Anaesthesia 2015, 70, 993–995
doi:10.1111/anae.13037
Case Report Laparoscopic sleeve gastrectomy in five awake obese patients using paravertebral and superficial cervical plexus blockade S. Kanawati,1 H. Fawal,2 H. Maaliki3 and Z. M. Naja4 1 Attending Physician, 4 Chair, Anaesthesia and Pain Management Department, 2 Attending Physician, Surgery Department, Makassed General Hospital, Beirut, Lebanon 3 Attending Physician, Anaesthesia Department, Saad Specialist Hospital, Al Khobar, Saudi Arabia
Summary We report laparoscopic sleeve gastrectomy in five awake obese patients, completed under regional anaesthesia provided by paravertebral and superficial cervical plexus blockade. The technique was acceptable to patients, surgeons and anaesthetists. .................................................................................................................................................................
Correspondence to: Z. M. Naja Email: [email protected] Accepted: 21 January 2015
Introduction We have used paravertebral blocks for a variety of operations [1–3]. Bilateral paravertebral blockade has been used to provide analgesia after laparoscopic cholecystectomy as well as to provide anaesthesia for ventral hernia repair [2, 3]. Paravertebral blockade can make general anaesthesia unnecessary, allowing patients to be awake and cooperative during surgery [1], which is associated with fewer pulmonary complications, postoperative nausea and vomiting, pain and analgesic consumption, especially opioids [4–6]. We are unaware of studies of paravertebral blockade for laparoscopic sleeve gastrectomy. We report a series of five obese patients who had laparoscopic sleeve gastrectomy while awake, with anaesthesia provided by a combination of paravertebral blockade and superficial cervical plexus blockade.
Case series Following approval from the Institutional Review Board, written informed consent was obtained from © 2015 The Association of Anaesthetists of Great Britain and Ireland
five patients, three women and two men, of ASA physical status 2–3, who were admitted for laparoscopic sleeve gastrectomy (Table 1, Fig. 1). Case 1 was a 42-year-old man. He smoked heavily and had a history of asthma, cardiac disease, chronic obstructive pulmonary disease and hypertension. Case 2 was a 56-year-old woman, with a history of asthma, hypertension and depression. She refused general anaesthesia because of complications associated with a total abdominal hysterectomy. Case 3 was a 21-year-old woman, with a history of obstructive sleep apnoea, who refused general anaesthesia because she associated it with the death of a relative. Case 4 was a 76-year-old woman, with a history of coronary artery disease, hypertension, diabetes, chronic obstructive pulmonary disease and obstructive sleep apnoea. Case 5 was a 26-year-old man, with a history of obstructive sleep apnoea. He refused general anaesthesia because of a previous associated complication. We performed bilateral paravertebral blocks guided by a nerve stimulator in all patients in the 993
Anaesthesia 2015, 70, 993–995
Kanawati et al. | Sleeve gastrectomy in awake obese patients
Table 1 Characteristics and intra-operative details of five patients who underwent awake laparoscopic sleeve gastrectomy using a combination of paravertebral and superficial cervical plexus blockade. Values are median (IQR [range]).
Age; years 42 (24–66 [21–76]) BMI; kg.m 2 43 (41–51 [40–54]) Surgery duration; min 105 (73–123 [70–130]) Agent dose in the local anaesthetic Bupivacaine; mg 64 (64–66 [64–68]) Lidocaine 2%; mg 326 (316–385 [306–426]) Lidocaine 2%*; mg 153 (153–158 [153–162]) Fentanyl; lg 100 (100–125 [100–150])
*Combined with 1:200 000 adrenaline. 120
(a)
Heart rate (bpm)
100 80 60 40 20 0
Mean arterial blood pressure (mmHg)
140
Baseline
Incision
Insuffla on
Stomach removal
End of surgery
Incision
Insuffla on
Stomach removal
End of surgery
(b)
120 100 80 60 40 20 0
Baseline
Figure 1 Intra-operative (a) heart rate and (b) mean arterial pressure during awake sleeve gastrectomy. Solid line, median; dashed line, 25th percentile; dotted line, 75th percentile. lateral decubitus position. We gave the first three cases intravenous midazolam 1 mg and fentanyl 50 lg before performing the paravertebral block. We did not give any sedation to the remaining two cases. We injected 4–5 ml local anaesthetic mixture at each thoracic level from T11 to T6. Each 20 ml of the mixture contained: 6 ml lidocaine 2%; 6 ml lidocaine 2% with 994
