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Paravertebral Block Versus Intercostal Nerve Block in Non-Intubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial
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Heart, Lung and Circulation (2019) xx, 1–8 1443-9506/04/$36.00 https://doi.org/10.1016/j.hlc.2019.04.013
ORIGINAL ARTICLE
Paravertebral Block Versus Intercostal Nerve Block in Non-Intubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial$© Mona Mohamed Mogahed, PhD a*, Mohamed Shafik Elkahwagy, PhD b a
Department of Anaesthesiology, SICU and pain therapy, Tanta University, El Bahr Road Department of Cardiothoracic surgery, Tanta University
b
Received 28 December 2018; received in revised form 15 February 2019; accepted 11 April 2019; online published-ahead-of-print xxx
Background
Non-intubated uniportal video-assisted thoracoscopic surgery (VATS) has been reported to be safe and feasible for patients with various thoracic diseases, including those who have respiratory dysfunction. This study examined the anaesthetic and analgesic sparing effects of either paravertebral block or intercostal nerve block on the non-intubated technique with spontaneous ventilation in patients under general anaesthesia (GA) using a supraglottic airway device. The primary aim was to compare the anaesthetic sparing effect of paravertebral block versus intercostal nerve block in non-intubated GA with airway support via a supraglottic airway device during VATS surgery. The secondary aim was to compare the recovery characters and postoperative outcomes of the patients.
Methods
The study included 105 patients with American Society of Anesthesiologists (ASA) physical status II-III who had video-assisted thoracoscopy without endotracheal intubation and using a laryngeal airway. The patients were divided into three groups; each group consisted of 35 patients. Group I (35 patients): control group received only GA. Group 2 (35 patients): received a single-shot paravertebral block before induction of the GA. Group 3 (35 patients): received thoracoscopic intercostal block infiltration after induction of anaesthesia from the third to the eighth intercostal nerve block, in addition to intrathoracic vagal block. Heart rate, mean arterial pressure (MAP), and oxygen saturation were recorded before induction of GA (T0), after induction of GA (T1), 20 minutes later (T2), and before the end of the surgical procedure (T3).
Results
Heart rate was significantly lower in Groups 2 and 3 compared with Group 1, and lower in Group 2 compared with Group 3. The MAP was significantly lower in Groups 2 and 3 compared with Group 1, and there was no significant difference between Groups 2 and 3. Oxygen saturation was significantly higher in Group 2 and in Group 3 compared with Group 1 and there was no significance difference between Groups 2 and 3. Expiratory fraction of sevoflurane (Ef sevo) was significantly lower in Groups 2 and 3 compared with Group 1, with no difference between Group 2 and 3. Groups 2 and 3 had lower fentanyl requirements, time to spontaneous eye movement, time to spontaneous arm movement, time to purposeful movement, and time to laryngeal mask removal than Group 1.
$©
2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).
Published by Elsevier B.V. *Corresponding author. Email: [email protected] © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Mogahed MM, Elkahwagy MS. Paravertebral Block Versus Intercostal Nerve Block in NonIntubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial. Heart, Lung and Circulation (2019), https://doi.org/10.1016/j.hlc.2019.04.013
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Conclusions
Regional anaesthesia by either preoperative paravertebral block or thoracoscopic intercostal nerve block with ipsilateral vagal block provided an anaesthetic sparing effect, guided by lower Ef sevo concentration, with comparable bi-spectral index in patients undergoing uniportal thoracoscopic surgery.
Keywords
Non-intubated Video-assisted thoracoscopic surgery Paravertebral block Intercostal nerve block
Introduction With the increasing use of video-assisted thoracoscopic surgery (VATS) for most thoracic surgical procedures, there has been a strong drive to minimise the overall invasiveness and surgical stress [1,2]. Non-intubated VATS (NIVATS) avoids trauma to the trachea, oesophagus, and hypopharynx from double-lumen endobronchial tube placement; mechanical ventilator-induced lung injury; and the residual effects of neuromuscular blockade and general anaesthetic drugs, which may compromise cardiac performance and impair early postoperative respiratory function [3]. Thoracic epidural anaesthesia (TEA), intercostal nerve block, and paravertebral block are the most commonly employed techniques for non-intubated anaesthesia. Regional techniques in combination with general anaesthesia (GA) have been used to achieve better postoperative analgesia, lessen the surgical stress response, and have anaesthetic sparing effect by reducing the total amounts of general anaesthetics guided by the haemodynamic response and bi-spectral index (BIS) [4–10]. Effective regional techniques in combination with GA have been used for better postoperative pain control, to reduce the response to surgical stress, have an anaesthetic sparing effect, and reduce the total amounts of GA drugs, guided by the haemodynamic response and BIS [11–14]. It is believed that a non-intubated general anaesthetic technique with airway support via a supraglottic airway device during VATS surgery prevents patient anxiety and distress, minimises movement and coughing, and allows for superior airway control and oxygenation. The present study examined the anaesthetic sparing effect of paravertebral block versus intercostal nerve block on this type of surgery. The primary aim of this study was to compare the anaesthetic sparing effect of paravertebral block versus intercostal nerve block in non-intubated GA with airway support via a supraglottic airway device during VATS surgery. The secondary aim was to compare the recovery characters and postoperative outcomes of the patients.
Patients and methods The study included 105 patients with American Society of Anesthesiologists (ASA) physical status II-III who had videoassisted thoracoscopy without endotracheal intubation and using a laryngeal airway. Approval of the Ethical Committee was obtained prior to the trial and every patient had signed written informed consent. The patients were divided into three groups, each group consisted of 35 patients. The patients had video-assisted
thoracoscopy (VATS) for procedures with expected time <1 hour, such as non-anatomical lung resections, bullectomy, evacuation of a recent haemothorax, excision or biopsy of a simple mediastinal mass, intrapleural or parenchymal foreign body extraction, and pericardial window. Patients who had coagulopathy, significant encephalopathy, preexisting motor or sensory deficit, emotional instability, previous thoracic surgery, or other contraindications to local anaesthesia, such as allergies, were excluded from the study. Physical examination was performed for all patients prior to the planned procedure, with assessment of the cardiovascular and pulmonary reserves and general patient performance. Liver and renal function tests and coagulation profile were performed in all patients. Chest X-ray, computed tomography (CT) scan, and fibreoptic bronchoscope were performed prior to randomisation. Preoperative patient education was performed, including how to use the visual analogue scale (VAS), where 0 represents no pain and 100 the worst intolerable pain. Block randomisation was performed and the size of each block consisted of four to seven patients. The blocks were randomly generated online using https://www.randomizer. org/. Patients were randomised into three equal groups as follows: Group I (35 patients): control group received only GA. Group 2 (35 patients): received a single-shot paravertebral block before induction of GA. Group 3 (35 patients): received thoracoscopic intercostal block infiltration after induction of anaesthesia from the third to the eighth intercostal nerve block, in addition to intrathoracic vagal block. Intramuscular midazolam (0.15-0.25 mg/kg) was used 15 minutes before anaesthesia for sedation. The protocol for GA was the same in all groups. Induction of anaesthesia was performed with propofol 1.5-2 mg/kg IV, fentanyl 1m/kg IV, and sevoflurane 1-1.5 MAC, and insertion of a supraglottic airway device (the LMA Classic, Teleflex, Westmeath, Ireland). Spontaneous ventilation was permitted with 100% oxygen inspired fraction (FiO2), 2.5 L/minute fresh gas flow. The anaesthetic depth was controlled by varying sevoflurane concentration to maintain the BIS between 40-60. At any time during surgery, if the mean arterial pressure (MAP) and heart rate increased to 25% of the baseline, supplemental analgesic in the form of fentanyl 1 mg/kg IV was given and the total dose of fentanyl was noted. No central venous catheter, arterial catheter, or urinary catheter was placed. Surgical incision was allowed after 10 minutes of paravertebral bolus. Any episode of hypotension (systolic arterial pressure <90 mmHg) excluding surgical blood loss was treated with incremental doses of ephedrine, and bradycardia (heart rate <50/minute) was treated with atropine.
