Ultrasound-Guided Continuous Thoracic Paravertebral Block for Outpatient Acute Pain Management of...
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January 2013 • Volume 116 • Number 1 www.anesthesia-analgesia.org 255 C ontinuous thoracic paravertebral block for analgesia in patients with rib fractures has been reported. 1–4 More recently, ultrasound-guided thoracic paraver- tebral block has been suggested for greater precision over surface landmarks. 5,6 In our report, we discuss the use of continuous thoracic paravertebral block for analgesia to facilitate hospital discharge in a patient with multilevel uni- lateral rib fractures. We also describe the outpatient man- agement of the paravertebral catheter and the usefulness of ultrasound to determine the optimal level of catheter insertion. CASE DESCRIPTION Informed written consent for the continuous thoracic paravertebral block procedure and permission for publication of this report were obtained from the patient. A 61-year-old man (75 kg, 183 cm) was admitted to our medical center with multiple unilateral rib fractures (T3–T8) sustained during a bicycle accident. The patient’s medical history was unremarkable. His chest radiograph also revealed a fracture of his left clavicle and mild left apical pneumothorax. In-hospital care consisted of observation and pain management. Because IV morphine induced nausea and vomiting, pain management relied mainly on periodical IV ketorolac tromethamine (30 mg every 6 hours) and oral hydrocodone/acetaminophen (5 mg/500 mg) as required. Despite multimodal pain therapy, the patient experienced 5/10 pain at rest and 7/10 pain with activity in his left back (visual analog scale [VAS]: 0, no pain; 10, worst pain imagined), and his ability to breathe and cough effectively was substantially impaired. The regional anesthesia team was consulted to manage the patient’s acute pain and to improve respiratory function. On examination, the patient was hemodynamically stable; his O 2 saturation was 90% to 93% on 2 to 3 L/min O 2 via nasal cannula. His left lateral thoracic wall moved inward with inspiration (flail). A decision was made to per- form a continuous thoracic paravertebral block for pain management. No hematoma or subcutaneous emphysema was noted in the proposed site of needle/catheter insertion. In a right lateral decubitus position, a 13-MHz high-fre- quency linear transducer (GE Logic e, 12L; GE Healthcare, Waukesha, WI) confirmed the levels of the fractured ribs (T3–T8; Fig. 1). The transducer was placed transversely oblique in line with the rib. The most cephalad (T3) and most caudad (T8) fractured ribs were identified first. The fifth left rib fracture was then identified in the middle, and the rib was then traced back medially. An 18-gauge Tuohy needle was inserted in a lateral-to-medial direc- tion until the needle tip entered the paravertebral space (Fig. 2). Seven milliliters of 0.5% ropivacaine was injected into the paravertebral space while observing the pleura being moved downward. A 20-gauge catheter was advanced 3 cm beyond the needle tip. After negative aspiration, 3 mL of 0.5% ropivacaine was injected through the catheter while observing the displacement of the pleura, followed by an additional 10 mL of 0.5% ropivacaine to initiate analgesia. Five minutes later, the patient was able to breathe deeply and cough effectively; his oxygen saturation improved to 95% without supplemental oxygen; the VAS score with deep breaths decreased to 2/10. The catheter was then con- nected to a portable infusion pump (INFUSOR System with Patient Control Module; Baxter, Deerfield, IL), and an infu- sion of 0.2% ropivacaine was initiated (basal rate of 5 mL/h; Patient Control Module fill time 30 minutes and bolus vol- ume 5 mL). The following morning, the patient was much more comfortable (VAS, 