Giant tumor resection under ultrasound-guided nerve block in a patient with severe asthma:A case report

lNTRODUCTlON

General anesthesia is associated with a variety of complications, including respiratory depression, deep venous thrombosis, pulmonary embolism, postoperative hemorrhagic shock, pneumonia, and renal failure. Pulmonary complications represent a particular challenge in patients with existing pulmonary disease[1]. Regional anesthesia promotes postoperative recovery, and has been associated with reduced risk of postoperative complications[2]. Nerve block anesthesia could provide sufficient anesthesia if the surgery is confined to the area innervated by the target nerve, but has been limited by inaccuracy and local complications. Ultrasound guidance ensures accurate delivery of the anesthetic agent to the target area and improves the safety of nerve block anesthesia[3,4]. Brachial plexus block is primarily used in surgery of the upper limbs, whereas thoracic paravertebral block is used in thoracic surgery[5-7]. Here, we report combined use of brachial plexus block and thoracic paravertebral block to resect a giant lipoma (25, 15 and 5 cm in length, width and depth, respectively) that involved both the left shoulder and upper back in a patient with severe asthma.

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CASE PRESENTATlON

Chief complaints

A 70-year-old man (170 cm; 60 kg; body mass index 20.8 kg/m) presented with sharp, acupuncture-like intermittent pain for 7 d. The pain occurred at a frequency of five or six episodes per day, with each lasting for 1-2 min. The pain intensity was 3 on the visual analog scale (VAS). The patient disclosed a giant mass in the left shoulder and upper back. The mass had been growing at a slow pace for 10 years.

History of present illness

The patient had severe bronchial asthma for 8 years (3 attacks per day on average), and used salbutamol aerosol to control symptoms.

History of past illness

The patient had no other significant medical history.

Personal and family history

The surgery was completed with no incidents. The pain intensity remained 2-3 on the 10-point VAS scale during the first 8 h after surgery. Postoperative pathological examination revealed lipoma. The patient developed mild pulmonary infection on the third day after the operation, but recovered after empirical antibiotic treatment.

Physical examination

Body examination confirmed the giant mass (25, 15 and 5 cm in length, width and depth, respectively) that extended from the lateral side of the left scapula to the axillary midline, and from the fifth thoracic vertebra (T5) intercostal to the mid-medial section of the left upper arm. The mass was not tender.

Laboratory examinations

To prepare for surgery, a pulmonary function test was conducted. Forced expiratory volume in 1 second (FEV1) was 0.49 L (about 20% of the predicted value), and FEV1/forced vital capacity (FEV1/FVC) was 54% of predicted value. The preoperative erythrocyte sedimentation rate was 20 mm/h; the percentage of neutrophils was 74.4%. Partial oxygen pressure, oxygen saturation and partial carbon dioxide pressure were 78 mmHg, 94% and 44 mmHg, respectively.

Imaging examinations

Ultrasound examination as well as computed tomography report from a local hospital (images not available) suggested clear boundary to surrounding tissues.

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Glucocorticoid treatment (budesonide inhalation twice daily) was initiated to control asthma to a reasonable condition. General anesthesia in this patient was risky. Thoracic epidural block was considered but not adopted considering the risk of hypotension as well as the technical difficulty[8]. Since the tumor was confined to the area of the seventh cervical vertebra (C7) to T5 (Figure 1), we decided to use a combination of brachial plexus block and thoracic paravertebral block[6,8]. Since the tumor occupied a wide range of area innervated by C7-T5 (Figure 1), surgery was conducted under brachial plexus block (0.4% ropivacaine 15 mL) plus thoracic paravertebral block (third-fourth thoracic vertebra, T3-4, 0.4% ropivacaine 15 mL) under ultrasound guidance using a 10-MHz linear array probe (Figure 2). Local infiltration anesthesia included 1% lidocaine (3 mL) for the block as well as the incision site (Figure 1).

FlNAL DlAGNOSlS

Ultrasound-guided brachial plexus block in combination with thoracic paravertebral block is a viable alternative for patients with poor cardiopulmonary function undergoing shoulder, back and axillary surgery.

TREATMENT

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OUTCOME AND FOLLOW-UP

Family history was unremarkable.

DlSCUSSlON

In comparison to general anesthesia, nerve block anesthesia promotes postoperative recovery[14], and reduces the risk of pulmonary, circulatory and intestinal complications, especially for patients with preoperative cardiopulmonary problems. As such, combination of nerve block anesthesia could be appropriate in a much wider setting than in the index patient, for example, frail elderly patients with limited cardiopulmonary reserve.

CONCLUSlON

The final diagnosis was benign tumor of the shoulder and back.

Many types of brachial plexus block, including intermuscular sulcus block, supraclavicular brachial plexus block, infraclavicular brachial plexus block and axillary brachial plexus block, are available for surgery in the upper limbs depending on the specific location. Supraclavicular brachial block provides anesthesia from the distal end of the upper limb to the mid humerus, part of the area occupied by the tumor mass in the index patient. The incidence of pleural puncture and pneumothorax after paravertebral block is 1.1% and 0.5%, respectively. The incidence of pulmonary complications and hypotension, however, is lower than with epidural anesthesia. The incidence of permanent nerve injury is also lower after paravertebral block than epidural anesthesia[6,8]. Ultrasound-guided bronchial plexus block in combination with thoracic paravertebral block has been used for postoperative analgesia or auxiliary anesthesia in breast surgery[6,8,9]. The index patient had severe asthma. General anesthesia could induce asthma attack upon tracheal intubation due to high airway responsiveness[10,11]. In regional nerve block, the airway is not manipulated/stimulated, thus minimizing the risk asthma attack[11]. Previous studies have suggested, that in patients undergoing thoracotomy, paravertebral block is superior to thoracic epidural anesthesia[12]. In a recent case report, a giant tumor that involved both the chest wall and axillary envelope was resected under ultrasound-guided interscalene brachial plexus block and serratus anterior plane block[8]. Exact location and size of the tumor in the index case are different. In another case report, combination of block anesthesia was used a patient with tumor in the area innervated by both the brachial plexus and T1-5 intercostal nerves[13]. Such a combination of block anesthesia could in theory provide adequate anesthesia, but the possibility of incomplete block is high due to anatomical specificity[4]. In the index case, the patient required local infiltration anesthesia at the site of incision, suggesting that the nerve block was incomplete (Figure 1). Nonetheless, supraclavicular brachial plexus block plus T3-4 paravertebral block was the most appropriate combination based on the tumor location in our opinion.

The authors thank the index patient for agreeing to publish this report.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

Liu Q, Zhong Q and Zhou NN contributed equally to the work; all authors contributed to data analysis, drafting or revising the manuscript, approved the final version to be published, and agreed to be accountable for all aspects of the work.

Informed written consent was obtained from the patients for the publication of this report and any accompanying images.

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The authors declare that they have no conflict of interest.

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Qian Liu 0000-0003-2886-1331; Qing Zhong 0000-0003-1317-6411; Ni-Na Zhou 0000-0001-5781-1670; Ling Ye 0000-0002-7558-8940.

Chen YL

Κerr C

The beggar-man led her out by the hand, and she was obliged to walk away on foot with him. When they came to a large forest14 she asked, To whom does that beautiful forest belong? It belongs to King Thrushbeard;15 if you had taken him, it would have been yours. Ah, unhappy girl that I am,16 if I had but taken King Thrushbeard!

Chen YL