Please cite this article in press as: Mogahed MM, Elkahwagy MS. Paravertebral Block Versus Intercostal Nerve Block in NonIntubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial. Heart, Lung and Circulation (2019), https://doi.org/10.1016/j.hlc.2019.04.013
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In the operating room, routine monitoring (Cardiocaps; Datex Ohmeda, Helsinki, Finland) included five-lead electrocardiogram (ECG), pulse oximeter, and non-invasive blood pressure (BP) measurement. Electrodes for monitoring the bispectral index (BSP) (BISTM, model A-2000s; Aspect Medical Systems, Norwood, MA, USA) were attached to the head. End-tidal carbon dioxide (ETCO2) concentration and end-expiratory concentration of sevoflurane were also recorded from the time of anaesthesia induction to the time of extubation. The respiratory rate (RR) was maintained between 12-20 breaths/minute by modifying the depth of anaesthesia. The BP, HR and SPO2 were recorded before induction of the GA, after induction of the GA, 20 minutes later, and immediately before the end of surgery. End-tidal carbon dioxide, expiratory fraction of Sevoflurane (Ef sevo) and RR were recorded after induction of the GA, 20 minutes later, and immediately before the end of surgery. The total amount of fentanyl used during surgery was also recorded. Paravertebral block was performed while the patient was sitting with the feet resting on a stool. The patient was asked to lean forwards to allow more kyphosis. After sterilising the back of the patient with povidone-iodine and under complete aseptic precautions, 5 mL of lidocaine 1% was infiltrated subcutaneously along the line where the injections would be made. An epidural needle (Tuohy 18 G; Braun, Melsungen, Germany) was inserted at the T4 level 2.5-3 cm lateral to the most upper aspect of the spinous process, and advanced slowly and perpendicularly to reach the transverse process of the vertebra below, at a depth ranging from 2-4 cm according to the build of the individual. If bone was not reached at this depth, it was possible that the needle tip was lying between two transverse processes. To prevent pleural puncture, it was important to detect the transverse process before advancing the needle any further. This was achieved by withdrawing the needle to the subcutaneous plane and redirecting it upwards and downwards to the same depth until bone was reached. If bone was still not reached, the needle was advanced a further centimetre and the above process was repeated until the transverse process was encountered. The needle was then gradually advanced above the transverse process until a loss of resistance to saline was felt, as the needle tip traversed the thin superior costotransverse ligament, usually within 1-1.5 cm from the superior edge of the transverse process. After gentle aspiration, local anaesthetic was injected. After induction of the GA in Group 3, 3-cm incision was made for thoracoscopy at the fifth intercostal space in the anterior axillary line. This procedure marked the start of one lung being ventilated because the incision created an artificial pneumothorax, and the lung gradually collapsed with the patient’s spontaneous breathing. In Group 3, thoracoscopic intercostal nerve blocks (TINBs) were administered by infiltration of local anaesthetic mixture (1.5 mL for each intercostal space) from the third to the eighth intercostal nerve under the parietal pleura, 2 cm lateral to the sympathetic chain, using an infusion needle. Thoracoscopic vagal nerve block was administered by infiltration of 3 mL of the local
anaesthetic mixture adjacent to the vagus nerve at the level of the lower trachea for right-sided procedures and at the level of the aortopulmonary window for left-sided procedures. Vagal block aids in preventing coughing during thoracoscopic manipulations. After finishing the surgery, the inhalational anaesthetic was turned off. Once consciousness was regained and protective reflexes had returned, gentle suction around the laryngeal mask in the pharynx and hypopharynx was performed, by asking the patient to open his or her mouth. The laryngeal mask was removed and replaced with an oxygen facemask. Spontaneous eye movement, spontaneous arm movement, purposeful movement, time of discharge to the recovery room, and postoperative VAS (0 = no pain, 100 = worst pain intolerable) at 15 minutes, 1 hour, and 2 hours postoperatively were recorded. A VAS score was 40, analgesia was given in the form of intramuscular ketoprofen 75 mg, with a maximum dose of 300 mg/day. If the patient suffered from nausea, with or without vomiting, ondansetron 4 mg IV was given, and repeated once if nausea persisted (maximum dose 8 mg/day). Patients were then transferred to a post-anaesthesia care unit (PACU) for 24 hours.
Statistical Analysis All statistical analyses were performed using SPSS (15) for windows. Continuous variables were tested for normal distribution by the Kolmogorov-Smirnov test. Parametric data were compared using analysis of variance (ANOVA). Between-group comparisons at different time intervals were assessed by using paired t-test. All categorical data were compared by using x2 test. A sample size of 35 patients in each group was needed to detect an intergroup difference of at least 20% ( = 0.01, twosided, power = 95%) with two sample t-test. Data were collected by a blinded observer and presented as mean SD or N (%). A p-value of <0.05 was considered significant.
Results Preoperative Patients’ Characteristics There was no difference in preoperative patients’ demographics among groups (Table 1). Preoperative forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and PO2 (partial pressure of oxygen) showed no between-group differences.
