
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Alexis M Schmid
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Pedro Pestaña
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Tito D Tubog
- Graduate Programs of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX.
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Karmakar MK, Sivakumar RK, Sheah K, Pangthipampai P, Lönnqvist PA. Quest for the Elusive Mechanism of Action for the Thoracic Paraspinal Nerve Block Techniques. Are We Ignoring the Anatomy of the "Retro Superior Costotransverse Ligament Space?". Anesth Analg 2023; 137:458-465. [PMID: 37450909 DOI: 10.1213/ane.0000000000006462] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Affiliation(s)
- Manoj Kumar Karmakar
- From the Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Faculty of Medicine, Prince of Wales Hospital, Hong Kong, China
| | - Ranjith Kumar Sivakumar
- From the Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Faculty of Medicine, Prince of Wales Hospital, Hong Kong, China
| | - Kenneth Sheah
- Department of Radiology, Orthopedic and Hand MRI (OHM) Novena, Novena Specialist Centre, Singapore
| | - Pawinee Pangthipampai
- Department of Anesthesiology, Mahidol University, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailandand
| | - Per-Arne Lönnqvist
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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Abstract
PURPOSE OF REVIEW The development of truncal and fascial plane blocks has created novel opportunities to apply regional analgesic techniques to patients undergoing spine surgery. This review will summarize recent literature devoted to evaluating candidate blocks for spine surgery, including erector spinae plane block, thoracolumbar interfascial plane block, midpoint transverse process to pleura block, and transversus abdominis plane block. Procedure-specific effects of blocks on patient and healthcare system outcomes will be presented and gaps in care and knowledge will be highlighted. RECENT FINDINGS The most studied paradigm was bilateral erector spinae plane block for lumbar spine surgery. The most common outcomes assessed were early postoperative pain scores, opioid consumption and related side effects, and length of hospital stay. All candidate blocks were associated with mixed evidence for analgesic and opioid-sparing benefits, and/or reductions in length of hospital stay. The magnitude of these effects was overall small, with many studies showing statistically but not clinically significant differences on outcomes of interest. This may reflect, at least in part, the current state of the (emerging) evidence base on this topic. SUMMARY Our understanding of the risks, benefits, and value of truncal and fascial plane blocks for spine surgery cohorts is evolving. Although the results derived from this body of literature are encouraging, further research is required before the widespread adoption of specified blocks into spine care can be recommended.
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Karmakar MK, Sivakumar RK, Sheah K, Pangthipampai P, Lönnqvist PA. The Retro Superior Costotransverse Ligament Space as a New Target for Ultrasound-Guided Intertransverse Process Block: A Report of 2 Cases. A A Pract 2022; 16:e01610. [DOI: 10.1213/xaa.0000000000001610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Syal R, Soni K, Kumar R, Kamal M. A novel indication of an advanced block: Mid-point transverse process to pleura block for rib cartilage harvesting in pinna reconstruction surgery-A case report. Indian J Anaesth 2022; 66:607-608. [PMID: 36274801 PMCID: PMC9580585 DOI: 10.4103/ija.ija_150_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/24/2022] [Accepted: 08/03/2022] [Indexed: 11/04/2022] Open
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Swathi KB, Kamal M, Kumar M, Kumar R, Chhabra S, Bhatia P. Comparison of analgesic efficacy of the conventional approach and mid-transverse process to pleura approach of the paravertebral block in video-assisted thoracoscopy surgeries: A randomised controlled trial. Indian J Anaesth 2021; 65:512-518. [PMID: 34321681 PMCID: PMC8312384 DOI: 10.4103/ija.ija_64_21] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/21/2021] [Accepted: 05/06/2021] [Indexed: 11/04/2022] Open
Abstract
Background and Aims The paravertebral block (PVB) is an effective alternative to thoracic epidural analgesia for post-operative analgesia in thoracic surgeries. Despite the use of ultrasound in PVB, the search for a safer approach continues. This study was conducted to compare the analgesic efficacy of conventional and mid-transverse process to the pleura (MTP) approach of the PVB. Methods Forty patients aged between 18-60 years, posted for video-assisted thoracoscopic surgery, were enroled for this study. Patients were randomised into two groups using a random number table, and group allocation was done by the sealed opaque envelope method. One group received PVB by conventional approach (group CP). In contrast, patients in the other group (group MP) received PVB by the mid-transverse process to pleura (MTP) approach before induction of general anaesthesia under ultrasound guidance. The study's primary aim was to compare analgesic consumption in the first 24 hours. Secondary aims were comparing the Visual Analogue Scale (VAS) score, block performance time, dermatomal spread, haemodynamic parameters such as heart rate (HR), oxygen saturation (SpO2), and non-invasive blood pressure (NIBP), patient satisfaction scores, and complications observed. Data were analysed using Statistical Package for the Social Sciences version 23. Results Demographic parameters, block performance time, and dermatomal distribution were comparable in both groups. We did not find any statistical difference in the analgesic consumption in the first 24 hours (P = 0.38), VAS at rest or on movement, complication rates, and patient satisfaction scores between the groups. Conclusion The MTP approach of the PVB is as effective as the conventional thoracic paravertebral approach for post-operative analgesia in video-assisted thoracoscopic surgeries.
