Paravertebral blocks

Safety and Complications of Landmark-based Paravertebral Blocks: A Retrospective Analysis of 979 Patients and 4983 Injections

OBJECTIVE

This study aimed to determine the incidence of complications after landmark-based paravertebral blocks for breast surgery.

METHODS

The medical records of patients who received a paravertebral block for breast surgery between 2019 and 2022 were reviewed. Patient age, sex, type of procedure, number of injections, volume of injected anesthetic, and possible complications were noted. A record was identified as a possible serious block-related complication if there was concern or treatment for local anesthetic systemic toxicity, pneumothorax, altered mental status, or intrathecal/epidural spread. Other complications recorded were immediate postblock hypotension and nausea/vomiting requiring treatment and unanticipated postsurgical admission. Patients receiving ultrasound-guided paravertebral blocks were excluded from this study.

RESULTS

Over a 3-year period, 979 patients received paravertebral blocks using the landmark technique for breast surgery, totaling 4983 injections. Overall, 6 patients required assessment for postblock issues (0.61%), including hypotension (2 patients), nausea (3 patients), and hypotension + altered mental status (1 patient). This latter patient was identified as having a serious complication related to the paravertebral block (0.1%). This patient had unintentional intrathecal spread and altered mental status that required mechanical ventilation. The incidence of block-related hypotension and nausea requiring treatment was thus 0.31% and 0.31% respectively. Four patients required unanticipated admission, but none were for block-related reasons. No patients in this study were found to have local anesthetic systemic toxicity or pneumothorax.

CONCLUSION

Our study suggests that landmark-based paravertebral blocks for breast surgery result in a very low complication rate and are a safe technique for postsurgical analgesia.

Empirical guide to a safe thoracic paravertebral block based on dimensions of paravertebral space when ultrasound visualization is challenging

Although ultrasound (US) guidance is the mainstay technique for performing thoracic paravertebral blocks, situations arise when US imaging is limited due to subcutaneous emphysema or extremely deep structures. A detailed understanding of the anatomical structures of the paravertebral space can be strategic to safely and accurately perform a landmark-based or US-assisted approach. As such, we aimed to provide an anatomic roadmap to assist physicians. We examined 50 chest CT scans, measuring the distances of the bony structures and soft-tissue surrounding the thoracic paravertebral block at the 2nd/3rd (upper), 5th/6th (middle), and 9th/10th (lower) thoracic vertebral levels. This review of radiology records controlled for individual differences in body mass index, gender, and thoracic level. Midline to the lateral aspect of the transverse process (TP), the anterior-to-posterior distance of TP to pleura, and rib thickness range widely based on gender and thoracic level. The mean thickness of the TP is 0.9±0.1 cm in women and 1.1±0.2 cm in men. The best target for initial needle insertion from the midline (mean length of TP minus 2 SDs) distance would be 2.5 cm (upper thoracic)/2.2 cm (middle thoracic)/1.8 cm (lower thoracic) for females and 2.7 cm (upper)/2.5 cm (middle)/2.0 cm (lower thoracic) for males, with consideration that the lower thoracic region allows for a lower margin of error in the lateral dimension because of shorter TP. There are different dimensions for the key bony landmarks of a thoracic paravertebral block between males and females, which have not been previously described. These differences warrant adjustment of landmark-based or US-assisted approach to thoracic paravertebral space block for male and female patients.

Paravertebral block for radiologically inserted gastrostomy tube placement in amyotrophic lateral sclerosis

INTRODUCTION

Radiologically inserted gastrostomy (RIG) placement in patients with amyotrophic lateral sclerosis (ALS) carries risks related to periprocedural sedation and analgesia. To minimize these risks, we used a paravertebral block (PVB) technique for RIG placement.

METHODS

We retrospectively reviewed patients with ALS undergoing RIG placement under PVB between 2013 and 2017.

RESULTS

Ninety-nine patients with ALS underwent RIG placement under PVB. Median (range) age was 66 (28 to 86) years, ALS Functional Rating Scale-Revised score was 27 (6 to 45), and forced vital capacity was 47% (8%-79%) at time of RIG placement. Eighty-five (85.9%) patients underwent RIG placement as outpatients, with a mean postanesthesia care unit stay of 2.3 hours. The readmission rate was 4% at both 1 and 30 days postprocedure.

