Title: Paravertebral Catheters for Post-Surgical Pain Management in a Bilateral Orthotopic Lung Transplant Patient

Authors: James Dunbar, MD; Megan Schramski, MD; Michael Canepa, MD; Matthew Lyman, MD

INTRO

• Providing effective post-operative analgesia for patients undergoing

bilateral lung transplant is critically important in the prevention of

subsequent complications. Acute pain after thoracotomy may

decrease the ability to breathe deeply, cough, and clear secretions.

When compounded, these factors may increase the risk for graft

dysfunction, atelectasis, and hypoxemia.

• While thoracic epidural analgesia (TEA) remains the “gold standard”

for pain control after lung transplantation, many factors can affect a

patient’s ability to receive an epidural. Often anticoagulation status

and coagulopathy preclude epidural placement, but in the case of

prior thoracic spine surgery or implanted epidural device (spinal

cord stimulator) paravertebral nerve block catheters can be placed

for effective analgesia post-operatively.

CASE DESCRIPTION

• A 56 year old female with past medical history of pulmonary

hypertension, obstructive sleep apnea, obesity, type 2 diabetes

mellitus, fibromyalgia, and chronic back pain s/p L5-S1 fusion with a

spinal cord stimulator in place presented for a bilateral lung

transplantation in the setting of Covid pneumonia with refractory

hypoxic respiratory failure. On postoperative day one, the patient

reported worsening incisional pain, for which the acute pain service

was consulted. Given her history of a spinal cord stimulator with

lead extension to the T7 vertebral body, the decision was made to

place bilateral T5-6 paravertebral catheters rather than thoracic

epidural.

CASE DESCRIPTION CONT.

• The paravertebral space was accessed bilaterally with an 18-gauge

Tuohy needle via ultrasound visualization. Bilateral 20-gauge

polyamide multi-orifice catheters were placed within the space after

administration of 15 mL of 0.25% bupivacaine. The procedure

proceeded without complication. The catheters were dosed with

Ropivacaine 0.2% 1 cc/hr infusion and 10 cc boluses every 4 hours.

• Over the subsequent days, the patient was able to breathe deeply,

cough, and ambulate with reported pain scores of zero. Bilateral chest

tubes removed post-op day 4. Catheters were discontinued on post-op

day five after suspected intravascular migration occurred. The

patient was successfully transitioned to oral analgesia and spinal cord

stimulator was turned back on during post-op day five.

DISCUSSION

• Several strategies exist to address post-surgical pain after bilateral

lung transplant. However, in patients with contraindications to thoracic

epidural analgesia (TEA), paravertebral catheters (PVCs) may

provide an alternate analgesic option without compromising quality of

pain control. Furthermore, paravertebral catheters may be associated

with less hemodynamic effects, pulmonary complications, nausea and

vomiting, and urinary retention postoperatively. Future efforts should

be aimed toward direct comparison of outcomes in post-transplant

patients with PVCs versus TEA.