Ann Thorac Surg 2007;83:1216-1218
© 2007 The Society of Thoracic Surgeons
How To Do It
Transient Diaphragmatic Paralysis by Continuous Para-Phrenic Infusion of Bupivacaine: A Novel Technique for the Management of Residual Spaces
José M. Clavero, MD*,
Juan E. Cheyre, MD,
María E. Solovera, MD,
Rodrigo P. Aparicio, MD
Department of General Thoracic Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
Accepted for publication April 24, 2006.
* Address correspondence to Dr Clavero, Department of Thoracic Surgery, Pontificia Universidad Católica de Chile, Marcoleta 352 interior Santiago Centro, Santiago, RM, 833-0033, Chile (Email: jclavero{at}med.puc.cl).
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Abstract
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Space problems are a common complication after thoracic surgery. Different procedures have been used to manage them. We describe a novel technique using transient diaphragmatic paralysis by continuous para-phrenic infusion of bupivacaine.
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Introduction
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Space problems are a relatively common complication after thoracic surgery. They can occur in 11% to 12% of lung resections, depending on the extent of the pulmonary resection, the volume and compliance of the remaining lung, and the presence of underlying parenchymal disease [1]. Space problems are difficult to manage and a potential source of serious complications. They can also produce delay in chest tube removal and prolonged hospital stay. Several procedures have been described to treat them, including pneumoperitoneum, pleural tents, phrenoplasty, phrenic nerve crushing, phrenic nerve section, and thoracoplasty [1, 2].
Space problems can also arise while dealing with a malignant pleural effusion, if complete lung re-expansion cannot be achieved after draining the effusion leading to a residual cavity. In this setting a pleural catheter or a pleuro-peritoneal shunt (PleurX pleural catheter and Denver Pleural Effusion Shunt [Denver Biomedical, Denver, CO]) can be used as alternative treatments, but with increased costs and nursing care requirements.
We describe a novel technique to manage these complicated cases that can be used during thoracotomy or video-assisted thoracoscopic surgery (VATS).
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Technique
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An incision is made in the mediastinal pleura in proximity to the phrenic nerve. A Tuohy needle is introduced in the chest cavity at the level of the eighth intercostal space, middle clavicular line. An epidural catheter is introduced in the chest through it. With thoracoscopic forceps during VATS or a curved clamp during thoracotomy, the catheter is introduced 4 to 5 cm under the pleura and left in proximity to the nerve. The Tuohy needle is withdrawn and the catheter is secured in this position with a suture or a vascular clip, taking care not to occlude the lumen (Fig 1). After surgery the catheter is connected to an elastomeric pump (Infusor [Baxter International Inc, Derrfield, IL]) for continuous infusion of bupivacaine 0.25% at 5 mL/h rate. The anesthetic infusion is usually maintained for 3 days, but it can be used for longer periods as needed. No special nursing care is required and the catheter is removed at bedside.
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Fig 1. Epidural catheter positioned close to the phrenic nerve, the Tuohy needle has been withdrawn. An infusion bupivacaine 0.25% at 5 mL/h is started after surgery.
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To illustrate this technique we present the case of a 59-year-old woman with a recurrent right pleural effusion secondary to non-Hodgkin lymphoma. She was taken to the operating room for right VATS and talc pleurodesis. After draining the effusion, the lung did not expand completely (Fig 2). Pleurodesis was postponed. A chest tube was placed and kept on 12 cm of water suction with the intention of performing a talc slurry pleurodesis when lung re-expansion was obtained. After 5 days the lung did not come up and a small air leak developed. The patient was taken back to the operating room. Only small pinhole leaks were found during VATS. They were stapled and the air leak ceased. We performed a thoracoscopic pleurectomy and placed an epidural catheter for continuous para-phrenic infusion of bupivacaine as described. The resulting elevation of the right diaphragm produced a complete resolution of the space (Fig 3). Bupicaine infusion was maintained at 5 mL/hr for 3 days. The catheter was withdrawn at bedside and the chest tube was removed without complications. A chest roentgenogram obtained 1 month after surgery did not show recurrence of the effusion and complete expansion of the lung.
