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Abstract
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Background and Aims We present a successful use of ultrasound guided paravertebral block using ropivacaine as postoperative pain control in Myasthenia Gravis patient who underwent video-assisted thoracoscopic surgery (VATS) for thymectomy.
Methods A 57-year-old/F, ASA II, with Myasthenia Gravis (MG), controlled with Pyridostigmine and Prednisone, underwent VATS. Medical history includes hypertension controlled with Telmisartan + Amlodipine, treated pulmonary tuberculosis, and chronic hepatitis B infection. Preoperatively, she received Ondansetron 4mg, Dexamethasone 8mg, and Neostigmine 0.75mg IV. Anesthesia was induced with Midazolam, Fentanyl, Propofol, and Rocuronium with train-of-four (TOF) monitoring to guide dosing. Double-lumen tube (DTL) placement was confirmed with fiberoptic bronchoscopy. Sevoflurane was used to maintain anesthesia, with depth monitored by bispectral index (BIS). For postoperative pain, ultrasound guided single shot thoracic paravertebral block with 0.5% Ropivacaine 20 mL each at T3 and T8 was performed. Sugammadex was given and within 5 mins, patient’s TOF returns to baseline indicating a full reversal of residual neuromuscular blockade. Extubation then proceeded uneventful.
Results On postoperative days 1 and 2, pain score was 1/10 (NRS). She also received acetaminophen 1,000 mg IV every 8 hours for two days as part of multimodal analgesia, and received no oral or iv opioids. Course in the ward was unremarkable hence sent home post op day 4 with daily follow-up assessment via phone call revealing satisfactory pain control ranging from 2-3/10 (NRS).
Conclusions Thoracic paravertebral block can be employed for post-operative pain, a minimally invasive technique offering excellent analgesia that optimizes respiratory function, prevents exacerbation of muscle weakness, and hastens recovery following VATS.
Ultrasound image showing thoracic paravertebral space at the level of T3 to T4
Ultrasound image of local anesthetic (Ropivacaine 0.5% 20 mL) injection into thoracic paravertebral space. Depression of the medial aspect of the pleura is noted just beneath the needle