Correspondence Address:
Dr. Ashutosh Kaushal
Department of Anesthesia, SGPGIMS, Lucknow - 226 014, Uttar Pradesh
India

Full Text

Sir,

Kvalheim and Reistad conceptualized interpleural analgesia in 1984 [1] which involves the injection of local anesthetics in between the visceral and parietal pleura to provide ipsilateral blockade of multiple somatic dermatomes. It provides reliable and safe analgesia following surgeries such as cholecystectomy, thoracotomy, renal, and breast surgeries. Non-surgical indications include multiple rib fractures, herpes zoster, thoracic, and abdominal surgeries. [2] The classical technique involves using a Tuohy's needle, which is inserted about 10 cm lateral to the posterior midline in sixth or seventh intercostal space and advanced until it rests on the cephalad edge of the rib below the intercostal space to be entered. A glass syringe filled with saline or air is then attached to the needle, and the whole assembly advanced slowly over the superior edge of the rib. As the tip of the needle enters the parietal pleura, the solution in the syringe is drawn into the chest cavity due to negative intrathoracic pressure. The assembly is disconnected and a catheter is inserted approximately 5-8 cm into the interpleural space and secured on the chest wall. Insertion of the catheter is a critical step as during this time air entrainment can cause pneumothorax when the syringe is detached from the needle for catheter insertion due to the negative intrapleural pressure, which can have catastrophic consequences.

To minimize this complication, we propose to use a Raulerson syringe. This syringe is specially designed for insertion of guidewire or catheter. It has a centrally placed hollow channel throughout the length of the plunger with valve. The valve prevents entry of air or spillage of blood during insertion of guidewire or catheter. Instead of a conventional syringe, a sterile Raulerson syringe filled with saline can be attached to the Tuohy's needle and this assembly can be used to locate the intrapleural space using the classical maneuver [Figure 1]a and b. When the space is localized (evidenced by drawing of the saline due to negative intrathoracic pressure) the catheter can be advanced inside the interpleural space directly through it ameliorating the need for disconnecting the syringe and abolishing the chances of development of pneumothorax. After insertion of the catheter, the Raulerson syringe, and the Tuohy needle assembly [Figure 1]b can be withdrawn gradually over the catheter, and the catheter can be fixed on the chest wall.{Figure 1}

Use of single shot interpleural injections or smaller gauge Touhy's needle (19-20 Gauge), [3] are suggested means to minimize the volume of air trapped during the procedure. However, single shot techniques restrict the option of top up doses to prolong analgesia. Use of smaller gauge Tuohy needles makes threading of the catheter difficult and injection through these small caliber catheters may require greater pressure. Another technique of using a saline-filled syringe with the removal of the plunger has been described, but it is cumbersome. [4] Thus, Raulerson syringe provides a safe option for placement of an interpleural catheter avoiding the requirement of syringe disconnection, air entrainment, and subsequent pneumothorax. Additional advantages include eliminating the chances of needle displacement during disconnection of the assembly for catheter passage and maintenance of sterility.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References