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Fig 2. Postoperative chest roentgenogram of a 59-year-old woman with right malignant pleural effusion from non-Hodgkin lymphoma. Lung expansion after video-assisted thoracic surgery was incomplete and pleurodesis was postponed. Chest tube was kept on suction.
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Fig 3. Chest roentgenogram of the same patient after second video-assisted thoracic surgical procedure with insertion of para-phrenic catheter and continuous infusion of bupivacaine. Note the significant elevation of the right hemi diaphragm and resolution of the space.
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We have used the para-phrenic infusion of bupivacaine in 4 patients so far (two VATS and two thoracotomies) with very good results, and with no complications related to the procedure. Now we are using this technique more liberally in patients with space problems or when a space problem is likely to occur, either during VATS or thoracotomy.
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Comment
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Different procedures have been described to manage air spaces after thoracic surgery. We present a new technique of transient phrenic nerve paralysis with continuous para-phrenic infusion of bupivacaine. Our technique is easy to perform during thoracotomy or VATS, extending surgical time in no more than 5 minutes. Costs are low and no special nursing care is required. We have not had any complications related to the procedure so far, with complete resolution of the air spaces in all cases.
The advantage of our technique over phrenic crush or phrenic nerve resection is that the diaphragmatic paralysis is only transitory. The diaphragmatic function is therefore completely recovered once the anesthetic infusion is discontinued, preserving an adequate ventilatory capacity and cough mechanism. We have not had respiratory complications related to the transitory impairment of diaphragmatic function in our patients. This technique is also more reproducible than pneumoperitoneum and much less radical and invasive than thoracoplasty.
Extra-pleural bupivacaine infusion has been extensively used for pain control after thoracotomy. In a recent review of the literature, local complications occurred in 0.6% of patients (ie, transient hypotension and transient Horner’s syndrome) and systemic complication (ie, confusion) in 0.8% [3]. The average plasma levels during continuous extrapleural infusion are 3 to 4 ug/mL with an accepted threshold for central nervous system toxicity of 5 ug/mL. Most authors used infusions of 5 to 7 mL of 0.5% bupivacaine with complications rarely occurring [3]. Furthermore some patients with plasma level of 7.48 and 10.25 ug/mL, well above the toxic level, did not experience complications [3, 4].
It is recognized that the toxic level of bupivacaine have been difficult to define, and the incidence of toxicity seems more related to the rapidity of administration [3, 5]. The threshold for serum bupivacaine toxicity was determined after intravenous injection of the drug. Toxic serum concentration of extravascular administration is not known [5]. Tissue binding retains 80% to 90% of the drug, and most of bupivacaine in the blood is bound to serum proteins and rendered biologically inactive. Measurement of free serum bupivacaine level has been recommended to assess the toxicity level [4].
In our patients we used an infusion of 0.25% bupivacaine at 5 mL/hr, a lower concentration than reported for extrapleural administration. We have not measured bupivacaine plasma levels, but theoretically they should be lower to those obtained with extrapleural infusion. Even if toxicity is difficult to predict as mentioned before, care should be taken when using this technique in conjunction with epidural infusion and the use of opioid epidural considered. In a further study we plan to measure serum and plasmatic concentrations of bupivacaine and assess possible complications in a larger group of patients.
In summary, this is a safe, low-cost and easy to perform technique. It should be kept in the armamentarium of thoracic surgeons and should be considered as an option for the management of space problems or as a prophylactic measure when a space problem is likely to occur.
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References
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- Barker WL. Natural history of residual air spaces after pulmonary resection Chest Clin North Am 1996;3:585-613.
- Silver AW, Espinas EE, Bron FW. The fate of the post-resection space Ann Torac Surg 1966;2:311-366.
- Detterbeck FC. Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy Ann Thorac Surg 2005;80:1550-1559.[Abstract/Free Full Text]
- Marret E, Bazelly B, Taylor G, et al. Paravertebral block with Ropivacaine 0.5% versus systemic analgesia for pain relief after thoracotomy Ann Thorac Surg 2005;79:2109-2113.[Abstract/Free Full Text]
- Dauphin A, Gupta RN, Young JE, Morton WD. Serum bupivacaine concentrations during continuous extrapleural infusion Can J Anaesth 1997;44:367-370.[Medline]
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Abstract
Introduction
