Thoracic Paravertebral Catheter Research Articles

Ropivacaine pharmacokinetics in the arterial and venous pools after ultrasound-guided continuous thoracic paravertebral nerve block.

Although thoracic paravertebral blockade (TPVB) is employed in thoracic surgery to ensure satisfactory postoperative analgesia, large doses of anesthetics are required and manifestations of local anesthetic systemic toxicity (LAST) may appear. Currently, there are limited data on the pharmacokinetics of ropivacaine after continuous TPVB. The aim of this prospective study was to investigate ropivacaine kinetics, in the arterial and venous pools, after continuous TPVB and assess the risk of LAST. Immediately after induction of general anesthesia, an ultrasound-guided continuous TPVB at T5 or T6 or T7 thoracic level was performed in 18 adult patients subjected to open thoracotomy. A 25-ml single bolus injection of ropivacaine 0.5% was administered through thoracic paravertebral catheter, followed by a 14 ml/h continuous infusion of ropivacaine 0.2% starting at the end of surgery. Quantification of total ropivacaine concentrations was performed using a validated high-performance liquid chromatography method. Population pharmacokinetic models were developed separately for arterial and venous ropivacaine data. The best model was one-compartment disposition with an additional pre-absorption compartment corresponding to thoracic paravertebral space. Gender had a significant effect on clearance, with females displaying lower elimination than males. Some patients had ropivacaine concentrations above the toxic threshold, but none displayed evidence of LAST. Continuous thoracic paravertebral nerve blocks provided adequate postoperative analgesia. Ropivacaine doses at the upper end of clinical use (800 mg/d) did not inflict the manifestations of LAST and provided adequate postoperative pain control. Pharmacokinetic models were developed, and the effect of gender was identified.

Thoracic paravertebral versus interpleural catheter for post-thoracotomy pain control in minimally invasive cardiac surgery.

The aim of this study was to compare efficacy and safety of paravertebral block (PVB) and interpleural analgesia (IPA) after minimally invasive cardiac surgery through thoracotomy in terms of quality of analgesia, post-operative mechanical ventilation time, intensive care unit (ICU) and hospital length of stay (LOS) and complications. A randomized, prospective study. A total of 50 adult patients (18-50 years old) undergoing minimally invasive cardiac surgery via thoracotomy. Patients were randomized for group A: paravertebral epidural catheter (n = 25), group B: interpleural catheter (n = 25). All patients were given Inj. Bupivacaine 0.125%, 8 ml and Inj. Tramadol 100 mg as an adjuvant, total volume 10 ml. After obtaining institutional review board approval, data collected and analysed - visual analogue score (VAS) at rest and on coughing, haemodynamic and respiratory parameters, time to extubation, supplementary analgesia requirement, LOS and complications. VAS was recorded at 0, 2, 3, 4, 8, 12 and 24 h post-extubation, while blood gases at-after shifting, 4, 8, 12 and 24 h. There were no significant differences in haemodynamic or respiratory parameters, VAS at rest and on coughing, ventilation duration, ICU and hospital LOS between two groups. The requirement of rescue analgesia was in one patient of mini coronary artery bypass in group B, while one patient in group A required reintubation due to respiratory acidosis and got successfully extubated on next day morning. PVB and IPA both are safe and effective techniques for minimally invasive cardiac surgery with thoracotomy. It allows optimal pain control and safe ICU fast-track post-operative course.

Effectiveness of one minute per level intercostal nerve cryoablation for postoperative analgesia after surgical correction of pectus excavatum

