American Society of Regional Anesthesia and Pain Medicine May 2018 - 18

planned general anesthetic, keeping in mind that positive pressure
ventilation may create a pneumothorax during the surgery.
Possible options include placing a prophylactic pigtail chest tube
preoperatively, proceeding with surgery with a plan to place the
pigtail tube (or chest tube) intraoperatively if it becomes necessary,
or rescheduling the case.
Pawa: Yes, I would elect to proceed with the planned anesthesia
and surgery.
Feinstein: If the patient remains asymptomatic, we would proceed
to the operating room with increased vigilance for the possible
development of intraoperative pneumothorax. To lessen the risk, we
would avoid nitrous oxide and maintain spontaneous ventilation.

In the setting of an inadvertent pleural puncture, how would
you elect to proceed?
Warren: I would proceed with the procedure under sole regional
technique.
Pawa: Most subpleural needle placements do not lead to
pneumothorax. Also, intrapleural administration of local anesthetic
is a recognized mode of analgesia (although not one I usually
practice). I think that in the absence of cough or dyspnea, the
sensible approach is to perform point-of-care ultrasonography
to assess for pneumothorax (the absence of lung sliding or the
observation of a lung point). If any doubt exists, a chest x-ray can
also be performed.
Feinstein: After a known pleural puncture, the patient's lungs
would be examined with ultrasonography and chest x-ray to look
for a pneumothorax. Although ultrasonography has been shown in
some studies to be more sensitive in diagnosing a pneumothorax,
a chest x-ray can determine the extent of pneumothorax and help
dictate care from the percentage of pneumothorax.

You elect to proceed with the case and it is conducted
uneventfully. Four hours following the block, the surgical team
asks if to inject a local anesthetic into the wound and, if so,
how much. How do you respond?
Warren: I would ask the surgical team members what they are
trying to accomplish. Paravertebral block duration usually exceeds
the local infiltration duration. However, if they feel strongly about
wound infiltration, I would ask that they avoid injecting into a blood
vessel and use bupivacaine 0.25% with epinephrine (to reduce
vascular absorption) up to 40-50 mL. I would request a smallervolume injection if the patient has a reduced ejection fraction or
hepatic or renal insufficiency.
Pawa: I am not entirely sure why the further injection of local
anesthetic into the wound would be necessary after insertion of
bilateral paravertebral blocks, unless there was axillary wound
extension and I had not performed PECS blocks. As a result,
although it is theoretically possible, I would ask them to refrain
from injecting any further local anesthetic.

Additionally, pleural puncture does not always lead to
pneumothorax. If the needle is not open to room air and there is
no insult to the parenchyma of the lung, then a pneumothorax is
unlikely to occur.

Feinstein: The surgical team may use additional local anesthetic.
The dose depends on the amount used in the preoperative block,
time since the preoperative block, and the patient's risk factors
for toxicity (eg, heart and liver failure, age, weight). We would
direct the surgical team to address the areas at risk for insufficient
coverage from the paravertebral blocks (eg, axilla). We use a
maximum of 3 mg/kg in a 4-hour time frame before considering
additional local usage.

Assuming chest x-ray and/or ultrasonography fail(s) to
demonstrate any pneumothorax, would you proceed with the
planned general anesthetic?

The patient is extubated uneventfully and taken to the
postanesthesia care unit. You are called to evaluate her for 8/10
bilateral axillary pain. How would you evaluate and manage?

Warren: This becomes a bigger discussion with the surgeon and
the patient. If there is no evidence of pneumothorax (sonographic
or radiographic assessment), then I would proceed with the

Warren: A physical exam is necessary to make sure that no physical
reason is causing pain (eg, bleeding, hematoma development, arm
ischemia, nerve compression) and to determine the actual site of pain.

American Society of Regional Anesthesia and Pain Medicine
2018

Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine May 2018