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Affiliation(s)
- K B Swathi
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Manoj Kamal
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mritunjay Kumar
- Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Kumar
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Swati Chhabra
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pradeep Bhatia
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Xiao YK, She SZ, Xu LX, Zheng B. Serratus Anterior Plane Block Combined with General Analgesia and Patient-Controlled Serratus Anterior Plane Block in Patients with Breast Cancer: A Randomized Control Trial. Adv Ther 2021; 38:3444-3454. [PMID: 34021888 DOI: 10.1007/s12325-021-01782-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/07/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Anterior serratus muscle plane block is a novel regional block technique for blockade of the sensory plane of the lateral cutaneous branch of the intercostal nerve (T2-T9), which effectively relieves the pain of patients and improves the quality of recovery. This study aimed to observe the early effectiveness and safety of serratus anterior plane block combined with general anesthesia and patient-controlled serratus anterior plane block in early postoperative recovery in breast cancer. METHODS The study involved a total of 84 patients undergoing radical mastectomy in our hospital. The patients were randomly divided into three groups: the serratus anterior block + general anesthesia + patient-controlled serratus anterior plane block group (PCSAPB group), the serratus anterior block + general anesthesia + patient-controlled intravenous analgesia group (PCIA group), and the general anesthesia + PCIA group (control group), with n = 28 cases in each group. RESULTS The visual analogue scale (VAS) scores of the three groups were compared before and after the operation (P < 0.001), and the anxiety visual analogue scale (AVAS) scores after operation were compared among the three groups (P < 0.001). The total number of postoperative analgesic pumps in the PCSAPB group was significantly lower than that in the control group (P < 0.05). The incidence of adverse reactions in the three groups was statistically significant (P < 0.05). CONCLUSION The combination of anterior serratus plane block and general anesthesia and patient-controlled anterior serratus plane block reduced pain and adverse events, alleviating anxiety, improving the quality of early postoperative recovery among patients with breast cancer after modified radical mastectomy.
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Ultrasound-Guided Midpoint Transverse Process to Pleura Nerve Block for Medical Thoracoscopy: A Case Report. A A Pract 2021; 14:e01240. [PMID: 32643903 DOI: 10.1213/xaa.0000000000001240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We performed the midpoint transverse process to pleura (MTP) block in a patient with a recurrent pleural effusion requiring medical thoracoscopy, drainage of pleural effusion, talc poudrage, and placement of tunneled pleural catheter under sedation while in the left lateral decubitus position. Forty milliliters of a combination of bupivacaine hydrochloride and lidocaine, with dexamethasone and clonidine as adjuvants, was injected at the T6 level under ultrasound guidance with satisfactory intra- and postoperative analgesia.