Operative Data Heart rate (Figure 1), MAP (Figure 2) and oxygen saturation (Figure 3) were recorded in all patients before induction of anaesthesia (GA) (T0), after induction of GA (T1), 20 minutes later (T2), and before the end of the surgical procedure (T3). Heart rate was significantly lower in Groups 2 and 3 compared with Group 1 (p < 0.001) and lower in Group 2 compared with Group 3 (p = 0.012). The MAP was significantly lower in Groups 2 and 3 compared with Group 1 (p < 0.001)
Please cite this article in press as: Mogahed MM, Elkahwagy MS. Paravertebral Block Versus Intercostal Nerve Block in NonIntubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial. Heart, Lung and Circulation (2019), https://doi.org/10.1016/j.hlc.2019.04.013
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Table 1 Patients characteristics. Group 1 (n = 35)
Group 2 (n = 35)
Group 3 (n = 35)
P-value
Age (years) BMI (kg/m2)
42.88 9.63 27.77 1.80
43.54 10.51 27.80 1.84
43.97 9.29 27.54 9.74
0.89 0.81
Male
23 (65.7%)
23 (65.7%)
26 (74.3%)
0.67 0.58
ASA physical status II
20 57.1
24 68.6
23 65.7
III
15 42.9
11 31.4
12 34.3
FEV1
85.34 3.98
85.57 3.74
85.80 4.19
0.89
FVC
86.82 2.28
86.65 2.28
86.62 2.07
0.92
PO2
85.97 2.51
85.71 2.34
85.77 1.84
0.88
Continuous variables are presented as mean SD. Categorical variables are presented as number and percent. Abbreviations: ASA, American Society of Anesthesiologists; FEV1, forced expiratory volume in 1 second; FVC, forced viral capacity; BMI, body mass index; PO2, partial pressure of oxygen.
Figure 1 Heart rate changes among the three groups.
Figure 2 Mean arterial blood pressure (MAP) changes among the three groups.
and there was no significant difference between Groups 2 and 3 (p = 0.270). Oxygen saturation was significantly higher in Group 2 (p = 0.042) and in Group 3 (p = 0.034) compared with Group 1 and there was no significant difference between Groups 2 and 3 (p = 0.932) (Table 2). End tidal CO2 (ETCO2), Ef sevo, and RR were measured at time intervals T1, T2 and T3. The ETCO2 was significantly lower in Group 2 (p = 0.001) and Group 3 (p < 0.001) compared with Group 1; there was no difference between Groups 2 and 3 (p = 0.621) (Figure 2). Ef sevo was significantly lower in Groups 2 and 3 compared with Group 1 (p < 0.001) and there was no difference between Groups 2 and 3 (p = 0.778). Respiratory rate was lower in Groups 2 and 3 compared with Group 1 (p < 0.001) and there was no difference between Groups 2 and 3 (p = 0.648) (Table 2) and (Figures 4–6). Groups 2 and 3 had lower fentanyl requirements, time to spontaneous eye movement, time of spontaneous arm movement, time of purposeful movement, and time to laryngeal
Figure 3 Oxygen saturation changes among the three groups.
Please cite this article in press as: Mogahed MM, Elkahwagy MS. Paravertebral Block Versus Intercostal Nerve Block in NonIntubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial. Heart, Lung and Circulation (2019), https://doi.org/10.1016/j.hlc.2019.04.013
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Table 2 Between-group comparison of the change in heart rate, mean arterial pressure, oxygen saturation, end-tidal carbon dioxide, Ef sevo, respiratory rate, and visual analogue scale. Coefficient
P-value
95% CI
Heart rate Group 1 vs 2
–5.24
<0.001
–6.57 to –3.90
Group 1 vs 3
–3.53
<0.001
–4.86 to –2.19
Group 2 vs 3
1.70
0.012
0.37-3.04
Mean arterial pressure Group 1 vs 2
–5.42
<0.001
–7.43 to –3.42
Group 1 vs 3
–4.29
<0.001
–6.30 to –2.29
Group 2 vs 3
1.13
0.270
–0.88-3.13
Figure 4 End-tidal carbon dioxide (CO2) changes in the three groups.
Oxygen saturation Group 1 vs 2 Group 1 vs 3
0.5 0.53
0.042 0.034
0.017-0.997 0.04-1.02
Group 2 vs 3
0.02
0.923
–0.47-0.51
End-tidal carbon dioxide Group 1 vs 2
–3.57
0.001
–5.69 to –1.46
Group 1 vs 3
–4.10
<0.001
–6.22 to –1.990
Group 2 vs 3
–0.53
0.621
–2.65-1.58
Group 1 vs 2
–1.02
<0.001
–1.21 to –0.83
Group 1 vs 3
–1.05
<0.001
–1.24 to –0.86
Group 2 vs 3
–0.03
0.773
–0.22-0.16
Group 1 vs 2
–1.71
<0.001
–2.37 to –1.06
Group 1 vs 3 Group 2 vs 3
–1.87 –0.15
<0.001 0.648
–2.52 to –1.21 –0.81-0.50
Ef sevo
Figure 5 Expiratory fraction of Sevoflurane (Ef sevo) changes in the three groups.
Respiratory rate
Visual analogue scale (VAS) Group 1 vs 2
–8
<0.001
–11.74 to –4.26
Group 1 vs 3
–11.05
<0.001
–14.79 to –7.30
Group 2 vs 3
–3.05
0.111
–6.79-0.70
Abbreviations: Ef sevo, expiratory fraction of sevoflurane.
mask removal than Group 1 (Table 3). The postoperative VAS score was measured 15 minutes, 1 hour, and 2 hours postoperatively. The VAS score was significantly lower in Groups 2 and 3 compared with Group 1 (p < 0.001) at 15 minutes and 1 hour, and there was no significant difference among the groups at 2 hours (p = 0.15) (Table 2 and Figure 7).
Figure 6 Respiratory rate changes in the three groups.
Table 3 Total fentanyl consumption and recovery criteria of the three groups. Group 1 (n = 35)
Group 2 (n = 35)
Group 3 (n = 35)
p 1-2
p 1-3
p 2-3
Total fentanyl consumption (m)
145.42 29.23
21.71 35.12
17.14 32.25
<0.001
<0.001
1.00
Time of spontaneous eye movement (minutes)
6.60 1.19
2.50 0.73
1.95 0.49
<0.001
<0.001
0.028
Time of spontaneous arm movement (minutes)
4.84 0.72
2.14 0.64
1.42 0.74
<0.001
<0.001
<0.001
Time of purposeful movement (minutes) Time of laryngeal mask removal (minutes)
5.94 0.71 14.77 1.43
3.27 0.77 5.28 1.36
2.67 0.79 4.85 1.21
<0.001 <0.001
<0.001 <0.001
<0.001 0.553
Please cite this article in press as: Mogahed MM, Elkahwagy MS. Paravertebral Block Versus Intercostal Nerve Block in NonIntubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial. Heart, Lung and Circulation (2019), https://doi.org/10.1016/j.hlc.2019.04.013
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Figure 7 Visual analogue scale (VAS) score changes in the three groups.
