Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs.
OBJECTIVE
To evaluate the efficacy of a continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with unilateral multiple fractured ribs (MFR).


METHODS
Prospective nonrandomized case series.


METHODS
Multidisciplinary tertiary hospital.


METHODS
Fifteen patients with unilateral MFR.


METHODS
Insertion of a catheter into the thoracic paravertebral space. We administered an initial injection of 0.3 mL/kg (1.5 mg/kg) bupivacaine 0.5% with 1:200,000 epinephrine followed 30 min later by an infusion of bupivacaine 0.25% at 0.1 to 0.2 mL/kg/h for 4 days.


RESULTS
The following parameters were measured during the initial assessment before thoracic paravertebral block (TPVB), 30 min after the initial injection, and during follow-up on day 1 and day 4 after commencing the infusion of bupivacaine: visual analog pain score at rest and during coughing; respiratory rate; arterial oxygen saturation (SaO(2)); bedside spirometry (ie, FVC, FEV(1), FEV(1)/FVC ratio, and peak expiratory flow rate [PEFR]); arterial blood gas measurements; and O(2) index (ie, PaO(2)/fraction of inspired oxygen ratio). There were significant improvements in pain scores (at rest, p = 0.002; during coughing, p = 0.001), respiratory rate (p < 0.0001), FVC (p = 0.007), PEFR (p = 0.01), SaO(2) (p = 0.04), and O(2) index (p = 0.01) 30 min after the initial injection, which were sustained for the 4 days that the thoracic paravertebral infusion was in use (p < 0.05). PaCO(2) did not change significantly after the initial injection, but on day 4 it was significantly lower than the post-TPVB value (p = 0.04). One patient had an inadvertent epidural injection, and another developed transient ipsilateral Horner syndrome with sensory changes in the arm. No patient exhibited clinical signs of inadvertent intravascular injection or local anesthetic toxicity.


CONCLUSIONS
Our results confirmed that continuous thoracic paravertebral infusion of bupivacaine is a simple and effective method of providing continuous pain relief in patients with unilateral MFR. It also produced a sustained improvement in respiratory parameters and oxygenation.
Karmakar
Manoj K
MK
Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong. karmakar@cuhk.edu.hk
Critchley
Lester A H
LA
Ho
Anthony M-H
AM
Gin
Tony
T
Lee
Tak Wai
TW
Yim
Anthony P C
AP
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015360:Analgesia, Epidural; D002045:Bupivacaine; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000188:drug therapy*; D010147:Pain Measurement; D011446:Prospective Studies; D012253:Rib Fractures / Q000503:physiopathology*; D013904:Thoracic Vertebrae; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000503:physiopathology*
D002045:Bupivacaine