Otake Hiroshi

Spread of local anesthetic solution in the erector spinae plane block

The erector spinae plane (ESP) block, with local anesthetic injected deep to the erector spinae muscle, has been reported to be able to block the dorsal and ventral rami of the thoracic spinal nerves [1,2]. Furthermore, the ESP block has been recently reported to be able to block the sympathetic nerve fibers [3]. However, the mechanism of sympathetic block is unknown. We investigated the spread of local anesthetic solution in the ESP block. Three patients, who experienced the chronic pain due to lung cancer, were selected. A catheter was inserted deep to the erector spinae muscle at the level of the sixth thoracic spinous process in all patients. Fluoroscopy was performed by injecting 15 ml of the radiocontrast agent through the catheter. After 20 min, we investigated the flow and spread of the local anesthetic. The local anesthetic solution spread to the thoracic paravertebral space in all cases. We noted spread of the solution across more than five intervertebral spaces. Following this,

Lumbar vertebra surgery performed with a bilateral posterior quadratus lumborum block

• The methods for perioperative pain management have remained limited for lumbar vertebrae surgery.

Intermittent bilateral anterior sub-costal quadratus lumborum block for effective analgesia in lower abdominal surgery

As one of new quadratus lumborum (QL) blocks, the anterior subcostal QL blockhas been reported to be an effective analgesic in lower abdominal surgery [1]. However, there have been no reports on the efficacy of the anterior sub-costal QL block over the long postoperative period. In this article, we report two successful cases of intermittent anterior subcostal QL block in lower abdominal surgery for painmanagement during the long postoperative period. Case 1 was that of a 61-year-old woman (155 cm, 53 kg) with no complications who underwent an appendectomy. Because of severe intestinal adhesion in the intraoperative period, we added an intermittent anterior sub-costal QL block to the general anesthesia after the appendectomy. The patient was moved from a lateral to a supine position, and the anterior sub-costal QL block was administered via injection of 0.375% levobupivacaine (20 mL) into the perinephric fat tissue under the right QL muscle at the 12th rib, and the catheter was inserted into the space. The right catheter was attached to a CADD®-Solis with Programmed Intermittent Bolus (PIB) units (Smiths Medical Japan Ltd., Tokyo, Japan, CADD), the CADD®-Solis with PIB is a patient-controlled analgesia device. The set flow rate of the CADD®-Solis was an intermittent bolus of 15 mL levobupivacaine 0.1% every 6 h for 3 days. After the catheterwas inserted, the patientwas extubatedwithout any problems. No additional analgesiawas administered during the long postoperative period. Case 2 was that of a 55-year-old man (175 cm, 63 kg) with severe renal dysfunction who underwent a sigmoidectomy. To provide good perioperative pain management, we performed a bilateral anterior subcostal QL block prior to general anesthesia with the patient in the prone position. We performed the QL block before a general anesthesia

Incidence of lower-extremity muscle weakness after quadratus lumborum block

[1] Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesthesiol Clin Pharmacol 2013;29:550–2. [2] Ueshima H, Otake H, Lin JA. Ultrasound-guided quadratus lumborum block: an updated review of anatomy and techniques. Biomed Res Int 2017;2017:2752876. [3] Wikner M. Unexpected motor weakness following quadratus lumborum block for gynaecological laparoscopy. Anaesthesia 2017;72:230–2.

Optimal site of administration of the PECS 1 block

• PECS 1 block injected local anesthetic into the space between the PMM and the PmM at third ribs.

A successful case of subcutaneous implantable cardioverter-defibrillator implantation performed under the transversus thoracic muscle plane block ☆ ☆☆ ★

First introduced to clinical practice in 1980 [1], an implantable cardioverter-defibrillator (ICD) improves survival in patients at high risk for sudden cardiac death [2]. In recent years, a subcutaneous ICD (S-ICD; Cameron Health/Boston Scientific) represents an exciting development in ICD technology [3] (Fig. 1). Its primary advantage of negating the risks associated with transvenous systems makes it an alluring alternative to the conventional ICD, particularly in patients who are exposed to the risks of chronic intravascular lead complications. This time, we reported a successful case of S-ICD implantation performed under the combination transversus thoracic muscle plane (TTP) block and thoracic paravertebral nerve block (TPVB) without a general anesthesia. A 60-year-old man on home oxygen therapy for chronic pulmonary hypertension was scheduled for S-ICD implantation. Considering the early ambulation and postoperative complications, we selected the combination TTP block and TPVB without a general anesthesia. After the patient entered a hybrid operating room, the ultrasound-guided TPVB injection was firstly performed in the following manner: 20 mL of 0.375% levobupivacaine at T5 level on the left side with 20-gauge Touhys needle in lateral position. Subsequently, the ultrasound-guided TTP block injection was performed: 20 mL on left TTP between the third and fourth ribs connecting at the sterum [4,5]. Fifteen minutes after applying these blocks, the S-ICD implantation was performed