Discussion General anaesthesia with one-lung ventilation (OLV) using a double-lumen endotracheal tube or bronchial blocker has traditionally been the first choice for thoracoscopic surgery. However, GA with mechanical ventilation may carry a risk of side-effects related to tracheal intubation and GA such as airway complications, ventilation-induced lung injury, and residual neuromuscular blockade [15–17]. Non-intubated spontaneous ventilation provides another anaesthetic option for high-risk thoracic surgery patients who may not tolerate intubated GA, to lessen possible complications related to intubation and OLV [18]. This technique is still relatively uncommon; however, a few randomised trials and a metaanalysis have shown that non-intubated thoracic surgery with spontaneous ventilation is more physiological and has more advantages than mechanical ventilation [19–23]. In surgical literature, the definition of non-intubated thoracoscopy includes a spectrum from awake or slightly sedated patients receiving a thoracic epidural or paravertebral block to patients under general anaesthetic with a supraglottic airway device [24]. Sometimes anaesthetists need to change awake anaesthesia to GA because of unfavourable circumstances such as major bleeding, haemodynamic instability, massive adhesions, or persistent decrease in oxygen saturation [25,26]. The current study used a laryngeal mask airway as a nonintubating method for ventilating patients undergoing uniportal VATS. Guo et al. used laryngeal masks as rescue devices to support ventilation in patients who were hypoxic or hypercarbic [24]. Ambrogi et al. conducted a study to determine the safety and feasibility of performing non-intubated thoracoscopic procedures under laryngeal mask airway; this allowed spontaneous ventilation with adequate analgesia [27]. Patients underwent thoracoscopic wedge resection of lung nodules under LMA and sevoflurane anaesthesia, and the authors found that use of LMA provided both good operating conditions and patient comfort, and it is a better alternative to tracheal intubation in
patients who are at high risk of pulmonary complications, like those patients suffering from severe chronic obstructive pulmonary disease [27]. Theresa A et al. showed that the use of a supraglottic airway is an excellent alternative to intubation in patients undergoing thoracoscopy and may carry some additional benefits, especially to high-risk patients in whom intubation is not recommended [28]. Irons et al., in a retrospective study for minor thoracoscopic procedures over an 8-month period, compared 31 patients who underwent non-intubated ventilation under GA with a laryngeal mask airway with 31 patients under GA with a double-lumen endobronchial tube and muscle relaxation [29]. The anaesthesiologist decided which anaesthetic technique was used. Within these two groups, the anaesthetic technique was not standardised. Most of the patients in the first group received a sevoflurane-based anaesthetic, while most of the patients in the second group received a total intravenous anaesthetic. The two groups also differed by the type of analgesic block performed for the procedure and by the operative technique. The patients in both received either a single-shot paravertebral block, intercostal nerve block, or local infiltration either by the surgeon or anaesthesiologist. The current study included three groups: Group I (35 patients), control group, received only GA; Group 2 (35 patients) received single-shot paravertebral block before induction of the GA; and Group 3 (35 patients) received thoracoscopic intercostal block infiltration after induction of anaesthesia from the third to the eighth intercostal nerve block, in addition to intrathoracic vagal block. It found that patients with regional block either in Group 2 or Group 3 consumed lesser amounts of sevoflurane, guided by commonly used anaesthetic monitoring such as blood pressure, heart rate, and BIS. This has great benefit for patients undergoing uniportal VATS, as in the lateral decubitus position, the chest movement is impaired and chest expansion of the dependent lung is decreased, which can compromise respiration. Induction of general anaesthetics, muscle relaxants, and initiation of mechanical ventilation improves these unwanted effects. Relaxation of both hemidiaphragms impedes positive pressure ventilation of the dependent lung and as a consequence, in the lateral decubitus position, ventilation is better in the nondependent lung, with better compliance and perfusion in the dependent lung as a result of gravity, which causes a ventilation and perfusion mismatch and increases the risk of hypoxaemi [30]. In non-intubated patients with spontaneous ventilation, the operative lung collapses after surgically induced pneumothorax, perfusion continues in the collapsed lung without being ventilated, which may lead to a large right-to-left intrapulmonary shunt. Intraoperative hypoxaemia may appear as a result of the widened alveolar-to-arterial oxygen gradient. Hypoxic pulmonary vasoconstriction (HPV) is an adaptive vasomotor response to alveolar hypoxia. This intrinsic physiologic mechanism prevents right-to-left shunt by vasoconstriction of the pulmonary arteries and redistribution of the blood flow to the alveoli, where there is more oxygen. This intrinsic
Please cite this article in press as: Mogahed MM, Elkahwagy MS. Paravertebral Block Versus Intercostal Nerve Block in NonIntubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial. Heart, Lung and Circulation (2019), https://doi.org/10.1016/j.hlc.2019.04.013
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HPV mechanism is an important protective response during OLV; however, most anaesthetic regimens during thoracic surgery have variable effects on HPV, which may increase the incidence of hypoxaemia [31], especially with volatile anaesthetics, which have been reported to inhibit HPV and may enhance hypoxaemia during OLV [30,32] This was supported by experimental studies, which showed that all inhalational anaesthetics, including sevoflurane, directly inhibit the HPV mechanism [33]. This effect of inhalational anaesthetics may be due to release of endogenous nitric oxide (NO) [34]. A previous study by Wang M et al. showed that for comparable blood pressure and BIS levels, intraoperative nerve blocks provide a satisfactory depth of anaesthesia following surgical stimulation in addition to an anaesthetic sparing effect by a significant decrease of the BIS-targeted propofol infusion [35]. The adequacy of anaesthetic levels with TINBs can be shown by maintaining blood pressure and BIS level with pulmonary traction and manipulation. This study also showed that TINBs and vagal nerve block adequately diminished the stress response from surgical stimulation and also gave rise to an anaesthetic sparing effect. Blocking stimulation from the parietal pleura can be achieved by TINBs; surgical stimulation for small airways and visceral pleura may induce cough, even with intravenous anaesthesia. Ipsilateral vagal nerve block is a good choice for preventing the cough reflex. Ipsilateral vagal nerve block caused the slight but significant increases in heart rate observed in their study, and they were not related to the inadequacy of anaesthesia. They concluded that with higher haemodynamic stability, multilevel TINBs could be a beneficial choice of thoracic epidural anaesthesia in patients with inadequate cardiovascular reserve.
Conclusion Regional anaesthesia by either preoperative paravertebral block or thoracoscopic intercostal nerve block with ipsilateral vagal block provide an anaesthetic sparing effect guided by lower Ef sevo concentration with comparable BIS in patients undergoing uniportal thoracoscopic surgery.
Conflict of Interest None.
Funding Tanta University.
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[31] Von Dossow V, Welte M, Zaune U, Martin E, Walter M, Ru¨ckert J, et al. Thoracic epidural anesthesia combined with general anesthesia: the preferred anesthetic technique for thoracic surgery. Anesth Analg 2001;92. 848e54. [32] Pompeo E, Mineo TC. Awake operative videothoracoscopic pulmonary resections. Thorac Surg Clin 2008;18. 311e20. [33] Ishibe Y, Gui X, Uno H, Shiokawa Y, Umeda T, Suekane K. Effect of sevoflurane on hypoxic pulmonary vasoconstriction in the perfused rabbit lung. Anesthesiology 1993;79:1348–53. [34] Lennon PF, Murray PA. Attenuated hypoxic pulmonary vasoconstriction during isoflurane anesthesia is abolished by cyclooxygenase inhibition in chronically instrument dogs. Anesthesiology 1996;84:404–14. [35] Wang Man-Ling, Hung Ming-Hui, Chan Kuang-Cheng, Chen Jin-Shing, Cheng Ya-Jung. Intraoperative multiple intercostal nerve blocks exert anesthetic-sparing effect: a retrospective study on the effect-site concentration of propofol infusion in nonintubated thoracoscopic surgery. Acta Anaesthesiologica Taiwanica 2016;54. 77e80.
