Paravertebral Catheters

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Have been doing a lot of PV blocks last couple months for thoracotomies. They have been working great however we don't have a set protocol in place yet at our institution. Some attendings like one solution, some like another. Some use ultrasound approach, some use blind technique. Thankfully almost all have abandoned multiple paravertebral bolus shots (I find these to be cumbersome, painful, and rarely give good relief). Most of our thoracic surgeons now request PV catheters for their patients.

Just curious, how are some you guys doing them out there?

Been using a lot of different approaches/solutions but find this to work pretty well:
1) US guided, in plane (lateral to medial needle approach) with direct visualization of needle tip and confirmation via pleura displacement. Prefer sitting position but sometimes due to pt pain, will do it in lateral decub.
2) Bolus: 20 cc 0.25% bupivicaine. Solution: 0.125% bupivicaine running PCPA 8 cc/hr with 4 cc q20min lockout (16 cc 1 hour max).

Curious what other out there are doing. I've never used opiates in the solution and I've never seen a lumbar paravertebral block.

Why not bolus 0.5%bupiv for single shot?

Blind technique. Large bolus (20-30 ml given incrementally over ~2 minutes) gets multilevel coverage. Set standard local only epidural pump at 8-10 ml per hour.
Lumbar easier than thoracic because no risk of pneumo. Existing chest tube ipsilaterally is a bonus for thoracic PV blocks. Pneumo is easy to get if you have little experience, or sometimes even if you have done many.
I have been very impressed with the level of coverage you can get. Had a patient that had a thoracotomy and an ex lap. Split the difference and did lower thoracic and, surprisingly, got good coverage at both locations (n=1 for that situation).

Gawd I want to start doing TPVB.

we do the same thing as the OP, same solution and everything, for one of our CT surgeons who hates thoracic epidurals, this guy also wants those cathaters placed post-op so we do them in the lateral position. They work great, we've doing a bunch as well. Haven't seen anyone do them blind yet.

Originally Posted by RussianJoo

we do the same thing as the OP, same solution and everything, for one of our CT surgeons who hates thoracic epidurals, this guy also wants those cathaters placed post-op so we do them in the lateral position. They work great, we've doing a bunch as well. Haven't seen anyone do them blind yet.

PA Lohnquist boluses himself then has the surgeon place the catheters under direct vision for chest cases. Seems like a sweet way to go.

Originally Posted by RxBoy

Have been doing a lot of PV blocks last couple months for thoracotomies. They have been working great however we don't have a set protocol in place yet at our institution. Some attendings like one solution, some like another. Some use ultrasound approach, some use blind technique. Thankfully almost all have abandoned multiple paravertebral bolus shots (I find these to be cumbersome, painful, and rarely give good relief). Most of our thoracic surgeons now request PV catheters for their patients.

Just curious, how are some you guys doing them out there?

Been using a lot of different approaches/solutions but find this to work pretty well:
1) US guided, in plane (lateral to medial needle approach) with direct visualization of needle tip and confirmation via pleura displacement. Prefer sitting position but sometimes due to pt pain, will do it in lateral decub.
2) Bolus: 20 cc 0.25% bupivicaine. Solution: 0.125% bupivicaine running PCPA 8 cc/hr with 4 cc q20min lockout (16 cc 1 hour max).

Curious what other out there are doing. I've never used opiates in the solution and I've never seen a lumbar paravertebral block.

Same technique as me. I bolus 25 mls of 0.5 percent Ropivacaine. I also start a Rop infusion of 0.2 percent at 10 ml/hr. I like the PCA bolus option of 4 mls with a 20 min lockout.

I prefer Rop over Bup but other than that we are in agreement. Your technique is the one most u/s gurus are using these days

Originally Posted by Oggg

Gawd I want to start doing TPVB.

Get a set of balls and do it. Why not just go to a conference or a day trip to DA U to watch one? It ain't rocket science and is technically easier after a few than a thoracic Epidural in many patients.

i do 2 boluses per side, usually 10 cc at T2 and T5 for mastectomy, i am a fan of PVB catheter for thoracotomy, simply because we see so much postop hypotension with the fluid restrictive practices. hasnt really caught on here, but i did a few postop last year, went smoothly. also sometimes for mid-CAB upon request.

