Bupi vs Ropi for paravertebral blocks

[YadaYadaNext]

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Our local institution has been replacing epidurals with either unilateral or bilateral paravertebral blocks. Open hearts frequently receive bilateral paravertebrals before or after the OR. Same for belly cases. Surgeon buy in has been very good, and thus far there has been less incidence of hypotension requiring excess fluids, lower extremity motor weakness requiring bed rest, and urinary retention. We typically use 0.2% ropi at 6cc bolus q30min through our pumps- no basal rate. The only problem has been cost. Would anyone be worried about higher incidence of LAST/cardiac symptoms if switching to bupi?

 

[vector2]

No

 

[deleted875186]

Interesting. I have never done a paravertebral block. Are you doing them landmark based or US? What levels are you doing? Are you getting enough spread?

 

[dhb]

Bilateral paravertebrals + pumps is a bit overkill for hearts isn't it?

 

[deleted875186]

Bilateral paravertebrals + pumps is a bit overkill for hearts isn't it?

Not just that, I thought the spread to multiple levels was poor with a PVB. Wouldn’t you need multiple levels on both sides to cover an ex lap?

 

[AdmiralChz]

Bilateral paravertebrals + pumps is a bit overkill for hearts isn't it?

Definitely. They actually aren’t in as much pain post op as you’d think (compare to VATS or thoracotomies!). Bilateral PVTs with catheters sounds like a time drain, plus you aren’t going to cover the entire sternum with a single shot so you’d need at least 4 blocks (2 on each side). That much work for minimal gain - no thanks!

We did that on Lung Transplants in residency (4 PVT catheters) and I swore I’d never do that crap again.

 

[deleted875186]

Interesting that you see less hypotension than an epidural. I thought the quality of the block was similar but with less spread. Don’t you still get a sympathectomy? Perhaps less hypotension because it’s less spread?

 

[deleted875186]

Sorry to detail this thread, but how do other practices limit the hypotension with a thoracic epidural? Avoid boluses? How dilute are your mixes? What rate?

Or do you think it doesn’t matter, you get hypotension no matter what?

 

[Urzuz]

Sorry to detail this thread, but how do other practices limit the hypotension with a thoracic epidural? Avoid boluses? How dilute are your mixes? What rate?

Or do you think it doesn’t matter, you get hypotension no matter what?

If you're worried about hypotension run 0.0625% bupi + 2 mcg/ml of fentanyl. Start rate at ~ 6 ml/hr (may need to be adjusted based on how many dermatomes you're trying to cover). Definitely will see less hypotension with a lower concentration of local anesthetic.

 

[woopedazz]

Disclaimer: Non-heart department, and I don't answer OPs question in any way, shape or form.

We've largely discarded paravertebrals and previous recipients receive either an epidural or erector spinae(s). More user-friendly and less complications is the departments thought process. I've never actually done a paravertebral myself.

The exception is one dude who throws paravertebrals in from accross the room in about 5 seconds flat and makes my butt clench whenever I see them go in. About 1/3 get pretty bad hypotension and the analgesia is probably worse overall (secondary to our dosing regimes not the block itself) when compared to ES cathethers (anecdotally from pain rounds).

Analgesia being crap is secondary to our bolus dosing - we also don't run them on infusions. Our wards prefer 0.2% Ropivacaine 3-6hrly, but will give 2hrly without much fuss. Anything less = nursing staff cannot handle the workload, which is fair. We do not set bolus regimes on pumps, we require nurses to administer each bolus due to some historical issues we've had with pumps on the ward. ICU/HDU can handle whatever we ask for, but we've also had some significant issues with any regimes that are not consistent with ward doses (handovers, equipment, medication errors, etc). It's easier just to keep it consistent.

Because we stretch the dosing (normally to 4 hourly) we have to give decent boluses, and with paravertebrals it smashes their BP too hard or wears off too early; it's difficult to get a nice middle ground while still covering multiple segments. With our ward setups it's much easier to achieve better analgesia with less hypotension with ES blocks or with cont. low-dose epidural infusions with intermittent low-dose boluses.

I'm aware that didn't answer anything, but it's nice to see what other departments are doing every now and then.

- 6mL seems like a very low bolus dose, even with the high frequency... do you get enough spread with that?
- Do you do similar regimes for non-heart cases?
- Do you do many ES or mainly just PV/epidurals in your department?

 

[vector2]

Anyone doing transversus thoracis blocks for sternotomy? Thoughts?

 

[sethco]

Anyone doing transversus thoracis blocks for sternotomy? Thoughts?

My surgeons have been very satisfied with Bilateral Parasternal Subpectoral Plane Blocks

 

[psychbender]

Anyone doing transversus thoracis blocks for sternotomy? Thoughts?

I've only read about them, but I'm interested in learning, if others have good experiences. I could probably sell one surgeon easily, and may offer to do them when I'm in the unit, if I can figure out how billing would work when I'm wearing my other hat.

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