Continuous thoracic paravertebral block for analgesia in patients with rib fractures has been reported.1–4 More recently, ultrasound-guided thoracic paravertebral block has been suggested for greater precision over surface landmarks.5,6 In our report, we discuss the use of continuous thoracic paravertebral block for analgesia to facilitate hospital discharge in a patient with multilevel unilateral rib fractures. We also describe the outpatient management of the paravertebral catheter and the usefulness of ultrasound to determine the optimal level of catheter insertion.
Informed written consent for the continuous thoracic paravertebral block procedure and permission for publication of this report were obtained from the patient. A 61-year-old man (75 kg, 183 cm) was admitted to our medical center with multiple unilateral rib fractures (T3–T8) sustained during a bicycle accident. The patient’s medical history was unremarkable. His chest radiograph also revealed a fracture of his left clavicle and mild left apical pneumothorax. In-hospital care consisted of observation and pain management. Because IV morphine induced nausea and vomiting, pain management relied mainly on periodical IV ketorolac tromethamine (30 mg every 6 hours) and oral hydrocodone/acetaminophen (5 mg/500 mg) as required. Despite multimodal pain therapy, the patient experienced 5/10 pain at rest and 7/10 pain with activity in his left back (visual analog scale [VAS]: 0, no pain; 10, worst pain imagined), and his ability to breathe and cough effectively was substantially impaired. The regional anesthesia team was consulted to manage the patient’s acute pain and to improve respiratory function.
On examination, the patient was hemodynamically stable; his O2 saturation was 90% to 93% on 2 to 3 L/min O2 via nasal cannula. His left lateral thoracic wall moved inward with inspiration (flail). A decision was made to perform a continuous thoracic paravertebral block for pain management. No hematoma or subcutaneous emphysema was noted in the proposed site of needle/catheter insertion. In a right lateral decubitus position, a 13-MHz high-frequency linear transducer (GE Logic e, 12L; GE Healthcare, Waukesha, WI) confirmed the levels of the fractured ribs (T3–T8; Fig. 1). The transducer was placed transversely oblique in line with the rib. The most cephalad (T3) and most caudad (T8) fractured ribs were identified first. The fifth left rib fracture was then identified in the middle, and the rib was then traced back medially. An 18-gauge Tuohy needle was inserted in a lateral-to-medial direction until the needle tip entered the paravertebral space (Fig. 2). Seven milliliters of 0.5% ropivacaine was injected into the paravertebral space while observing the pleura being moved downward. A 20-gauge catheter was advanced 3 cm beyond the needle tip. After negative aspiration, 3 mL of 0.5% ropivacaine was injected through the catheter while observing the displacement of the pleura, followed by an additional 10 mL of 0.5% ropivacaine to initiate analgesia. Five minutes later, the patient was able to breathe deeply and cough effectively; his oxygen saturation improved to 95% without supplemental oxygen; the VAS score with deep breaths decreased to 2/10. The catheter was then connected to a portable infusion pump (INFUSOR System with Patient Control Module; Baxter, Deerfield, IL), and an infusion of 0.2% ropivacaine was initiated (basal rate of 5 mL/h; Patient Control Module fill time 30 minutes and bolus volume 5 mL). The following morning, the patient was much more comfortable (VAS, 0–4/10), stable, free of IV opioids, and able to ambulate, breathe, and cough normally. As a result, he was discharged home by the surgical team. The patient was seen at the hospital 24 hours after the discharge. Because of his 6/10 VAS score during the visit, an additional bolus of 15 mL 0.5% ropivacaine was injected through the catheter, and the patient was sent home after an observation period of 1 hour. After 60 hours of continuous infusion with ropivacaine 0.2% at home, the patient’s family removed the catheter following the instructions that were provided at discharge. The residual chest and clavicle pain was well controlled by oral hydrocodone/acetaminophen (5 mg/500 mg) every 4 hours as required; the patient consumed 2 to 4 tablets daily.
Continuous thoracic paravertebral block is reportedly an effective method of providing continuous pain relief in patients with multiple rib fractures.1–3,7 Compared with most commonly used analgesic regimens consisting of opioid therapy, thoracic paravertebral block is a more potent, site-specific analgesia modality without the side effects of opioid therapy.3 Thoracic paravertebral block can also result in sustained improvement in respiratory mechanics and oxygenation.2
Ultrasound guidance offers several potential advantages over landmark-based techniques. The visualization of the needle and the pleura during the procedure may decrease the risk of pleural puncture and confirm entry of the needle tip into the paravertebral space. In addition, the confirmation of local anesthetic spread in the paravertebral space can be documented by observing displacement of the pleura. Although the chest radiograph was adequate for diagnosis of the rib fractures, the use of ultrasound to trace the fractured ribs back to the relevant paravertebral space helped to objectively determine the optimal level for the catheter placement (T5). Ultrasound detection of possible injury within the paravertebral space by the trauma that caused rib fractures or pneumothorax may also be helpful to guide the indication of thoracic paravertebral block or help reduce the risk of complications.8
The ideal infusion rate for thoracic paravertebral block in patients with multiple rib fractures has not been determined; it reportedly ranges from 0.1 to 0.2 mL/kg/h.1,2 Considering outpatient management, we selected a lower infusion rate. However, continuous infusion of ropivacaine at 5 mL/h (0.067 mL/kg/h) was insufficient in our patient; an additional bolus of local anesthetic was needed for adequate analgesia. This suggests that larger volumes of local anesthetic solution may be necessary for analgesia in patients with multilevel unilateral rib fractures.7,9
In conclusion, we report a successful use of ultrasound-guided continuous thoracic paravertebral block to facilitate hospital discharge and manage pain in an outpatient with multilevel unilateral rib fractures. Ultrasound guidance was also helpful in determining the site of rib fractures and the optimal level for catheter placement. More data from prospective trials are necessary to recommend management protocols for similar clinical scenarios.
Name: Hiroaki Murata, MD.
Contribution: This author helped analyze the data and write the manuscript.
Attestation: Hiroaki Murata approved the final manuscript.
Name: Emine Aysu Salviz, MD.
Contribution: This author helped analyze the data and write the manuscript.
Attestation: Emine Aysu Salviz approved the final manuscript.
Name: Stephanie Chen, MD.
Contribution: This author helped analyze the data and follow-up with the patients.
Attestation: Stephanie Chen approved the final manuscript.
Name: Catherine Vandepitte, MD.
Contribution: This author helped write the manuscript.
Attestation: Catherine Vandepitte approved the final manuscript.
Name: Admir Hadzic, MD, PhD.
Contribution: This author helped write the manuscript and perform Paravertebral block.
Attestation: Admir Hadzic approved the final manuscript.
This manuscript was handled by: Terese T. Horlocker, MD.
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