The application of paravertebral block for open cholecystectomy in a high-risk patient with an implantable cardioverter-defibrillator: a case report.

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.