Anesthesiology, Article

A modified paravertebral block to reduce risk of mortality in a patient with multiple rib fractures

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

A modified paravertebral block to reduce risk of mortality in a patient with multiple rib fractures?,??

Abstract

The risk of mortality due to multiple rib fractures elevates with in- creasing age or severity of injury. Although sufficient pain relief with thoracic epidural block or paravertebral block has been recommended for prevention of critical pneumonia that causes late death, their indica- tions are limited in patients with coagulation disorder. We tested a new modified ultrasound-guided paravertebral block, retrolaminar block (RB)/costovertebral canal block (CVCB), instead of the recommended regional analgesic techniques in a 79-year-old multiple-injured man with routine Antiplatelet therapy. He had rib fractures (mainly left Th5, 6) and other multiple injuries. Despite initial pain management with systemic fentanyl, maintenance of Arterial oxygen saturation greater than 90% had become difficult due to left chest pain when coughing. On the third day, the ultrasound-guided RB/CVCB was started with 30 mL of 0.5% ropivacaine 3 times a day through a catheter placed on the Th5 lamina, which reduced the intractable pain down to numer- ical rating scale of 1-2/10. With this improved pain management, he was able to avoid tracheal intubation and mechanical ventilation and had gradual recovery of oxygenation. Because the ultrasound-guided RB/CVCB is based on a concept of injecting Local anesthetics above the lamina, accidental hemorrhage due to puncture of vessels located beyond the transverse process can be prevented. In addition, visualizing the tip of advancing needle with ultrasound guidance allows operators to safely ac- complish the block without requiring particular positioning. Thus, the ultrasound-guided RB/CVCB may be an alternative analgesic technique to reduce the risk of mortality in patients with multiple rib fractures.

The risk of mortality due to multiple rib fractures elevates with increas- ing age or severity of injury [1]. Posttraumatic pneumonia is one of the most important risk factors of late death, even if patients escape from im- mediate death after trauma [2,3]. Sufficient pain relief to facilitate coughing up with regional analgesic techniques such as thoracic epidural block or paravertebral block rather than systemic opioids has been recommended for prevention of critical pneumonia [4,5]. However, their indications are limited in patients with coagulation disorder caused by trauma-induced hemorrhage or routine anticoagulant and/or antiplatelet therapy.

Recently, 2 groups of physicians have reported a novel modified tech- nique of paravertebral block using ultrasound guidance for ipsilateral an-

? Funding: Supported by the Department of Emergency and Disaster Medicine and the Department of Anesthesiology, Hirosaki University Graduate School of Medicine.

?? Presentations: This case was presented at the 41st Annual Meeting of Japanese Soci-

ety of Intensive Care Medicine in Kyoto, Japan, February-March 2014.

algesia of the trunk, which is available to patients with coagulation disorder, and suggested the name ultrasound-guided retrolaminar block (RB) [6] or costovertebral canal block (CVCB) [7]. Ultrasound-guided RB/CVCB has been shown to provide successful analgesia in relatively younger patients with isolated rib fractures [6], whereas it has been un- known whether the block would effectively improve prognosis in trauma patients with greater risks of mortality as recommended regional analge- sic techniques. Thus, we report here a case of pain management with the ultrasound-guided RB/CVCB in an elderly patient with severe multiple in- juries including rib fractures who successfully returned to his daily life.

A 79-year-old man with antiplatelet medication, 100 mg of aspirin, for cerebral infarction suffered from thoracic and abdominal Blunt injuries when he fell off a car for spraying pesticide. Contrast-enhanced computed tomography revealed multiple rib fractures (left Th3, 5-11, and right Th6, 7), left pneumothorax, lumbar spine transverse process fractures (left L2- 5), and Retroperitoneal hematoma with active contrast extravasation, which was subsequently treated with transcatheter arterial embolization. His injury was classified as very severe: 26 on the Injury Severity Score [1]. Fig. 1 shows the clinical course of respiratory variables and pain re- lief. Despite initial pain management with continuous infusion and Bolus injections of fentanyl, his respiratory status had been deteriorat- ing with a venturi mask at increased inspired oxygen of 0.6 because of left chest pain when coughing. Because the patient had received anti- platelet therapy, we tried the ultrasound-guided RB/CVCB to relieve the intractable pain after having confirmed that the displaced rib frac- tures (left Th5, 6) mainly caused the respiratory deterioration using in- tercostal nerve blocks. The patient was placed in right lateral position without neck flexion or knee-chest position. When the tip of the needle reached to the left Th5 lamina in a sagittal view showing a series of tho- racic laminas obtained ?1 cm lateral to the spinous processes (Fig. 2), a catheter was placed. Routine injections of 30 mL of 0.5% ropivacaine 3 times a day through the catheter provided satisfactory pain relief: loss of cold sensation at left Th3-9 dermatomes and the numerical rating scale when coughing of 1-2/10. The systemic fentanyl had become un- necessary by the 10th day despite RB/CVCB having been discontinued on the 9th day. As pain management improved, oxygenation gradually recovered without tracheal intubation or mechanical ventilation being

