Ultrasoundguided retrolaminar paravertebral block

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stigmine and pethidine have been supplied in almost identically col- oured boxes and ampoules (Fig. 5). It has been argued that similar packaging ensures that ...
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Anaesthesia 2013, 68, 640–654

Interestingly, none of this would necessarily avoid the drug error described in Muddanna et al.’s letter, and colour-coding of drugs would not have prevented any of our incidents. On our delivery suite, Syntocinon (or carbetocin depending on our guidelines) is never drawn up in advance of caesarean section and when drawn up ahead of administration, we encourage that it is kept separate from all other drugs on a different part of the anaesthetic machine. Even better would be to draw it up at the time it is needed whilst following our ten commandments. There will never be a failsafe method and colour-coding does not solve all problems, but formal teaching of our juniors is a sensible step and stressing our tenth commandment, we hope, will result in extra vigilance by the anaesthetist administering the drug. G. Jackson J. Bird Royal Berkshire Hospital Reading, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia Correspondence website: http://www.anaesthesia correspondence.com.

References 1. Muddanna A, Lowings M, O’Sullivan G. Colour-coded labels for uterotonics. Anaesthesia 2013; 68: 114–5. 2. Fasting S, Gisvold SE. Adverse drug errors in anaesthesia, and the impact of coloured syringe labels. Canadian Journal of Anesthesia 2000; 47: 1060–7. doi:10.1111/anae.12234

Figure 5 Similar presentations of glycopyrronium/neostigmine and pethidine.

Colour-coding of drug packaging In addition to the question of whether there are sufficient colour label varieties [1], we are surely not alone in wondering why, when we have adopted international colours for labelling syringes, we have not done the same for the packaging and ampoules themselves? Hospitals change drug suppliers frequently in order to minimise costs, but this means that drug boxes and ampoules can change, altering familiar visual stimuli. Recently, at our hospital, glycopyrronium/neostigmine and pethidine have been supplied in almost identically coloured boxes and ampoules (Fig. 5). It has been argued that similar packaging ensures that boxes and labels are read more carefully, but the time taken to identify the required box might limit the time one takes to read the ampoule accurately in an emergency situation. Anaesthesia has recognised the potential for limiting adverse events with colour-coding of vaporisers and pin index systems for

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a long time. Surely this is another area where a commonsense approach should be taken? C. van Hamel P. Sant Great Western Hospital Swindon, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia Correspondence website: http://www. anaesthesiacorrespondence.com.

Reference 1. Muddanna A, Lowings M, O’Sullivan G. Colour-coded labels for uterotonics? Anaesthesia 2013; 68: 114–5. doi:10.1111/anae.12235

Ultrasound-guided retrolaminar paravertebral block Paravertebral nerve blockade is considered an advanced technique due to the proximity of the neuraxis, pleura, abundant vasculature and 649

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other ‘danger zones’. The risk of pneumothorax associated with the traditional technique (‘walking’ the block needle off a transverse process into the paravertebral space), with or without ultrasound guidance, remains high [1, 2]. This risk may be lessened by directing the block needle more medially, posterior to the vertebral lamina [3, 4], whilst avoiding unintentional neuraxial injection. We investigated whether the retrolaminar technique might be improved by ultrasound guidance. A 37-year-old woman was scheduled for bilateral prophylactic mastectomies and tissue expander reconstruction under general anesthesia with bilateral continuous ultrasound-guided retrolaminar blocks, after the risks, benefits and the novel aspects of these blocks

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negative aspiration, creating a fluidfilled space between laminae and paraspinous muscles, without pain or paresthesia. The tips of two 20-G multi-orifice catheters (Perifixâ, B. Braun Medical Inc., Bethlehem, PA, USA) were inserted into this space, with the catheters secured to the patient’s skin. The patient received 150 lg fentanyl intra-operatively and 0.8 mg hydromorphine intravenously over 2 h in the recovery unit, where a further bolus of 15 ml ropivacaine 0.5% per side was given and mepivacaine 0.75% infusions commenced at 10 ml.h 1, bilaterally. On the first postoperative day, the patient required no opioids and had visual analogue pain scores of 1–4/10, with reduced sensation to sharp stimuli in the T3-T4 dermatomes on the right side and T3-T5 dermatomes on the left side. Para-