PurposeIntraoperative intercostal nerve cryoablation has emerged as a promising modality for postoperative analgesia following Surgical Correction of Pectus Excavatum (SCOPE). Most centers use two-minute cryoablation per level, although data from histologic and adult studies suggest the effectiveness of one-minute freezes. We aimed to describe our center's experience with one minute per level cryoablation. MethodsA retrospective single institution review of patients undergoing SCOPE was performed to compare patients pre- and post-intercostal nerve cryoablation implementation. Cryoablation was performed as one minute for each of the thoracic intercostal nerves T3-T7. Multivariable regression analyses were conducted to compare the outcomes and cost between pre- and post-implementation groups. ResultsDuring the study period, 198 patients underwent SCOPE with one Nuss bar, receiving either intraoperative intercostal nerve cryoablation (Cryo, n = 100) or preoperative thoracic paravertebral catheters (NoCryo, n = 98). Surgical time was on average 9 min longer for the Cryo group (p<0.01). Median length of stay for the Cryo group was 3 days shorter compared to the NoCryo group (p<0.01). The Cryo group had a 19-fold and 5.6-fold reduction in average inpatient and total postoperative opioid usage, respectively (p<0.01). Total hospital costs were significantly lower in the Cryo group (p<0.01). Overall complication rate was not statistically significant different between the two groups. ConclusionsIntraoperative one minute per level cryoablation is a potent approach to postoperative analgesia for SCOPE patients that led to a shorter hospital length of stay, lower hospital costs, and decreased opioid use compared to conventional analgesia at our institution. Pediatric surgeons performing correction of chest wall deformities should consider offering this technique.

Ultrasound-guided erector spinae plane catheter versus video-assisted paravertebral catheter placement in minimally invasive thoracic surgery: comparing continuous infusion analgesic techniques on early quality of recovery, respiratory function and chronic persistent surgical pain: study protocol for a double-blinded randomised controlled trial

BackgroundCompared to conventional thoracotomy, minimally invasive thoracic surgery (MITS) can reduce postoperative pain, reduce tissue trauma and contribute to better recovery. However, it still causes significant acute postoperative pain. Truncal regional anaesthesia techniques such as paravertebral and erector spinae blocks have shown to contribute to postoperative analgesia after MITS. Satisfactory placement of an ultrasound-guided thoracic paravertebral catheter can be technically challenging compared to an ultrasound-guided erector spinae catheter. However, in MITS, an opportunity arises for directly visualised placement of a paravertebral catheter by the surgeon under thoracoscopic guidance. Alongside with thoracic epidural, a paravertebral block is considered the “gold standard” of thoracic regional analgesic techniques. To the best of our knowledge, there are no randomised controlled trials comparing surgeon-administered paravertebral catheter and anaesthesiologist-assisted erector spinae catheter for MITS in terms of patient-centred outcomes such as quality of recovery.MethodsThis trial will be a prospective, double-blinded randomised controlled trial. A total of 80 eligible patients will be randomly assigned to receive either an anaesthesiologist-assisted ultrasound-guided erector spinae catheter or a surgeon-assisted video-assisted paravertebral catheter, in a 1:1 ratio following induction of general anaesthesia for minimally assisted thoracic surgery. Both groups will receive the same standardised analgesia protocol for both intra- and postoperative periods. The primary outcome is defined as Quality of Recovery (QoR-15) score between the two groups at 24 h postoperative. Secondary outcomes include assessment of chronic persistent surgical pain (CPSP) at 3 months postoperative using the Brief Pain Inventory (BPI) Short Form and Short Form McGill (SF-15) questionnaires, assessment of postoperative pulmonary function, area under the curve for Verbal Rating Score for pain at rest and on deep inspiration versus time over 48 h, total opioid consumption over 48 h, QoR-15 at 48 h, and postoperative complications and morbidity as measured by the Comprehensive Complication Index.DiscussionDespite surgical advancements in thoracic surgery, severe acute postoperative pain following MITS is still prevailing. This study will provide recommendations about the efficacy of an anaesthesia-administered ultrasound-guided erector spinae catheter or surgeon-administered, video-assisted paravertebral catheter techniques for early quality of recovery following MITS.Trial registrationClinicalTrials.govNCT04729712. Registered on 28 January 2021. All items from the World Health Organization Trial Registration Data Set have been included.

Use of regional analgesia and risk of delirium in older adults with multiple rib fractures: An Eastern Association for the Surgery of Trauma multicenter study.

