Ph Gautier

ULTRASOUND-GUIDED

THORACIC PARAVERTEBRAL BLOCK

ULTRASOUND-GUIDED

THORACIC PARAVERTEBRAL BLOCK

PHILIPPE GAUTIER

Clinique Ste Anne-St Remi - CHIREC Brussels

BELGIUM

Ph Gautier

DOES ULTRASOUND GUIDED PVB OFFER ANY

ADVANTAGE OVER THE CONVENTIONAL

TECHNIQUE?

Ph Gautier

Ph Gautier

57 Y

147 cm – 80 kg (BMI=37)

Right lateral – Intubated –sedated

Severe bruising – subcutaneous emphyseme

Experienced anaethetist

PVB after Ultrasound assitance

Technique: LORA and PNS

Ph Gautier

1 contralat

1 epidural

Ph Gautier

The PVB space & the funnel concept

Spinal

process

lamina

Epidural

space

Transverse process

foramen

PLEURA

Ph Gautier

The PVB space & the funnel concept Spinal

process

lamina

Epidural

space

foramen

PLEURA

Probe tilt

lamina

dura

TP

pleura

pleura

Ph Gautier

Ph Gautier

WHICH IS THE BEST

ULTRASOUND

TECHNIQUE?

Ph Gautier

The PVB space & the funnel concept Spinal

process

lamina

Epidural

space

foramen

PLEURA

Needle tract

Ph Gautier

Introduction Anatomy techniques

Lateral PVB

Transverse

In line

Sagital

Out of plane

Medial PVB

Historical Oblique Transverse in

line

Ph Gautier USRA.CA Karmakar. Anesthesiology 2001

Transverse P

Lateral

Superfici

al

Inf Art P

Medial

Deeper

Ph Gautier Shibata.CA

lateral

Intercostal

Ph Gautier

Ph Gautier

rib

rib

lung

pleura

IC M

INTERSCOSTAL SCAN

Bony shadow

ALL WHITE LINES ARE NOT EQUAL

Ph Gautier

Ph Gautier

RIB

Parietal

pleu

ra

visceral

Innermost

muscle?

Int intercostal M

INTERSCOSTAL SCAN

Ext intercostal M

Ph Gautier

Ph Gautier

MULTIPLE LEVEL US GUIDED INTERCOSTAL NERVE BLOCKS

FOR THORACIC WALL SURGERY IN A PATIENT WITH

DUCHENE MUSCULAR DYSTROPHY.

Vandepitte, Gautier: Acta Anesth Belgica

Ph Gautier

Acta anes belgica 2013

Ph Gautier

PVB: different approaches

Lateral PVB more superficial

Better needle visualisation

close to the pleura – in line with the

foramen

intermediate level

Medial PVB deeper

poor needle visual.

closer to the foramen

advanced level

lat

ant

LUNG

Ph Gautier

Transverse scan –

Shibata

Paramedian sagital scan –

Marhofer

Oblique scan - Luyet

TECHNIQUES OF US GUIDED THORACIC PVB BLOCK

POSITIONING THE PROBE Ph Gautier

Ph Gautier

Introd Anatomy techniques

Lateral PVB

Transverse

In plane

Sagital

Out of plane

Medial PVB

Historical Oblique Transverse

out of plane Transverse in

plane

Needle: out of plane, in plane Probe:

Ph Gautier

Ph Gautier

LATERAL PVB

TRANSVERSE SCAN – IN Plane APROACH

Shibata -http://www.usra.ca

ceph

shoulder

caud hips

lat

Ph Gautier Shibata -http://www.usra.ca

Lateral P V B

TRANSVERSE SCAN – IN LINE APROACH

Renes S. R A P M: 2010 ; 35 , 212-216 Cowie. An An 2010 Bouzinac A. AFAR 2011

Ph Gautier

Ph Gautier

TP

INTERNAL INTERCOSTAL

MEMBRANE

PLEURA

Ph Gautier

TP RIB

SCAPULA

Ph Gautier

Ph Gautier

SINGLE inj

1X20 ml

DUAL inj

2X10 ml

Cowie, Barrington. A&A 2010 Cadaveric dissection of thorax after

removal of intrathoracic viscera.

ANT VIEW

Ph Gautier

After removal dissection into the

paravertebral space,

the sympathetic trunk is well visualised

with rami communicantes

and the origins of splanchnic nerves,

all surrounded with contrast dye.

Cowie, Barrington. A&A 2010

Ph Gautier

TP

Rib

Lateral P V B

TRANSVERSE SCAN – IN plane APPROACH Drawback:

The pleura

The foramen

Ph Gautier

Ph Gautier

0.2 ml

10 ml

Ph Gautier

Ph Gautier

TP

SP

Ph Gautier

Ph Gautier Manuscript in preparation

rib

0.12 ml 10 ml

TP

Ph Gautier

Anesthesiology 73

Ph Gautier

BJA 2010

Lateral P V B

Sagital SCAN –

Out of plane APPROACH

Drawback:

The Pleura

&

The needle

visualisation LA

head

lat

Ph Gautier

Introd Anatomy techniques

Lateral PVB

Transverse

In plane

Sagital

Out of plane

Medial PVB

Historical Oblique

In plane

Transverse out of plane

Transverse in plane

Needle: out of plane, in plane Probe:

Ph Gautier

Ph Gautier

Ph Gautier

• 20 punctures

– 1 pleural catheter

– 30% of epidural spread

Ph Gautier

Rib Transverse process Inf art process

Paravertebral space

PVB space

Probe position

Ph Gautier

Introd Anatomy techniques

Lateral PVB

Transverse

In plane

Sagital

Out of plane

Medial PVB

Historical Oblique Transverse

out of plane Transverse

in plane

Ph Gautier BJA 2011; 106: 246-54

Drawback ??

