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Paravertebral  Nerve  Block   Paravertebral  Nerve  Block    Indica�ons:  Rib  fractures,  breast  surgery,  thoracic  surgery,  unilateral  abdominal  surgery,  hernia  repair.    Benefits:  Less  hypotension  than  epidurals,  poten�al  for  outpa�ent  use    Complica�ons(  <2.6%):    Epidural  spread,  paraspinal  muscle  spasm,  Brachial  plexus  block,  pressure  parathesia,  pneumothorax.    Breast  surgery:  General  anesthesia  vs  associa�on  with  PONV.  

PVB  vs  Epidural  for  Thoracotomy  

Less hypotension with PVBs

Pintaric et al, RAPM 2011

Paravertebral  Nerve  Block:  In-­‐plane  approach  

Paravertebral:  Rib  vs.  Pleura   Paravertebral:  Probe  Posi�on  Transverse Process Pleura

Move probe slightly caudal to obtain pleura only (no transverse process) Now probe is exactly intercostal Intercostal muscles Pleura

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Paravertebral:  Probe  Posi�on   In-­‐Plane  Paravertebral  Nerve  Block  

Pleura  

MEDIAL

LATERAL

Endothoracic fascia

Paramedian  Saggital  Scanning:  Probe  Posi�on  

Parasaggital  In-­‐Plane  Paravertebral  Block  

CAUDAL

CRANIAL

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Parasaggital  In-­‐Plane  Paravertebral  Block  

CAUDAL

CRANIAL

Parasaggital  Out-­‐Of-­‐Plane  Paravertebral    CAUDAL

CRANIAL

Paravertebral  Spread:  Endothoracic  fascia  

If underneath the endothoracic fascia, the longitudinal spread pattern is observed. Njaa et al, Anaesthesia 2004

Out-­‐of-­‐Plane  Paravertebral  Block  

Glue Secure with Dressings

Paravertebral  Details  o  Primary  Anesthe�c  

–  Mul�ple  injec�on  technique,  every  level  works  best  –  5  –  10mL  at  each  level  –  0.5%-­‐1%  Ropivacaine  with  1:400,000  epi  –  Be  wary  of  rapid  systemic  absorp�on  

o  Catheters  –  Put  catheter  in  middle  of  incision  –  Example:  T4  catheter  for  mastectomy  –  Run  at  6-­‐10mL/hr  

o  Post  op  pain  –  Single  Injec�on  –  Ok  to  skip  levels  (example:  T2,  T4,  T6)  –  Injec�on  of  larger  volumes  (10-­‐25mL)  –  Error  above  the  target  site  (injectate  spreads  preferen�ally  caudal)  –  8-­‐24  hours  analgesia  

Paravertebral  Absorp�on  

Use epinephrine to delay absorption. Karmakar 2005 et al, Anesthesiology 2005

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Paravertebral  Spread  

Larger volume / kg resulted in more spread. Njaa et al, Anaesthesia 2004

Paravertebral  Spread  

20mL injectate resulted in 3-4 level spread on MRI. Marhofer et al, Anesthesiology 2013

Paravertebral  Spread  

Spread is highly variable and multiple injections work best for full coverage. Cowie et al, Anesth Analg 2010