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Heart, Lung and Circulation (2019) xx, 1–8 1443-9506/04/$36.00 https://doi.org/10.1016/j.hlc.2019.04.013
ORIGINAL ARTICLE
Paravertebral Block Versus Intercostal Nerve Block in Non-Intubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial$© Mona Mohamed Mogahed, PhD a*, Mohamed Shafik Elkahwagy, PhD b a
Department of Anaesthesiology, SICU and pain therapy, Tanta University, El Bahr Road Department of Cardiothoracic surgery, Tanta University
b
Received 28 December 2018; received in revised form 15 February 2019; accepted 11 April 2019; online published-ahead-of-print xxx
Background
Non-intubated uniportal video-assisted thoracoscopic surgery (VATS) has been reported to be safe and feasible for patients with various thoracic diseases, including those who have respiratory dysfunction. This study examined the anaesthetic and analgesic sparing effects of either paravertebral block or intercostal nerve block on the non-intubated technique with spontaneous ventilation in patients under general anaesthesia (GA) using a supraglottic airway device. The primary aim was to compare the anaesthetic sparing effect of paravertebral block versus intercostal nerve block in non-intubated GA with airway support via a supraglottic airway device during VATS surgery. The secondary aim was to compare the recovery characters and postoperative outcomes of the patients.
Methods
The study included 105 patients with American Society of Anesthesiologists (ASA) physical status II-III who had video-assisted thoracoscopy without endotracheal intubation and using a laryngeal airway. The patients were divided into three groups; each group consisted of 35 patients. Group I (35 patients): control group received only GA. Group 2 (35 patients): received a single-shot paravertebral block before induction of the GA. Group 3 (35 patients): received thoracoscopic intercostal block infiltration after induction of anaesthesia from the third to the eighth intercostal nerve block, in addition to intrathoracic vagal block. Heart rate, mean arterial pressure (MAP), and oxygen saturation were recorded before induction of GA (T0), after induction of GA (T1), 20 minutes later (T2), and before the end of the surgical procedure (T3).
Results
Heart rate was significantly lower in Groups 2 and 3 compared with Group 1, and lower in Group 2 compared with Group 3. The MAP was significantly lower in Groups 2 and 3 compared with Group 1, and there was no significant difference between Groups 2 and 3. Oxygen saturation was significantly higher in Group 2 and in Group 3 compared with Group 1 and there was no significance difference between Groups 2 and 3. Expiratory fraction of sevoflurane (Ef sevo) was significantly lower in Groups 2 and 3 compared with Group 1, with no difference between Group 2 and 3. Groups 2 and 3 had lower fentanyl requirements, time to spontaneous eye movement, time to spontaneous arm movement, time to purposeful movement, and time to laryngeal mask removal than Group 1.
$©
2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).
Published by Elsevier B.V. *Corresponding author. Email: [email protected] © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Mogahed MM, Elkahwagy MS. Paravertebral Block Versus Intercostal Nerve Block in NonIntubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial. Heart, Lung and Circulation (2019), https://doi.org/10.1016/j.hlc.2019.04.013
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Conclusions
Regional anaesthesia by either preoperative paravertebral block or thoracoscopic intercostal nerve block with ipsilateral vagal block provided an anaesthetic sparing effect, guided by lower Ef sevo concentration, with comparable bi-spectral index in patients undergoing uniportal thoracoscopic surgery.
Keywords
Non-intubated Video-assisted thoracoscopic surgery Paravertebral block Intercostal nerve block
Introduction With the increasing use of video-assisted thoracoscopic surgery (VATS) for most thoracic surgical procedures, there has been a strong drive to minimise the overall invasiveness and surgical stress [1,2]. Non-intubated VATS (NIVATS) avoids trauma to the trachea, oesophagus, and hypopharynx from double-lumen endobronchial tube placement; mechanical ventilator-induced lung injury; and the residual effects of neuromuscular blockade and general anaesthetic drugs, which may compromise cardiac performance and impair early postoperative respiratory function [3]. Thoracic epidural anaesthesia (TEA), intercostal nerve block, and paravertebral block are the most commonly employed techniques for non-intubated anaesthesia. Regional techniques in combination with general anaesthesia (GA) have been used to achieve better postoperative analgesia, lessen the surgical stress response, and have anaesthetic sparing effect by reducing the total amounts of general anaesthetics guided by the haemodynamic response and bi-spectral index (BIS) [4–10]. Effective regional techniques in combination with GA have been used for better postoperative pain control, to reduce the response to surgical stress, have an anaesthetic sparing effect, and reduce the total amounts of GA drugs, guided by the haemodynamic response and BIS [11–14]. It is believed that a non-intubated general anaesthetic technique with airway support via a supraglottic airway device during VATS surgery prevents patient anxiety and distress, minimises movement and coughing, and allows for superior airway control and oxygenation. The present study examined the anaesthetic sparing effect of paravertebral block versus intercostal nerve block on this type of surgery. The primary aim of this study was to compare the anaesthetic sparing effect of paravertebral block versus intercostal nerve block in non-intubated GA with airway support via a supraglottic airway device during VATS surgery. The secondary aim was to compare the recovery characters and postoperative outcomes of the patients.