Originally Posted by RussianJoo

we do the same thing as the OP, same solution and everything, for one of our CT surgeons who hates thoracic epidurals, this guy also wants those cathaters placed post-op so we do them in the lateral position. They work great, we've doing a bunch as well. Haven't seen anyone do them blind yet.

Blind is old school. Most didn't start placing Paravertebral blocks with u/s until around 2010. So, you are learning the cutting edge stuff doing them under u/s. I have put a catheter or 2 into the pleural space using the blind technique. U/S is superior especially on your thin, frail patients.

Originally Posted by BLADEMDA

Get a set of balls and do it. Why not just go to a conference or a day trip to DA U to watch one? It ain't rocket science and is technically easier after a few than a thoracic Epidural in many patients.

As for the "PCPA"... I found that the initial bolus usually gives a good level from T2 all the way to T10. But in the morning when we would do educational rounds on our epidural/peripheral catheter patients, the PV blocks would oftentimes regress to something like T3 to T6, while others continued to have a large spread. There is a large patient variance in TPVB spread probably due to anatomical differences and catheter location.

After we started incorporating patient controlled boluses, we found that the block would consistently cover T2 to T10 range. For those that didn't need the extra volume, they simply didn't push the button.

I would prefer ropivacaine as well. The literature swings both ways (better vs. no change). But in our institution it comes down to the Benjamens. Pharmacy prefers us to use the cheaper stuff.

For those that haven't done it yet, it makes a world of difference for the CT surgeons. They will love the minimal hemodynamic changes. The tough part is selling it. But once you do, they'll demand it.

Reg Anesth Pain Med. 2011 May-Jun;36(3):256-60.
Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery.

Pintaric TS, Potocnik I, Hadzic A, Stupnik T, Pintaric M, Jankovic VN.
Source

Department of Anesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia. tatjanas38@gmail.com

Abstract

BACKGROUND:

Epidural analgesia can result in perioperative hypotension in patients having thoracotomy. This randomized prospective study assessed the effects of epidural and paravertebral analgesia on hemodynamics during thoracotomy.
METHODS:

Thirty-two patients were randomized to receive either epidural analgesia (n = 16, 0.25% levobupivacaine and 30 μg/kg morphine) or paravertebral block (n = 16; 0.5% levobupivacaine and 30 μg/kg morphine). Oxygen delivery, stroke volume and systemic vascular resistance indices, heart rate, and mean arterial pressure measurements were performed before administration of local anesthetic, after induction of general anesthesia, institution of 1-lung ventilation, first skin incision, retractor placement, lung-inflation maneuver, and at last skin suture. The primary end point was the volume of the colloid infusion necessary to maintain oxygen delivery index of 500 mL/min per squared meter or higher. Postoperative analgesia was provided immediately after surgery by an infusion of 0.125% levobupivacaine and 20 μg/mL morphine in epidural/paravertebral infusion. Pain, rescue-analgesia consumption, arterial pressure, and heart rate were recorded at 6, 24, and 48 hrs after surgery. Administration of anesthesia and data collection were done by research staff blinded to the regional analgesia technique.
RESULTS:

The groups did not differ significantly in heart rate, mean arterial blood pressure, or systemic vascular resistance indices. However, to maintain the targeted oxygen delivery index, a greater volume of colloid infusion and phenylephrine were required, respectively, in the epidural than in the paravertebral group (554 ± 50 vs 196 ± 75 mL, P = 0.04; and 40 ± 10 vs 17 ± 4 μg, P = 0.04). Pain intensity before and after respiratory physiotherapy as well as 24 hr rescue piritramide consumption was similar in the epidural (4.1 ± 3.1 mg) and the paravertebral (2.5 ± 1.5 mg) groups (P = 0.14). Systolic blood pressure after 24 and 48 hrs was lower in the epidural group.
CONCLUSIONS:

Under the conditions of our study, continuous paravertebral block resulted in similar analgesia but greater hemodynamic stability than epidural analgesia in patients having thoracotomy. Paravertebral block also required smaller volume of colloids and vasopressors to maintain the target oxygen delivery index (DO2I).