Single-center data demonstrates that regional analgesia (RA) techniques are associated with reduced risk of delirium in older patients with multiple rib fractures. We hypothesized that a similar effect between RA and delirium would be identified in a larger cohort of patients from multiple level I trauma centers. Retrospective data from seven level I trauma centers were collected for intensive care unit (ICU) patients 65 years or older with ≥3 rib fractures from January 2012 to December 2016. Those with a head and/or spine injury Abbreviated Injury Scale (AIS) score of ≥ 3 or a history of dementia were excluded. Delirium was defined as one positive Confusion Assessment Method for the Intensive Care Unit score in the first 7 days of ICU care. Poisson regression with robust standard errors was used to determine the association of RA (thoracic epidural or paravertebral catheter) with delirium incidence. Data of 574 patients with a median age of 75 years (interquartile range [IQR], 69-83), Injury Severity Score of 14 (IQR, 11-18), and ICU length of stay of 3 days (IQR, 2-6 days) were analyzed. Among the patients, 38.9% were women, 15.3% were non-White, and 31.4% required a chest tube. Regional analgesia was used in 19.3% patients. Patient characteristics did not differ by RA use; however, patients with RA had more severe chest injury (chest AIS, flail segment, hemopneumothorax, thoracostomy tube). In univariate analysis, there was no difference in the likelihood of delirium between the RA and no RA groups (18.9% vs. 23.8% p = 0.28). After adjusting for age, sex, Injury Severity Score, maximum chest AIS, thoracostomy tube, ICU length of stay, and trauma center, RA was associated with reduced risk of delirium (incident rate ratio [IRR], 0.65; 95% confidence interval [CI], 0.44-0.94) but not with in-hospital mortality (IRR, 0.42; 95% CI, 0.14-1.26) or respiratory complications (IRR, 0.70; 95% CI, 0.42-1.16). In this multicenter cohort of injured older adults with multiple rib fractures, RA use was associated with a 35% lower risk of delirium. Further studies are needed to standardize protocols for optimal pain management and prevention of delirium in older adults with severe thoracic injury. Therapeutic, level IV; Epidemiologic, level III.

Thoracic paravertebral nerve catheter reduces postoperative opioid use for vertebral body tethering patients.

Vertebral body tethering is increasingly being performed, yet postoperative pain management has not yet been optimized. We sought to determine whether the addition of a thoracic paravertebral block in addition to a standard multimodal postoperative pain management program could provide greater pain relief, reduced analgesic requirement, and reduced length of stay. Patients who underwent VBT at a single tertiary referral center were retrospectively reviewed. All patients received a single-shot intrathecal (IT) injection at the completion of the procedure in addition to a standardized multimodal pain management program. 45 patients received a thoracic paravertebral catheter with lidocaine infusion (TPVB) which was left in place for 4-6days, whereas 24 control patients did not have a TPVB. Length of stay, maximum postoperative Numeric Pain Intensity Scale (NPIS), and total dose of opioids, ibuprofen, ketorolac and acetaminophen administered during hospitalization were evaluated. 69 patients met inclusion criteria. The mean cumulative dose of opioids administered during hospitalization was 148 oral morphine milligram equivalent (MME) in the control group vs. 47 MME in the TPVB group (p < 0.0001). Severe postoperative NPIS of ≥ 7 was reported in 9 out of the 24 control patients (38%) and in 13 out of the 45 patients (29%) who received a TPVB in addition to the standardized care (p = 0.46). There was no significant difference in the mean cumulative dose of NSAIDs (ibuprofen, ketorolac) consumed by the control group compared to the TPVB group (2632mg vs. 1630mg, p = 0.77). Mean length of stay in the control group was 3.8 vs. 3.0days in the TPVB group (p < 0.001). There were no major complications associated with use of the TPVB. In this series compared to controls, patients treated with a TPVB had reduced postoperative requirement of opioids and decreased length of hospital stay.

R15. Initiation of Clinical Care Guidelines for Pectus Excavatum Patients: A Retrospective Review

Adolescents undergoing pectus deformity repairs typically have significant postoperative pain. Management following repair consists of opioids, non-opioid adjuvants with either a thoracic epidural or paravertebral catheter.1,2 Enhanced Recovery After Surgery (ERAS) protocols have been established in the adult population and are now becoming more common in pediatrics and adolescents.2,3 A standardized Pectus Pain Management Clinical Pathway (PPMCP) was established in 2017 at our institution by the anesthesiology team. Later a multidisciplinary clinical care guideline (CCG) was established in May 2019 through collaboration with the surgery, anesthesia, physical therapy and nursing teams. The acute pain team at Lurie Children's Hospital of Chicago have observed improvement in the postoperative course of these patients since the establishment of both the PPMCP and then the CCG. Therefore, a retrospective study was done to evaluate the effects of standardization of care for patients undergoing pectus excavatum repair.

