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Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
Address correspondence and reprint requests to Chester C. Buckenmaier III, MD, Regional Anesthesia Section, Anesthesia & Operative Services, Walter Reed Army Medical Center, Washington, DC 20307. Address e-mail to chester.buckenmaier{at}na.amedd.army.mil
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Abstract |
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 Top Abstract IntroductionCase 1DiscussionAppendix A.References |
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IMPLICATIONS: Paravertebral somatic nerve block is an alternative to general anesthesia for breast surgery. We describe a novel needle system for paravertebral catheter insertion linked to a disposable infusion pump for prolonged analgesia at home after breast surgery.
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Introduction |
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TopAbstractIntroductionCase 1DiscussionAppendix A.References |
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Case 1 |
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TopAbstractIntroductionCase 1DiscussionAppendix A.References |
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A PVB with an indwelling catheter and intraoperative sedation were planned. In the preoperative holding area, routine monitors were applied and supplemental oxygen was delivered via facemask. Midazolam 3 mg and fentanyl 150 µg IV were titrated for sedation.
In the sitting position using aseptic technique, the patient underwent single-injection PVB at 2 thoracic levels, T1 and T6, with 5 mL of 1% ropivacaine using the technique described by Greengrass and Steele (5). The T1 and T6 blocks were placed for complete surgical anesthesia of the breast. In our experience, these segments are inconsistently blocked with a single-injection block at T3.
For catheter placement at T3, a 25-gauge spinal needle was initially inserted to estimate depth of the T3 transverse process. An 18-gauge, 9-cm Tuohy needle attached to a hemostatic valve and sideport (B. Braun Medical Inc., Bethlehem, PA; Fig. 1), was then advanced to the transverse process (bevel up), walked off caudad, and advanced a maximum of 1 cm. A loss of resistance was noted as the needle passed through the superior costotransverse ligament into the paravertebral space. Correct needle location was further confirmed by decreased resistance to local anesthetic injection through the needle system by the assistant. After incremental injection of 20 mL of 0.5% ropivacaine, a 20-gauge, open-tipped epidural catheter was advanced 2 cm beyond the tip of the needle. The catheter was secured with medical adhesive, Steri-StripsTM, and a transparent dressing. A test dose of 5 mL of the local anesthetic solution was administered via the catheter. All local anesthetic solutions used contained epinephrine 1:400,000 as an intravascular marker.
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After the 2-h incident-free procedure, the patient was taken to the postanesthesia care unit (PACU) awake and pain free. Her initial pain assessment in the PACU by verbal analog scale (VAS; 0 = no pain, 10 = worst pain imaginable) was zero. The patient was transferred to the 23-h recovery care center where the same local anesthetic infusion was continued. In addition, she was given oral acetaminophen 650 mg and IV ketorolac 30 mg every 6 h. Oral and IV opioid medications were available but not used by the patient.
The following morning, the patient was pain free and was discharged home with a continuous infusion of local anesthetic via a disposable infusion pump for an additional day. The patient’s catheter was connected to an AccufuserTM 275 10 mL/h (McKinley Medical, Wheat Ridge, CO) containing 275 mL of 0.2% ropivacaine. Detailed verbal and written (see Appendix) instructions about local anesthetic toxicity, pump function, and catheter removal were given. Telephone numbers to an anesthesiologist were also provided.
The patient was contacted the following day. She remained pain free and did not use any oral opioid. A family member had no difficulty with catheter removal, and the patient was satisfied with her anesthetic care.
Case 2
A 66-yr-old woman, ASA physical status II (95 kg; 165 cm) had undergone a left lumpectomy and a axillary dissection 1 mo earlier under regional anesthesia and T3 paravertebral catheter technique. The patient presented for bilateral simple mastectomies with tissue expanders. Her history included breast cancer, hypertension, chronic bronchitis, 30 pack-year smoking, and obesity. Her oral medication included hydrochlorothiazide 50 mg daily.
The patient requested paravertebral anesthesia with catheters for her mastectomies based on her previous positive experience with the technique. Bilateral T3 paravertebral catheters were placed using the technique and medications described in Case 1. To reduce total local anesthetic dose, 5 mL of 0.5% ropivacaine was used for the bilateral T1 and T6 blocks with an additional 30 mL injected at T3 bilaterally (15 mL each side). Management of this patient in the operating room was similar to Case 1.
