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LETTERS TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 37-38
 

Ultrasound-guided continuous paravertebral block in management of Askin's tumor in an elderly patient


Department of Anaesthesiology and Critical Care, AIIMS, Raipur, Chhattisgarh, India

Date of Web Publication22-May-2018

Correspondence Address:
Dr. Tuhin Mistry
26, Unique Park, P. Majumdar Road, P.O. Haltu, P.S. Garfa, Kolkata - 700 078, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_44_17

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How to cite this article:
Mistry T, Singha SK, Sinha M, Kumar M. Ultrasound-guided continuous paravertebral block in management of Askin's tumor in an elderly patient. Indian Anaesth Forum 2018;19:37-8

How to cite this URL:
Mistry T, Singha SK, Sinha M, Kumar M. Ultrasound-guided continuous paravertebral block in management of Askin's tumor in an elderly patient. Indian Anaesth Forum [serial online] 2018 [cited 2019 Oct 22];19:37-8. Available from: http://www.theiaforum.org/text.asp?2018/19/1/37/232909




Sir,

Thoracic epidural block (TEB) is usually considered the gold standard technique for postthoracotomy pain relief. However, a recent Cochrane systemic review has revealed that the analgesic efficacy of thoracic paravertebral block (TPVB) is comparable to TEB in controlling acute pain.[1]

Peripheral primary neuroectodermal tumors (PPNETs) are extremely malignant, small, round cell tumors, which mainly involve bones and soft tissues. PPNET limited to the thoracopulmonary region is also known as Askin's tumor, which belongs to the Ewing family of tumors due to their cytogenetic appearance.[2] It has a peak incidence in the second decade of life, with 80% of presentations being <20 years of age. However, rarely, it may affect older patients.[3] A 66-year-old man (weight 47.1 kg, height 154 cm, American Society of Anesthesiologists physical status II), known hypertensive (on amlodipine 5 mg and Telmisartan 40 mg) and smoker, was posted for resection of the tumor arising from the anterior aspect of the left 4th rib. Left-sided TPVB was planned for perioperative analgesia, and the targeted paravertebral space (T4–T5) was identified with a scout scan using a high-frequency (8–13 MHz) linear probe (SonoSite MicroMaxx) in sagittal plane [Figure 1]. In the theater, an 18G Tuohy needle was inserted to the selected space under US guidance by the sagittal in-plane approach. 10 ml of injection bupivacaine 0.5% was injected slowly in small increments after negative aspiration and confirmation (downward displacement of pleura) with 3 ml of 0.9% saline. A catheter (20G) was inserted (4 cm into the paravertebral space), and the tip position was confirmed with 1 ml of air [Figure 2]. Anesthesia was induced with propofol 80 mg, fentanyl 80 μg, and vecuronium 4 mg, and his trachea was intubated with 8.0 mm ID cuffed ET tube. An infusion of 0.25% bupivacaine at 5 mL/h was started after 1 h of bolus dose which was also continued in the postoperative period. The tumor arising from the anterior aspect of the left 4th rib involving pectoralis minor muscle and parietal pleura, having well-defined margins, was removed through the left anterolateral thoracotomy. The rib was reconstructed with Antibiotic Simplex (bone cement with erythromycin and colistin). His emergence from anesthesia was smooth and pain free, and he was comfortable in the immediate postoperative period. The paravertebral catheter was removed on the 4th postoperative day. Paracetamol, ketorolac and gabapentine were used as a part of multimodal analgesia. No additional dose of opioid was required during the intraoperative or postoperative period. The patient is currently undergoing postoperative chemotherapy.
Figure 1: Scout scan showing paravertebral space

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Figure 2: Catheter tip position

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TPVB is a simple and safe method which provides unilateral segmental analgesia. Use of ultrasound for performing TPVB has increased the safety margin and reliability. It also helps in attenuation of the neuroendocrine stress response and has lower incidence of side effects with reduced frequency of urinary retention and hypotension and postoperative respiratory morbidity as compared to intercostal block or TEB.[4] Continuous unilateral TPVB, as a part of multimodal analgesia, in our patient ensured effective control of postoperative pain and early recovery without any adverse event or hemodynamic changes.

To conclude, in management of Askin's tumor, ultrasound-guided continuous TPVB rendered good perioperative unilateral segmental analgesia in our patient for rib resection and reconstruction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yeung JH, Gates S, Naidu BV, Wilson MJ, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016;2:CD009121.  Back to cited text no. 1
[PUBMED]    
2.
Xu Q, Xu K, Yang C, Zhang X, Meng Y, Quan Q, et al. Askin tumor: Four case reports and a review of the literature. Cancer Imaging 2011;11:184-8.  Back to cited text no. 2
    
3.
Ribeiro L, Apolinário D, Cunha J, Guimarães F. Askin's tumor. A Rare diagnosis in an elderly patient. Arch Bronconeumol 2017;53:642-3.  Back to cited text no. 3
    
4.
Tighe SQ, Greene MD, Rajadurai N. Paravertebral block. Contin Educ Anaesth Crit Care Pain 2010;10:133-7.  Back to cited text no. 4
    


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