Paravertebral Blocks

[GA8314]

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Any tips on doing these? I've done them in plane and out of plane. I've had difficulty using the in plane approach a couple time. Out of plane has required us to use too much salin (or LA) to hydrodissect tissue such that we can estimate where the needle tip actually is.

We use a non-echogenic needle but I'm looking for recommendations as to the best echogenic needle to use for these, as I think this is a big reason why we're not doing this more deftly.

What needle size do you use, gague and length?

Also, any tips you can offer are appreciated. We are just doing single shot blocks, no catheters planned for these at this time.

 

[dhb]

What procedures are you doing them for?

 

[GA8314]

What procedures are you doing them for?

Thoracic and breast, mostly.

 

[epidural man]

yes, here is my suggestion.

TAP/Serratus plane/rectus sheath blocks instead. 😉

 

[sleepallday]

Any tips on doing these? I've done them in plane and out of plane. I've had difficulty using the in plane approach a couple time. Out of plane has required us to use too much salin (or LA) to hydrodissect tissue such that we can estimate where the needle tip actually is.

We use a non-echogenic needle but I'm looking for recommendations as to the best echogenic needle to use for these, as I think this is a big reason why we're not doing this more deftly.

What needle size do you use, gague and length?

Also, any tips you can offer are appreciated. We are just doing single shot blocks, no catheters planned for these at this time.

In which plane are you holding the transducer? I prefer holding the transducer in the longitudinal plane and then using the out of plane technique. The reason being is that I see the pleura much clearer in this orientation and out of plane allows me to approach the paravertebral space with a more manageable angle.

And for the needle, I prefer the 17g touhy. Its echogenicity and stiffness have worked for me.

 

[Random Anesthesiologist]

Its echogenicity and stiffness have worked for me.

That's what she said.

 

[sleepallday]

That's what she said.

Well played, sir/ma'am!

 

[Foodie]

I use Braun 22G 4" echogenic needle for breast lumpectomies and mastectomies (if pt has a skinny back, I've gotten away with 2" echogenic needle). In-plane longitudinal. I've found that placing the echo probe in a slight cephalad position makes for an easier visualization of needle trajectory and tip. I also suggest that you keep an eye on both the depth of the paravertebral space on the screen and needle depth to minimize pneumothrax risk. This method has worked for me so far. Out-of-plane technique would be plan B if in-plane seems too difficult in an individual pt.

I've never worked with Pajunk needles, and would love to hear what other people's experience with it has been.

 

[Mman]

Any tips on doing these? I've done them in plane and out of plane. I've had difficulty using the in plane approach a couple time. Out of plane has required us to use too much salin (or LA) to hydrodissect tissue such that we can estimate where the needle tip actually is.

We use a non-echogenic needle but I'm looking for recommendations as to the best echogenic needle to use for these, as I think this is a big reason why we're not doing this more deftly.

What needle size do you use, gague and length?

Also, any tips you can offer are appreciated. We are just doing single shot blocks, no catheters planned for these at this time.

here's a question, why are you using the ultrasound? IMHO U/S imaging while great for vascular access and peripheral nerve blocks is relatively far worse for neuraxial type blocks/catheters. I find doing a PVB is infinitely faster without the U/S (and I'm a person that uses U/S frequently for all sorts of procedures).

 

[Random Anesthesiologist]

Well played, sir/ma'am!

Ma'am, but I'm about 12 years old when it comes to humor sometimes!

 

[Planktonmd]

Ma'am, but I'm about 12 years old when it comes to humor sometimes!

I think it was good... for the level of humor this forum had lately 😉

 

[Planktonmd]

here's a question, why are you using the ultrasound? IMHO U/S imaging while great for vascular access and peripheral nerve blocks is relatively far worse for neuraxial type blocks/catheters. I find doing a PVB is infinitely faster without the U/S (and I'm a person that uses U/S frequently for all sorts of procedures).

When you do it without ultrasound do you seek a true loss of resistance when you walk your needle off the transverse process?

 

[Mman]

When you do it without ultrasound do you seek a true loss of resistance when you walk your needle off the transverse process?

Not really. I merely do it by advancing 1 cm past the depth I hit the transverse process at and then aspirating and injecting. Injection should be smooth like butter. So there is no resistance to injection, but I'm not really advancing and checking like I do with an epidural.

 

[Phyrst]

Agreed...when we use U/S for PVB cath, we use a 17G Touhy. Single shot U/S guided we use the 4 inch 22G echogenic Braun. But, for the most part, we've gotten away from U/S and use an anatomical approach. Mostly doing these for mastectomies/reconstruction and rib fractures.