0–4/10), stable, free of IV opioids, and able to ambulate, breathe, and cough normally. As a result, he was discharged home by the surgical team. The patient was seen at the hospital 24 hours after the discharge. Because of his 6/10 VAS score during the visit, an additional bolus of 15 mL 0.5% ropivacaine was injected through the catheter, and the patient was sent home after an observation period of 1 hour. After 60 hours of continuous infusion with ropivacaine 0.2% at home, the patient’s family removed Ultrasound-Guided Continuous Thoracic Paravertebral Block for Outpatient Acute Pain Management of Multilevel Unilateral Rib Fractures Hiroaki Murata, MD,* Emine Aysu Salviz, MD,* Stephanie Chen, MD,* Catherine Vandepitte, MD,*† and Admir Hadzic, MD, PhD* Copyright © 2012 International Anesthesia Research Society DOI: 10.1213/ANE.0b013e31826f5e25 From the *Department of Anesthesiology, Columbia University, St Luke’s Roosevelt Hospital, New York, New York;and ‡Department of Anesthesiol- ogy, Catholic University of Leuven, Leuven, Belgium. Accepted for publication July 25, 2012. HM is currently with the Department of Anesthesiology, Nagasaki Univer- sity, Nagasaki, Japan. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Admir Hadzic, MD, PhD, Department of Anes- thesiology, Columbia University, St Luke’s Roosevelt Hospital, 1111 Amster- dam Avenue, New York, NY 10025. Address e-mail to [email protected]. A 61-year-old man with multiple unilateral rib fractures (T3–T8) gained the ability to breathe deeply and to ambulate after ultrasound-guided continuous thoracic paravertebral block and was discharged home after being observed for 15 hours after the block. The ultrasound guidance was helpful in determining the site of rib fractures and the optimal level for catheter placement. This report also discusses the management of analgesia using continuous paravertebral block in an outpatient with trauma. (Anesth Analg 2013;116:255–7) E CASE REPORT
Transcript of Ultrasound-Guided Continuous Thoracic Paravertebral Block for Outpatient Acute Pain Management of...
January 2013 • Volume 116 • Number 1 www.anesthesia-analgesia.org 255
Continuous thoracic paravertebral block for analgesia in patients with rib fractures has been reported.1–4 More recently, ultrasound-guided thoracic paraver-
tebral block has been suggested for greater precision over surface landmarks.5,6 In our report, we discuss the use of continuous thoracic paravertebral block for analgesia to facilitate hospital discharge in a patient with multilevel uni-lateral rib fractures. We also describe the outpatient man-agement of the paravertebral catheter and the usefulness of ultrasound to determine the optimal level of catheter insertion.
CASE DESCRIPTIONInformed written consent for the continuous thoracic paravertebral block procedure and permission for publication of this report were obtained from the patient. A 61-year-old man (75 kg, 183 cm) was admitted to our medical center with multiple unilateral rib fractures (T3–T8) sustained during a bicycle accident. The patient’s medical history was unremarkable. His chest radiograph also revealed a fracture of his left clavicle and mild left apical pneumothorax. In-hospital care consisted of observation and pain management. Because IV morphine induced nausea and vomiting, pain management relied mainly on periodical IV ketorolac tromethamine (30 mg every 6 hours) and oral hydrocodone/acetaminophen (5 mg/500 mg) as required. Despite multimodal pain therapy, the patient experienced 5/10 pain at rest and 7/10 pain with activity in his left back (visual analog scale [VAS]: 0, no pain; 10, worst pain imagined), and his ability to breathe and cough effectively was substantially impaired. The regional
anesthesia team was consulted to manage the patient’s acute pain and to improve respiratory function.
