title: Continuous thoracic paravertebral infusion of bupivacaine for pain management in patients with multiple fractured ribs.
abstract: 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.
authors.affiliation: 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
authors.forename: Manoj K
authors.initials: MK
authors.lastname: Karmakar
authors.forename: Lester A H
authors.initials: LA
authors.lastname: Critchley
authors.forename: Anthony M-H
authors.initials: AM
authors.lastname: Ho
authors.forename: Tony
authors.initials: T
authors.lastname: Gin
authors.forename: Tak Wai
authors.initials: TW
authors.lastname: Lee
authors.forename: Anthony P C
authors.initials: AP
authors.lastname: Yim
mesh_terms: 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*
chemical_list: D002045:Bupivacaine