TPVB after pneumonectomy

[Oggg]

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Surgeon refused the thoracic epidural. After pneumonectomy, would it be possible to do a TPVB or would the anatomy be messed up

 

[proman]

I don't see any reason why you couldn't. Of course if there's a complication the surgeon will sell you down the river. Your post reminds me how much I like it when my surgeons (vascular, thoracic, sometimes cardiac and hepatobiliary) call me before the case to make sure the patient has an epidural in.

 

[Somnus Tuto]

This article (systematic review) in British Journal of Anesthesia seems to suggest that not only are PVBs useful for post-thoracotomy analgesia, they are preferable (per this article) due to their more favorable short term side effect profile.

TPVBs appeared to provide similar analgesic benefits to those provide by TEPs.

Glancing cursorily at the article, Table 1 already seems to show an uneven distribution of patients. It appears the sicker patients (higher #s of HTN, DM, MI) received epidurals vs. those who received TEPs. hence the higher prevalance of side effects.

additionally, no comment was made on differences in mortality between the two groups.

I've only ever attempted TPVBs for post-traumatic rib fractures without trauma to the spine so I've never done these for thoracotomies but come CT rotation, I fully intend to give it a shot (depending of course on how adventurous my attendings are) 😀

 

[Idiopathic]

why does he hate his patients?

 

[urge]

Surgeon refused the thoracic epidural. After pneumonectomy, would it be possible to do a TPVB or would the anatomy be messed up

Why do you think the anatomy would be messed up?

 

[Oggg]

I dunno. I guess the pleura should be intact if the lung is gone. But there would be dead space or air or fluid in the thoracic cavity so I dont know if the pleura would look the same. Isn't the pleura all shimmery on ultrasound because of the interface between the chest pleura and the lung pleura?

On a separate note, I did my first TPVB at T7 for an open chole, prior to extubation. Yeah.

 

[Bertelman]

Seems like the standard where you are at is to do PVBs asleep.

 

[Oggg]

That pneumonectomy pt developed an infection on that side, so they came back for a high thoracotomy and clean out. The incision was about two ribs higher than the nipple, so I tried to do a T2 TPVB. During the cleaning you could see all this gnarly granulation tissue or whatever all along the chest wall. When I ultrasounded T1-3, I saw rib, intercostal muscle, transverse process, and I could imagine where the TPVS was, and it looked like a faint line was there, but it wasnt the nice shimmery line of pleura. I went for it, figuring I didn't have much to lose with a big chest tube in there.

 

[Oggg]

I did another rescue TPVB in PACU today. Left mini thoractomy VATS, pleurectomy, pleurodesis. Incision was almost under the axilla (T3). Surgeon didn't put local in! Fent 200 and morphine 10 in PACU, still grimacing and moaning with 4-7/10 pain. I lined up the intercostal approach to T3 and put my Tuohy tip a few mm short of the pleura, in plane, transverse approach. On injection, the local flowed laterally a few cm before pushing the pleura down. It seemed like the medial pleura right under my Tuohy was stuck! I put 20cc of 0.25%bup and crossed my fingers. Within 5 min the nurse could see improvement, and was 0/10 by 15min. I should upload the pic.

 

[nap$ter]

Surgeon refused the thoracic epidural. After pneumonectomy, would it be possible to do a TPVB or would the anatomy be messed up

why did you offer the epidural to the surgeon?

i woulda offered it to the patient...

 

[gasattack3]

I did another rescue TPVB in PACU today. Left mini thoractomy VATS, pleurectomy, pleurodesis. Incision was almost under the axilla (T3). Surgeon didn't put local in! Fent 200 and morphine 10 in PACU, still grimacing and moaning with 4-7/10 pain. I lined up the intercostal approach to T3 and put my Tuohy tip a few mm short of the pleura, in plane, transverse approach. On injection, the local flowed laterally a few cm before pushing the pleura down. It seemed like the medial pleura right under my Tuohy was stuck! I put 20cc of 0.25%bup and crossed my fingers. Within 5 min the nurse could see improvement, and was 0/10 by 15min. I should upload the pic.

Are US guided PVB's easy? Never done one, but you'd think that there would be a nice advantage with less hypotension, especially when they run those thoracic cases so dry in the first place.

 

[Oggg]

1. Surgeon requested no art line and no epidural. At our place, they usually request thoracic epidural for all thoracotkmies except when they expect to only do a washout or pleurodesis or small bx.
2. USG TPVB, in plane, transverse/intercostal approach, for me, has made the TPVB reliable and simple, with only a single injection required. Your results may vary. A lot of people advocate the out of plane approach, or the longitudinal/parasaggital approach, but I feel that needle visualization is reduced -- I'll try them after I master the first approach.