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Paravertebral block for the anesthetic management in a patient with severe ankylosing spondylitis: Single injection or multiple injections?
Journal of Clinical Anesthesia 44 (2018) 5–6
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Correspondence Paravertebral block for the anesthetic management in a patient with severe ankylosing spondylitis: Single injection or multiple injections?
1. Background and objective Open cholecystectomy surgery is conventionally performed under general anesthesia, however high thoracic epidural block or spinal anesthesia may also be performed [1]. Anesthetic management of a patient with ankylosing spondylitis (AS) for open cholecystectomy surgery is often challenging because of a potentially difficult airway, the risk of cardiovascular and respiratory complications, and the difficulty in performing central neuraxial block due to fusion of lumbar spine [2]. Paravertebral block has recently been reported to be successfully performed for open cholecystectomy surgery in the patients with cardiopulmonary pathologies [3,4]. In this case report, we aimed to represent an unexpected problem seen in the anesthetic management of open cholecystectomy performed with paravertebral block in a patient with severe ankylosing spondylitis. 2. Case Sixty one year old, 50 kg male patient applied to hospital due to right upper abdominal pain and diagnosed as cholelithiasis. He had an operation for gastric ulcer nearly 25 years ago, so he was scheduled for an open cholecystectomy surgery instead of a laparoscopic intervention. His comorbidities were hypothyroidism, hypertension, atherosclerosis, gastric ulcer, chronic obstructive pulmonary disease (COPD) with moderate decrease in pulmonary function and he has been suffering from AS for 37 years. Five years ago, he had an open inguinal hernia repair operation. In that operation, neuraxial block couldn't be performed and general anesthesia was not preferred due to possible difficult airway, so the surgery was performed under local anesthesia with midazolam and fentanyl sedation. Two years ago, he had femur fracture but surgical treatment couldn't be done due to severe restriction in joint movements. After that, the patient completely lost the ability to walk. The physical examination showed severely limited cervical spine mobility with approximately 10 degrees flexion and no extension. Preoperative anesthetic assessment revealed Mallampati Class IV oropharyngeal view. The thyromental distance was less than 6 cm and similarly his mouth opening was measured as four centimeters due to temporomandibular joint involvement. In the preoperative laboratory tests hemoglobin level was 9.5 g/dl, hematocrit was 29.6%, prothrombin time 14.2 s and international normalized ratio (INR) was 1.13. Other laboratory tests were in normal ranges. A unilateral paravertebral block (PVB) was planned for the anesthetic management. The patient was informed about both the anesthetic procedure and the possibility of tracheostomy intervention,
https://doi.org/10.1016/j.jclinane.2017.09.013 0952-8180/© 2017 Elsevier Inc. All rights reserved.
then the written informed consents were received. In the operating room routine monitoring with electrocardiogram, non-invasive blood pressure and fingertip arterial oxygen saturation (SpO2) was applied. His heart rate was 70 beats/min, blood pressure was 155/95 mm Hg and SpO2 was 95%. Laryngeal mask airway, intubation videolaryngoscope, fiberoptic bronchoscopy and tracheostomy equipment were kept ready in the operating room. After placement of a peripheral intravenous line, the patient was premedicated with one milligram midazolam and 50 mcg fentanyl. Oxygen was administered with 2 l/min flow by mask. An ultrasonographic view of the paravertebral space at the level of T7 was obtained in the sitting position (Fig. 1). Local anesthesia with 2% lidocaine was applied to skin and subcutaneous tissues under aseptic conditions. Then paravertebral space was entered by using 18-gauge 80-mm atraumatic neurostimulator (Contiplex E, B. Braun Melsungen AG, Germany) block needle. A right sided paravertebral block was performed with 100 mg 0.5% bupivacaine (Fig. 2). Then the patient was lied in the supine position and dexmedetomidine infusion is started. Twenty-five minutes later, the patient was evaluated by pinprick and hot-cold tests for determination of sensory block. Although it was expected between T5–T9 dermatomes, an effective sensory block was only achieved at T6–T7 levels and a patchy block was seen at T8 dermatome. As the extension of block was inadequate for anesthesia of open cholecystectomy surgery, the patient was positioned again for the second paravertebral injection. At the second attempt, 50 mg 0.5% bupivacaine was injected at the level of T8 and the patient was laid in the supine position again. Time to full onset of the block was 22 min. Meanwhile patient's heart rate was between 60 and 68 beats/min, systolic blood pressure was between 140 and 154 mm Hg, diastolic blood pressure was between 83 and 88 mm Hg and SpO2 was between 92%–99%. At the end of 55 min in the operating room, the surgical procedure started without any problems and lasted for 30 min. As the visual analogue scale (VAS) was 4 at the skin incision, dexmedetomidine infusion rate was increased. During the procedure patient's blood pressure remained to be slightly high but other vital signs were in normal ranges, he was breathing spontaneously. VAS was assessed at every 15 min intraoperatively and recorded between 0 and 2. At the end of the surgery, dexmedetomidine infusion was stopped and the patient was sent to the recovery room. The patient was followed for 30 min in the recovery room and then referred to the surgical ward. The first analgesic need was 12 h after the surgery and 75 mg diclofenac sodium was injected. On the 7th post-operative day, he was discharged without any problem.
