Ultrasound-Guided Thoracic Paravertebral Catheter Placement in a Patient Undergoing Thoracotomy Who Had the Relative Contraindication of Thrombocytopenia to Epidural Placement

Abstract

PAIN AFTER THORACOTOMY is severe, often leading to significant respiratory complications and postoperative morbidity. 1 Gerner P. Postthoracotomy pain management problems. Anesthesiol Clin. 2008; 26: 355-367 Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar The quality of postoperative analgesia is a major determinant of post-thoracotomy pulmonary function. 2 Richardson J. Sabanathan S. Shah R. Post-thoracotomy spirometric lung function: The effect of analgesia A review. J Cardiovasc Surg. 1999; 40: 445-456 PubMed Google Scholar Currently, thoracic epidural analgesia is used widely in the management of post-thoracotomy pain 3 Soto R.G. Fu E.S. Acute pain management for patients undergoing thoracotomy. Ann Thorac Surg. 2003; 75: 1349-1357 Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar and is the standard against which other modes of analgesia are compared. Epidural analgesia, however, can be limited because of the resulting sympathectomy and side effects of neuraxial opioids. There is an emerging body of evidence suggesting that thoracic paravertebral catheters are comparable in efficacy to epidural catheters with fewer side effects. 4 Davies R.G. Myles P.S. Graham J.M. A comparison of analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy A systematic review and meta-analysis of randomised trials. Br J Anaesth. 2006; 96: 418-426 Crossref PubMed Scopus (522) Google Scholar , 5 Joshi G.P. Bonnet F. Shah R. et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg. 2008; 107: 1026-1040 Crossref PubMed Scopus (458) Google Scholar , 6 Gulbahar G. Kocer B. Muratli S.N. et al. A comparison of epidural and paravertebral catheterization techniques in post-thoracotomy pain management. Eur J Cardiothorac Surg. 2010; 37: 467-472 PubMed Google Scholar Paravertebral catheters additionally offer the potential benefit of being placed in patients who are denied thoracic epidural analgesia because of the risk of epidural hematoma. However, prospective data to support this claim do not exist. The authors report a case of a patient undergoing thoracotomy whose thrombocytopenia (platelet count of 72 × 103/μL) represented a relative contraindication to epidural analgesia. Using real-time ultrasound guidance, a thoracic paravertebral catheter was placed successfully and used for postoperative analgesia.