1/36 pleural catheter ! In cadavers!

Modern US version of the original technique

TRANSVERSE POSITION of the PROBE / Out off plane

*

Ph Gautier

PLEURAL CATHETER Paravertebral space

Interpleural block –.Anaesthesia. 2007

Ph Gautier

PLEURAL : CT explanation

Depth of the

articular process

= 6 cm

« » 0.7 cm

Pathway of

the needle &

the catheter

Ph Gautier

Introd Anatomy techniques

Lateral PVB

Transverse

In plane

Sagital

Out of plane

Medial PVB

Historical Oblique Transverse

out of plane Transverse

in plane

Ph Gautier

Modified transverse / in plane or oop approach

Theoretical approach

PVB procedure

Pilot study

CT scan-- n patients

KT at 2cm- 4cm- 6cm

Cohort study

200 breast Sx cases/ 22 months

150 PVB / (50 no block)

40 CT evaluations Manuscripts in preparation

Ph Gautier

SAFETY ISSUE: THE FORAMEN & THE PLEURA

The inf articular process

Overhangs the foramen

Ph Gautier

Ph Gautier

Ph Gautier

Ph Gautier

Exit

vector

Safer entry point / angulation: 4 cm

Approach vector

C-T SCAN THEORETHICAL APPROACH Sardesai A. Anesthesiology 2006. 105: 9-13.

Risky approach

Ph Gautier

Spinal process

Transverse process

rib

Post

lat

PVB PROCEDURE

Probe position

Spinal

process

Ph Gautier

Ph Gautier

Theorical Needle course

Due to the poor needle visualisation

A preliminary needle track is drawn

Probe position

Inf art process

Ph Gautier

Ph Gautier

The three places to go astray: the foramen, the lung, the vessels

post

ext

Ph Gautier

post

lat

INTERCOSTAL ARTERY

pleura

TP

Ph Gautier

Ph Gautier

LUNG

S P

post

lat

post

Ph Gautier

Ph Gautier

S P I n a l

Transverse process rib

pleura

pleura

pleura

inf art process

Transverse process

lamina

P R o C E S s

S P I n a l

P

s P

lat

post

S p

S p

medial

Ph Gautier

Ph Gautier

rib

trachea

scapula

A

L

LA ANESTHESIC

Infiltration

4cm

PROCEDURE LA allows the visualisation of the needle, determination of the needle axis

The TUOHY needle is advanced +/- 1 cm beyond inf. art. proc.

SAFER

Needle pathway

23 G

21 G

Ph Gautier

Ph Gautier

TRANSVERSE P

T P

Catheter management

Costo-transverse

obstacle

Costo-vertebral

obstacle

Ph Gautier

Ph Gautier

R Zuercher &

dpt of anatomy university Bale

Ph Gautier

midline

Needle entry point

cranial

Patient positioning: lat left decubitus

Ph Gautier

Head

Ph Gautier Eryk Eisenberg

Ph Gautier

Ph Gautier

PILOT STUDY

37 PVB

BOLUS:

15 ml ROPI 0.75

N= 7

Catheter

2 cm

Elastomeric b

5ml/H Ro 0.2%

N= 20

Catheter

4 cm

Elastomeric b

5ml/H Ro 0.2%

N= 10

Catheter

6 cm

Elastomeric b

5ml/H Ro 0.2%

Ph Gautier

S

P

Tip of the catheter

1 ml

Assessment of the KT

Facing the FORAMEN

PRE

VTB

Ant

PVTB post

PVTB

Ph Gautier

Ph Gautier

10 ml

ribs

Assessment of the dye spread

Ph Gautier

Ph Gautier

Paravertebral spread

Intercostal backflow

Ph Gautier 0.2 ml

ponction

Ph Gautier

CATHETER TIP – PATHWAY- spread 4 cm beyond needle tip

0.2 ml 10 ml

1 1

Ph Gautier

Ph Gautier

7 7

TP

Rib

SP 0.15 ml

TP

IAP

Ph Gautier

Ph Gautier

6 6

Ph Gautier

1 ml 10 ml

Assessment of the LA spread

fourfold: Paravertebral

ant: Σ

post

Epidural

Intercostal

backflow

Assessment of the KT

THE EPIDURAL SPREAD IS PART OF THE PVB BLOCK

31

31

PVB: different components

Ph Gautier

4 4

10 ml Ph Gautier

Ph Gautier

10 ml

Ph Gautier

Ph Gautier

continuous PVB is safe but

Drawback:

Epidural

placement of the catheter

occured at a rate of 20% ...

Solution

Once positioned in the PVB,

The bevel of the Tuohy

Must be turned externally.

TP

IAP

Ph Gautier

BLOCK CLASSIFICATION: IS THERE A PLACE FOR A NEW CATEGORY ?

BLOCKS BASIC Intermediate ADVANCED EXPERT ???

axillar Iscal Cont Iscal

PVB

Femoral

Infraclav Supraclav

Spinal punct

Popliteal PLumbarPB

Sous-gluteal

Parasacral

Pain blocks

Spinal scan

Ph Gautier

First rib

TP

Catheter :

3rd IC space

10 ml

PVB Block:

Back to the future

Ph Gautier

In case off pneumothorax suscpition:

US PLEURAL CHECK

IN THE RECOVERY ROOM

Intraoperative Pneumothorax Identified with Transthoracic Ultrasound.

Ueda K, Ahmed W, Ross A

Anesthesiology. 115(3):653-655, September 2011. + editorial