Paravertebral Block and Catheters

Review: Thoracic Paravertebral Block. Anesthesiology. Sept 2001.

Ultrasound-Guided Paravertebral Block Anaesthesia Tutorial of the Week. April 2018. Tutorial #376.

YouTube: PVB catheter technique

YouTube: LSORA U/S-guided PVB

YouTube: U/S-guided PVB by Block Jocks

YouTube: nerveblocks U/S-guided PVB

YouTube: thoracic PVB and anatomy

YouTube: Ottawa Hospital PVB

From SPPM Newsletter

Insertion of paravertebral block catheters intraoperatively to reduce incidence of block failure. Interact Cardiovasc Thorac Surg. 2012 May; 14(5): 648–649.

Continuous paravertebral block using a thoracoscopic catheter-insertion technique for postoperative pain after thoracotomy: a retrospective case-control study. Journal of Cardiothoracic Surgery volume 12, Article number: 5 (2017)

From The mid‐point transverse process to pleura (MTP) block: a new end‐point for thoracic paravertebral block. https://onlinelibrary.wiley.com/doi/abs/10.1111/anae.14004
Table 3. Drug and Dosage for Thoracic Paravertebral Block

A Systematic Review of Randomized Trials Evaluating Regional Techniques for Postthoracotomy Analgesia. Anesthesia & Analgesia:September 2008 – Volume 107 – Issue 3 – p 1026-1040

Thoracic surgery: PVB, SAPB, TEpi, ESP block, Precedex

Paravertebral Catheter Use for Postoperative Pain Control in Patients After Lung Transplant Surgery: A Prospective Observational Study.  JCVA February 2017. Volume 31, Issue 1, Pages 142–146.

To place the PV catheter at the T4-5 level, the authors used an in-plane transverse technique under ultrasound guidance, with the probe in a transverse orientation. After identifying the anatomic landmarks on ultrasound, a 17-gauge Tuohy needle was advanced in a lateral to medial direction, until the tip was beneath the transverse process. For all recipients in the study, the authors further confirmed correct PV catheter placement with real-time infusion of a local anesthetic (1-3 mL of 1.5% lidocaine with epinephrine 1:200,000); they were able to visualize on ultrasound the spread from the tip of the catheter.

Once it was confirmed that the tip remained in position, the PV catheter was secured with skin glue (Dermabond®, Ethicon, Inc.; Somerville, NJ). Next, at the PV catheter insertion site, the authors placed an occlusive dressing on a chlorhexidine-impregnated sponge (BioPatch®, Johnson & Johnson Wound Management, a division of Ethicon, Inc.; Somerville, NJ). The PV catheter was connected to an elastomeric pump (ON-Q®, Halyard Health, Alpharetta, GA), an infusion of 0.2% ropivacaine was started at a rate of 0.2 to 0.25 mL/kg/h; the maximum dose was 7 mL/h per side in bilateral lung transplant recipients and 14 mL/h in unilateral single-lung transplant recipients.

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From NYSORA


Ultrasound-Guided Serratus Anterior Plane Block Versus Thoracic Epidural Analgesia for Thoracotomy Pain. JCVA February 2017. Volume 31, Issue 1, Pages 152–158.

Under sterile conditions and while patients still were in the lateral position with the diseased side up, a linear ultrasound transducer (10-12 MHz) was placed in a sagittal plane over the midclavicular region of the thoracic cage. Then the ribs were counted down until the fifth rib was identified in the midaxillary line (Fig 1).18 The following muscles were identified overlying the fifth rib: the latissimus dorsi (superficial and posterior), teres major (superior), and serratus muscles (deep and inferior). The needle (a 22-gauge, 50-mm Touhy needle) was introduced in plane with respect to the ultrasound probe, targeting the plane superficial to the serratus anterior muscle (Fig 2). Under continuous ultrasound guidance, 30 mL of 0.25% levobupivacaine was injected, and then a catheter was threaded. A continuous infusion of 5 mL/hour of 0.125% levobupivacaine then was started through the catheter.

Figure-17-Nagdev-2017-ACEP-Now-Ultrasound-Guided-Serratus-Anterior-Plane-Block-Can-Help-Avoid-Opioid-Use-for-Patients-with-Rib-Fractures-
From http://painandpsa.org/rnb/


Erector Spinae Plane Block


Effect of Continuous Paravertebral Dexmedetomidine Administration on Intraoperative Anesthetic Drug Requirement and Post-Thoracotomy Pain Syndrome After Thoracotomy: A Randomized Controlled Trial. JCVA February 2017. Volume 31, Issue 1, Pages 159–165.

Adjuvants to prolong regional anesthesia

Erector Spinae Plane Block

After speaking to a colleague of mine regarding regional anesthesia for thoracotomy and mastectomy, I am reading up on Erector Spinae Plane (ESP) block.

 

Indications:

 

 

Other regional blocks

Continuous ESP block catheter (my current regimen and what I’m able to get at my institution):

  • Braun Periflex catheter through 17g epidural needle
  • Cranial-to-caudal approach @ T5 (mastectomy, vats, rib fractures)
  • 20ml 0.25% bupi + epi prior to catheter
  • Catheter 5cm in space
  • 5 ml 0.25% bupi + epi after catheter placed
  • Mix: 0.125% bupi + fentanyl @ 10 ml/hr
  • If PCEA available, bolus 15ml every 3 hours; continuous as mix above.

Paravertebral block basics and cancer recurrence #paravetebral #block #regional #ultrasound #anesthesia #cancer

From J Anaesthesiol Clin Pharmacol. 2011 Jan-Mar; 27(1): 5–11.
Why do paravertebral blocks?
Paravertebral blocks and decreased cancer recurrence
Paravertebral block techniques
From NYSORA

But wait… what about the potential side effects/adverse events from a paravertebral block?

Why not do a TIVA with propofol and dexmetetomedine and local anesthesia via surgeon?  Where’s that study to compare?

** Update **  July 20, 2016 –> What about the PEC 1&2 Blocks as well as Serratus block?

Prolonging blockade with adjuvants: