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REGIONAL ANESTHESIA

Intercostally Placed Paravertebral Catheterization: An Alternative Approach to Continuous Paravertebral Blockade

David A. Burns, MD^*, Bruce Ben-David, MD, Jacques E. Chelly, MD, PhD, MBA, and J. Eric Greensmith, MD, PhD

From the *Department of Anesthesiology, Director of the Regional Anesthesia Fellowship Program and Associate Division Chief of Acute Pain Management Services, Pennsylvania State Hershey Medical Center, Pennsylvania; Department of Anesthesiology, University of Pittsburgh Medical Centers and Associate Director of the Acute Interventional Perioperative Pain Service, UPMC Presbyterian-Shadyside Hospital, Pennsylvania; Department of Anesthesiology, University of Pittsburgh Medical Centers and Director of Orthopedic Anesthesia and Acute interventional Perioperative pain, UPMC Presbyterian-Shadyside Hospital, Pittsburgh, Pennsylvania; and Department of Anesthesiology and Division Chief of Acute Pain Management Services, Pennsylvania State Hershey Medical Center, Pennsylvania.

Address correspondence and reprint requests to David A. Burns, MD, PA State Hershey Medical Center, Department of Anesthesiology, H187 Room C2830, 500 University Drive, Hershey, PA 17033. Address e-mail to dburns{at}hmc.psu.edu.

	Abstract

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BACKGROUND: Continuous paravertebral nerve blocks can provide effective postoperative analgesia after abdominal and thoracic surgery. While offering a number of advantages compared with thoracic epidural analgesia, access to the paravertebral space using a classic approach is not always easily accomplished and/or possible. In this regard, continuous paravertebral blockade via a percutaneous intercostal approach may theoretically serve as an alternative approach to the paravertebral space.

METHODS: One hundred ten patients undergoing major abdominal, thoracic, or retroperitoneal procedures had preoperative placement of unilateral or bilateral paravertebral catheter(s) via an intercostal approach. At a point 8 cm lateral to the midline a 5 cm, 18 G Tuohy needle was advanced with the needle tip angled 45 degrees cephalad and 60 degrees medial to the sagittal plane to come in contact with the lower third of the rib. The needle was "walked-off" the inferior border of the rib while maintaining its orientation and advanced a further 5 to 6 mm under the rib to lie in the subcostal groove. After injection of 5 mL ropivacaine 0.5%, a catheter was advanced medially the estimated distance to the paravertebral space. Postoperatively 0.2% ropivacaine was continuously infused at 10 mL/h in each catheter with hourly boluses of 5 mL available for breakthrough pain.

RESULTS: Median pain scores averaged 2 on a scale of 0–10 and patient-controlled analgesia hydromorphone consumption averaged only 1.69 mg for the first 24 h postoperatively. There were no clinically significant complications of the technique.

CONCLUSION: The intercostally placed paravertebral catheter provides postoperative analgesia after major surgery of the chest, abdomen, or retroperitoneum.

	Introduction

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Continuous paravertebral nerve block has the advantages of equivalent analgesia as an epidural technique but with less risk of block failure, dural puncture, cord trauma, and clinically significant side effects, including hypotension. Additionally, urinary catheterization is not necessary.1

The classical approach to the paravertebral space uses a needle insertion lateral to the spinous process,2 but presents several disadvantages. The technique is unfamiliar to many practitioners and may be technically difficult, particularly with regard to passage of the catheter.3 Although uncommon, there is a risk of inadvertent neuraxial placement of the needle or of potentially puncturing a dural sleeve with subsequent intrathecal injection.4 Additionally, nearly 10% of patients have a clinically significant parasympathetic discharge at needle placement, resulting in hypotension, bradycardia, and near syncope.5 Furthermore, continuous paravertebral nerve block may also be problematic in patients with spinal anomalies, trauma, or a history of spine surgery.

In light of the significant advantages of continuous paravertebral nerve block and with recognition of its shortcomings, we describe an alternative technique for continuous paravertebral block, an intercostally placed paravertebral catheter. This technique takes advantage of the continuity between the intercostal and paravertebral spaces to provide a method of continuous paravertebral blockade that may offer advantages over classical continuous paravertebral nerve block.

	METHODS

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Data prospectively collected by the acute pain service of 143 patients, ASA physical status 1 to 3, who received an intercostally placed paravertebral catheter, were reviewed after IRB approval. Thirty-three patients met exclusion criteria that included preoperative opioid consumption or other adjuvant pain medications and patients who remained ventilated postoperatively for surgical reasons, as many of these patients were heavily sedated, making meaningful pain scores and opioid requirements impossible to obtain.