Effect of catheter type on dye spread in the thoracic paravertebral space: a cadaveric study in 16 subjects

Because of difficulties in placing catheters and inconsistent analgesic spread,[1][1] thoracic paravertebral catheter (TPVC) is not routinely used. Factors that influence perineural catheter success placement and efficacy are: technical approach,[2][2]...

Continuous paravertebral block by intraoperative direct access versus systemic analgesia for postthoracotomy pain relief

BackgroundSystemic analgesia with paracetamol and nonsteroidal anti-inflammatory drugs plus opioids as a rescue medication had reported to be better than that depend mainly on opioids for postoperative pain relief. Thoracic paravertebral block reported to provide a comparable postthoracotomy pain relief to epidural analgesia, with fewer side effects due to its unilateral effect. Thoracic paravertebral catheter can be inserted intraoperatively under direct vision during thoracic surgery (Sabanathan’s technique). This prospective randomized study was designed to evaluate the safety and efficacy of this technique with continuous infusion of lidocaine compared to systemic analgesia for postthoracotomy pain relief.ResultsSixty-three patients were randomized to receive a continuous infusion of lidocaine in the paravertebral catheter for 3 postoperative days (thoracic paravertebral group, n = 32) or systemic analgesia (systemic analgesia group, n = 31). All patients underwent standard posterolateral thoracotomy. There were no significant differences between both groups in age, sex, side, type, and duration of operation. Pain scores measured on visual analogue scale and morphine consumption were significantly lower in thoracic paravertebral group in all postoperative days. Spirometric pulmonary functions were not reaching the preoperative values in the third postoperative day in both groups, but restorations of pulmonary functions were superior in paravertebral group. No complications could be attributed to the paravertebral catheter. Side effects, mainly nausea and vomiting followed by urinary retention, were significantly more in systemic analgesia group (P = 0.03). Also, pulmonary complications were more in systemic analgesia group but not reaching statistical significance (P = 0.14).ConclusionContinuous paravertebral block by direct access to the paravertebral space using a catheter inserted by the surgeon is a simple technique, with low risk of complications, provides effective pain relief with fewer side effects, and reduces the early loss of postoperative pulmonary functions when compared to systemic analgesia.

Cryoanalgesia Reduces Postoperative Pneumonia in Patients Undergoing Double Lung Transplantation Compared to Thoracic Paravertebral Catheters and Traditional Opiate Based Analgesia

Postoperative pain for bilateral lung transplant patients is often poorly controlled and may negatively impact recovery. Intercostal cryoanalgesia (IC-CRYO) may provide an additional modality to pain control. We hypothesize that IC-CRYO may enhance recovery compared to traditional opiate based analgesia (OBA) and thoracic paravertebral catheter (TPVC) analgesia. Consecutive patients from January 2015 to May 2019 receiving a double lung transplant were included in this retrospective review. Pediatric age, single lung and redo lung transplants were excluded. TPCV group received 4 bilateral catheters at T4 and T8 levels postoperatively in the intensive care unit. IC-CRYO was performed intraoperatively by the surgeon from intercostal nerves 3-7 bilaterally. A total of 66 patients received IC-CRYO, 51 patients received OBA, and 89 received TPVC. The IC-CRYO group was significantly older (59 vs 52; p = 0.01) and had higher BMI (25.8 vs 24.2; p = 0.05) compared to OBA. Both the restrictive lung disease patients (62% IC-CRYO, 46% TPVC and 47% OBA) and the lung allocation scores (52 IC-CRYO, 47 TPVC and 51 OBA) were higher in IC-CRYO. There were no differences in time on the ventilator, ICU or hospital length of stay. There was a trend to lesser need for tracheostomy in IC-CRYO compared to OBA (5% vs 16%; p = value 0.06). IC-CRYO showed a significant decrease in post operative pneumonia compared to OBA (3% vs 22%; p = 0.03) and to TPVC (3% vs 17%; p = 0.03). There were no complications related to TPVC or IC-CRYO. The present data suggest IC-CRYO and TPVC are effective as adjuncts to pain control for patients undergoing bilateral lung transplant. The data suggest IC-CRYO is strongly associated with functional improvements in patient recovery from bilateral lung transplant when compared with TPVC and OBA for postoperative pain control.