Originally Posted by RxBoy

As for the "PCPA"... I found that the initial bolus usually gives a good level from T2 all the way to T10. But in the morning when we would do educational rounds on our epidural/peripheral catheter patients, the PV blocks would oftentimes regress to something like T3 to T6, while others continued to have a large spread. There is a large patient variance in TPVB spread probably due to anatomical differences and catheter location.

After we started incorporating patient controlled boluses, we found that the block would consistently cover T2 to T10 range. For those that didn't need the extra volume, they simply didn't push the button.

I would prefer ropivacaine as well. The literature swings both ways (better vs. no change). But in our institution it comes down to the Benjamens. Pharmacy prefers us to use the cheaper stuff.

For those that haven't done it yet, it makes a world of difference for the CT surgeons. They will love the minimal hemodynamic changes. The tough part is selling it. But once you do, they'll demand it.

Are you placing them at T4 or T5? I like the 10 ml bolus idea at T2 and T5 for breast surgey. That sounds like a great study.

Marhofer et al (2010) investigated the anatomy of the lateral paravertebral space using a high-frequency linear ultrasound transducer in twenty women undergoing breast cancer surgery. After identification of the transverse process, internal intercostal membrane (IIM), and pleura at the T3 and T6 levels, an out-of-plane needle guidance technique was used to perform the PVB with 12 ml ropivacaine 0.75% at these two levels in the sitting position and the PVB was successful in all these cases. [16]

Eur J Anaesthesiol. 2006 Aug;23(8):658-64.
Sensory blockade after thoracic paravertebral injection of ropivacaine or bupivacaine.

Hura G, Knapik P, Misiołek H, Krakus A, Karpe J.
Source

Centre of Oncology, Department of Anaesthesiology, Bielsko-Biala, Poland. ghura@wp.pl

Abstract

BACKGROUND AND OBJECTIVE:

No clinical trials comparing the characteristics of sensory blockade caused by various local anaesthetics in thoracic paravertebral blockade have been published. The aim of this prospective study was a clinical assessment of sensory blockade after paravertebral injection of ropivacaine or bupivacaine in patients undergoing modified radical mastectomy.
METHODS:

Seventy ASA I-II patients were randomized to receive a single injection of ropivacaine 0.5% (n = 35) or bupivacaine 0.5% (n = 35) at the T4 level. General anaesthesia with propofol and fentanyl was provided during the procedure and patients were not intubated. The following parameters were analysed: duration and dynamics of the sensory blockade and the patient's and surgeon's assessment.
RESULTS:

Both ropivacaine and bupivacaine provided a similar level of analgesia. Ropivacaine was characterized by more rapid onset - after only 5 min 53% of patients in this group had the extent of sensory blockade wide enough to perform modified radical mastectomy in comparison to only 20% after bupivacaine (P 9 segments blocked) was noted more often in the ropivacaine group (88% vs. 65%, P < 0.05), lasted longer and appeared to be wider than sensory blockade produced by bupivacaine. Regression of sensory blockade was initially similar, but after 24 h sensory blockade in the ropivacaine group still had a potential to provide analgesia for modified radical mastectomy in 81% of patients in comparison to only 50% of such patients in the bupivacaine group (P < 0.05). Degree of postoperative pain, performance of the cardiovascular system, consumption of medications and complications were all similar between the study groups.
CONCLUSIONS:

Both agents provide satisfactory conditions for mastectomy, but ropivacaine seems to be superior to bupivacaine for thoracic paravertebral blockade during breast cancer surgery.

I prefer Rop over Bup but other than that we are in agreement. Your technique is the one most u/s gurus are using these days[/QUOTE]


Don't think so, maybe the K-man in China, but I just went to a cadaver workshop with Chelly--parasagittal just like the space runs.

Originally Posted by BLADEMDA

Are you placing them at T4 or T5? I like the 10 ml bolus idea at T2 and T5 for breast surgey. That sounds like a great study.

T4. We have been doing them exclusively for thoracotomies. I found if placed too low, the block misses the chest tube site.

This was a great reference for me:

http://usra.ca/tpbmovie.php

The second video is my favorite approach. I've done inplane sagittal as well but it feels very awkward. There are more links on the left that describe other aspects of the block.

