An anaesthetic simulator program that runs on an IBM personal computer system has been developed. The program allows an operator to observe the uptake and distribution of the volatile anaesthetic agent halothane by a standard 75kg patient. The "patient's" breathing is assisted by a ventilator and the anaesthetic gas is supplied through a simulated circle breathing circuit. The most important component of a simulator is a mathematical model of the system being simulated. In this case a model of the uptake and distribution of the anaesthetic agent halothane by the human cardiovascular and respiratory systems was required. Such a model was developed by combining features of several existing non-linear multi-compartmental models and adapting the equations to allow them to be implemented on a digital computer. The simulator software that was developed allows an operator to adjust physical parameters such as fresh gas flow rate, halothane concentration, and breathing parameters from the keyboard of an IBM PC computer and observe the way various model parameters respond on a graphics screen. The speed of the simulation is adjustable. i.e., the state of the model can be repetitively calculated and displayed at 1, 10, or 60 second intervals. Model parameters can be displayed in bar graph or line-graph form and may also be dumped to a text file for use by other plotting programs. The software package developed should provide a useful teaching aid to understand the distribution of patient.

Thoracic paravertebral block (TPVB) consists of an injection of local anaesthetic alongside the thoracic vertebra close to where the spinal nerves emerge from the intervertebral foramen. Clinically TPVB can be accomplished either as a single-injection or as a multiple-injection. It can also be used as a continuous paravertebral infusion through an indwelling catheter for continuous pain relief. However compared to an epidural block, TPVB is less well understood and not commonly used for anaesthesia and or analgesia in anaesthetic practice. I hypothesized that TPVB is effective for producing unilateral segmental thoracic anaesthesia and managing pain of unilateral origin from the thorax. / The objective of this thesis was to develop the technique of TPVB so that it becomes a useful technique for anaesthesia and pain management. So to test my hypothesis a series of clinical studies were performed on 416 patients (396 adults and 20 young infants), presenting for anaesthesia and or acute pain management, to evaluate various aspects of TPVB, namely; clinical application, anatomy of the thoracic paravertebral space, technique and safety, and pharmacology of local anaesthetic after TPVB. Also included are 9 published case reports and letters-to-editor (Appendix 1-9) based on my research that have provided new insights into the mechanism and applications of TPVB. The following section summarizes my research... / Karmakar, Manoj Kumar. / Thesis (M.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 270-285). / Appendix includes Chinese. / ABSTRACT --- p.v / PREFACE --- p.xxvii / STATEMENT OF WORK --- p.xxviii / ACKNOWLEDGEMENTS --- p.xxix / PUBLICATIONS AND PRESENTATIONS --- p.xxxii / LIST OF ABBREVIATIONS --- p.xxxviii / LIST OF TABLES --- p.xli / LIST OF FIGURES --- p.xliii / Chapter Part 1. --- Introduction --- p.1 / Chapter Chapter 1. --- Objective and Plan of Research --- p.2 / Chapter Chapter 2. --- Thoracic Paravertebral Block A Review of the Literature. --- p.7 / Chapter 2.1. --- Introduction --- p.7 / Chapter 2.2. --- History --- p.7 / Chapter 2.3. --- Anatomy: --- p.9 / Chapter 2.4. --- Techniques --- p.17 / Chapter 2.4.1. --- Anatomical Landmark Based Techniques --- p.20 / Chapter 2.4.1.1. --- Loss-of-resistance Technique --- p.20 / Chapter 2.4.1.2. --- Advancing the Block Needle by a pre-determined Distance --- p.23 / Chapter 2.4.1.3. --- Other Landmark Based Techniques --- p.24 / Chapter 2.4.2. --- Fluoroscopic Guidance or Injection of Radiopaque Contrast medium --- p.24 / Chapter 2.4.3. --- Peripheral Nerve Stimulation --- p.25 / Chapter 2.4.4. --- Pressure Measurement Technique --- p.26 / Chapter 2.5. --- Thoracic Paravertebral Catheter Placement --- p.27 / Chapter 2.6. --- Ultrasound Guided Thoracic Paravertebral Block --- p.32 / Chapter 2.6.1. --- Two Dimensional (2D) Sonoanatomy of the Thoracic Paravertebral Region --- p.32 / Chapter 2.6.1.1. --- Basic Considerations --- p.32 / Chapter 2.6.1.2. --- Transverse Scan of the Thoracic Paravertebral Region --- p.33 / Chapter 2.6.1.3. --- Sagittal Scan of the Thoracic Paravertebral Region --- p.42 / Chapter 2.6.2. --- Three Dimensional (3D) Sonoanatomy of the Thoracic Paravertebral Region --- p.46 / Chapter 2.6.3. --- Ultrasound Guided Thoracic Paravertebral Block - Techniques --- p.49 / Chapter 2.6.3.1. --- Transverse scan with short axis needle insertion (Technique 1) --- p.54 / Chapter 2.6.3.2. --- Paramedian Sagittal scan with in-plane needle insertion (Technique 2) --- p.56 / Chapter 2.6.3.3. --- Transverse scan with in-plane needle insertion or the Intercostal approach to the TPVS (Technique 3) --- p.58 / Chapter 2.7. --- Mechanism and Spread of Anaesthesia --- p.58 / Chapter 2.8. --- Indications --- p.65 / Chapter 2.9. --- Contraindications --- p.65 / Chapter 2.10. --- Drugs Used and Dosage --- p.68 / Chapter 2.11. --- Pharmacokinetic Considerations --- p.70 / Chapter 2.12. --- Failure Rate and Complications --- p.72 / Chapter 2.13. --- Clinical Applications of Thoracic Paravertebral Block --- p.76 / Chapter 2.13.1. --- Pain Relief after Thoracic Surgery --- p.76 / Chapter 2.13.2. --- Pain Relief after Multiple Fractured Ribs --- p.78 / Chapter 2.13.3. --- Anaesthesia and Analgesia for Breast Surgery --- p.80 / Chapter 2.13.4. --- Thoracic Paravertebral Block and Chronic Pain after Breast Cancer Surgery --- p.84 / Chapter 2.13.5. --- Thoracic Paravertebral Block and Cancer Recurrence after Breast Cancer Surgery --- p.85 / Chapter 2.13.6. --- Anaesthesia and Analgesia for Inguinal Herniorrhaphy --- p.87 / Chapter 2.13.7. --- Pain Relief after Cholecystectomy and Renal Surgery --- p.90 / Chapter 2.13.8. --- Anaesthesia and Analgesia for Liver and Biliary Tract Surgery --- p.91 / Chapter 2.13.9. --- Analgesia after Cardiac Surgery --- p.92 / Chapter 2.13.10. --- Thoracic Paravertebral Block and Chronic Pain Management --- p.94 / Chapter 2.13.11. --- Bilateral Thoracic Paravertebral Block --- p.94 / Chapter 2.13.12. --- Miscellaneous Applications --- p.95 / Chapter Part 2. --- Studies Evaluating the Efficacy of Thoracic Paravertebral Block in Adults. --- p.96 / Chapter Chapter 3. --- Prospective Randomized Evaluation of the Effects of Combining a Single-injection Thoracic Paravertebral Block with General Anesthesia in Patients Undergoing Modified Radical Mastectomy. --- p.97 / Chapter Chapter 4. --- Continuous Thoracic Paravertebral Infusion of Bupivacaine for Postthoracotomy Analgesia A Prospective, Randomized, Double Blind, Controlled Trial. --- p.120 / Chapter Chapter 5. --- Continuous Thoracic Paravertebral Infusion of Bupivacaine for Pain Management in Patients with Multiple Fractured Ribs. --- p.137 / Chapter Chapter 6. --- Thoracic Paravertebral Block and Its Effects on Chronic Pain and Health-related Quality of Life after Modified Radical Mastectomy. --- p.154 / Chapter Chapter 7. --- Right Thoracic Paravertebral Anaesthesia for Percutaneous Radiofrequency Ablation of Liver Tumours. --- p.186 / Chapter Part 3. --- Studies Evaluating The Efficacy Of Thoracic Paravertebral Block In Children. --- p.198 / Chapter Chapter 8. --- Continuous Extrapleural Paravertebral Infusion of Bupivacaine for Postthoracotomy Analgesia in Young Infants. --- p.199 / Chapter Part 4. --- Studies Evaluating The Anatomy Relevant For Thoracic Paravertebral Block. --- p.213 / Chapter Chapter 9. --- Thoracic Paravertebral Sonography - A Quantitative Evaluation of the Paramedian Sagittal Window for Visualizing the Anatomy Relevant for Thoracic Paravertebral Block. --- p.214 / Chapter Chapter 10. --- Volumetric 3D Ultrasound Imaging of the Anatomy Relevant for Thoracic Paravertebral Block. --- p.228 / Chapter Part 5. --- Pharmacokinetics of Ropivacaine after Thoracic Paravertebral Block. --- p.242 / Chapter Chapter 11. --- Arterial and Venous Pharmacokinetics of Ropivacaine With and Without Epinephrine after Thoracic Paravertebral Block. --- p.243 / Chapter Part 6. --- Summary and Conclusions --- p.266 / Chapter Chapter 12. --- Summary and Conclusions --- p.266 / Chapter Part 7. --- Bibliography --- p.270 / Chapter Part 8. --- Appendix --- p.296 / Chapter A. --- Published Case Reports and Letters-to-editor. --- p.297 / Chapter Appendix: 1.0. --- Variability of a Thoracic Paravertebral Block. Are we ignoring the endothoracic fascia? (Published Commentary) --- p.297 / Chapter Appendix: 2.0. --- Ipsilateral Thoraco-lumbar Anaesthesia and Paravertebral Spread after Low Thoracic Paravertebral Injection. (Published Case Report) --- p.301 / Chapter Appendix: 3.0. --- The Use of a Nerve Stimulator for Thoracic Paravertebral Block Reply. (Published Letter-to-editor) --- p.310 / Chapter Appendix: 4.0. --- Bilateral Continuous Paravertebral Block Used for Postoperative analgesia in an Infant having Bilateral Thoracotomy. (Published Case Report) --- p.312 / Chapter Appendix: 5.0. --- Thoracic Paravertebral Block: Radiological evidence of Contralateral Spread Anterior to the Vertebral Bodies. (Published Case Report) --- p.317 / Chapter Appendix: 6.0. --- Lymphatic Drainage of the Thoracic Paravertebral Space A Reply. (Published Letter-to-editor) --- p.325 / Chapter Appendix: 7.0. --- Thoracic Paravertebral Block for Management of Pain Associated with Multiple Fractured Ribs in Patients with Concomitant lumbar Spinal Trauma. (Published Case Report) --- p.328 / Chapter Appendix: 8.0. --- Right Thoracic Paravertebral Analgesia for Hepatectomy. (Published Case Report) --- p.340 / Chapter Appendix: 9.0. --- Resolution of ST-segment Depression after High Thoracic Paravertebral Block during General Anesthesia. (Published Case Report) --- p.348 / Chapter B. --- Medical Outcomes Study 36-Item Short-Form Questionnaire (SF-36) - Appendix 10. --- p.353 / Chapter C. --- Hospital Anxiety and Depression Scale - Appendix 11. --- p.362 / Chapter D. --- Postoperative Telephone Follow Up Questionnaire: Appendix 12. --- p.364