required prior to the patient’s transfer to a rehabilitation hospital.

The ultrasound-guided RB/CVCB derives from the thoracic paravertebral block in the lamina technique, in which placement of a needle depends on the anatomical landmarks and the sense of contact with lamina [8,9]. Recently, Voscopoulos et al [6] clearly reported the re- lationship between such anatomical landmarks and ultrasound images. They also discussed that local anesthetics injected posteriorly to the

0735-6757/(C) 2014

Fig. 1. Clinical course of respiratory variables and pain relief. FIO2, fraction of inspired oxy- gen (?); SpO2, arterial oxygen saturation (?); NRS, Numeric rating scale (?); ICNB, inter- costal nerve block. An asterisk shows a bolus injection.

lamina may penetrate the paravertebral space to reach the dorsal ramus of the spinal nerve. In contrast, Satoh [7] showed using x-ray fluorosco- py that local anesthetics were vertically distributed in a canal-like area and suggested the name costovertebral canal, which consists of the spi- nous processes, the lamina, and the muscle of back proper: 3:7, domi- nantly caudad. In this present case, we chose an injection site according to this reported vertical distribution rate; ropivacaine injected at the Th5 lamina provided ipsilateral loss of cold sensation of 7 dermatomes that ranged from Th3 to Th9, which led to satisfactory pain relief for recovery of deteriorated respiratory condition.

The ultrasound-guided RB/CVCB has 3 advantages over the thoracic epidural block or the thoracic paravertebral block in emergency medical conditions. First, the ultrasound-guided RB/CVCB is available for pa- tients with coagulation disorder. The ultrasound-guided RB/CVCB is based on a concept of injecting local anesthetics above the lamina, which can prevent accidental puncture of vessels, nerves, or pleura placed beyond the transverse process. Second, particular positioning such as neck flexion and knee-chest position is not needed. Besides

Fig. 2. Sagittal ultrasound image showing RB/CVCB. We used an ultrasound machine with a convex probe (Micromaxx, SonoSite, Bothell, WA) and an 18G Tuohy needle.

the sitting position [6], this present case showed that lateral decubitus position was also acceptable. Third, ultrasound guidance may allow operators even with less skilled hands to safely accomplish the block by visualizing the tip of advancing needle. Thus, the ultrasound- guided RB/CVCB may be an alternative analgesic technique to reduce the risk of mortality in patients with multiple rib fractures.

Acknowledgment

The authors thank Dr Yutaka Sato (Department of Anesthesia, Tsugaru General Hospital, Goshogawara, Japan) and Dr Paul Hollister (Misawa, Japan) for their valuable comments.

Hitoshi Yoshida, MD, PhD* Shinya Yaguchi, MD

Department of Emergency and Disaster Medicine Hirosaki University Graduate School of Medicine

Hirosaki, Aomori, Japan

*Corresponding author. Department of Emergency and Disaster Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan Tel.:+81 172 39 5429; fax:+81 172 39 5316

E-mail address: hyoshida@cc.hirosaki-u.ac.jp

Atsufumi Matsumoto, MD, PhD Department of Endocrinology and Metabolism Hirosaki University Graduate School of Medicine

Hirosaki, Aomori, Japan

Hiroyuki Hanada, MD, PhD Department of Emergency and Disaster Medicine Hirosaki University Graduate School of Medicine

Hirosaki, Aomori, Japan

Hidetomo Niwa, MD, PhD Masatou Kitayama, MD, PhD Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan

http://dx.doi.org/10.1016/j.ajem.2014.10.032

References

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