Patients and methods The study included 105 patients with American Society of Anesthesiologists (ASA) physical status II-III who had videoassisted thoracoscopy without endotracheal intubation and using a laryngeal airway. Approval of the Ethical Committee was obtained prior to the trial and every patient had signed written informed consent. The patients were divided into three groups, each group consisted of 35 patients. The patients had video-assisted
thoracoscopy (VATS) for procedures with expected time <1 hour, such as non-anatomical lung resections, bullectomy, evacuation of a recent haemothorax, excision or biopsy of a simple mediastinal mass, intrapleural or parenchymal foreign body extraction, and pericardial window. Patients who had coagulopathy, significant encephalopathy, preexisting motor or sensory deficit, emotional instability, previous thoracic surgery, or other contraindications to local anaesthesia, such as allergies, were excluded from the study. Physical examination was performed for all patients prior to the planned procedure, with assessment of the cardiovascular and pulmonary reserves and general patient performance. Liver and renal function tests and coagulation profile were performed in all patients. Chest X-ray, computed tomography (CT) scan, and fibreoptic bronchoscope were performed prior to randomisation. Preoperative patient education was performed, including how to use the visual analogue scale (VAS), where 0 represents no pain and 100 the worst intolerable pain. Block randomisation was performed and the size of each block consisted of four to seven patients. The blocks were randomly generated online using https://www.randomizer. org/. Patients were randomised into three equal groups as follows: Group I (35 patients): control group received only GA. Group 2 (35 patients): received a single-shot paravertebral block before induction of GA. Group 3 (35 patients): received thoracoscopic intercostal block infiltration after induction of anaesthesia from the third to the eighth intercostal nerve block, in addition to intrathoracic vagal block. Intramuscular midazolam (0.15-0.25 mg/kg) was used 15 minutes before anaesthesia for sedation. The protocol for GA was the same in all groups. Induction of anaesthesia was performed with propofol 1.5-2 mg/kg IV, fentanyl 1m/kg IV, and sevoflurane 1-1.5 MAC, and insertion of a supraglottic airway device (the LMA Classic, Teleflex, Westmeath, Ireland). Spontaneous ventilation was permitted with 100% oxygen inspired fraction (FiO2), 2.5 L/minute fresh gas flow. The anaesthetic depth was controlled by varying sevoflurane concentration to maintain the BIS between 40-60. At any time during surgery, if the mean arterial pressure (MAP) and heart rate increased to 25% of the baseline, supplemental analgesic in the form of fentanyl 1 mg/kg IV was given and the total dose of fentanyl was noted. No central venous catheter, arterial catheter, or urinary catheter was placed. Surgical incision was allowed after 10 minutes of paravertebral bolus. Any episode of hypotension (systolic arterial pressure <90 mmHg) excluding surgical blood loss was treated with incremental doses of ephedrine, and bradycardia (heart rate <50/minute) was treated with atropine.
Please cite this article in press as: Mogahed MM, Elkahwagy MS. Paravertebral Block Versus Intercostal Nerve Block in NonIntubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial. Heart, Lung and Circulation (2019), https://doi.org/10.1016/j.hlc.2019.04.013
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In the operating room, routine monitoring (Cardiocaps; Datex Ohmeda, Helsinki, Finland) included five-lead electrocardiogram (ECG), pulse oximeter, and non-invasive blood pressure (BP) measurement. Electrodes for monitoring the bispectral index (BSP) (BISTM, model A-2000s; Aspect Medical Systems, Norwood, MA, USA) were attached to the head. End-tidal carbon dioxide (ETCO2) concentration and end-expiratory concentration of sevoflurane were also recorded from the time of anaesthesia induction to the time of extubation. The respiratory rate (RR) was maintained between 12-20 breaths/minute by modifying the depth of anaesthesia. The BP, HR and SPO2 were recorded before induction of the GA, after induction of the GA, 20 minutes later, and immediately before the end of surgery. End-tidal carbon dioxide, expiratory fraction of Sevoflurane (Ef sevo) and RR were recorded after induction of the GA, 20 minutes later, and immediately before the end of surgery. The total amount of fentanyl used during surgery was also recorded. Paravertebral block was performed while the patient was sitting with the feet resting on a stool. The patient was asked to lean forwards to allow more kyphosis. After sterilising the back of the patient with povidone-iodine and under complete aseptic precautions, 5 mL of lidocaine 1% was infiltrated subcutaneously along the line where the injections would be made. An epidural needle (Tuohy 18 G; Braun, Melsungen, Germany) was inserted at the T4 level 2.5-3 cm lateral to the most upper aspect of the spinous process, and advanced slowly and perpendicularly to reach the transverse process of the vertebra below, at a depth ranging from 2-4 cm according to the build of the individual. If bone was not reached at this depth, it was possible that the needle tip was lying between two transverse processes. To prevent pleural puncture, it was important to detect the transverse process before advancing the needle any further. This was achieved by withdrawing the needle to the subcutaneous plane and redirecting it upwards and downwards to the same depth until bone was reached. If bone was still not reached, the needle was advanced a further centimetre and the above process was repeated until the transverse process was encountered. The needle was then gradually advanced above the transverse process until a loss of resistance to saline was felt, as the needle tip traversed the thin superior costotransverse ligament, usually within 1-1.5 cm from the superior edge of the transverse process. After gentle aspiration, local anaesthetic was injected. After induction of the GA in Group 3, 3-cm incision was made for thoracoscopy at the fifth intercostal space in the anterior axillary line. This procedure marked the start of one lung being ventilated because the incision created an artificial pneumothorax, and the lung gradually collapsed with the patient’s spontaneous breathing. In Group 3, thoracoscopic intercostal nerve blocks (TINBs) were administered by infiltration of local anaesthetic mixture (1.5 mL for each intercostal space) from the third to the eighth intercostal nerve under the parietal pleura, 2 cm lateral to the sympathetic chain, using an infusion needle. Thoracoscopic vagal nerve block was administered by infiltration of 3 mL of the local
anaesthetic mixture adjacent to the vagus nerve at the level of the lower trachea for right-sided procedures and at the level of the aortopulmonary window for left-sided procedures. Vagal block aids in preventing coughing during thoracoscopic manipulations. After finishing the surgery, the inhalational anaesthetic was turned off. Once consciousness was regained and protective reflexes had returned, gentle suction around the laryngeal mask in the pharynx and hypopharynx was performed, by asking the patient to open his or her mouth. The laryngeal mask was removed and replaced with an oxygen facemask. Spontaneous eye movement, spontaneous arm movement, purposeful movement, time of discharge to the recovery room, and postoperative VAS (0 = no pain, 100 = worst pain intolerable) at 15 minutes, 1 hour, and 2 hours postoperatively were recorded. A VAS score was 40, analgesia was given in the form of intramuscular ketoprofen 75 mg, with a maximum dose of 300 mg/day. If the patient suffered from nausea, with or without vomiting, ondansetron 4 mg IV was given, and repeated once if nausea persisted (maximum dose 8 mg/day). Patients were then transferred to a post-anaesthesia care unit (PACU) for 24 hours.
Statistical Analysis All statistical analyses were performed using SPSS (15) for windows. Continuous variables were tested for normal distribution by the Kolmogorov-Smirnov test. Parametric data were compared using analysis of variance (ANOVA). Between-group comparisons at different time intervals were assessed by using paired t-test. All categorical data were compared by using x2 test. A sample size of 35 patients in each group was needed to detect an intergroup difference of at least 20% ( = 0.01, twosided, power = 95%) with two sample t-test. Data were collected by a blinded observer and presented as mean SD or N (%). A p-value of <0.05 was considered significant.
Results Preoperative Patients’ Characteristics There was no difference in preoperative patients’ demographics among groups (Table 1). Preoperative forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and PO2 (partial pressure of oxygen) showed no between-group differences.
