1. No category

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Paravertebral Nerve Block PVB vs Epidural for Thoracotomy Less hypotension with PVBs
Paravertebral Nerve Block 7  Indica�ons: Rib fractures, breast surgery, thoracic surgery, unilateral abdominal surgery, hernia repair. 7  Benefits: Less hypotension than epidurals, poten�al for outpa�ent use 7  Complica�ons( <2.6%): Epidural spread, paraspinal muscle spasm, Brachial plexus block, pressure parathesia, pneumothorax. 7  Breast surgery: General anesthesia vs associa�on with PONV. Paravertebral Nerve Block: In-­‐plane approach Pintaric et al, RAPM 2011
Paravertebral: Rib vs. Pleura Paravertebral: Probe Posi�on Transverse
Process
Pleura
Move probe slightly caudal to obtain
pleura only (no transverse process)
Now probe is exactly intercostal
Intercostal muscles
Pleura
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4/24/15
Paravertebral: Probe Posi�on In-­‐Plane Paravertebral Nerve Block L
A
T
E
R
A
L
M
E
D
I
A
L
Pleura Endothoracic
fascia
Paramedian Saggital Scanning: Probe Posi�on Parasaggital In-­‐Plane Paravertebral Block C
R
A
N
I
A
L
C
A
U
D
A
L
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Parasaggital In-­‐Plane Paravertebral Block Parasaggital Out-­‐Of-­‐Plane Paravertebral C
R
A
N
I
A
L
C
A
U
D
A
L
C
R
A
N
I
A
L
Paravertebral Spread: Endothoracic fascia C
A
U
D
A
L
Out-­‐of-­‐Plane Paravertebral Block Glue
Secure with Dressings
If underneath the endothoracic fascia, the longitudinal spread pattern is observed.
Njaa et al, Anaesthesia 2004
Paravertebral Details o  Primary Anesthe�c – 
– 
– 
– 
Paravertebral Absorp�on Mul�ple injec�on technique, every level works best 5 – 10mL at each level 0.5%-­‐1% Ropivacaine with 1:400,000 epi Be wary of rapid systemic absorp�on o  Catheters –  Put catheter in middle of incision –  Example: T4 catheter for mastectomy –  Run at 6-­‐10mL/hr o  Post op pain – Single Injec�on – 
– 
– 
– 
Ok to skip levels (example: T2, T4, T6) Injec�on of larger volumes (10-­‐25mL) Error above the target site (injectate spreads preferen�ally caudal) 8-­‐24 hours analgesia Use epinephrine to delay absorption.
Karmakar 2005 et al, Anesthesiology 2005
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Paravertebral Spread Larger volume / kg resulted in more spread.
Njaa et al, Anaesthesia 2004
Paravertebral Spread 20mL injectate resulted in 3-4 level spread on MRI.
Marhofer et al, Anesthesiology 2013
Paravertebral Spread Spread is highly variable and multiple injections work best for full coverage.
Cowie et al, Anesth Analg 2010
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