had been discussed with the patient, and her consent given. With the patient in a sitting position and the skin sterilised, we passed a L38 linear ultrasound probe (SonoSite M-Turbo, SonoSite, Inc., Bothel, WA, USA) in a sagittal plane from medial to lateral at the mid-thoracic level, and identified the hyperechoic laminae, transverse processes, ribs and pleura (Fig. 6). The T3 laminae were identified approximately 4 cm subcutaneously, and an 18-G Tuohy-tip 10-cm block needle (SonoLongâ, Pajunk Medizinteechnologie GmbH, Geisingen, Germany) was inserted in-plane, cephalad to caudad. After lamina contact and negative aspiration, 15 ml ropivacaine 0.5% was injected at low pressure (B-SmartTMPressure Manometer, Concert Medical, Norwell, MA, USA) with intermittent

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Figure 6 Sagittal plane ultrasound images from medial to lateral, showing (a) laminae, (b) transverse vertebral processes and (c) ribs; (d) simulated sagittal probe orientation showing final needle tip placement and direction of catheter advancement; (e) a schematic view of paravertebral anatomy, showing how retrolaminar needle placement (x) avoids neural and pleural damage compared with traditional paravertebral needle placement (y); (f) a sonographic image during block administration, showing vertebral lamina, block needle and injectate. 650

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Anaesthesia 2013, 68, 640–654

vertebral infusions were discontinued and the catheters removed on the second postoperative day; the patient received 20 mg oral oxycodone and 2 mg oral hydromorphone that evening, and was discharged home on day 3, with adequate pain control. We have performed more than 20 such blocks subsequently, with similar results and no complications, in patients undergoing uni/ bilateral mastectomies, thoracotomy (3) or laparotomy (1), or with multiple rib fractures. J. L. Zeballos C. Voscopoulos M. Kapottos D. Janfaza K. Vlassakov Brigham and Women’s Hospital Boston, MA, USA Email: [email protected] Published with the written consent of the patient described. No external funding and no competing interests declared.

References

€nnqvist PA. Thoracic par1. Richardson J, Lo avertebral block. British Journal of Anaesthesia 1998; 81: 230–8. €nnqvist PA, MacKenzie J, Soni AK, 2. Lo Conacher ID. Paravertebral blockade. Failure rate and complications. Anaesthesia 1995; 50: 813–5. €ne S, Richter3. Pfeiffer G, Oppitz N, Scho €hne M, Koltermann C. AnalHeine I, Ho gesia of the axilla using a paravertebral catheter in the lamina technique. Anaesthetist 2006; 55: 423–7. €ttner T, Werdehausen R, Hermanns H, 4. Ju et al. The paravertebral lamina technique: a new regional anesthesia approach for breast surgery. Journal of Clinical Anesthesia 2011; 23: 443–50. doi:10.1111/anae.12296

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Figure 7 (a) Bag of mannitol 20% with linear volume markings and (b) bag of saline 0.9% with non-linear volume markings, both showing meniscus levels after removal of sequential 100-ml aliquots.

Inaccuracy of fluid container volume markings During an emergency neurosurgical procedure, a patient was given 250 ml mannitol 20%. The volume was estimated visually according to the gradations marked on either side of the 500-ml fluid bag, but there was a suspicion that these did not correlate closely with the volume infused. Postoperatively, the residual volume of mannitol was drawn off using a 50-ml syringe, and found to measure 270 ml. On withdrawing 100-ml aliquots from suspended bags of mannitol 20% and saline 0.9% (both Baxter, Thetford, UK) using a 50ml syringe (BD Plastipak, BD, Oxford, UK), sequential meniscus

Anaesthesia © 2013 The Association of Anaesthetists of Great Britain and Ireland

levels were found to differ considerably from their isovolumetric bag markings (Figs 7a and 7b). It is clear that the fluid bag gradations do not represent the remaining volume. As misinformation is less desirable than no information, I suggest these markings are removed. An alternative would of course be accurate placement of the same. R. W. A. Nowicki Nottingham University Hospitals NHS Trust Nottingham, UK Email: [email protected] No external funding or competing interests declared. doi:10.1111/anae.12252

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