DISCUSSION

PVB for RIG placement has a low rate of adverse events and provides effective periprocedural analgesia in patients with ALS, the majority of whom can be treated as outpatients.

Regional Anesthesia for Ambulatory Anesthesiologists

Proper pain control is critical for ambulatory surgery. Regional anesthesia can decrease postoperative pain, improve patient satisfaction, and expedite patient discharge. This article discusses the techniques, clinical pearls, and potential pitfalls associated with those blocks, which are most useful in an ambulatory perioperative setting. Interscalene, supraclavicular, infraclavicular, axillary, paravertebral, erector spinae, pectoralis, serratus anterior, transversus abdominis plane, femoral, adductor canal, popliteal, interspace between the popliteal artery and capsule of the knee, and ankle blocks are described.

Development of a blunt chest injury care bundle: An integrative review

BACKGROUND

Blunt chest injuries (BCI) are associated with high rates of morbidity and mortality. There are many interventions for BCI which may be able to be combined as a care bundle for improved and more consistent outcomes.

OBJECTIVE

To review and integrate the BCI management interventions to inform the development of a BCI care bundle.

METHODS

A structured search of the literature was conducted to identify studies evaluating interventions for patients with BCI. Databases MEDLINE, CINAHL, PubMed and Scopus were searched from 1990-April 2017. A two-step data extraction process was conducted using pre-defined data fields, including research quality indicators. Each study was appraised using a quality assessment tool, scored for level of evidence, then data collated into categories. Interventions were also assessed using the APEASE criteria then integrated to develop a BCI care bundle.

RESULTS

Eighty-one articles were included in the final analysis. Interventions that improved BCI outcomes were grouped into three categories; respiratory intervention, analgesia and surgical intervention. Respiratory interventions included continuous positive airway pressure and high flow nasal oxygen. Analgesia interventions included regular multi-modal analgesia and paravertebral or epidural analgesia. Surgical fixation was supported for use in moderate to severe rib fractures/BCI. Interventions supported by evidence and that met APEASE criteria were combined into a BCI care bundle with four components: respiratory adjuncts, analgesia, complication prevention, and surgical fixation.

CONCLUSIONS

The key components of a BCI care bundle are respiratory support, analgesia, complication prevention including chest physiotherapy and surgical fixation.

Bilateral thoracic paravertebral nerve blocks for placement of percutaneous radiologic gastrostomy in patients with amyotrophic lateral sclerosis: a case series

BACKGROUND AND AIMS

To assess the efficacy of bilateral thoracic paravertebral nerve blocks (PVB) in providing procedural anesthesia and post-procedural analgesia for placement of percutaneous radiologic gastrostomy tubes (PRG) in patients with amyotrophic lateral sclerosis (ALS).

METHODS

We prospectively observed 10 patients with ALS scheduled for PRG placement that had bilateral thoracic PVBs at thoracic 7, 8, and 9 levels with administration of a mixture of 3 mL of 1% ropivacaine, 0.5 mg/mL dexamethasone, and 5 μg/mL epinephrine at each level. The success of the block was assessed after 10 minutes. PRG placement was done in the interventional radiology suite without sedation. All patients were followed up via phone 24 hours after the procedure.

RESULTS

All 10 patients had successful placement of PRG with PVBs as the primary anesthetic. Segmental anesthesia over the surgical site in all cases was successful with first attempt of the blocks. Three patients had significant hypotension after the block, requiring boluses of vasopressors and intravenous fluids. All patients reported high levels of satisfaction and sleep quality on the night of the procedure.

CONCLUSIONS

Bilateral thoracic PVBs provided satisfactory procedural anesthesia and post-procedural analgesia, and thus, seem promising as a safe alternative to sedation in ALS patients having PRG placement.

Ultrasound-guided paravertebral neurolytic block: a report of two cases

Paravertebral block is commonly used in the treatment for acute and chronic pain. The duration of paravertebral block could theoretically be prolonged with neurolytic agents. We report two cases of ultrasound-guided neurolytic paravertebral blocks in patients suffering from intense cancer-related thoracic pain. Ultrasound was used to identify the space and plane of injection at the mid-thoracic level. Absolute alcohol was used to block the nerves at different segments. The two patients had great pain relief. Neurolytic paravertebral block can be a useful technique in patients with intractable cancer pain. Because of the risk of complication, it is recommended that this technique should be limited to relief of intractable pain in cancer patients with a poor prognosis.