3. Discussion Ankylosing spondylitis (AS) is a chronic immune-mediated inflammatory disease. It is characterized by inflammation that predominantly affects the axial skeleton with variable involvement of peripheral joints and nonarticular structures [5], so performing spinal and epidural anesthesia is technically difficult. Unfortunately airway management is also difficult due to the involvement of the cervical spine and the temporomandibular joint [6]. In the current case, neuraxial block couldn't be performed in the previous anesthesia experience and cervical movements were severely limited, so we had to try an alternative anesthetic
6
Correspondence
Fig. 1. Ultrasonographic view of T6–T7 paravertebral space.
approach. Paravertebral block has been previously performed for the anesthetic management of open cholecystectomy surgery in limited cases [3,4]. Serpetinis et al. have investigated the effectiveness of paravertebral block for open cholecystectomy surgery in eight cardiopulmonary compromised patients. They have injected 5 ml of 2% ropivacaine at each point between T6–T9 levels and placed a epidural-type catheter at the level of T7. They have reported that no patients complained of discomfort or pain intraoperatively, paravertebral block maintained adequate anesthesia for the surgery [3]. On the other hand Beyaz et al. have preferred “single shot” paravertebral block for open cholecystectomy surgery in two patients with COPD and cerebrovascular infarction. They have performed unilateral paravertebral block at the level of T7 with 20 ml 0.5% bupivacaine and reported that at the end of the 25 min, they achieved adequate anesthesia between T4–T8 dermatomes [4]. Similar to Beyaz et al. we performed “single shot” unilateral paravertebral block at the level of T7 to decrease the risk of complications such as pneumothorax or
bleeding. Unfortunately 25 min later the sensory block was found to be only at T6–T7 dermatomes. Inadequate block is blamed to be the most important problem of single-shot technique. The factors influencing the pattern of local anesthetic spreading during a single paravertebral injection are still uncertain. Naja et al. have reported that injections made anterior to the endothoracic fascia resulted in a multisegmental “longitudinal” spreading pattern, while injections made dorsal to the endothoracic fascia resulted in a less predictable “cloud-like” spreading pattern with limited distribution in their study. They have suggested that a nerve stimulatorguided technique appeared to be helpful in achieving the more desirable longitudinal spreading pattern [7]. In the current case, we performed the paravertebral block with the guidance of ultrasonography which maintained the opportunity of real-time visualization of the block side. However we can't be sure if the paravertebral block was ventral or dorsal to the endothoracic fascia, as we didn't use a radio-opaque dye during the procedure. We think that the most possible cause of inadequate spread of local anesthetic in our patient is ankylosing spondylitis. The fusion and rigid, kyphoid deformity of spines probably prevented the multisegment longitudinal spreading of local anesthetic and resulted in inadequate anesthesia. Naja et al. have compared the clinical distribution of local anesthetic mixture at one to four paravertebral injections and found that multilevel paravertebral injections resulted in more reliable clinical distribution compared with a single-injection technique [8]. As a result, we conclude that if paravertebral block is planned for the anesthetic management in a patient with severe ankylosing spondylitis, multilevel injections may provide better anesthetic conditions instead of single-shot technique. Acknowledgements None. References [1] Paleczny J, Zipser P, Pysz M. Paravertebral block for open cholecystectomy. Anestezjol Intens Ter 2009;41(2):89–93. [2] Chen L, Liu J, Yang J, Zhang Y, Liu Y. Combined fascia iliaca and sciatic nerve block for hip surgery in the presence of severe ankylosing spondylitis: a case-based literature review. Reg Anesth Pain Med 2016;41(2):158–63. [3] Serpetinis I, Bassiakou E, Xanthos T, Baltatzi L, Kouta A. Paravertebral block for open cholecystectomy in patients with cardiopulmonary pathology. Acta Anaesthesiol Scand 2008;52(6):872–3. [4] Beyaz SG, Ozocak H, Ergonenc T, Erdem AF. The thoracic paravertebral block performed for open cholecystectomy operation in order to anesthesia: two cases. Anesth Essays Res 2014;8(2):239–42. [5] Sieper J, Braun J, Rudwaleit M, Boonen A, Zink A. Ankylosing spondylitis: an overview. Ann Rheum Dis 2002;61(Suppl. 