adrenaline 5 lg.ml 1; 5 ml bupivacaine 0.5%; 50 lg fentanyl (1 ml); and 2 ml saline 0.9% [3]. We placed patients in the semi-sitting and reverse Trendelenburg position for surgery, at the beginning of which we injected 4 mg ondansetron and 50 mg ranitidine intravenously. Following incision, the abdomen was insufflated to a pressure of 12–14 mmHg. For the first case, we injected 50 mg propofol intravenously to facilitate the insertion of a 36-G orogastric tube, 20 min after insufflation of the abdomen. We combined an intravenous injection of 20 mg propofol with three sprays of lidocaine 10% intravenously to the base of the tongue to reduce the gag reflex in the second case. We used only topical lidocaine 10% spray for subsequent cases. We injected methylene blue dye to establish anastomotic integrity [7], after which the abdomen was deflated and the orogastric tube was removed. We used a nerve stimulator to guide superficial cervical blockade to relieve shoulder pain in all patients: on the left side in cases 1, 3 and 5, on the right side in case 4 and bilaterally in case 2. To determine the point of injection, we first passed the nerve stimulator needle over the skin following aseptic preparation, from the distal to proximal part of the posterior border of the sternocleidomastoid. A mark was placed when the muscle contracted. We infiltrated the skin mark with 1 ml lidocaine 1%. We subsequently advanced a 22-G, 10-cm nerve stimulator needle through the skin weal by 0.5–1 cm, while passing a 5–8.5 mA current at 1 Hz (Stimuplex; B. Braun, Melsungen, Germany). We reduced the stimulating current to 0.5–0.6 mA while maintaining muscle contraction, at which point we injected 3–5 ml of the anaesthetic mixture that we had used for paravertebral blockade. There were no pneumothoraces, episodes of hypoxaemia or other complications.
Discussion We have reported five patients in whom laparoscopic sleeve gastrectomy was completed without recourse to general anaesthesia. Superficial cervical plexus block was sufficient to relieve the shoulder pain that can be caused by laparoscopic surgery and abdominal insufflation [8]. Paravertebral block provided intra-operative haemodynamic stability without the need for further medication. The patients were awake and cooperative © 2015 The Association of Anaesthetists of Great Britain and Ireland
Kanawati et al. | Sleeve gastrectomy in awake obese patients
during the operation. At the end of the operation, they were able to move on their own from the surgical table to a stretcher. Cases 3 and 5 were able to walk directly after the operation. In conclusion, paravertebral blockade combined with superficial cervical plexus blockade provides a satisfactory alternative to general anaesthesia for laparoscopic sleeve gastrectomy.
Anaesthesia 2015, 70, 993–995
2.
3.
4.
Acknowledgement We thank Drs Zeina Naja and Ahmad Salah Naja for their assistance in preparing the case series.
5.
Competing interests
6.
No external funding and no competing interests declared. Published with the patients’ written consent.
7.
References 1. Naja ZM, Ziade FM, El-Rajab MA, Naccash N, Ayoubi JM. Guided paravertebral blocks with versus without clonidine
© 2015 The Association of Anaesthetists of Great Britain and Ireland
8.
for women undergoing breast surgery: a prospective double-blinded randomized study. Anesthesia and Analgesia 2013; 117: 252–8. Naja MZ, Ziade MF, Lonnqvist PA. General anaesthesia combined with bilateral paravertebral blockade (T5-6) vs. general anaesthesia for laparoscopic cholecystectomy: a prospective, randomized clinical trial. European Journal of Anaesthesiology 2004; 21: 489–95. Naja MZ, Ziade MF, Lonnqvist PA. Bilateral paravertebral somatic nerve block for ventral hernia repair. European Journal of Anaesthesiology 2002; 19: 197–202. Naja MZ, Ziade MF, Lonnqvist PA. Nerve stimulator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial. European Journal of Anaesthesiology 2003; 20: 897–903. Richardson J, Lonnqvist PA, Naja Z. Bilateral thoracic paravertebral block: potential and practice. British Journal of Anaesthesia 2011; 106: 164–71. Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001; 95: 771–80. Baltasar A, Serra C, Perez N, Bou R, Bengochea M, Ferri L. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obesity Surgery 2005; 15: 1124–8. Berberoglu M, NuriDilek O, Ercan F, Kati I, Ozmen M. The effect of CO2 insufflation rate on the postlaparoscopic shoulder pain. Journal of Laparoendoscopic and Advanced Surgical Techniques 1998; 8: 273–7.