On examination, the patient was hemodynamically stable; his O2 saturation was 90% to 93% on 2 to 3 L/min O2 via nasal cannula. His left lateral thoracic wall moved inward with inspiration (flail). A decision was made to per-form a continuous thoracic paravertebral block for pain management. No hematoma or subcutaneous emphysema was noted in the proposed site of needle/catheter insertion. In a right lateral decubitus position, a 13-MHz high-fre-quency linear transducer (GE Logic e, 12L; GE Healthcare, Waukesha, WI) confirmed the levels of the fractured ribs (T3–T8; Fig. 1). The transducer was placed transversely oblique in line with the rib. The most cephalad (T3) and most caudad (T8) fractured ribs were identified first. The fifth left rib fracture was then identified in the middle, and the rib was then traced back medially. An 18-gauge Tuohy needle was inserted in a lateral-to-medial direc-tion until the needle tip entered the paravertebral space (Fig. 2). Seven milliliters of 0.5% ropivacaine was injected into the paravertebral space while observing the pleura being moved downward. A 20-gauge catheter was advanced 3 cm beyond the needle tip. After negative aspiration, 3 mL of 0.5% ropivacaine was injected through the catheter while observing the displacement of the pleura, followed by an additional 10 mL of 0.5% ropivacaine to initiate analgesia. Five minutes later, the patient was able to breathe deeply and cough effectively; his oxygen saturation improved to 95% without supplemental oxygen; the VAS score with deep breaths decreased to 2/10. The catheter was then con-nected to a portable infusion pump (INFUSOR System with Patient Control Module; Baxter, Deerfield, IL), and an infu-sion of 0.2% ropivacaine was initiated (basal rate of 5 mL/h; Patient Control Module fill time 30 minutes and bolus vol-ume 5 mL). The following morning, the patient was much more comfortable (VAS, 0–4/10), stable, free of IV opioids, and able to ambulate, breathe, and cough normally. As a result, he was discharged home by the surgical team. The patient was seen at the hospital 24 hours after the discharge. Because of his 6/10 VAS score during the visit, an additional bolus of 15 mL 0.5% ropivacaine was injected through the catheter, and the patient was sent home after an observation period of 1 hour. After 60 hours of continuous infusion with ropivacaine 0.2% at home, the patient’s family removed
Ultrasound-Guided Continuous Thoracic Paravertebral Block for Outpatient Acute Pain Management of Multilevel Unilateral Rib FracturesHiroaki Murata, MD,* Emine Aysu Salviz, MD,* Stephanie Chen, MD,* Catherine Vandepitte, MD,*† and Admir Hadzic, MD, PhD*
Copyright © 2012 International Anesthesia Research SocietyDOI: 10.1213/ANE.0b013e31826f5e25
From the *Department of Anesthesiology, Columbia University, St Luke’s Roosevelt Hospital, New York, New York;and ‡Department of Anesthesiol-ogy, Catholic University of Leuven, Leuven, Belgium.
Accepted for publication July 25, 2012.
HM is currently with the Department of Anesthesiology, Nagasaki Univer-sity, Nagasaki, Japan.
The authors declare no conflicts of interest.
Reprints will not be available from the authors.
Address correspondence to Admir Hadzic, MD, PhD, Department of Anes-thesiology, Columbia University, St Luke’s Roosevelt Hospital, 1111 Amster-dam Avenue, New York, NY 10025. Address e-mail to [email protected].
A 61-year-old man with multiple unilateral rib fractures (T3–T8) gained the ability to breathe deeply and to ambulate after ultrasound-guided continuous thoracic paravertebral block and was discharged home after being observed for 15 hours after the block. The ultrasound guidance was helpful in determining the site of rib fractures and the optimal level for catheter placement. This report also discusses the management of analgesia using continuous paravertebral block in an outpatient with trauma. (Anesth Analg 2013;116:255–7)
E CASE REPORT
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E CASE REPORT
the catheter following the instructions that were provided at discharge. The residual chest and clavicle pain was well controlled by oral hydrocodone/acetaminophen (5 mg/500 mg) every 4 hours as required; the patient consumed 2 to 4 tablets daily.