Multicenter longitudinal cross-sectional study comparing effectiveness of serratus anterior plane, paravertebral and thoracic epidural for the analgesia of multiple rib fractures

BackgroundThere is a paucity of data comparing effectiveness of various techniques for pain management of traumatic rib fractures. This study compared the quality of analgesia provided by serratus anterior plane...

Safety, complications and clinical outcome after ultrasound-guided paravertebral catheter insertion for rib fracture analgesia: a single-centre retrospective observational study.

Rib fractures are associated with significant morbidity and mortality. Ultrasound-guided thoracic paravertebral catheter insertion has been described for the management of pain secondary to rib fractures. We conducted a retrospective observational study of all patients with rib fractures who had a paravertebral catheter inserted for analgesia provision over a 4-year period. Data from the Trauma Audit and Research Network were used to compare patients with rib fractures who were managed with paravertebral catheters to those managed with systemic analgesia. A total of 314 consecutive paravertebral catheters were inserted in 290 patients. Five (1.9%) catheters were removed due to ineffective analgesia. Other minor complications occurred in three cases (0.96%). The proportion of rib fracture patients managed with paravertebral catheters increased from 31/200 (15.5%) in the first year of study to 81/168 (48.2%) in the fourth; over this time-period the observed:predicted mortality ratio fell from 1.04 to 0.66. Proportional hazard regression with and without propensity score matching demonstrated a reduction in mortality associated with paravertebral catheter use, but this became statistically non-significant when time-dependent analysis was used. Paravertebral catheters are a safe and effective technique for rib fracture analgesia; however, our data were insufficient to demonstrate any improvement in mortality.

Vasovagal Attack during Insertion of Thoracic Paravertebral Catheter: A known but Rarely Reported Incident

Vasovagal syncope is defined as a sudden and transient loss of consciousness. We report a case of vasovagal attack during insertion of thoracic paravertebral cathether. A 28 year old male ASA I, case of bronchus Schwannomas was posted for left sided Pneumonectomy. Past history of 2 episodes of dizziness and fainting on visualization of blood. During insertion of the catheter through the needle, patient felt paraesthesia and complained of giddiness and became unconscious. The monitor showed sudden bradycardia and hypotension. The blood glucose was found to be 55 mg/dl. 25% dextrose 100 ml was given to correct hypoglycemia. Patient was resuscitated and surgery completed. Therefore, Vasovagal episodes along with regional anesthesia can be a significant hazard. Attention must be given to patients with history of vasovagal episodes. Adequate comfortable positioning, reassurance, adequate sedatives to relieve anxiety and preprocedure optimization of blood glucose may be useful in such patients.

Thoracic paravertebral block versus thoracic epidural analgesia for post-operative pain control in open pancreatic surgery: A randomized controlled trial

Study objectiveThe purpose of this study was to compare the efficacy of bilateral ultrasound guided thoracic paravertebral catheters to a thoracic epidural after open pancreatic surgery. DesignThis was a prospective non-blinded randomized controlled trial. SettingAcademic hospital operating room, postoperative recovery area, and ward. Patients53 patients aged 18 and above who had open pancreatic surgery. InterventionsPatients received either bilateral thoracic paravertebral block at T8 with an infusion of 0.2% ropivacaine or thoracic epidural analgesia at T7/8 with an infusion of 0.125% bupivacaine with hydromorphone 6 μg/mL. MeasurementsPain scores, opioid use, length of recovery room and hospital stay, adverse events, and incidence of nausea and vomiting. Main resultsThere was no difference in baseline demographics between the two groups. There were no significant differences in pain scores between the two groups in each of the first five days after surgery. There was no difference in length of stay nor nausea and vomiting. There was significantly less modality related adverse events in the paravertebral group compared to the epidural group (p = 0.02). ConclusionsThe use of thoracic paravertebral catheters provided comparable analgesia and less modality related adverse events when compared to a thoracic epidural in patients undergoing open pancreaticoduodenectomy.