Originally Posted by imfrankie

I prefer Rop over Bup but other than that we are in agreement. Your technique is the one most u/s gurus are using these days

Don't think so, maybe the K-man in China, but I just went to a cadaver workshop with Chelly--parasagittal just like the space runs.[/QUOTE]

The probe is slightly parasagittal in the bigger patients and in the smaller ones you can end up very parasagittal. I usually start with a modified parasagittal approach lateral to medial.

Ropivacaine does not appear to accumulate in the same linear manner as bupivacaine, and is seen by some authors as a safer choice for PVB.162853 The trials that evaluated the use of ropivacaine for PVB142853 did not explicitly report on LA toxicity, and this review can therefore present no safety data to compare bupivacaine with other LAs. Ropivacaine appears equipotent with bupivacaine, despite being given in doses far closer to the recommended maximum.2

http://www.youtube.com/watch?v=w070GgtNUfs

[QUOTE=RxBoy;12678739I would prefer ropivacaine as well. The literature swings both ways (better vs. no change). But in our institution it comes down to the Benjamens. Pharmacy prefers us to use the cheaper stuff.[/QUOTE]

Paravertebral ropivacaine, 0.3%, and bupivacaine, 0.25%, provide similar pain relief after thoracotomy.

Navlet MG, Garutti I, Olmedilla L, Pérez-Peña JM, San Joaquin MT, Martinez-Ragues G, Gomez-Caro L.
Source

Department of Anesthesiology, Gregorio Marañón General Hospital, Madrid, Spain. martagnavlet@hotmail.com <martagnavlet@hotmail.com>

Abstract

OBJECTIVE:

This study was designed to determine whether ropivacaine plus fentanyl was as effective as bupivacaine plus fentanyl in a continuous thoracic paravertebral block after posterolateral thoracotomy.
DESIGN:

Patients were randomly assigned in a blinded fashion to receive 1 of 2 solutions for paravertebral analgesia.
SETTING:

Multi-institutional university hospital.
PARTICIPANTS:

Sixty patients undergoing elective thoracotomy. Interventions: A continuous paravertebral infusion of 0.1 mL/kg/h of either 0.3% ropivacaine/fentanyl, 3 microg/mL, or 0.25% bupivacaine/fentanyl, 3 microg/mL, was started on admission to the intensive care unit.
MEASUREMENTS AND MAIN RESULTS:

Pain scores (rest, deep breathing, and coughing), spirometry, subcutaneous opioids, or nonsteroidal anti-inflammatory drug consumption and adverse events were assessed for 48 hours. Both techniques provided adequate pain relief for the first 2 days after posterolateral thoracotomy. There were no differences between groups in pain scores at rest, coughing, or movement. There was an improvement of spirometry values between the first and second day in both groups. There were no differences in the requirements for rescue analgesia and side effects between groups.
CONCLUSIONS:

It is concluded that both bupivacaine, 0.25%, and ropivacaine, 0.3%, with fentanyl are equally effective for post-thoracotomy pain control when used via continuous paravertebral blockade.

Possible LA toxicity (manifested by confusion that resolved after LA administration was stopped, convulsions or cardiac dysrhythmias) was the only complication reported in the majority of studies. Only 15 of the 19 studies using bupivacaine81315252933464752657072758384 reported specifically whether this complication occurred or not. Neurological effects which may have been due to LA toxicity occurred in four of 225 patients in the higher dose bupivacaine trials, compared with two of 110 patients in the lower dose trials (P=1.0). Cardiac arrhythmias occurred in two of 173 patients who received higher dose bupivacaine, and none of the 69 patients who received lower dose bupivacaine (P=1.0) (Table 7). No lasting patient harm was reported due to possible LA toxicity.

Originally Posted by RxBoy

Paravertebral ropivacaine, 0.3%, and bupivacaine, 0.25%, provide similar pain relief after thoracotomy.