3):iii8–18. [6] Balcı ŞTA, Çınar Ö, Bircan H, Sekmen Ü. Alternative anaesthetic management in ankylosing spondylitis. AĞRI 2014;26(4):196–7. [7] Naja MZ, Ziade MF, El Rajab M, El Tayara K, Lonnqvist PA. Varying anatomical injection points within the thoracic paravertebral space: effect on spread of solution and nerve blockade. Anaesthesia 2004;59(5):459–63. [8] Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tayara K, Younes F, et al. Thoracic paravertebral block: influence of the number of injections. Reg Anesth Pain Med 2006;31(3):196–201.
Başak Altıparmak, MD* Ali İhsan Uysal, MD Gülseda Dede, MD Mustafa Turan, MD Bakiye Uğur, MD Muğla Sıtkı Koçman University, Department of Anesthesiology and Reanimation, Muğla 48000, Turkey *Corresponding author. E-mail addresses: [email protected], [email protected] (B. Altıparmak).
Fig. 2. Ultrasonographic view of the needle and local anesthetic injection to the T6–T7 paravertebral space.
7 August 2017 Available online xxxx
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Correspondence Paravertebral block for the anesthetic management in a patient with severe ankylosing spondylitis: Single injection or multiple injections?
1. Background and objective Open cholecystectomy surgery is conventionally performed under general anesthesia, however high thoracic epidural block or spinal anesthesia may also be performed [1]. Anesthetic management of a patient with ankylosing spondylitis (AS) for open cholecystectomy surgery is often challenging because of a potentially difficult airway, the risk of cardiovascular and respiratory complications, and the difficulty in performing central neuraxial block due to fusion of lumbar spine [2]. Paravertebral block has recently been reported to be successfully performed for open cholecystectomy surgery in the patients with cardiopulmonary pathologies [3,4]. In this case report, we aimed to represent an unexpected problem seen in the anesthetic management of open cholecystectomy performed with paravertebral block in a patient with severe ankylosing spondylitis. 2. Case Sixty one year old, 50 kg male patient applied to hospital due to right upper abdominal pain and diagnosed as cholelithiasis. He had an operation for gastric ulcer nearly 25 years ago, so he was scheduled for an open cholecystectomy surgery instead of a laparoscopic intervention. His comorbidities were hypothyroidism, hypertension, atherosclerosis, gastric ulcer, chronic obstructive pulmonary disease (COPD) with moderate decrease in pulmonary function and he has been suffering from AS for 37 years. Five years ago, he had an open inguinal hernia repair operation. In that operation, neuraxial block couldn't be performed and general anesthesia was not preferred due to possible difficult airway, so the surgery was performed under local anesthesia with midazolam and fentanyl sedation. Two years ago, he had femur fracture but surgical treatment couldn't be done due to severe restriction in joint movements. After that, the patient completely lost the ability to walk. The physical examination showed severely limited cervical spine mobility with approximately 10 degrees flexion and no extension. Preoperative anesthetic assessment revealed Mallampati Class IV oropharyngeal view. The thyromental distance was less than 6 cm and similarly his mouth opening was measured as four centimeters due to temporomandibular joint involvement. In the preoperative laboratory tests hemoglobin level was 9.5 g/dl, hematocrit was 29.6%, prothrombin time 14.2 s and international normalized ratio (INR) was 1.13. Other laboratory tests were in normal ranges. A unilateral paravertebral block (PVB) was planned for the anesthetic management. The patient was informed about both the anesthetic procedure and the possibility of tracheostomy intervention,
https://doi.org/10.1016/j.jclinane.2017.09.013 0952-8180/© 2017 Elsevier Inc. All rights reserved.