995
doi:10.1111/anae.13037
Case Report Laparoscopic sleeve gastrectomy in five awake obese patients using paravertebral and superficial cervical plexus blockade S. Kanawati,1 H. Fawal,2 H. Maaliki3 and Z. M. Naja4 1 Attending Physician, 4 Chair, Anaesthesia and Pain Management Department, 2 Attending Physician, Surgery Department, Makassed General Hospital, Beirut, Lebanon 3 Attending Physician, Anaesthesia Department, Saad Specialist Hospital, Al Khobar, Saudi Arabia
Summary We report laparoscopic sleeve gastrectomy in five awake obese patients, completed under regional anaesthesia provided by paravertebral and superficial cervical plexus blockade. The technique was acceptable to patients, surgeons and anaesthetists. .................................................................................................................................................................
Correspondence to: Z. M. Naja Email: [email protected] Accepted: 21 January 2015
Introduction We have used paravertebral blocks for a variety of operations [1–3]. Bilateral paravertebral blockade has been used to provide analgesia after laparoscopic cholecystectomy as well as to provide anaesthesia for ventral hernia repair [2, 3]. Paravertebral blockade can make general anaesthesia unnecessary, allowing patients to be awake and cooperative during surgery [1], which is associated with fewer pulmonary complications, postoperative nausea and vomiting, pain and analgesic consumption, especially opioids [4–6]. We are unaware of studies of paravertebral blockade for laparoscopic sleeve gastrectomy. We report a series of five obese patients who had laparoscopic sleeve gastrectomy while awake, with anaesthesia provided by a combination of paravertebral blockade and superficial cervical plexus blockade.
Case series Following approval from the Institutional Review Board, written informed consent was obtained from © 2015 The Association of Anaesthetists of Great Britain and Ireland
five patients, three women and two men, of ASA physical status 2–3, who were admitted for laparoscopic sleeve gastrectomy (Table 1, Fig. 1). Case 1 was a 42-year-old man. He smoked heavily and had a history of asthma, cardiac disease, chronic obstructive pulmonary disease and hypertension. Case 2 was a 56-year-old woman, with a history of asthma, hypertension and depression. She refused general anaesthesia because of complications associated with a total abdominal hysterectomy. Case 3 was a 21-year-old woman, with a history of obstructive sleep apnoea, who refused general anaesthesia because she associated it with the death of a relative. Case 4 was a 76-year-old woman, with a history of coronary artery disease, hypertension, diabetes, chronic obstructive pulmonary disease and obstructive sleep apnoea. Case 5 was a 26-year-old man, with a history of obstructive sleep apnoea. He refused general anaesthesia because of a previous associated complication. We performed bilateral paravertebral blocks guided by a nerve stimulator in all patients in the 993
Anaesthesia 2015, 70, 993–995
Kanawati et al. | Sleeve gastrectomy in awake obese patients
Table 1 Characteristics and intra-operative details of five patients who underwent awake laparoscopic sleeve gastrectomy using a combination of paravertebral and superficial cervical plexus blockade. Values are median (IQR [range]).
Age; years 42 (24–66 [21–76]) BMI; kg.m 2 43 (41–51 [40–54]) Surgery duration; min 105 (73–123 [70–130]) Agent dose in the local anaesthetic Bupivacaine; mg 64 (64–66 [64–68]) Lidocaine 2%; mg 326 (316–385 [306–426]) Lidocaine 2%*; mg 153 (153–158 [153–162]) Fentanyl; lg 100 (100–125 [100–150])
*Combined with 1:200 000 adrenaline. 120
(a)
Heart rate (bpm)
100 80 60 40 20 0
Mean arterial blood pressure (mmHg)
140
Baseline
Incision
Insuffla on
Stomach removal
End of surgery
Incision
Insuffla on
Stomach removal
End of surgery
(b)
120 100 80 60 40 20 0
Baseline
Figure 1 Intra-operative (a) heart rate and (b) mean arterial pressure during awake sleeve gastrectomy. Solid line, median; dashed line, 25th percentile; dotted line, 75th percentile. lateral decubitus position. We gave the first three cases intravenous midazolam 1 mg and fentanyl 50 lg before performing the paravertebral block. We did not give any sedation to the remaining two cases. We injected 4–5 ml local anaesthetic mixture at each thoracic level from T11 to T6. Each 20 ml of the mixture contained: 6 ml lidocaine 2%; 6 ml lidocaine 2% with 994