Navlet MG, Garutti I, Olmedilla L, Pérez-Peña JM, San Joaquin MT, Martinez-Ragues G, Gomez-Caro L.
Source

Department of Anesthesiology, Gregorio Marañón General Hospital, Madrid, Spain. martagnavlet@hotmail.com <martagnavlet@hotmail.com>

Abstract

OBJECTIVE:

This study was designed to determine whether ropivacaine plus fentanyl was as effective as bupivacaine plus fentanyl in a continuous thoracic paravertebral block after posterolateral thoracotomy.
DESIGN:

Patients were randomly assigned in a blinded fashion to receive 1 of 2 solutions for paravertebral analgesia.
SETTING:

Multi-institutional university hospital.
PARTICIPANTS:

Sixty patients undergoing elective thoracotomy. Interventions: A continuous paravertebral infusion of 0.1 mL/kg/h of either 0.3% ropivacaine/fentanyl, 3 microg/mL, or 0.25% bupivacaine/fentanyl, 3 microg/mL, was started on admission to the intensive care unit.
MEASUREMENTS AND MAIN RESULTS:

Pain scores (rest, deep breathing, and coughing), spirometry, subcutaneous opioids, or nonsteroidal anti-inflammatory drug consumption and adverse events were assessed for 48 hours. Both techniques provided adequate pain relief for the first 2 days after posterolateral thoracotomy. There were no differences between groups in pain scores at rest, coughing, or movement. There was an improvement of spirometry values between the first and second day in both groups. There were no differences in the requirements for rescue analgesia and side effects between groups.
CONCLUSIONS:

It is concluded that both bupivacaine, 0.25%, and ropivacaine, 0.3%, with fentanyl are equally effective for post-thoracotomy pain control when used via continuous paravertebral blockade.

They are both effective but I bet 0.2% Rop is more effective than 1/8% Bup and safer to boot.

Originally Posted by BLADEMDA

They are both effective but I bet 0.2% Rop is more effective than 1/8% Bup and safer to boot.

Agreed... Just wish our pharmacy did.

I'm ready to do TPVB (transverse US lateral to medial); my obstacles are 1) getting my old fogie breast surgeons to let me do it and 2) I hate and distrust our thoracic surgeons (they will stab me in the back if anything goes wrong)

no need for a probe. one of the easier landmark blocks, not-quite-zero risk of ptx but if you arent too aggressive shouldnt be a problem. easier than an epidural, and ive yet to have one fail. (n is less than 20 however)

Originally Posted by Oggg

I'm ready to do TPVB (transverse US lateral to medial); my obstacles are 1) getting my old fogie breast surgeons to let me do it and 2) I hate and distrust our thoracic surgeons (they will stab me in the back if anything goes wrong)

quote this study to your surgeons. dont mention it to the patients and dont accept it as fact, but i come back to it any time i want to really push for a PVB in a mastectomy patient.

Originally Posted by Oggg

I'm ready to do TPVB (transverse US lateral to medial); my obstacles are 1) getting my old fogie breast surgeons to let me do it and 2) I hate and distrust our thoracic surgeons (they will stab me in the back if anything goes wrong)

What about single shots? A bit quicker to place than with catheters (albeit with less post-op analgesia); once the surgeons see the benefit, you might be able to sell them on the worth of catheters.

At one of our hospitals, the Chairman of Urology requests 6 single shot PVNB (bilateral T8-T10) for his open prostatectomies. The vast majority of his patients go home POD 1. It's very impressive...

Originally Posted by bigdan

What about single shots? A bit quicker to place than with catheters (albeit with less post-op analgesia); once the surgeons see the benefit, you might be able to sell them on the worth of catheters.

At one of our hospitals, the Chairman of Urology requests 6 single shot PVNB (bilateral T8-T10) for his open prostatectomies. The vast majority of his patients go home POD 1. It's very impressive...

a catheter can sometimes be more trouble than its worth. i would really only place one for a thoracotomy or VATS with chest tube. I love the single shot PVB and would place those for many different things. the surgeons dont mind them as much since there is no catheter to cause trouble and they are comfortable POD1

Originally Posted by bigdan

What about single shots? A bit quicker to place than with catheters (albeit with less post-op analgesia); once the surgeons see the benefit, you might be able to sell them on the worth of catheters.

At one of our hospitals, the Chairman of Urology requests 6 single shot PVNB (bilateral T8-T10) for his open prostatectomies. The vast majority of his patients go home POD 1. It's very impressive...

