50th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

Case Report: Optimizing Post-Operative Pain Management After Thoracic Surgery using Paravertebral Blocks and Catheters

Shauna Maty, MD, MPH1; Aidan Hoie, MD1; Matthew Lyman, MD1; Jacob Loyd, MD1

University of Colorado Anschutz1

Introduction:

Paravertebral blocks (PVBs) and paravertebral catheters (PVCs) are gaining attention for pain control in thoracic surgery
PVBs and PVCs have been shown to provide effective pain control, improve cardiovascular stability, enhance respiratory function, and reduce complications
This case report further explores the benefits of PVBs/PVCs in a patient undergoing extensive chest wall and mediastinal resection, contributing to the growing body of evidence supporting their use in thoracic surgery

Case Report:

24-year-old female with a past medical history of asthma, daily marijuana use, and recurrent mediastinal follicular dendritic sarcoma, status post sternotomy and resection presented for surgery to resect a left anterior mediastinal & chest wall mass
Underwent a partial manubriectomy and sternectomy, partial rib resection, left partial claviculectomy, and reconstruction of the chest wall
Preop: Acute Pain Service performed bilateral PVBs using 0.25% bupivacaine + 10mg dexamethasone
20cc local on L T2-3. 10 cc local on L T3-4, and 15cc local R T3-4
POD 1: the PVBs provided excellent initial pain relief but wore off by the afternoon, so a left-sided paravertebral catheter (PVC) was placed at T6-7
20cc bolus of 0.25% bupivacaine followed by a continuous infusion of 0.2% ropivacaine at 8cc/hr
POD 4: chest tube removed
POD 6: patient transitioned to oral pain control and PVC was weaned off and removed
POD 7: patient was discharged on stable oral pain regimen

Main Takeaways:

A case report illustrating successful paravertebral blocks in conjunction with paravertebral catheter placement for partial manubriectomy and sternectomy, partial rib resection, left partial claviculectomy, and reconstruction of the chest wall in a 24-year-old patient with recurring follicular dendritic sarcoma

Literature review highlights strong evidence supporting the efficacy of PVB/PVC over thoracic epidurals in thoracic surgery, particularly in terms of fewer complications, shorter hospitalizations, and largely equal pain control profile
Given the location of the surgery and the very high placement of the PVBs and PVC, there is a paucity of data involving paravertebral catheter placement in similar cases

Discussion:

Kalaca & Pribish showed effective pain control with T1 and T2 PVBs followed by T1 PVC after first rib resection
Elsayed et al. found PVB/PVCs offered better cardiovascular stability, improved respiratory function, less urinary retention, and shorter hospital stays compared to thoracic epidurals
Vogt et al. demonstrated significant reductions in postoperative pain with single-shot paravertebral blocks
Improving pain management in similar scenarios with consideration of PVC placement prior to PVB resolution
This case supports the potential benefits of PVB/PVCs in high thoracic surgery, even in patients with complex pain management needs, such as this young marijuana user

Resources:

Kalava A, Pribish AM. T1 Paravertebral Catheter for Postoperative Pain Management After First Rib Resection for Venous Thoracic Outlet Syndrome: A Case Report. A A Pract. 2018 Jul 1;11(1):1-3. doi: 10.1213/XAA.0000000000000698. PMID: 29634572.
Elsayed H, McKevith J, McShane J, Scawn N. Thoracic epidural or paravertebral catheter for analgesia after lung resection: is the outcome different? J CardiothoracVascAnesth. 2012 Feb;26(1):78-82. doi: 10.1053/j.jvca.2011.09.019. Epub 2011 Nov 16. PMID: 22088752.
Vogt A, Stieger DS, Theurillat C, Curatolo M. Single-injection thoracic paravertebral block for postoperative pain treatment after thoracoscopic surgery. Br J Anaesth. 2005 Dec;95(6):816-21. doi: 10.1093/bja/aei250. Epub 2005 Sep 30. PMID: 16199417.

CASE REPORT: OPTIMIZING POST-OPERATIVE PAIN MANAGEMENT AFTER THORACIC SURGERY USING PARAVERTEBRAL BLOCKS AND CATHETERS