then the written informed consents were received. In the operating room routine monitoring with electrocardiogram, non-invasive blood pressure and fingertip arterial oxygen saturation (SpO2) was applied. His heart rate was 70 beats/min, blood pressure was 155/95 mm Hg and SpO2 was 95%. Laryngeal mask airway, intubation videolaryngoscope, fiberoptic bronchoscopy and tracheostomy equipment were kept ready in the operating room. After placement of a peripheral intravenous line, the patient was premedicated with one milligram midazolam and 50 mcg fentanyl. Oxygen was administered with 2 l/min flow by mask. An ultrasonographic view of the paravertebral space at the level of T7 was obtained in the sitting position (Fig. 1). Local anesthesia with 2% lidocaine was applied to skin and subcutaneous tissues under aseptic conditions. Then paravertebral space was entered by using 18-gauge 80-mm atraumatic neurostimulator (Contiplex E, B. Braun Melsungen AG, Germany) block needle. A right sided paravertebral block was performed with 100 mg 0.5% bupivacaine (Fig. 2). Then the patient was lied in the supine position and dexmedetomidine infusion is started. Twenty-five minutes later, the patient was evaluated by pinprick and hot-cold tests for determination of sensory block. Although it was expected between T5–T9 dermatomes, an effective sensory block was only achieved at T6–T7 levels and a patchy block was seen at T8 dermatome. As the extension of block was inadequate for anesthesia of open cholecystectomy surgery, the patient was positioned again for the second paravertebral injection. At the second attempt, 50 mg 0.5% bupivacaine was injected at the level of T8 and the patient was laid in the supine position again. Time to full onset of the block was 22 min. Meanwhile patient's heart rate was between 60 and 68 beats/min, systolic blood pressure was between 140 and 154 mm Hg, diastolic blood pressure was between 83 and 88 mm Hg and SpO2 was between 92%–99%. At the end of 55 min in the operating room, the surgical procedure started without any problems and lasted for 30 min. As the visual analogue scale (VAS) was 4 at the skin incision, dexmedetomidine infusion rate was increased. During the procedure patient's blood pressure remained to be slightly high but other vital signs were in normal ranges, he was breathing spontaneously. VAS was assessed at every 15 min intraoperatively and recorded between 0 and 2. At the end of the surgery, dexmedetomidine infusion was stopped and the patient was sent to the recovery room. The patient was followed for 30 min in the recovery room and then referred to the surgical ward. The first analgesic need was 12 h after the surgery and 75 mg diclofenac sodium was injected. On the 7th post-operative day, he was discharged without any problem.
3. Discussion Ankylosing spondylitis (AS) is a chronic immune-mediated inflammatory disease. It is characterized by inflammation that predominantly affects the axial skeleton with variable involvement of peripheral joints and nonarticular structures [5], so performing spinal and epidural anesthesia is technically difficult. Unfortunately airway management is also difficult due to the involvement of the cervical spine and the temporomandibular joint [6]. In the current case, neuraxial block couldn't be performed in the previous anesthesia experience and cervical movements were severely limited, so we had to try an alternative anesthetic
6
Correspondence
Fig. 1. Ultrasonographic view of T6–T7 paravertebral space.