The Pattern of Contrast Dye through the Thoracic Paravertebral Catheter Does Not Predict Analgesic Efficacy after Breast Cancer Surgery: A Prospective Cohort Study

Purpose: We examined whether or not the spreading pattern of contrast dye through the catheter into the thoracic paravertebral space (TPVS) was associated with acute post-operative pain relief after breast cancer surgery. Methods: Sixty patients were recruited. After surgery, patients received thoracic paravertebral block (TPVB). The catheter was inserted within the TPVS, and radiographic contrast dye was injected through the catheter. Based on the main spreading patterns of the dye, the patients were divided into a cloud-like (spreading to the posterior compartment of the TPVS) or a longitudinal spread group (spreading to the anterior compartment of the TPVS). The primary endpoint of the study was pain intensity by numeric rating scale (NRS) and additional analgesic requirements within 12 h after surgery. Results: In 22 patients, the spread of contrast dye was not noted in the PVS. Of the 38 eligible patients, 9 patients were assigned to the cloud-like spread group, 28 patients to the longitudinal spread group and 1 patient was excluded. There were no significant differences in the NRS between the two groups both at rest and on moving. No significant differences were found in the frequency of requiring additional analgesics. Conclusions: There is no marked difference in the analgesic efficacy after breast cancer surgery based on the spread of the contrast dye to the posterior or anterior compartment of the TPVS. We should not insert the needle deeply within the TPVS, as the risk of the migration of catheters into the pleural space can be quite high.

Breakage and retention of thoracic paravertebral catheter: a case report

BackgroundParavertebral catheters are generally inserted and removed without complications. However, catheter breakage occurs rarely. This is the first report describing breakage of a thoracic paravertebral catheter and retention of the catheter fragment within the patient.Case presentationA 65-year-old female patient complained of an unusual sensation in her back during postoperative chemotherapy for lung cancer. A catheter fragment was identified in the soft tissues of the back on computed tomography. The paravertebral catheter had been placed 2 years prior left lower lobectomy. The patient had neither neurological symptoms nor infection signs around the fragment. However, the potential side effects of chemotherapy, including coagulopathy and immunosuppression, increased the risk of late-onset hematoma and abscess formation around the fragment. Therefore, we surgically removed the catheter fragment. Analysis of the fragment revealed that the catheter had been severed by the cutting edge of the Tuohy needle or the suture needle.ConclusionIn this report, a paravertebral catheter fragment was retained in the posterior mediastinum for 2 years. The catheter was likely damaged during the insertion procedure. We suggest that catheters should not be withdrawn through the Tuohy needle, but be withdrawn together with the Tuohy needle. Although secure fixation of the catheter can be achieved with sutures, to reduce the risk of damage to the catheter, alternative methods, such as surgical tapes or skin glue should be considered. After removal of a catheter, its tip should be checked to ensure that the entire catheter has been completely removed. If a catheter fragment is retained within the patient, removal of the fragment should be considered according to the patient’s condition and risks.

Abstract PR515

Background & Objectives: Paravertebral block has become a popular technique and is considered as effective as epidural block for pain control. Local anesthetic (LA) spread pattern within the thoracic paravertebral space (PVS) could be highly variable. Injection of LA into the posterior compartment or the anterior compartment of the PVS results in a cloud-like spread or a longitudinal multisegmental spread image, respectively1). However, There are no reports to examine the relationship between the pattern of the local anesthetics spread and analgesic effects after the same operation. We investigated the spread pattern of contrast dye through the catheter into the PVS in patients undergoing breast cancer operation and whether the spread pattern could be related with analgesic effects for acute post operative pain. Materials & Methods: Between June 2014 and January 2016, we designed a prospective study of 60 patients submitted to unilateral breast cancer surgery without reconstruction. After the operation, the catheter was placed into the PVS using the ultrasound-guided out-of-plane needle insertion approach at the forth thoracic vertebral level under general anesthesia. When we could confirm an anterior movement of the pleura by injection of 25mL of 0.33% ropivacaine, the catheter was judged to be in the PVS. A 5ml of radiographic contrast dye was injected through the catheter and the spread pattern was assessed by X-ray images. Patients recieved continuous 0.2% ropivacaine infusion at the rate of 3ml/h. A numeric rating scale (NRS) was used to assess pain intensity at rest and on moving at 1, 6 and 12 h after operation. Analgesic consumption was also noted. Results: The catheters were judged to be in the PVS in 43 among 60 patients. Fifteen patients showed multisegmental longitudinal spread pattern and 7 patients showed cloud-like spread pattern. Their median NRS (Interquartile range) at 1 h after operation were 3 (0.5-5.5) in multisegmental longitudinal pattern group and 4 (1.5-8) in cloud-like pattern group. Patients who required rescue analgesics within 1 h after operation were 66.7% or 42.9% in multisegmental longitudinal pattern group or in cloud-like pattern group, respectively. Conclusion: Multisegmental longitudinal pattern and cloud-like pattern of paravertebral block had the same analgesic effect after breast cancer operation. Therefore, pattern of contrast dye through the thoracic paravertebral catheter dose not predict analgesic efficacy.

