Letters to the Editor 2. Lechner TJ, van Wijk MG, Jongenelis AA, Rybak M, van Niekerk J, Langenberg CJ. The use of a sound-enabled device to measure pressure during insertion of an epidural catheter in women in labour. Anaesthesia. 2011;66:568–573.

A Novel Paralaminar In-Plane Approach for Ultrasound-Guided Continuous Thoracic Paravertebral Block Using Microconvex Array Transducer Accepted for publication: March 30, 2015. To the Editor: e have evaluated a novel approach of in-plane ultrasound-guided thoracic paravertebral block (USG-TPVB) using a microconvex array probe that provides good needle visualization as well as safe and reliable catheterization. After obtaining written informed consent, we placed the patient in either a lateral decubitus position (with the side to be


Regional Anesthesia and Pain Medicine • Volume 40, Number 4, July-August 2015

blocked on top) or in a prone position and confirmed the target intervertebral level. After the skin was disinfected, an 8- to 5-MHz microconvex probe was placed on the patient, vertically against the skin surface, in a transverse position to the vertebral column. The probe was moved cephalad or caudad to visualize the transverse process and the parietal pleura (PP) on the same screen (Fig. 1A). Moving the probe more caudally diminished the hyperechoic line of the transverse process and silhouetted the lamina arcus vertebrae and PP (Fig. 1B). A landmark of this approach is the lateral edge of lamina arcus vertebrae, which we refer to as “lamina’s cliff ” (Fig. 1B). A 17- to 18-gauge Tuohy needle was inserted vertically against the skin from the inner side of the probe (Fig. 1C). The needle grazed the right outside “cliff ” and reached the thoracic paravertebral space with a sense that the tip penetrated the superior costotransverse ligament. We injected 10 to 20 mL of saline to ensure the PP was pressed ventrally (Fig. 1D). The catheter was inserted and left at a distance of 2 to 2.5 cm plus the needle depth. This approach was established by modifying the method of Luyet et al.1 We

applied this to an in-line approach with a microconvex probe for safer USG-TPVB, for fair needle visualization and easy advancement regardless of patients’ physique or which paravertebral level is chosen. We suggest that this “paralaminar in-line approach” could become a useful approach for USG-TPVB. The depiction ability of microconvex probes in assessing deep structures awaits further improvement. Yasuko Taketa, MD, PhD Taro Fujitani, MD Department of Anesthesiology and Critical Care Ehime Prefectural Central Hospital Matsuyama, Japan

The authors declare no conflict of interest. This work was presented at the 62nd Annual Meeting of the Japanese Society of Anesthesiologists in Kobe, Japan, May 29, 2015. REFERENCE 1. Luyet C, Herrmann G, Ross S, et al. Ultrasound-guided thoracic paravertebral puncture and placement of catheters in human cadavers: where do catheters go? Br J Anaesth. 2011;106:246–254.

A Troubling Definition of the “Administration” of Anesthesia Accepted for publication: February 20, 2015. To the Editor: avid Eddinger, a technical director at the Centers for Medicare & Medicaid Services, recently provided a troubling new definition of the “administration” of anesthesia: The professional who pushes the plunger on the syringe that contains a medication is the person who administers that medication. If that medication is for analgesia (minimal or moderate sedation), the medication may be administered by a trained RN under the personal supervision of the physician. However, if the medication is anesthesia, that medication can only be administered by a person qualified to administer anesthesia in accordance with [section] 482.52 (in hospitals).1 Although Eddinger’s comments pertained to the emergency department setting, this oversimplified definition of “administering” anesthesia could have far-reaching consequences in other locales where sedation, analgesia, and anesthesia are provided. Those practices whose anesthesiologists use regional analgesia and anesthesia techniques (RA) could be significantly affected by Eddinger’s remarks should those


FIGURE 1. A, Ultrasound cross-sectional images visualized the transverse process. B, The probe is moved caudally and showed the thoracic paravertebral space (yellow dot line). The lateral edge of the lamina arcus vertebrae (Lamina’s cliff ) is visualized (ultrasound image of prepuncture). C, Probe setting and needle insertion at T4-5 intervertebral in the lateral decubitus position. Needle guide is attached to the probe. The needle is advanced along the medial side of the probe. D, Ultrasound image of undertaking paravertebral block. The needle line is visualized (yellow arrows), and the parietal pleura is pressed ventrally by saline injection (white arrows). TP, transverse process; VL, lamina arcus vertebrae.


© 2015 American Society of Regional Anesthesia and Pain Medicine

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A Novel Paralaminar In-Plane Approach for Ultrasound-Guided Continuous Thoracic Paravertebral Block Using Microconvex Array Transducer.

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