Operative Data Heart rate (Figure 1), MAP (Figure 2) and oxygen saturation (Figure 3) were recorded in all patients before induction of anaesthesia (GA) (T0), after induction of GA (T1), 20 minutes later (T2), and before the end of the surgical procedure (T3). Heart rate was significantly lower in Groups 2 and 3 compared with Group 1 (p < 0.001) and lower in Group 2 compared with Group 3 (p = 0.012). The MAP was significantly lower in Groups 2 and 3 compared with Group 1 (p < 0.001)
Please cite this article in press as: Mogahed MM, Elkahwagy MS. Paravertebral Block Versus Intercostal Nerve Block in NonIntubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial. Heart, Lung and Circulation (2019), https://doi.org/10.1016/j.hlc.2019.04.013
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Table 1 Patients characteristics. Group 1 (n = 35)
Group 2 (n = 35)
Group 3 (n = 35)
P-value
Age (years) BMI (kg/m2)
42.88 9.63 27.77 1.80
43.54 10.51 27.80 1.84
43.97 9.29 27.54 9.74
0.89 0.81
Male
23 (65.7%)
23 (65.7%)
26 (74.3%)
0.67 0.58
ASA physical status II
20 57.1
24 68.6
23 65.7
III
15 42.9
11 31.4
12 34.3
FEV1
85.34 3.98
85.57 3.74
85.80 4.19
0.89
FVC
86.82 2.28
86.65 2.28
86.62 2.07
0.92
PO2
85.97 2.51
85.71 2.34
85.77 1.84
0.88
Continuous variables are presented as mean SD. Categorical variables are presented as number and percent. Abbreviations: ASA, American Society of Anesthesiologists; FEV1, forced expiratory volume in 1 second; FVC, forced viral capacity; BMI, body mass index; PO2, partial pressure of oxygen.
Figure 1 Heart rate changes among the three groups.
Figure 2 Mean arterial blood pressure (MAP) changes among the three groups.
and there was no significant difference between Groups 2 and 3 (p = 0.270). Oxygen saturation was significantly higher in Group 2 (p = 0.042) and in Group 3 (p = 0.034) compared with Group 1 and there was no significant difference between Groups 2 and 3 (p = 0.932) (Table 2). End tidal CO2 (ETCO2), Ef sevo, and RR were measured at time intervals T1, T2 and T3. The ETCO2 was significantly lower in Group 2 (p = 0.001) and Group 3 (p < 0.001) compared with Group 1; there was no difference between Groups 2 and 3 (p = 0.621) (Figure 2). Ef sevo was significantly lower in Groups 2 and 3 compared with Group 1 (p < 0.001) and there was no difference between Groups 2 and 3 (p = 0.778). Respiratory rate was lower in Groups 2 and 3 compared with Group 1 (p < 0.001) and there was no difference between Groups 2 and 3 (p = 0.648) (Table 2) and (Figures 4–6). Groups 2 and 3 had lower fentanyl requirements, time to spontaneous eye movement, time of spontaneous arm movement, time of purposeful movement, and time to laryngeal
Figure 3 Oxygen saturation changes among the three groups.
Please cite this article in press as: Mogahed MM, Elkahwagy MS. Paravertebral Block Versus Intercostal Nerve Block in NonIntubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial. Heart, Lung and Circulation (2019), https://doi.org/10.1016/j.hlc.2019.04.013
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Table 2 Between-group comparison of the change in heart rate, mean arterial pressure, oxygen saturation, end-tidal carbon dioxide, Ef sevo, respiratory rate, and visual analogue scale. Coefficient
P-value
95% CI
Heart rate Group 1 vs 2
–5.24
<0.001
–6.57 to –3.90
Group 1 vs 3
–3.53
<0.001
–4.86 to –2.19
Group 2 vs 3
1.70
0.012
0.37-3.04
Mean arterial pressure Group 1 vs 2
–5.42
<0.001
–7.43 to –3.42
Group 1 vs 3
–4.29
<0.001
–6.30 to –2.29
Group 2 vs 3
1.13
0.270
–0.88-3.13
Figure 4 End-tidal carbon dioxide (CO2) changes in the three groups.
Oxygen saturation Group 1 vs 2 Group 1 vs 3
0.5 0.53
0.042 0.034
0.017-0.997 0.04-1.02
Group 2 vs 3
0.02
0.923
–0.47-0.51
End-tidal carbon dioxide Group 1 vs 2
–3.57
0.001
–5.69 to –1.46
Group 1 vs 3
–4.10
<0.001
–6.22 to –1.990
Group 2 vs 3
–0.53
0.621
–2.65-1.58
Group 1 vs 2
–1.02
<0.001
–1.21 to –0.83
Group 1 vs 3
–1.05
<0.001
–1.24 to –0.86
Group 2 vs 3
–0.03
0.773
–0.22-0.16
Group 1 vs 2
–1.71
<0.001
–2.37 to –1.06
Group 1 vs 3 Group 2 vs 3
–1.87 –0.15
<0.001 0.648
–2.52 to –1.21 –0.81-0.50
Ef sevo
Figure 5 Expiratory fraction of Sevoflurane (Ef sevo) changes in the three groups.
Respiratory rate
Visual analogue scale (VAS) Group 1 vs 2
–8
<0.001
–11.74 to –4.26
Group 1 vs 3
–11.05
<0.001
–14.79 to –7.30
Group 2 vs 3
–3.05
0.111
–6.79-0.70
Abbreviations: Ef sevo, expiratory fraction of sevoflurane.
mask removal than Group 1 (Table 3). The postoperative VAS score was measured 15 minutes, 1 hour, and 2 hours postoperatively. The VAS score was significantly lower in Groups 2 and 3 compared with Group 1 (p < 0.001) at 15 minutes and 1 hour, and there was no significant difference among the groups at 2 hours (p = 0.15) (Table 2 and Figure 7).
Figure 6 Respiratory rate changes in the three groups.
Table 3 Total fentanyl consumption and recovery criteria of the three groups. Group 1 (n = 35)
Group 2 (n = 35)
Group 3 (n = 35)
p 1-2
p 1-3
p 2-3
Total fentanyl consumption (m)
145.42 29.23
21.71 35.12
17.14 32.25
<0.001
<0.001
1.00
Time of spontaneous eye movement (minutes)
6.60 1.19
2.50 0.73
1.95 0.49
<0.001
<0.001
0.028
Time of spontaneous arm movement (minutes)
4.84 0.72
2.14 0.64
1.42 0.74
<0.001
<0.001
<0.001
Time of purposeful movement (minutes) Time of laryngeal mask removal (minutes)
5.94 0.71 14.77 1.43
3.27 0.77 5.28 1.36
2.67 0.79 4.85 1.21
<0.001 <0.001
<0.001 <0.001
<0.001 0.553
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Figure 7 Visual analogue scale (VAS) score changes in the three groups.