DISCUSSIONContinuous thoracic paravertebral block is reportedly an effective method of providing continuous pain relief in patients with multiple rib fractures.1–3,7 Compared with most commonly used analgesic regimens consisting of opi-oid therapy, thoracic paravertebral block is a more potent, site-specific analgesia modality without the side effects of
opioid therapy.3 Thoracic paravertebral block can also result in sustained improvement in respiratory mechanics and oxygenation.2
Ultrasound guidance offers several potential advantages over landmark-based techniques. The visualization of the needle and the pleura during the procedure may decrease the risk of pleural puncture and confirm entry of the needle tip into the paravertebral space. In addition, the confirmation of local anesthetic spread in the paravertebral space can be documented by observing displacement of the pleura. Although the chest radiograph was adequate for diagnosis of the rib fractures, the use of ultrasound to trace the fractured ribs back to the relevant paravertebral space helped to objectively determine the optimal level for the catheter placement (T5). Ultrasound detection of possible injury within the paravertebral space by the trauma that caused rib fractures or pneumothorax may also be helpful to guide the indication of thoracic paravertebral block or help reduce the risk of complications.8
The ideal infusion rate for thoracic paravertebral block in patients with multiple rib fractures has not been deter-mined; it reportedly ranges from 0.1 to 0.2 mL/kg/h.1,2 Considering outpatient management, we selected a lower infusion rate. However, continuous infusion of ropi-vacaine at 5 mL/h (0.067 mL/kg/h) was insufficient in our patient; an additional bolus of local anesthetic was needed for adequate analgesia. This suggests that larger volumes of local anesthetic solution may be necessary for analgesia in patients with multilevel unilateral rib fractures.7,9
In conclusion, we report a successful use of ultrasound-guided continuous thoracic paravertebral block to facilitate hospital discharge and manage pain in an outpatient with multilevel unilateral rib fractures. Ultrasound guidance was also helpful in determining the site of rib fractures and the optimal level for catheter placement. More data from pro-spective trials are necessary to recommend management protocols for similar clinical scenarios. E
DISCLOSURE
Name: Hiroaki Murata, MD.Contribution: This author helped analyze the data and write the manuscript.Attestation: Hiroaki Murata approved the final manuscript.Name: Emine Aysu Salviz, MD.Contribution: This author helped analyze the data and write the manuscript.Attestation: Emine Aysu Salviz approved the final manuscript.Name: Stephanie Chen, MD.Contribution: This author helped analyze the data and fol-low-up with the patients.Attestation: Stephanie Chen approved the final manuscript.Name: Catherine Vandepitte, MD.Contribution: This author helped write the manuscript.Attestation: Catherine Vandepitte approved the final manuscript.Name: Admir Hadzic, MD, PhD.Contribution: This author helped write the manuscript and perform Paravertebral block.Attestation: Admir Hadzic approved the final manuscript.This manuscript was handled by: Terese T. Horlocker, MD.
Figure 1. Ultrasound image of a fractured rib on the lateral aspect of the chest. Rib fractures on the 6 consecutive left ribs were con-firmed by cephalad and caudal sliding of the probe. Arrow indicates the fracture.
Figure 2. Ultrasound image of needle tip placement and local anes-thetic (arrow) spread into the thoracic paravertebral space. Arrowhead indicates the needle shaft; TP, transverse process; PL, pleura; EIM, external intercostal muscle.
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Ultrasound-Guided Continuous Thoracic Paravertebral Block
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Analgesic Properties of the Novel Amino Acid, Isovaline: Erratum
In the April 2010 issue of Anesthesia & Analgesia, in the Pain Mechanisms report by MacLeod et al., “An-algesic Properties of the Novel Amino Acid, Isovaline” (Anesth Analg 2010; 110:1206-14), there was an error in Figure 2B. Figure 2B had an incorrect point depicting that isovaline (log 1.7 mg/kg) produced a 100% mean reduction in formalin-induced licking during phase 1. The corrected point (8% mean maxi-mum reduction) is presented here. The authors apologize for this error which was made during data transcription in the last stages of submitting the figures. The error does not change the text statements of an unclear dose-response relationship or the conclusions of the article in any way.
Reference:
1. MacLeod BA, Wang JTC, Chung CCW, Ries CRR, Schwartz SKW, Puil E. Analgesic properties of the novel amino acid, Isovaline. Anesth Analg 2010;110:1206–14
DOI: 10.1213/ANE.0b013e3182804801
