Ultrasound-guided continuous edge of laminar block in thoracotomy
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TO THE EDITOR:
Post-thoracotomy pain is responsible for ineffective ventilation with an inability to breathe deeply and for mucous plugging, leading to atelectasis, hypoxia, and ventilation-perfusion mismatch, predisposing the patient to pulmonary infection and pulmonary complications. Several modalities have been employed to offer adequate pain management, including intrathecal, thoracic epidural, thoracic paravertebral, intercostal, interpleural, and continuous retrolaminar blocks [1,2]. Shu et al. [3] described a novel approach to the retrolaminar block (RLB), designated as the edge of the laminar block (ELB), to provide sensory analgesia during rib fracture surgery. A local anesthetic was deposited at the lateral edge of the lamina. Here, we report our experience with continuous ELB for postoperative analgesia during thoracotomy surgery in four patients. Written informed consent was obtained from all patients for publication. All patients, age groups 25–50, body mass index < 35, and American Society of Anesthesiologists I and II, received continuous ELB. The block was administered after general anesthesia with the patient in the lateral position. Block technique: A linear ultrasound probe (M-Turbo, Fujifilm Sonosite, Inc.) was placed in the midline longitudinal position at the spinous process of the T7 vertebra. After the probe was switched to a transverse position, it slid laterally to identify the T7 vertebral lamina, transverse process (TP), and rib. A Tuohy needle was advanced in-plane to the probe until the needle tip contacted the lateral edge of the lamina with some resistance (Fig. 1). Tissue hydrodissection was performed using 5 ml normal saline, followed by epidural catheter placement. After negative aspiration of blood, cerebrospinal fluid, and air, 20 ml volume of 0.25% bupivacaine was injected via the catheter, and the spread of the injected drug was confirmed by tissue movement on ultrasound. The catheter was secured using the double-tunneling method. Intraoperatively, there was no additional opioid requirement, and the vital signs were normal. During the postoperative period, 0.125% bupivacaine (20 ml) was administered every 8 h. During the postoperative period, intravenous paracetamol (10 mg/kg) was administered every 6 h as a part of multimodal analgesia. The postoperative pain score was measured using a numerical rating scale (NRS) at different time points, both at rest and during movement. The mean NRS score was 2 for rest and 4.5 for movement for all patients. Rescue analgesia was not required during the postoperative period, and the catheter was removed after 72 h. No adverse effects were observed in any patient. A similar study by Kumari et al. [4] reported ELB in patients who underwent percutaneous nephrolithotomy and found a significant reduction in the mean pain score in the postoperative period. Gao et al. [5] compared the edge of the laminar block with the thoracic paravertebral (TPVB) and retrolaminar blocks in video-assisted thoracic surgery. Their results showed better analgesia with the ELB than with the TPVB or RLB. They hypothesized that in the ELB, blockade of both the anterior and posterior branches of the thoracic nerve occurs, whereas in the TPVB, local anesthetics mainly infiltrate the anterior thoracic nerve and the RLB posterior branch. Continuous ELB can be used to provide effective and prolonged analgesia in patients undergoing thoracic surgery or those with multiple rib fractures.
Ultrasound-guided continuous edge of laminar block. (A) Needle probe position, (B) sonoanatomy, blue arrow: Needle path. TOF: train-of-four.
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FUNDING
None.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.
DATA AVAILABILITY STATEMENT
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
AUTHOR CONTRIBUTIONS
Writing - original draft: Poonam Kumari, Satish Kumar, Neha Mary Noble, Lakshmi Sinha. Writing - review & editing: Poonam Kumari, Amarjeet Kumar, Satish Kumar, Neha Mary Noble, Lakshmi Sinha. Conceptualization: Poonam Kumari. Data curation: Satish Kumar. Methodology: Amarjeet Kumar.