Presented at the 2013 AAPM Annual Meeting « Back

Perioperative Analgesia for a Left Hepatectomy in a Child: A Bilateral Thoracic Paravertebral Approach

William L. McCoy, DO MPH, wmccoy@anest.ufl.edu¹, Linda T. Le-Wendling, MD², Andre P. Boezaart, MD, PhD¹, (1) University of Florida, Gainesville, Florida, (2) University of Florida College of Medicine, Gainesville, Florida

Abstract: We describe the management of perioperative pain for a 2-year-old 8 kilogram boy who underwent a left hepatectomy for hepatoblastoma. Our Acute Pain service was consulted prior to emergence to assist with postoperative analgesia. The patient’s incision was a large subcostal incision extending from the right anterior axillary line to left anterior axillary. Bilateral ultrasound assisted thoracic paravertebral catheters were placed at the T6 level. Ultrasound was used to measure the depth from skin to the transverse processes and from transverse process to lungs bilaterally. Using a two inch Tuohy needle a loss of resistance to saline was achieved at a depth of 2 and 2.5 cm bilaterally. Each stimulating catheter (© 2012 Teleflex Incorporated) was advanced 3 centimeters beyond the needle tip along with an intercostal muscle twitch, and lack of intravascular placement was confirmed with a test dose consisting of 3 mL of lidocaine 1.5% with 1:200,000 epinephrine. Our patient experienced excellent postoperative analgesia and required minimal narcotics during the immediate postoperative period Discussion: This case highlights some challenging issues in the management of severe perioperative pain in a child. The patient had undergone a left lobe hepatectomy, and it is unclear what the postoperative course of their coagulation status would take. Therefore, the decision was made to place bilateral thoracic paravertebral catheters to avoid any neuraxial complications. Little literature exists in the use of bilateral paravertebral catheters for the perioperative pain management for open abdominal surgery in children. References: 1) M.K KARMAKAR MD, FRCA, P.D BOOKER FRCA, R FRANKS FRCS: Bilateral continuous paravertebral block used for postoperative analgesia in an infant having bilateral thoracotomy. Pediatric Anesthesia: Volume 7, Issue 6, pages 469–471 2) P.-A. Lönnqvist MD: Continuous paravertebral block in children, Initial experience. Anaesthesia Volume 47, Issue 7, pages 607–609, July 1992 3) P. A. LÖNNQVIST M.D., G. L. OLSSON: Paravertebral vs epidural block in children. Effects on postoperative morphine requirement after renal surgery. Acta Anaesthesiologica Scandinavica Volume 38, Issue 4, pages 346–349, May 1994.

Funding: None