Video-assisted thoracoscopic placement of

British Journal of Anaesthesia 1994; 72: 462-464

Video-assisted thoracoscopic placement of paravertebral catheters: a technique for postoperative analgesia for bilateral thoracoscopic surgery A. K. SONI, I. D. CONACHER, D. A. WALLER AND C. J. HILTON

Paravertebral catheters were placed bilaterally through a Tuohy needle under direct video control in a patient undergoing video-assisted thoracoscopic (VAT) surgery for recurrent, bilateral pneumothoraces. Postoperative analgesia was produced by infusing bupivacaine through the catheters. This provided good analgesia. VAT placement of paravertebral catheters is easily accomplished and may be a part of the surgical procedure. (Br. J. Anaesth. 1994; 72: 4 6 2 ^ 6 4 ) KEY WORDS Equipment: videos. Anaesthetic vertebral. Pain: postoperative.

techniques, regional: para-

Surgery is indicated in patients with a history of developing bilateral pneumothoraces [1]. Parietal pleurectomy, performed by staged bilateral thoracotomy or median sternotomy, results in the lowest recurrence rate. Recent developments in videoassisted thoracoscopic (VAT) surgery offer a minimally invasive alternative. Pleural stripping is still painful [2] and there remains a need for good analgesia. We report a novel approach to the insertion of paravertebral catheters under thoracoscopic vision to provide postoperative analgesia.

METHODS AND RESULTS

A 30-yr-old female weighing 47 kg was referred for surgical treatment of bilateral spontaneous pneumothorax. Preoperative spirometry showed her forced expiratory volume in 1 s (FEV,) to be 2.65 litres (90 % predicted) and forced vital capacity (FVC) 3.1 litres (90 % predicted). Her peak expiratory flow rate (PEFR) was 450 litre min"1. She was premedicated with morphine 10 mg and atropine 0.3 mg. Anaesthesia was induced with fentanyl 100 ng, thiopentone 250 mg and neuromuscular block was produced with vecuronium 6 mg. A small left-sided Robertshaw endobronchial tube was inserted. The lungs were ventilated with a mixture of 50 % nitrous oxide and 1 % enflurane in oxygen. The patient was prepared in the supine position with both shoulders abducted. A 2-cm incision was

made in the sixth intercostal space in the anterior axillary line through which a 10-mm video thoracoscope was inserted via a 10.5-mm Thoracoport (Autosuture). Two further small incisions were made, in the sixth intercostal space in the midaxillary line and in the fourth intercostal space in the anterior axillary line, to facilitate apical bullectomy. A 16-gauge Tuohy needle (Portex Ltd, Hythe, U.K.) was inserted through the fifth intercostal space in the posterior axillary line and under video control was advanced in the extrapleural space in a cranial and medial direction. The bevel of the needle was rotated away from the pleura and the rounded side of the tip was used to lift the pleura while advancing. In the process the pleura was torn at two places. The technique was then modified. A plane was developed by injecting 0.9 % saline through the needle. An 18-gauge extradural catheter was inserted via the needle to lie in the paravertebral gutter, up to the level of the fourth rib posteriorly, and connected to a bacterial filter. Apical parietal pleurectomy was performed using blunt curved forceps from the level of the lowest incision [3] taking care not to remove the pleura covering the paravertebral gutter and the catheter. The process was repeated on the left side. Apical chest drains were inserted via the midaxillary incisions and were left in situ with a suction pressure of 13 kPa. Neuromuscular block was antagonized and the endobronchial tube removed. A dose of 0.125 % bupivacaine 10 ml was instilled on both sides via the indwelling paravertebral catheters. In the high dependency unit (HDU) an infusion of 0.125 % bupivacaine 4 ml h~' was started on each side. A patient-controlled analgesia system (Graseby Medical Ltd, U.K.) was also attached using bolus doses of morphine 1 mg with a lockout time of 5 min and no background infusion. For the first 24 h, PEFR, verbal rating score (VRS) (0-3) for pain, sensory level (sensation to cold) and morphine use were recorded every 2 h. Pain was scored using a four-point scale: 0 = no pain at rest or on ipsilateral arm movement; 1 = no pain at rest but mild pain