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Beiranvand S, Karimi A, Haghighat Shoar M, Baghizadeh Baghdashti M. The Effects of Magnesium Sulfate with Lidocaine for Infraclavicular Brachial Plexus Block for Upper Extremity Surgeries. J Brachial Plex Peripher Nerve Inj 2020; 15:e33-e39. [PMID: 33173542 PMCID: PMC7647732 DOI: 10.1055/s-0040-1715578] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 06/30/2020] [Indexed: 01/01/2023] Open
Abstract
Background An addition of analgesic to anesthetic agents is likely to increase the effects of anesthesia and reduce associated adverse outcomes. Several adjuvants are studied in this regard. The aim of this study is to investigate the effects of adding a magnesium adjunct to lidocaine for the induction of infraclavicular block. Methods Patients referred to Shohada Ashayer Hospital, Khorramabad, for wrist and hand surgery were enrolled in this study. The intervention/case group included patients who received 18 mL lidocaine (2%) + 2 mL magnesium sulfate (50%), 10 mL normal saline; control group: 18 mL lidocaine (2%) + 12 mL of normal saline. After the induction of ultrasound-guided infraclavicular block, parameters such as duration of reach with respect to complete sensory and motor block, hemodynamic parameters (hypotension and bradycardia), and postoperative pain, using visual analogue scale criteria, were measured. The obtained data were analyzed using a Bayesian path analysis model. Results A total of 30 patients were included in each group. In the case group, sensory and motor block was achieved for 12.136 ± 4.96 and 13 ± 3.589 minutes more than those in the control group. The duration of sedation and immobilization was 2.57 ± 0.764 minute and 4.66 ± 0.909 minutes lengthier in the case group. Regarding the hemodynamic parameters, blood pressure was 0.217 ± 5.031 and 1.59 ± 5.14 units lower in the case group, immediately following the block and the surgery. Similarly, heart rate was 0.776 ± 4.548 and 0.39 ± 3.987 units higher in the case group, after 30 minutes and 2 hours of the procedure. A decrease in the pain was seen at 8, 10, and 12 hours after the surgery, as compared with the control group. An addition of magnesium to lidocaine for infraclavicular block resulted in a significantly longer sedation and immobilization period and decreased postoperative pain at 12 hours. Conclusion Heart rate and blood pressure did not decrease significantly in the case group. It can be concluded that addition of magnesium sulfate to lidocaine can produce better anesthetic and analgesic outcomes with low-to-no adverse effects.
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Affiliation(s)
- Siavash Beiranvand
- Department of Anesthesiology, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Arash Karimi
- Department of Anesthesiology, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Majid Haghighat Shoar
- Department of Anesthesiology, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
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Syal R, Kumar R, Chhabra S, Agha M. Is the mid-transverse process to pleura block a better technique for patients with obesity undergoing modified radical mastectomy? Korean J Anesthesiol 2020; 73:462-464. [PMID: 32098008 PMCID: PMC7533182 DOI: 10.4097/kja.20067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 02/23/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Rashmi Syal
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Rakesh Kumar
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Swati Chhabra
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mussavvir Agha
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Watton DE, Rose PGD, Abdallah FW, Thompson CP, Maziak DE, Costache I. Midpoint transverse process to pleura catheter placement for postoperative analgesia following video-assisted thoracoscopic surgery. Anaesth Rep 2019; 7:65-68. [PMID: 32051952 PMCID: PMC6931300 DOI: 10.1002/anr3.12018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2019] [Indexed: 01/16/2023] Open
Abstract
The ultrasound-guided midpoint transverse process to pleura block has been described as an alternative end-point for thoracic paravertebral blockade. Although originally described as a single-level block, midpoint transverse process to pleura blockade may cover more than one level when larger volumes of injectate are used. Moreover, a continuous catheter midpoint transverse process to pleura blockade technique was previously thought to be unfeasible. We report three cases where a midpoint transverse process to pleura continuous catheter technique was successfully used for postoperative analgesia following video-assisted thoracoscopic surgery.
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Affiliation(s)
- D. E. Watton
- Department of Anesthesiology and Pain MedicineUniversity of OttawaONCanada
| | - P. G. D. Rose
- Department of Anesthesiology and Pain MedicineUniversity of OttawaONCanada
| | - F. W. Abdallah
- Department of Anesthesiology and Pain MedicineUniversity of OttawaONCanada
| | - C. P. Thompson
- Department of Anesthesiology and Pain MedicineUniversity of OttawaONCanada
| | - D. E. Maziak
- Surgical Oncology Division of Thoracic SurgeryThe Ottawa HospitalUniversity of OttawaONCanada
- University of OttawaONCanada
| | - I. Costache
- Department of Anesthesiology and Pain MedicineUniversity of OttawaONCanada
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