A cadaver pilot study to evaluate the impact of the needle bevel orientation on the ease of paravertebral catheter inser
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A cadaver pilot study to evaluate the impact of the needle bevel orientation on the ease of paravertebral catheter insertion Maxim Roy, MD . Florian Robin, MD . Detlev Grabs, MD, PhD . Laurent Letourneau-Guillon, MD, MSc, FRCPC . Monique Ruel, RN, CCRP . Franc¸ois Girard, MD, FRCPC . Se´bastien Garneau, MD, FRCPC
Received: 8 May 2019 / Revised: 8 August 2019 / Accepted: 8 August 2019 Ó Canadian Anesthesiologists’ Society 2019
To the Editor, The paravertebral block is a well-established analgesic modality, but a single-injection technique is limited to a maximum effect of approximately ten hours.1 To prolong analgesia beyond that, a continuous catheter-based technique is favoured.2 Nevertheless, a cadaver study has shown that up to 30% of catheters are impossible to insert.3 Even after successful insertion of the catheter, its migration in the paravertebral space is often unpredictable, resulting in an additional 33% incidence of misplacement.4 When a longitudinal parasagittal in-plane approach is used with the bevel oriented in a cephalad direction (as in our centre), we believe that the insertion of the catheter could be either partially or entirely impeded by the ‘‘rib-transverse process’’ osseous complex, which forms an incomplete anterior boundary of each paravertebral level and thus would be in close contact with the needle tip.5 The M. Roy, MD (&) M. Ruel, RN, CCRP F. Girard, MD, FRCPC S. Garneau, MD, FRCPC Department of Anesthesiology, Centre Hospitalier de l’Universite´ de Montre´al (CHUM), Montreal, QC, Canada e-mail: [email protected] F. Robin, MD Department of Anesthesiology, Centre Hospitalier de l’Universite´ de Montre´al (CHUM), Montreal, QC, Canada Department of Anesthesiology, Centre Hospitalier Universitaire Pellegrin, Bordeaux, France D. Grabs, MD, PhD Department of Anatomy, Universite´ du Que´bec a` Trois-Rivie`res (UQTR), Trois-Rivie`res, QC, Canada L. Letourneau-Guillon, MD, MSc, FRCPC Department of Radiology, Centre Hospitalier de l’Universite´ de Montre´al (CHUM), Montreal, QC, Canada
orientation of the needle bevel would thus represent a potentially important factor to investigate, since it is easy to modify. In this prospective, randomized, blinded, cadaver study, we hypothesized that a caudal orientation of the Tuohy needle bevel should orient the catheter towards the ventral pleuro-vertebral part of the paravertebral space and would facilitate catheter insertion by diverting it away from the osseous components of the paravertebral space. Following ethics approval from the Centre Hospitalier de l’Universite´ de Montre´al, continuous paravertebral thoracic blocks were performed with 18G Tuohy needles and multi-orifice catheters (B-Braun Contiplex, B-Braun Medical Inc., Bethlehem, PA, USA) on ten cadavers by an experienced anesthesiologist, using a parasagittal, in-plane, cephaladto-caudad, ultrasound-guided approach at the T6 level. The primary endpoint of our study was the ease of insertion of the catheters, graded using a standardized scale as shown in the Fig
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