Comparison of spread of transversus thoracic plane block by sagittal and transverse approach in a clinical setting

An ultrasound-guided transversus thoracic plane (TTP) block, where local anesthetic is injected between the fourth and fifth ribs next to the sternum, has been reported to provide effective analgesia for breast cancer surgery and cardiac surgeries [1,2]. To provide good perioperative pain management, a wider spread of local anesthetic is important. Previously, we investigated the spread of the anesthetic on the TTP block, using ten Thiels embalmed human cadavers [3]. However, no study has investigated the difference in local anesthetic spread between the sagittal and transverse approaches of the TTP block in a clinical setting. The present study investigated this approach-based difference. The study was approved by the Showa University Hospital Institutional Review Board (approval number 2286), and was registered at the University Hospital Medical Information Network (UMIN ID number UMIN 000028206). From April 2015 to March 2017, patients who were

Clinical experiences of the continuous thoracolumbar interfascial plane (TLIP) block

An ultrasound-guided thoracolumbar interfascial plane (TLIP) block is reported as postoperative pain for lumbar vertebra surgery [1,2]. However, TLIP block cannot relieve longterm pain because the reported TLIP block can perform only single injection. This time, we report 2 cases that performed continuous TLIP block for lumbar vertebra surgeries. Case 1 was a 51-year-old woman who underwent lumbar laminoplasty at L3-4. She has had acetaminophen drug allergy and nonsteroidal anti-inflammatory drug allergy. Considering the efficacy of the postoperative analgesia, we selected continuous TLIP block as a postoperative pain. After the patient entered the operating room, she was anesthetizedwith general anesthesia. The general anesthesia was performed using total intravenous anesthesia (propofol, remifentanil, and rocuronium). Subsequently, the lumbar laminoplasty at L3-4 was performed. After the operation was finished, we performed continuous bilateral TLIP block. At first, 0.2% levobupivacaine 40mL in total (20mL injected into each side) was injected into the fascial plane between the multifidus and longissimus muscles on the back side of bilateral transverse processes at approximately the level of L3 using a low-frequency convex probe (Fig. 1), and each catheter on the bilateral side was inserted in the bilateral space. The bilateral catheter was attached to 2 CADD-Solis PIBs (CADD; Smiths Medical Japan Ltd, Tokyo), which is a patient-controlled analgesia device. The set flow rate of CADD was intermittent bolus of 12 mL in total (6 mL injected into each side) levobupivacaine 0.1% every hour and 3 mL levobupivacaine 0.1% lock out time: 30 minutes. After the catheter was inserted, she was extubated without any problems. The pinprick test at wake was from lumbar first to lumbar fourth. After 2 days, the pinprick test also was from lumbar first to lumbar fourth. There were no patient-controlled analgesia boluses and additional analgesia for postoperative pain relief in the perioperative period. Case

The Greater Tokyo Shock

Depopulation is a phenomenon that is steadily but quietly eroding Japanese society, even in the greater Tokyo metropolitan area. Decline at the outer edges is already underway in earnest in places such as Chiba and Kanagawa Prefectures, but a fall in dynamism and a weakening of the centripetal pull of the large cities is noticeable even in central commuter areas.

Transapical transcatheter aortic valve implantation performed with an erector spinae plane block

Pain management during transapical transcatheter aortic valve implantation (TA-TAVI) is an important factor that can influence early rising. However, effective pain management for TA-TAVI has not been clearly described [1,2]. An erector spinae plane (ESP) block is considered an effective perioperative pain management strategy for a wide variety of surgeries between the thoracic and lumbar regions [3,4]. Here, we report two cases where the ESP block was used successfully for perioperative pain management during TA-TAVI procedure. Case 1 was an 86-year-old woman (149 cm, 48.5 kg), who had undergone total gastrectomy 20 years ago, and an artificial renal replacement 5 years ago (because of severe renal dysfunction). For perioperative pain management, we scheduled an ESP block prior to general anesthesia. Monitors were connected to the patient after she was brought in to the operating room. Ultrasound-guided ESP block was performed using a highfrequency linear probe to inject 20mL of 0.25% levobupivacaine into the deep plane of the erector spinae muscle, at the level of T2/T3. Twenty minutes later, the analgesic effect from C5 to T7 was confirmed by performing the pinprick test. General anesthesia was induced subsequently. No remarkable events occurred during the operative period. The postoperative course was also uneventful. No additional analgesic was administered in the perioperative period for postoperative pain relief. Case 2 was a 90-year-old woman (140 cm, 38.5 kg) who had undergone an artificial renal replacement 30 years ago (because of severe renal dysfunction). Considering the efficacy of perioperative analgesia, the ESP block was selected for postoperative pain management. The dosage of the block was the same as that in Case 1. The postoperative course was uneventful, with no additional analgesic administered (in the perioperative period) for postoperative pain relief. These cases suggest that the ESP block is an effective perioperative pain management strategy for TA-TAVI. The consents for publication were gained.