adrenaline 5 lg.ml 1; 5 ml bupivacaine 0.5%; 50 lg fentanyl (1 ml); and 2 ml saline 0.9% [3]. We placed patients in the semi-sitting and reverse Trendelenburg position for surgery, at the beginning of which we injected 4 mg ondansetron and 50 mg ranitidine intravenously. Following incision, the abdomen was insufflated to a pressure of 12–14 mmHg. For the first case, we injected 50 mg propofol intravenously to facilitate the insertion of a 36-G orogastric tube, 20 min after insufflation of the abdomen. We combined an intravenous injection of 20 mg propofol with three sprays of lidocaine 10% intravenously to the base of the tongue to reduce the gag reflex in the second case. We used only topical lidocaine 10% spray for subsequent cases. We injected methylene blue dye to establish anastomotic integrity [7], after which the abdomen was deflated and the orogastric tube was removed. We used a nerve stimulator to guide superficial cervical blockade to relieve shoulder pain in all patients: on the left side in cases 1, 3 and 5, on the right side in case 4 and bilaterally in case 2. To determine the point of injection, we first passed the nerve stimulator needle over the skin following aseptic preparation, from the distal to proximal part of the posterior border of the sternocleidomastoid. A mark was placed when the muscle contracted. We infiltrated the skin mark with 1 ml lidocaine 1%. We subsequently advanced a 22-G, 10-cm nerve stimulator needle through the skin weal by 0.5–1 cm, while passing a 5–8.5 mA current at 1 Hz (Stimuplex; B. Braun, Melsungen, Germany). We reduced the stimulating current to 0.5–0.6 mA while maintaining muscle contraction, at which point we injected 3–5 ml of the anaesthetic mixture that we had used for paravertebral blockade. There were no pneumothoraces, episodes of hypoxaemia or other complications.
Discussion We have reported five patients in whom laparoscopic sleeve gastrectomy was completed without recourse to general anaesthesia. Superficial cervical plexus block was sufficient to relieve the shoulder pain that can be caused by laparoscopic surgery and abdominal insufflation [8]. Paravertebral block provided intra-operative haemodynamic stability without the need for further medication. The patients were awake and cooperative © 2015 The Association of Anaesthetists of Great Britain and Ireland
Kanawati et al. | Sleeve gastrectomy in awake obese patients
during the operation. At the end of the operation, they were able to move on their own from the surgical table to a stretcher. Cases 3 and 5 were able to walk directly after the operation. In conclusion, paravertebral blockade combined with superficial cervical plexus blockade provides a satisfactory alternative to general anaesthesia for laparoscopic sleeve gastrectomy.
Anaesthesia 2015, 70, 993–995
2.
3.
4.
Acknowledgement We thank Drs Zeina Naja and Ahmad Salah Naja for their assistance in preparing the case series.
5.
Competing interests
6.
No external funding and no competing interests declared. Published with the patients’ written consent.
7.
References 1. Naja ZM, Ziade FM, El-Rajab MA, Naccash N, Ayoubi JM. Guided paravertebral blocks with versus without clonidine
© 2015 The Association of Anaesthetists of Great Britain and Ireland
8.
for women undergoing breast surgery: a prospective double-blinded randomized study. Anesthesia and Analgesia 2013; 117: 252–8. Naja MZ, Ziade MF, Lonnqvist PA. General anaesthesia combined with bilateral paravertebral blockade (T5-6) vs. general anaesthesia for laparoscopic cholecystectomy: a prospective, randomized clinical trial. European Journal of Anaesthesiology 2004; 21: 489–95. Naja MZ, Ziade MF, Lonnqvist PA. Bilateral paravertebral somatic nerve block for ventral hernia repair. European Journal of Anaesthesiology 2002; 19: 197–202. Naja MZ, Ziade MF, Lonnqvist PA. Nerve stimulator guided paravertebral blockade vs. general anaesthesia for breast surgery: a prospective randomized trial. European Journal of Anaesthesiology 2003; 20: 897–903. Richardson J, Lonnqvist PA, Naja Z. Bilateral thoracic paravertebral block: potential and practice. British Journal of Anaesthesia 2011; 106: 164–71. Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001; 95: 771–80. Baltasar A, Serra C, Perez N, Bou R, Bengochea M, Ferri L. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation. Obesity Surgery 2005; 15: 1124–8. Berberoglu M, NuriDilek O, Ercan F, Kati I, Ozmen M. The effect of CO2 insufflation rate on the postlaparoscopic shoulder pain. Journal of Laparoendoscopic and Advanced Surgical Techniques 1998; 8: 273–7.
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