approach. Paravertebral block has been previously performed for the anesthetic management of open cholecystectomy surgery in limited cases [3,4]. Serpetinis et al. have investigated the effectiveness of paravertebral block for open cholecystectomy surgery in eight cardiopulmonary compromised patients. They have injected 5 ml of 2% ropivacaine at each point between T6–T9 levels and placed a epidural-type catheter at the level of T7. They have reported that no patients complained of discomfort or pain intraoperatively, paravertebral block maintained adequate anesthesia for the surgery [3]. On the other hand Beyaz et al. have preferred “single shot” paravertebral block for open cholecystectomy surgery in two patients with COPD and cerebrovascular infarction. They have performed unilateral paravertebral block at the level of T7 with 20 ml 0.5% bupivacaine and reported that at the end of the 25 min, they achieved adequate anesthesia between T4–T8 dermatomes [4]. Similar to Beyaz et al. we performed “single shot” unilateral paravertebral block at the level of T7 to decrease the risk of complications such as pneumothorax or
bleeding. Unfortunately 25 min later the sensory block was found to be only at T6–T7 dermatomes. Inadequate block is blamed to be the most important problem of single-shot technique. The factors influencing the pattern of local anesthetic spreading during a single paravertebral injection are still uncertain. Naja et al. have reported that injections made anterior to the endothoracic fascia resulted in a multisegmental “longitudinal” spreading pattern, while injections made dorsal to the endothoracic fascia resulted in a less predictable “cloud-like” spreading pattern with limited distribution in their study. They have suggested that a nerve stimulatorguided technique appeared to be helpful in achieving the more desirable longitudinal spreading pattern [7]. In the current case, we performed the paravertebral block with the guidance of ultrasonography which maintained the opportunity of real-time visualization of the block side. However we can't be sure if the paravertebral block was ventral or dorsal to the endothoracic fascia, as we didn't use a radio-opaque dye during the procedure. We think that the most possible cause of inadequate spread of local anesthetic in our patient is ankylosing spondylitis. The fusion and rigid, kyphoid deformity of spines probably prevented the multisegment longitudinal spreading of local anesthetic and resulted in inadequate anesthesia. Naja et al. have compared the clinical distribution of local anesthetic mixture at one to four paravertebral injections and found that multilevel paravertebral injections resulted in more reliable clinical distribution compared with a single-injection technique [8]. As a result, we conclude that if paravertebral block is planned for the anesthetic management in a patient with severe ankylosing spondylitis, multilevel injections may provide better anesthetic conditions instead of single-shot technique. Acknowledgements None. References [1] Paleczny J, Zipser P, Pysz M. Paravertebral block for open cholecystectomy. Anestezjol Intens Ter 2009;41(2):89–93. [2] Chen L, Liu J, Yang J, Zhang Y, Liu Y. Combined fascia iliaca and sciatic nerve block for hip surgery in the presence of severe ankylosing spondylitis: a case-based literature review. Reg Anesth Pain Med 2016;41(2):158–63. [3] Serpetinis I, Bassiakou E, Xanthos T, Baltatzi L, Kouta A. Paravertebral block for open cholecystectomy in patients with cardiopulmonary pathology. Acta Anaesthesiol Scand 2008;52(6):872–3. [4] Beyaz SG, Ozocak H, Ergonenc T, Erdem AF. The thoracic paravertebral block performed for open cholecystectomy operation in order to anesthesia: two cases. Anesth Essays Res 2014;8(2):239–42. [5] Sieper J, Braun J, Rudwaleit M, Boonen A, Zink A. Ankylosing spondylitis: an overview. Ann Rheum Dis 2002;61(Suppl. 3):iii8–18. [6] Balcı ŞTA, Çınar Ö, Bircan H, Sekmen Ü. Alternative anaesthetic management in ankylosing spondylitis. AĞRI 2014;26(4):196–7. [7] Naja MZ, Ziade MF, El Rajab M, El Tayara K, Lonnqvist PA. Varying anatomical injection points within the thoracic paravertebral space: effect on spread of solution and nerve blockade. Anaesthesia 2004;59(5):459–63. [8] Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tayara K, Younes F, et al. Thoracic paravertebral block: influence of the number of injections. Reg Anesth Pain Med 2006;31(3):196–201.
Başak Altıparmak, MD* Ali İhsan Uysal, MD Gülseda Dede, MD Mustafa Turan, MD Bakiye Uğur, MD Muğla Sıtkı Koçman University, Department of Anesthesiology and Reanimation, Muğla 48000, Turkey *Corresponding author. E-mail addresses: [email protected], [email protected] (B. Altıparmak).
Fig. 2. Ultrasonographic view of the needle and local anesthetic injection to the T6–T7 paravertebral space.
7 August 2017 Available online xxxx