Postoperative pain control with paravertebral catheters after pediatric total pancreatectomy and islet autotransplantation: a retrospective cohort study

Total pancreatectomy and islet autotransplantation (TPIAT) has been used to treat pediatric patients with chronic pancreatitis. The primary symptom of this disease is extreme poorly controlled pain. This results in significant alterations in the quality of life of the patient. We sought to determine if the addition of bilateral thoracic paravertebral catheters with continuous ropivacaine infusion would improve postoperative opioid use and pain control. The medical records of 32 patients who underwent TPIAT from March 2011 to July 2014 were analyzed retrospectively (15 without paravertebral catheters and 17 with paravertebral catheters). Maximum and minimum pain scores, opioid use (mg · kg(-1) · day(-1)), percent opioid use above baseline, length of stay, and complications were recorded. Those patients who had bilateral thoracic paravertebral catheters had decreased total opioid use in the first 7 days postoperatively when compared to those who did not (612 (95% CI: 432-792) vs 943.7 (95% CI: 650-1237) mg of morphine equivalents; P = 0.043). The total opioid use remained significantly decreased when corrected for weight (12.53 (95% CI: 9.19-15.44) vs 18.85 (95% CI: 13.69-24.03) mg · kg(-1) of morphine equivalents; P = 0.03). In addition, those on preoperative opioids had less percent opioid use above baseline on postoperative days 1, 2, and 7 as well as decreased opioid use (mg · kg(-1) · day(-1)) on postoperative days 1, 2, 3, and 7. There were no differences in complications or length of stay. Bilateral paravertebral catheters may provide decreased opioid use and improved postoperative pain control after TPIAT.

Intraoperative haemodynamic stability and stress response to surgery in patients undergoing thoracotomy: comparison between ultrasound-assisted thoracic paravertebral and epidural block

Objectives and aim Thoracotomy is a procedure usually associated with severe postoperative pain. This study aimed to evaluate intraoperative haemodynamics and stress response to thoracotomy in patients receiving thoracic epidural or thoracic paravertebral block. Patients and methods Sixty patients undergoing elective thoracotomy were randomly allocated into two equal groups: the thoracic paravertebral analgesia (TPVA) group, which received ultrasound-assisted thoracic paravertebral catheter, and the thoracic epidural analgesia (TEA) group, which received ultrasound-assisted thoracic epidural catheter. The primary outcome was the measuring of stress response to surgery using plasma cortisol level. The secondary outcomes included intraoperative haemodynamic parameters, visual analogue pain score and postoperative complications. Results Heart rate showed significantly lower values in the TEA group compared with the TPVA group. The mean arterial blood pressure showed significantly lower values in the TEA group compared with the TPVA group. In both groups, there was a significant increase in plasma cortisol level after surgical stress compared with basal values. Moreover, there were significantly lower values in the TPVA group compared with the TEA group at 2 h after surgical incision, 2 h postoperatively and 24 h postoperatively. Visual analogue pain score was noncomparable in both groups at all measurement timepoints. As regards complications, group TPVA had less complications compared with group TEA. Conclusion Thoracic paravertebral block is an effective analgesic technique showing greater haemodynamic stability and less stress response to surgery compared with epidural analgesia in patients undergoing thoracotomy.

Thoracic Paravertebral Catheter Placement for Acute Rib Pain in a Pregnant Patient with Cystic Fibrosis

A 30-year-old woman with cystic fibrosis at 33 weeks, 4 days' gestation sustained a rib injury during an acute pulmonary exacerbation, resulting in noncompliance with her chest wall oscillation therapy and worsening of her respiratory status with concern for inducing labor early. Insertion of an ultrasound-guided thoracic paravertebral catheter produced immediate pain relief, eliminating the need for further opioids, and she was able to tolerate her chest wall oscillation treatment. She was discharged home after 7 days and was able to deliver a healthy baby at 38 weeks via spontaneous vaginal delivery.