Discussion General anaesthesia with one-lung ventilation (OLV) using a double-lumen endotracheal tube or bronchial blocker has traditionally been the first choice for thoracoscopic surgery. However, GA with mechanical ventilation may carry a risk of side-effects related to tracheal intubation and GA such as airway complications, ventilation-induced lung injury, and residual neuromuscular blockade [15–17]. Non-intubated spontaneous ventilation provides another anaesthetic option for high-risk thoracic surgery patients who may not tolerate intubated GA, to lessen possible complications related to intubation and OLV [18]. This technique is still relatively uncommon; however, a few randomised trials and a metaanalysis have shown that non-intubated thoracic surgery with spontaneous ventilation is more physiological and has more advantages than mechanical ventilation [19–23]. In surgical literature, the definition of non-intubated thoracoscopy includes a spectrum from awake or slightly sedated patients receiving a thoracic epidural or paravertebral block to patients under general anaesthetic with a supraglottic airway device [24]. Sometimes anaesthetists need to change awake anaesthesia to GA because of unfavourable circumstances such as major bleeding, haemodynamic instability, massive adhesions, or persistent decrease in oxygen saturation [25,26]. The current study used a laryngeal mask airway as a nonintubating method for ventilating patients undergoing uniportal VATS. Guo et al. used laryngeal masks as rescue devices to support ventilation in patients who were hypoxic or hypercarbic [24]. Ambrogi et al. conducted a study to determine the safety and feasibility of performing non-intubated thoracoscopic procedures under laryngeal mask airway; this allowed spontaneous ventilation with adequate analgesia [27]. Patients underwent thoracoscopic wedge resection of lung nodules under LMA and sevoflurane anaesthesia, and the authors found that use of LMA provided both good operating conditions and patient comfort, and it is a better alternative to tracheal intubation in
patients who are at high risk of pulmonary complications, like those patients suffering from severe chronic obstructive pulmonary disease [27]. Theresa A et al. showed that the use of a supraglottic airway is an excellent alternative to intubation in patients undergoing thoracoscopy and may carry some additional benefits, especially to high-risk patients in whom intubation is not recommended [28]. Irons et al., in a retrospective study for minor thoracoscopic procedures over an 8-month period, compared 31 patients who underwent non-intubated ventilation under GA with a laryngeal mask airway with 31 patients under GA with a double-lumen endobronchial tube and muscle relaxation [29]. The anaesthesiologist decided which anaesthetic technique was used. Within these two groups, the anaesthetic technique was not standardised. Most of the patients in the first group received a sevoflurane-based anaesthetic, while most of the patients in the second group received a total intravenous anaesthetic. The two groups also differed by the type of analgesic block performed for the procedure and by the operative technique. The patients in both received either a single-shot paravertebral block, intercostal nerve block, or local infiltration either by the surgeon or anaesthesiologist. The current study included three groups: Group I (35 patients), control group, received only GA; Group 2 (35 patients) received single-shot paravertebral block before induction of the GA; and Group 3 (35 patients) received thoracoscopic intercostal block infiltration after induction of anaesthesia from the third to the eighth intercostal nerve block, in addition to intrathoracic vagal block. It found that patients with regional block either in Group 2 or Group 3 consumed lesser amounts of sevoflurane, guided by commonly used anaesthetic monitoring such as blood pressure, heart rate, and BIS. This has great benefit for patients undergoing uniportal VATS, as in the lateral decubitus position, the chest movement is impaired and chest expansion of the dependent lung is decreased, which can compromise respiration. Induction of general anaesthetics, muscle relaxants, and initiation of mechanical ventilation improves these unwanted effects. Relaxation of both hemidiaphragms impedes positive pressure ventilation of the dependent lung and as a consequence, in the lateral decubitus position, ventilation is better in the nondependent lung, with better compliance and perfusion in the dependent lung as a result of gravity, which causes a ventilation and perfusion mismatch and increases the risk of hypoxaemi [30]. In non-intubated patients with spontaneous ventilation, the operative lung collapses after surgically induced pneumothorax, perfusion continues in the collapsed lung without being ventilated, which may lead to a large right-to-left intrapulmonary shunt. Intraoperative hypoxaemia may appear as a result of the widened alveolar-to-arterial oxygen gradient. Hypoxic pulmonary vasoconstriction (HPV) is an adaptive vasomotor response to alveolar hypoxia. This intrinsic physiologic mechanism prevents right-to-left shunt by vasoconstriction of the pulmonary arteries and redistribution of the blood flow to the alveoli, where there is more oxygen. This intrinsic
Please cite this article in press as: Mogahed MM, Elkahwagy MS. Paravertebral Block Versus Intercostal Nerve Block in NonIntubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial. Heart, Lung and Circulation (2019), https://doi.org/10.1016/j.hlc.2019.04.013
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HPV mechanism is an important protective response during OLV; however, most anaesthetic regimens during thoracic surgery have variable effects on HPV, which may increase the incidence of hypoxaemia [31], especially with volatile anaesthetics, which have been reported to inhibit HPV and may enhance hypoxaemia during OLV [30,32] This was supported by experimental studies, which showed that all inhalational anaesthetics, including sevoflurane, directly inhibit the HPV mechanism [33]. This effect of inhalational anaesthetics may be due to release of endogenous nitric oxide (NO) [34]. A previous study by Wang M et al. showed that for comparable blood pressure and BIS levels, intraoperative nerve blocks provide a satisfactory depth of anaesthesia following surgical stimulation in addition to an anaesthetic sparing effect by a significant decrease of the BIS-targeted propofol infusion [35]. The adequacy of anaesthetic levels with TINBs can be shown by maintaining blood pressure and BIS level with pulmonary traction and manipulation. This study also showed that TINBs and vagal nerve block adequately diminished the stress response from surgical stimulation and also gave rise to an anaesthetic sparing effect. Blocking stimulation from the parietal pleura can be achieved by TINBs; surgical stimulation for small airways and visceral pleura may induce cough, even with intravenous anaesthesia. Ipsilateral vagal nerve block is a good choice for preventing the cough reflex. Ipsilateral vagal nerve block caused the slight but significant increases in heart rate observed in their study, and they were not related to the inadequacy of anaesthesia. They concluded that with higher haemodynamic stability, multilevel TINBs could be a beneficial choice of thoracic epidural anaesthesia in patients with inadequate cardiovascular reserve.
Conclusion Regional anaesthesia by either preoperative paravertebral block or thoracoscopic intercostal nerve block with ipsilateral vagal block provide an anaesthetic sparing effect guided by lower Ef sevo concentration with comparable BIS in patients undergoing uniportal thoracoscopic surgery.
Conflict of Interest None.
Funding Tanta University.
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Please cite this article in press as: Mogahed MM, Elkahwagy MS. Paravertebral Block Versus Intercostal Nerve Block in NonIntubated Uniportal Video-Assisted Thoracoscopic Surgery: A Randomised Controlled Trial. Heart, Lung and Circulation (2019), https://doi.org/10.1016/j.hlc.2019.04.013