All blocks were performed in a preoperative area before surgery by the same anesthesiologist (D.B.). After placement of an IV and standard monitors, each patient was positioned seated. The appropriate rib (at the midpoint of the anticipated surgical incision) was marked 8 cm lateral to the midline. Patients were sedated with 0–1 mg of midazolam and/or 0–50 µg of fentanyl IV. After standard skin disinfection with chlorhexidine gluconate, the skin and periosteum of the rib were anesthetized with 1% lidocaine. A 5 cm, 18 G, Tuohy needle was advanced to come in contact with the rib. The needle was then oriented, with the bevel directed medially, such that the tip was angled 45 degrees cephalad and 60 degrees medial to the sagittal plane (Fig. 1). This angle of needle entry facilitates catheter advancement toward the paravertebral space in the desired tissue plane and may reduce the likelihood of pleural puncture by presenting the needle's rounded "shoulder" against the pleura. The needle was "walked-off" the inferior border of the rib while maintaining its orientation. Once under the rib it was advanced a further 5–6 mm to enter the intercostal neurovascular space. Five milliliters of 0.5% ropivacaine was injected after which a 20 G polyamide catheter was advanced through the needle and left at the skin at a distance of 8 cm plus the needle depth, bringing its tip to the paravertebral space (Fig. 2).

View larger version (101K): [in this window] [in a new window]   Figure 1. The needle tip is directed 45 degrees cephalad and 60 degrees medial to the sagittal plane with the bevel directed medially to allow directed egress of the catheter toward the paravertebral gutter.

View larger version (50K): [in this window] [in a new window]   Figure 2. Injection of 10 mL contrast dye via the intercostal catheter reveals both extrapleural and paravertebral spread over multiple levels. Dye spread is 2 levels cephalad and 3 levels caudad to the catheter tip with the 10 mL injection. Arrow indicates the path of the catheter.

All patients received a general anesthetic for surgery consisting of propofol, neuromuscular blockade, a volatile anesthetic, and fentanyl as the only narcotic given. Postoperatively in the postanesthesia care unit, an infusion of 0.2% ropivacaine was commenced at a rate of 10 mL/h and increased to 12 mL/h if greater spread of local anesthetic was required. The nursing staff could administer supplemental bolus doses of 5 mL/h as needed for pain scores more than 5/10. Concurrently, patients were provided hydromorphone patient-controlled analgesia (PCA). Nursing staff recorded pain scores both at rest and with activity at least every 2–4 h along with the quantity of PCA hydromorphone usage.

	RESULTS

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All patients were assessed daily by the acute pain service for effectiveness and complications. No clinically apparent pneumothorax, nerve injury, hematoma, infection, or neuraxial blockade was observed. No patient experienced a vasovagal response at catheter placement.

Over the first 24 h after surgery, patients’ median pain scores were maintained at an average of 2 on a scale of 0–10. Total PCA hydromorphone consumption averaged 1.69 mg for this first 24-h period (Table 1). All catheters were maintained to provide postoperative analgesia for 3–9 days until the patients tolerated oral intake. Boluses given ranged from none to 6 in the first 24 h.

Injection of 10 mL contrast medium was used in six cases to document intercostally placed paravertebral catheter placement and local anesthetic spread (Fig. 2).

	DISCUSSION

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Intercostal nerve block has been used for many years for a wide variety of surgical cases. Unfortunately, this technique requires multiple injections and has a limited duration of action. Catheterization of the intercostal space has been performed under direct vision by thoracic surgeons for decades with variable success.6 Our intercostally placed paravertebral catheter approach to paravertebral blockade differs from the surgical approach in that we preoperatively introduce 8 cm of catheter into the intercostal space with advancement toward the paravertebral space.

Our data provide evidence that the use of an intercostally placed paravertebral catheter was associated with only mild postoperative pain and limited opioid consumption. In the absence of a control group, it is difficult to quantify the true analgesic efficacy of this technique. Since we did not formally assess the presence of paravertebral block, failures may have occurred. Importantly, the opioid consumption observed in our series was 63% less than the one reported with a surgically positioned continuous intercostal block.6 Although this series had no complications of the block, a larger number of patients is required to evaluate absolute and relative safety compared with conventional techniques.

In conclusion, the intercostally placed paravertebral catheter technique of continuous paravertebral blockade is an interesting alternative for postoperative analgesia. The technique seems to provide all of the benefits of the classical approach to continuous paravertebral nerve block with the added advantages of the simplicity of a more superficial anatomy, and the applicability to certain patients who may not otherwise be good candidates for classical continuous paravertebral nerve block. Further studies are warranted to substantiate the efficacy and safety of the technique.

	Footnotes

 
Accepted for publication March 12, 2008.

Work performed at UPMC Presbyterian-Shadyside with funding from the Department of Anesthesiology, University of Pittsburgh School of Medicine.

	REFERENCES

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1. Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side effects of paravertebral vs. epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials. Br J Anaesth 2006;96:418–26[Abstract/Free Full Text]
2. Eason MJ, Wyatt R. Paravertebral thoracic block —a reappraisal. Anaesthesia 1979;34:638–42[Web of Science][Medline]
3. Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade: failure rate and complications. Anaesthesia 1995;50: 813–5[Web of Science][Medline]
4. Lekhah B, Bartley C, Conacher ID, Nouraei SM. Total spinal anesthesia in association with insertion of a paravertebral catheter. Br J Anaesth 2001;86:280–2[Abstract/Free Full Text]
5. Merman R, Burman K, Uskova, A, Chelly JE. Hypotensive bradycardic events and paravertebral blocks in the sitting position. Anesth Analg 2006;102:S–134
6. Watson DS, Panian S, Kendall V. Pain control after thoracotomy: bupivacaine versus lidocaine in continuous extra pleural intercostal nerve blockade. Ann Thorac Surg 1999;67:825–9[Abstract/Free Full Text]

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