Paravertebral block restore diaphragmatic motility ...

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Jul 24, 2017 - tive method of assessing the diaphragmatic motion in normal and pathological situations [2]. The norm of mean diaphragmatic excursion.
Journal of Clinical Anesthesia 42 (2017) 55–56

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Journal of Clinical Anesthesia

Correspondence Paravertebral block restore diaphragmatic motility measured by ultrasonography in patients with multiple rib fractures☆ Keywords: Paravertebral block Paravertebral catheter Diaphragmatic dysfunction Ultrasound diaphragmatic course Chest wall traumatism Rib fractures

To the Editor Multiple rib fractures are associated with severe pain, leading to alteration of pulmonary function. Paravertebral block (PVB) rather than systemic opioids have been recommended for prevention of critical pneumonia due to sufficient pain relief to facilitate coughing up [1]. Sonographic evaluation of the diaphragm is an accepted qualitative method of assessing the diaphragmatic motion in normal and pathological situations [2]. The norm of mean diaphragmatic excursion is 18 ± 3 mm during quiet breathing and 66 ± 13 mm during deep breathing [2]. The aim of our study was to evaluate the ability of PVB to restore diaphragmatic motility in patients with unilateral multiple rib fractures. This prospective observational study was conducted in the intensive care unit of Narbonne Hospital (France). Ten patients admitted for multiple rib fractures with a numerical pain rating scale (NPRS) at rest ≥3 were included. The Ultrasound-guided PVB was centred on the fractured zone. The sagittal technique at the Transverse Process, in-plane, was used [3]. The 16 gauge Tuohy's needle was inserted in-plane at the lower border of the transducer and advanced in a cephalad position with real-time ultrasound sonography. When the needle tip was placed in the paravertebral space, 25 ml of 0.375% ropivacaine was slowly injected after negative aspiration. The catheter was then inserted through the needle and positioned up to 5 cm from skin entry directing upwards in the paravertebral space. A patient controlled analgesia was connected to the paravertebral catheter with a continuous infusion of 0.375% ropivacaine at a rate of 3 ml/h plus a bolus dose of 7 ml with a lockout time of 2 h. During the night a bolus dose was systematically triggered each 4 h by the nurses. If the NPRS on coughing was N5 or if the patient requested additional analgesia, a supplemental bolus of 15 ml was injected each 24 h. The paravertebral catheter was removed when the patient requested no bolus dose, without exceeding 7 days.

☆ Disclosures: We disclose no financial conflict of interests.

http://dx.doi.org/10.1016/j.jclinane.2017.08.019 0952-8180/© 2017 Elsevier Inc. All rights reserved.

Diaphragmatic excursion was assessed using a low frequency probe (2–4 MHz) posterolaterally [4]. After identifying the dome of the hemidiaphragm, its excursion was measured in the M-mode during rest and forced inspiration. The measurements were performed before PVB, 30 min, 2 h, 24 h, and 48 h after the PVB. Differences between pre-PVB and post-PVB measurements were assessed by paired t-test or Wilcoxon signed rank. A two-sided p-value b 0.05 was considered significant. Diaphragmatic excursion during deep breathing was significantly improved 30 min after PVB (Fig. 1): the increase of the diaphragmatic course during forced inspiration was 10 ± 6 mm on the wounded side and 12 ± 9 mm on the healthy side. During tidal respiration, only the wounded side showed a significant improvement of diaphragmatic excursion (6 ± 5 mm). NPRS at rest was significantly reduced 30 min after PVB (Pre PVB: 4 [range, 3–7] versus 1 [range, 0–3] 30 min after PVB, p b 0.01). Similarly, NPRS at cough was significantly reduced 30 min after PVB (Pre PVB: 9 [range, 7–10] versus 3 [range, 0–5] 30 min after PVB, p b 0.01). The benefits of the PVB were maintained during the 48 h of follows-up. The median [range] duration of paravertebral catheter was 5 [2–7] days. No complication of regional anaesthesia appeared. The systematic decrease of NPRS after PVB could explain the increase of diaphragmatic excursion during deep breathing. This is in accordance with previous studies showing the analgesic efficacy of PVB for chest trauma [5]. Moreover, because there is no need for use of opioids, respiratory depression, urinary retention, pruritus, nausea and constipation are not concerns with PVB [1]. In conclusion, PVB improved significantly diaphragmatic motility in patient with multiples rib fractures, particularly during forced inspiration. Acknowledgements This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References [1] Ho AM, Karmakar MK, Critchley LA. Acute pain management of patients with multiple fractured ribs: a focus on regional techniques. Curr Opin Crit Care 2011;17:323–7. [2] Boussuges A, Gole Y, Blanc P. Diaphragmatic motion studied by m-mode ultrasonography: methods, reproducibility, and normal values. Chest 2009;135: 391–400. [3] Krediet AC, Moayeri N, van Geffen GJ, Bruhn J, Renes S, Bigeleisen PE, et al. Different approaches to ultrasound-guided thoracic paravertebral block: an illustrated review. Anesthesiology 2015;123:459–74. [4] Borgeat A, Perschak H, Bird P, Hodler J, Gerber C. Patient-controlled interscalene analgesia with ropivacaine 0.2% versus patient-controlled intravenous analgesia after major shoulder surgery: effects on diaphragmatic and respiratory function. Anesthesiology 2000;92:102–8. [5] Yeying G, Liyong Y, Yuebo C, Yu Z, Guangao Y, Weihu M, et al. Thoracic paravertebral block versus intravenous patient-controlled analgesia for pain treatment in patients with multiple rib fractures. J Int Med Res 2017 300060517710068.

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Fig. 1. Time course and extent of diaphragmatic excursion measured by ultrasonography before (Pre PVB) and after paravertebral block (30 min, 2 h, 24 h and 48 h). The hemidiaphragmatic excursion was measured on the wounded side (A) and on the healthy side (B) during deep breathing (reed line) and quiet breathing (blue line). Values are expressed as mean ± SD. * p b 0.05 versus Pre PVB during deep breathing; † p b 0.05 versus Pre PVB during quiet breathing. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Benoît Bataille* Bastian Nucci Jade De Selle Michel Mora Pierre-Etienne Moussot Pierre Cocquet Service de Réanimation Polyvalente, Centre, Hospitalier de Narbonne, Bd Dr Lacroix, F-11100 Narbonne, France *Corresponding author at: Narbonne Hospital Centre, Intensive Care Unit, Bd Dr Lacroix, F-11100 Narbonne, France. E-mail address: [email protected] (B. Bataille).

Stein Silva Pôle Anesthésie-Réanimation, Centre Hospitalier Universitaire, CHU Purpan, Place du Dr Baylac, F-31059 Toulouse Cedex 9, France 24 July 2017 Available online xxxx