Ultrasound-Guided Paravertebral Block in an Infant

Abstract

Thoracic paravertebral block (PVB) is a regional anesthetic technique wherein a local anesthetic is injected into the thoracic paravertebral space to produce a unilateral blockade of the spinal nerves and sympathetic chain. It provides effective analgesia after unilateral thoracic surgery and may reduce perioperative opioid requirements. Ultrasound guidance facilitates identification of the transverse process, superior costotransverse ligament, pleura, and needle trajectory, and allows accurate local anesthetic deposition. This video demonstrates a left-sided, ultrasound-guided thoracic PVB at the fourth thoracic level in a 4-month-old, 7.6-kg male infant undergoing division of the vascular ring through a left fourth intercostal thoracotomy. The video underscores the identification of the relevant sonoanatomy, continuous visualization of the true needle tip, avoidance of the pleura and intercostal vessels, and careful advancement of the needle into the thoracic paravertebral space. A total of 3.8 mL of 0.25% ropivacaine was administered, corresponding to a dosage of 0.5 mL/kg and 1.23 mg/kg. The block was successfully performed without immediate block-related complications and provided effective perioperative analgesia for the thoracotomy. This video presents practical considerations for safe and reliable ultrasound-guided thoracic PVB in infants and young children.

Keywords

Infant; thoracic surgery; ultrasonography, interventional; analgesia; spinal nerves.

Case Overview

Background

The thoracic paravertebral space is bounded anteriorly by the parietal pleura, posteriorly by the superior costotransverse ligament, and medially by the vertebral body and the intervertebral discs. The thoracic paravertebral block (PVB) is a regional anesthetic technique wherein a local anesthetic is injected into the thoracic paravertebral space to produce a unilateral blockade of the spinal nerves and sympathetic chain.

In pediatric patients, PVB provides effective analgesia for unilateral thoracic and upper abdominal surgeries, including lateral thoracotomy for lung resection, patent ductus arteriosus ligation, vascular ring division, and selected upper abdominal procedures. Furthermore, bilateral PVB reduces perioperative opioid requirements and facilitates early extubation after pediatric cardiac surgery.¹ Moreover, studies of the PVB in pediatric abdominal surgery have demonstrated improved early postoperative analgesia and high parental and surgeon satisfaction.²

Ultrasound guidance enables direct visualization of the pleura, transverse process, superior costotransverse ligament, and needle trajectory, whereby both the precision and safety of PVB are improved.

This video demonstrates an ultrasound-guided thoracic PVB in a pediatric patient and underscores the practical technical considerations for safe and effective block performance.

Focused History of the Patient

The patient was a 4-month-old male infant with a vascular ring who weighed 7.6 kg and who was scheduled to undergo division of the vascular ring through a left fourth intercostal thoracotomy. A left-sided, ultrasound-guided thoracic PVB was performed at the fourth thoracic level to provide perioperative analgesia for the surgical incision.

Physical Exam

An examination of the planned puncture site revealed no evidence of local infection or other contraindications to thoracic PVB.

Imaging

No preoperative imaging was performed. Immediately before performing the block, real-time ultrasonography was used to identify the transverse process, superior costotransverse ligament, and pleura, which enabled the localization of the thoracic paravertebral space and safe planning of the needle trajectory.

Options for Treatment

Several options are available for perioperative analgesia in pediatric thoracic surgery, including intravenous opioids, thoracic epidural analgesia, local anesthetic wound infiltration, and ultrasound-guided regional anesthesia techniques, such as thoracic PVB, erector spinae plane block, and intercostal nerve block. The choice of technique depends on the surgical procedure, anticipated postoperative pain, patient characteristics, and institutional practices.

Rationale for Treatment

A left-sided, ultrasound-guided thoracic PVB was selected to provide effective analgesia for the left thoracotomy while reducing perioperative opioid requirements.

Special Considerations

In infants and young children, continuous visualization of the needle tip is essential because advancing the needle beyond the target site may result in pleural puncture. Color Doppler may be helpful for identifying intercostal vessels, and careful calculation of the total local anesthetic dose is necessary to minimize the risk of local anesthetic systemic toxicity.

Discussion

Thoracic PVB is often considered technically demanding because of the proximity of the pleura and the potential risk of pneumothorax. However, in infants and young children, the thoracic paravertebral space is relatively superficial, allowing excellent visualization of both the target structures and the advancing needle. Consequently, ultrasound-guided PVB may be technically easier to perform in pediatric patients than in adults once the relevant sonoanatomy is understood.

A key technical consideration is meticulous visualization of the true needle tip throughout the procedure. Because the pleura lies immediately deep to the target site, advancing the needle beyond the thoracic paravertebral space may result in pleural puncture with little tactile resistance. Therefore, the needle should be advanced slowly under continuous real-time ultrasound guidance, and local anesthetic should be injected only after the needle tip has been clearly identified within the thoracic paravertebral space.

According to the New York School of Regional Anesthesia (NYSORA),³ the maximum recommended dose of ropivacaine is 2.5 mg/kg. In this case, 3.8 mL of 0.25% ropivacaine (0.5 mL/kg; 1.23 mg/kg) was administered, which did not exceed the recommended maximum dose.

The thoracic PVB was successfully performed without block-related complications and provided effective analgesia for the left thoracotomy. This video highlights practical technical points that may facilitate safe and reliable ultrasound-guided thoracic PVB in infants and young children.

Equipment

• High-frequency linear ultrasound transducer (13–6 MHz)
• Sterile ultrasound probe cover
• Sterile ultrasound gel
• 25-gauge, 38-mm regular-bevel needle

Disclosures

The author reports no conflicts of interest, financial relationships, funding, sponsorship, equipment support, or other relationships that could be perceived to influence the content of this article.

Statement of Consent

The parent of the patient referred to in this video article provided informed consent for the patient to be filmed and is aware that information and images will be published online.

Acknowledgments

The author thanks the operating room staff and perioperative team for their assistance with patient care and video production.