Ph Gautier ULTRASOUND-GUIDED THORACIC PARAVERTEBRAL BLOCK ULTRASOUND-GUIDED THORACIC PARAVERTEBRAL BLOCK PHILIPPE GAUTIER Clinique Ste Anne-St Remi - CHIREC Brussels BELGIUM
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