Župčić Miroslav, Tomulić Brusich Katarina, Nadarević Tin, Graf Župčić Sandra, Duzel Viktor, Redžepi Gzim
Miroslav Župčić, Department of Anesthesiology, Intensive Care and Pain Medicine, Clinical Hospital Center Rijeka, Krešimirova st. 42, 51000 Rijeka, Croatia,
Croat Med J. 2025 Jul 5;66(3):227-230.
We present a case of a 57-year-old male patient (American Society of Anesthesiologists status IV) undergoing open cholecystectomy under unilateral thoracic paravertebral block (TPVB) and sedation. The patient had severe heart failure, a reduced ejection fraction of approximately 16%, and an implanted subcutaneous implantable cardioverter-defibrillator. Using ultrasound, we identified the thoracic (Th) paravertebral spaces on the right side at four levels (from Th6 to Th9) and administered 3.5 mL of 0.5% levobupivacaine per level, for a total of 14 mL. Twenty minutes after TPVB application, we confirmed sensory blockade from the Th5 to Th10 dermatomes. Ten minutes into surgery, during liver capsule retraction, the patient experienced some pain (5/10 on the visual analogue scale, VAS). The pain was successfully treated with rescue analgesia of 10 µg of intravenous (IV) sufentanil and a sedation dose of 50 mg IV propofol. The surgery lasted 45 minutes and was completed uneventfully. For continued intraoperative sedation, we used 10 mg/h remimazolam, maintaining hemodynamic stability. Nine hours after surgery, the patient reported a VAS pain score of 5 and received 75 mg of IV diclofenac sodium, with no further analgesia required. The patient was discharged on postoperative day six. In conclusion, the application of TPVB combined with remimazolam sedation could present a feasible anesthetic and analgesic technique for open cholecystectomy in high-risk cardiac patients.
我们报告一例57岁男性患者（美国麻醉医师协会分级为IV级），在单侧胸椎旁神经阻滞（TPVB）和镇静下接受开腹胆囊切除术。该患者患有严重心力衰竭，射血分数约为16%，并植入了皮下植入式心脏复律除颤器。我们使用超声在右侧识别出四个节段（从T6到T9）的胸椎旁间隙，每个节段注射3.5 mL 0.5%左旋布比卡因，共14 mL。TPVB实施20分钟后，我们确认T5至T10皮节出现感觉阻滞。手术进行10分钟时，在牵拉肝包膜过程中，患者感到一些疼痛（视觉模拟评分法[VAS]为5/10）。通过静脉注射10 μg舒芬太尼进行补救镇痛和静脉注射50 mg丙泊酚镇静剂量成功缓解了疼痛。手术持续45分钟，顺利完成。为持续进行术中镇静，我们使用10 mg/h瑞马唑仑，维持血流动力学稳定。术后9小时，患者报告VAS疼痛评分为5分，接受了75 mg静脉注射双氯芬酸钠，无需进一步镇痛。患者于术后第六天出院。总之，TPVB联合瑞马唑仑镇静可为高危心脏患者的开腹胆囊切除术提供一种可行的麻醉和镇痛技术。