A. K. SONI, M.D., F.F.A.R.C.S.I., F.R.C.A., I. D. CONACHER, M.D., F.R.C.P.(EDIN.), F.R.C.A. (Department of Cardiothoracic Anaesthesia); D. A. WALLER, B.MED.SCL, F.R.C.S., C. J. HILTON, F.R.C.S.

(Department of Cardiothoracic Surgery); Regional Cardiothoracic Centre, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN. Accepted for Publication: October 25, 1993.

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SUMMARY

THORACOSCOPIC INSERTION OF PARAVERTEBRAL CATHETERS

463

Intercostal spread of dye

Longitudinal spread of dye in paravertebral space

Catheter

FIG. 1. Postoperative chest radiograph after injection of contrast medium into the paravertebral catheters. The longitudinal distribution of contrast can be seen in the paravertebral spaces.

on movement; 2 = intermittent pain at rest but moderate pain on movement; and 3 = continuous pain at rest and severe pain on movement. The contrast medium, iopamidol 5 ml (Niopam 150) and 0.125% bupivacaine 10 ml were injected into each catheter before obtaining a routine chest xray. The spread of local anaesthetic along the paravertebral space was confirmed (fig. 1). Infusion of the local anaesthetic was continued for 48 h when the catheters were removed. Initial pain scores were high (VRS 2) but after the second bolus dose at 6 h the score was 0 and remained so for the rest of the infusion period. The patient stated that initially pain was more on the right side than on the left. Sensory block covered the second to the eighth thoracic dermatomes on the left and from the third to the sixth on the right. PEFR averaged 100 litre min"1 in the first 6 h and by 12 h had improved to 250 litre min"1. Total morphine consumption was 36 mg of which 29 mg were used in the first 6 h. The postoperative period was uneventful. COMMENT

Video-assisted thoracoscopy for pleurectomy has several advantages compared with conventional thoracotomy. Early mobilization, faster postoperative recovery and shorter hospital stay have been reported [3]. Wound pain is less but it is our experience that pleural stripping is associated with significant discomfort after operation [2]. With a bilateral procedure, i.v. opioid analgesia alone is insufficient and additional analgesia with regional techniques may be required. Continuous paravertebral local anaesthetic infusion via percutaneously placed extrapleural catheter has been found to be effective after unilateral thoracotomy [4]. It is our experience, in this patient and others, that the placement of paravertebral catheters under direct videoscopic vision can be performed without much difficulty. The technique, more akin to placement at

thoracotomy [5], is preferable to blind percutaneous methods as catheter direction and position can be controlled under direct vision. The advance of the catheter can be eased by injecting saline via the needle, catheter, or both, to dissect the pleura. In this case the spread of local anaesthetic in the left paravertebral gutter, being more uniform, probably accounts for better analgesia initially on that side. On the right side there is characteristic distribution [4] along an intercostal space. On the left side the distribution is more characteristic of some intrapleural injection and as this has been shown to produce analgesia in its own right [5, 6] it cannot be discounted as the reason for better analgesia. After the second bolus dose, zero pain scores and improved peak expiratory flow rates were observed. Hypotension, although anticipated, did not occur at any stage in the postoperative period. Bilateral video-assisted thoracoscopic placement of paravertebral catheters for continuous postoperative local anaesthetic infusions has proved effective and is tolerated well. Catheter insertion is accomplished easily and may be a routine part of surgery. The technique is recommended for patients undergoing bilateral procedures, particularly if respiratory function is less than optimum.

ACKNOWLEDGEMENT We thank Mr David Crawford for producing an artistic impression of the x-ray film.

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