key: cord-0939202-mbcbo4ml authors: Gong, Wen-Yi; Zhang, Jing-Yu; Wang, Ai-Zhong; Fan, Kun title: The combination of paravertebral block and cervical vagus nerve block applied alone for anaesthesia of open appendectomy during COVID-19 date: 2022-04-26 journal: Anaesth Crit Care Pain Med DOI: 10.1016/j.accpm.2022.101091 sha: 5cb2a9404d3d5bcf9c0589405d84af09bcb168c2 doc_id: 939202 cord_uid: mbcbo4ml nan The combination of paravertebral block and cervical vagus nerve block applied alone for anaesthesia of open appendectomy during COVID-19 Dear editor, Nowadays, laparoscopic appendectomy under general anaesthesia is commonly usedfor appendicitis [1] . However, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak brings challenge to using the common surgical procedure. Asymptomatic infection and false negative swab testing represent factors of potential risk of SARS-COV-2 transmission during laparoscopic appendectomy under general anaesthesia [2, 3] . Hence, open appendectomy (OA) under spinal anaesthesia fin patients with acute appendicitis and failed conservative management during COVID-19 has been suggested [1] . Neuraxial anaesthesia is the most common technique for regional anaesthesia for OA. However, some patients experience pain and require administration of rescue opioids or even use of general anaesthesia during surgery [1] . In addition, nausea and vomiting, hypotension, bradycardia, and even cardiac arrest for vagal hyperexcitability caused by stimulation of the appendix and peritoneum also increase the risk of neuraxial anaesthesia [4] . Anatomically, the skin, subcutaneous tissue and muscles involved in OA are innervated by spinal nerves from T10 to L2 [5] . The appendix, adjacent midgut and peritoneum are innervated by visceral nerves, including the sympathetic nerves originating from T6 to T12 and the vagus nerve [5] . Hence, we speculated that blockingthe somatic and visceral nerves simultaneously by using a combination of paravertebral block could be applied alone for anaesthesia of OA. We report the successful use of ultrasound-guided paravertebral block combined with vagus nerve block for anaesthesia in 22 patients undergoing OA during the COVID-19 pandemic from the 1 st of May 2020 to the 31 st of October 2021. The study was approved by the local ethics committee and written informed consent for publication of this report was provided by the patients. Ultrasound-guided PVB was performed by administering 10 ml of 0.33% ropivacaineat each of the four paravertebral spaces of the affected side (T7, T9, T11 and L1) [6] . Right vagus nerve block was obtained with 3 ml of 1% lidocaine injected between the common carotid artery and the internal jugular vein at any level between C4 and C7 (Fig. 1) [7] . Immediately after vagus nerve block, the patient developed hoarseness. Thirty minutes after blockade, patients felt no sensation at the surgical area using pinprick testand the operation started. The patients did not complain of any pain and were restful and cooperative with stable vital signs during surgical procedures. No patient required any additional opioids or transition to general anaesthesia. The hoarseness disappeared 1.4-3.2 h after surgery. Thirty mg of ketorolac tromethamine was administered every 12 h after surgery, twice in total. The VAS score was < 3 in all patients during 24 h postoperatively and no nerve block-related complications occurred. The present technique is more targeted than spinal anaesthesia with a precise level of somatic and sympathetic blockade, which is not only beneficial to the control of somatic and visceral pain intraoperatively, but also associated with respiratory and circulatory stability. In addition, this technique also avoids the occurrence of the nausea and vomiting, hypotension, and even cardiac arrest by inhibition of vagal hyperexcitability. During the COVID-19 pandemic, the combined nerve block was used as an attractive option for OA anaesthesia to prevent the ovidance of cross-transmission during airway manipulation. In addition, this technique might be proposed for difficult patients, when general (refusal, allergies) or spinal anaesthesia (ankylosing spondylitis, spinal deformity, history of spinal surgery) is challenging. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Open Appendicectomy under Spinal Anesthesia-A Valuable Alternative during COVID-19 Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review Clipping of the appendix induced cardiac arrest during appendectomy under spinal anesthesia Gray's anatomy: The anatomical basis of clinical practice Thoracic Paravertebral Block (TPVB) in nonintubated open reduction and internal rib fixation Combined cervical vagus nerve and multilevel thoracic paravertebral blocks in the internal rib fixation and thoracoscopic exploration The authors declare no competing interests.