One hour after the start of the operation, infusions of 0.2% ropivacaine at 6 mL/h were started via each catheter (12 mL/h total). Heart rate and blood pressure measurements remained within 20% of her initial values throughout the operation.
The patient was alert and comfortable in the PACU. During her overnight stay, both paravertebral catheters were infused. Her VAS remained <2 throughout the evening with the exception of a headache rated as an 8 that was treated with morphine 4 mg IV. The patient was comfortable the following morning. AccufuserTM 5 mL/h pumps were connected to each catheter and the patient was discharged with detailed instructions as previously described. The following morning, she complained of a VAS of 4 in her right breast that she treated with 4 tablets of oxycodone 5 mg with acetaminophen 325 mg during the night. Her left breast remained pain free. Interestingly, the patient noted that the right infusion pump did not appear to be infusing because no change in the fluid reservoir was observed compared with the left pump. The catheters were removed during the telephone interview. The patient’s spouse noted that the right catheter appeared to have become dislodged and kinked under the dressing. Despite this difficulty, the patient expressed satisfaction.
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Discussion |
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TopAbstractIntroductionCase 1DiscussionAppendix A.References |
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The use of paravertebral catheters in the management of thoracic pain after surgery or trauma has been well described (6–8). Percutaneous paravertebral catheters have traditionally been placed using the method described by Eason and Wyatt (9) using loss of resistance to air or saline with needle and syringe. In contrast, our system uses equipment that allows for loss of resistance technique whereas facilitating placement of the catheter with minimal needle manipulation. The system is also closed to atmospheric pressure, thus minimizing pneumothorax development should the needle violate the pleura. The initial use of a 25-gauge spinal needle to identify the depth of the transverse process before placement of the 18-gauge Tuohy needle may also reduce the risk of patient injury. Caudad needle redirection is preferred; accidental initial needle contact with a rib will result in contact with the transverse process at a more shallow depth instead of the pleura (10).
Pneumothorax after paravertebral catheter placement is a potential disadvantage of this technique (11); however, the incidence of pneumothorax after single-injection techniques is rare when the blocks are performed by experienced anesthesiologists (2,12). Catheter placement with a larger-gauge needle may increase this risk. An additional concern, particularly in outpatients, is spread of local anesthetic into the epidural space. This could result in bilateral blockade or hypotension. To address this concern, test doses were administered through the catheters, patients were observed overnight and evaluated before discharge, and we chose local anesthetic infusions that have previously been used safely in thoracotomy patients (13).
Local anesthetic toxicity is another concern with this technique. In our experience, adult patients tolerate the dosages described well. Unfortunately, data describing blood concentrations of ropivacaine at these dosages are unavailable.
Careful patient selection for home infusion techniques is essential for success. Patients must be able to understand pump function, recognize warning signs of toxicity, and have a dedicated home care provider to assist with catheter management and removal. Patient education with written and verbal instructions on home catheter management is essential. Finally, patients must be able to communicate questions or concerns to an anesthesiologist any time during the course of the home infusion.
These cases demonstrate an alternative method of paravertebral catheter insertion and outpatient analgesia delivery for breast surgery. Further investigation examining safety and feasibility compared with conventional treatments is warranted.
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Appendix A. |
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TopAbstractIntroductionCase 1DiscussionAppendix A.References |
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Acknowledgments |
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References |
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TopAbstractIntroductionCase 1DiscussionAppendix A.References |
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  T. Sidiropoulou, O. Buonomo, E. Fabbi, M. B. Silvi, G. Kostopanagiotou, A. F. Sabato, and M. Dauri A Prospective Comparison of Continuous Wound Infiltration with Ropivacaine Versus Single-Injection Paravertebral Block After Modified Radical Mastectomy Anesth. Analg., March 1, 2008; 106(3): 997 - 1001. [Abstract] [Full Text] [PDF]
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B. M. Ilfeld and F. K. Enneking Continuous Peripheral Nerve Blocks at Home: A Review Anesth. Analg., June 1, 2005; 100(6): 1822 - 1833. [Abstract] [Full Text] [PDF]
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