Why not just increase the dose of local to 12 mls per side and do 1 single injection at T9?
This would allow adequate spread on each side while reducing the number of needle sticks to 2 instead of 6.

Originally Posted by Idiopathic

no need for a probe. one of the easier landmark blocks, not-quite-zero risk of ptx but if you arent too aggressive shouldnt be a problem. easier than an epidural, and ive yet to have one fail. (n is less than 20 however)

I disagree. For breast surgery the use of u/s adds additional safety to the procedure especially for outpatients. I recommend its use on all patients who are not getting a chest tube after the surgical procedure.

I like "old school" paravertebral nerve blocks but u/s is simply "DA BOMB" for enhanced safety when doing these blocks.

How long would you expect a one level single shot TPVB of 20cc of 0.5% bupiv to last? 12h? 18h?

How technically challenging do you guys find paravertebrals? (as compared to say TEP or standard PNBs such as sci/saph/ISB/ax/etc.)

We don't do a lot of these yet (mostly mastectomies) and the regional fellows seem to steal all of them.

Originally Posted by okayplayer

How technically challenging do you guys find paravertebrals? (as compared to say TEP or standard PNBs such as sci/saph/ISB/ax/etc.)

We don't do a lot of these yet (mostly mastectomies) and the regional fellows seem to steal all of them.

It's on par with a Supraclavicular block once you do about 5 of them. The lung is very close to your needle and that is what makes you sweat. This is exactly like doing a SCB on a thin patient where the lung markings seem to be just a few mm from the first rib.
Hence, you can't rush this type of bock or be distracted when doing it (no talking on the cell here).

Originally Posted by BLADEMDA

Hence, you can't rush this type of bock or be distracted when doing it (no talking on the cell here).

Which blocks lend themselves to cell phone conversations?

Originally Posted by Gern Blansten

Which blocks lend themselves to cell phone conversations?

I'm pretty sure I could easily do a femoral block while chewing gum and talking on the cell phone (not that I recommend it)

Blade have you tried decadron with TPVB?

Originally Posted by Oggg

Blade have you tried decadron with TPVB?

The only way to get 16 hours of solid pain relief from single shot TPVBs is using 0.5% Rop with Decadron. If possible, consider 2-3 single shot TPVBs for open thoractomies with chest tube.

Exparel will allow the use of an echogenic needle for single shot TPVB. Perhaps, T3, T5 and T7 and the patient will be pain free for 72 hours.

Blade have you compared Bupiv vs Ropiv for TPVB? I would think bupiv w/decadron would last longer than ropiv w/decadron. My pharmacy is basically is telling us to limit our ropiv use.

Originally Posted by Oggg

Blade have you compared Bupiv vs Ropiv for TPVB? I would think bupiv w/decadron would last longer than ropiv w/decadron. My pharmacy is basically is telling us to limit our ropiv use.

Bupivacaine costs $1.80 for a 30 ml bottle. Ropivacaine is around $14 per 30 ml bottle.

I would think Bup with Decadron would last a few hours longer for TPVB. Remember, we are injectiong old, sick, frail patients at times so be cognizant of your total mg of Bup.
Are you really going to give 150 mg of Bup in the TPV space to a 50 kg 85 year old patient?

I've been giving 20cc of 0.25% bupiv in pacu or at the end of a GA. One pt got exactly 12h. I don't have plans to try to do a breast surgery awake with TPVB, so I don't think I'll be using 0.5% bup for this block.

TPVB catheters... Thoracotomies if the CT surgeons trusted me and vice versa. I was thinking open nephrectomies, but they're getting replaced by laparoscopic. I don't know if mastectomies with ax LND could justify a catheter -- Maybe it woul reduce a 23h stay to a same day discharge. Open chole seems like a good choice, but amazingly one of our surgeons had two in a row and both had minimal pain in PACU with just local. Last week we had a thoracic spinal fusion via a thoracotomy, and the surgeon did intercostal blocks just proximal to his wound. The pt had pain posterior and proximal to the local injection.

Damn I wanted to do a right T8 TVPB catheter for this open chole in a little 65kg lady, but my partner got there first and placed a thoracic epidural. Zero pain in PACU but surprise, patient had SBP in the low 80s.