Ultrasound-guided continuous paravertebral block in isolated thoracic trauma – providing sufficient analgesia for weaning and non-invasive-ventilation (NIV) on ICU for a 46 year old patient after high-speed trauma

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Purpose:

After acute high-velocity injury it is desirable to avoid thoracic epidural analgesia to povide neurological examination of the spinal cord function. Systemic analgesia is often insufficient to tolerante non-invasive ventilation (NIV) in massive thoracic trauma and often leads to reintubation and subsequent dilation tracheotomy.

Patient and Methods:

A 46 year old Pat. (ASA I) suffered from a high speed injury with prolonged extrincation, during which he required intubation and a thoracic drain. Following the standard trauma diagnostic in our institution (FAST & whole-body-trauma-CT) only a massive left sided thoraxtrauma (Rib fractures I – XI, haematopneumothorax and dorsal lung consolidation) could be revealed. The patient was scheduled for extubation and NIV. After reaching normothermia on ICU and good blood gas values in prone position (left side up) a continuous paravertebral block (cPVB) was placed in the 5th intercostalspace using ultrasound-guided (LAX – in-plane) technique (1) under sterile conditions and tunneling (2).

Results:

After a bolus of 10mlRopivacaine 0,375% the patient was turned on his back and successfully extubated 45 Minutes later and NIV could be supplied immediately (VAS <4). The spread of hypaesthesia covered the segments Th2– Th7. The continous infusion of Ropivacain 0,33% (8ml/h) was gradually reduced. After 5 days extensive NIV on ICU the catheter was paused and on the sixth day removed. The patient was then transfered to a normal ward. A second patient was subsequently treated according to the same regime two month later, which provide again a profund analgetic quality.

References:

1.) Ben-Ari et al.; Anesth Analg 2009; 109: 1691–4

2.) Reisig et al.; Anaesthesist 2011; 60: 942–945

3.) Agnoletti et al.; Br J Anaesth 2011; 106: 916–7

4.) Lyet et al.; Br J Anaesth. 2011; 106: 246–54

5.) Rens et al.; Reg Anesth Pain Med. 2010; 35:212–6.

Conclusion: The placement of a cPVB provided good analgesia for an acute isolated throax trauma. This finding is comparable to results derived from elective thoracic surgery (3). The spread of analgesia was comparable to recent findings in cadaver studies (4) and in preliminary clinicalsudies (5) as well.

Ultrasound guided continous paravetebral analgesia in the hands of the experienced sonographer is an excellent alternative for cases where thoracic epiduralshould be avoided.

regional anaesthesia - nerve block - ultrasound - paravertebral block - acut pain therapy - ICU