Paravertebral catheter placement for acute rib pain in a pregnant patient with cystic fibrosis
Abstract Number: T 60
Abstract Type: Case Report/Case Series
Introduction: Cystic fibrosis (CF) is an autosomal recessive disease secondary to a mutation of a gene on chromosome 7. It leads to reduced chloride conductance, increased viscosity of secretions, leading to pulmonary and gastrointestinal compromise. Due to recent advances in management of patients with cystic fibrosis, life expectancy and quality of life have increased greatly (Thorpe-Beeston et al. BJOG. 2013 Feb;120(3):354-61). With these improvements comes an increased incidence of CF patients becoming pregnant.
Case description: A 30-year-old G2P0010 at 33 weeks 4 days gestation with cystic fibrosis suffering from an acute exacerbation was admitted to the medical intensive care unit. During an acute coughing spell she felt a “pop” on her left side. She then had worsening pain and hypoxia. Unable to tolerate 4 times daily vest therapy, she was likely not going to be able to wait until her goal of 37 weeks for induction of labor. The medical ICU and obstetric services were discussing whether or not to induce labor early or she might need to be intubated for worsening oxygenation secondary to worsening lung function and increased need of narcotics for pain. At this point the acute pain service was consulted to evaluate her.
It was decided she could possible benefit from a nerve block. A paravertebral (PV) catheter was placed with ultrasound guidance between the ninth and tenth thoracic vertebrae on the left. The patient tolerated the procedure well and there were no complications. After an intravenous test dose of 1.5% lidocaine with Epinephrine 1:200,000 and infusion of 0.2% ropivacaine was started at a rate of 6 milliliters per hour. She noted almost immediate pain relief and improvement in ease of respiration. The catheter was left in place for seven days and her pain scores ranged from 0 /10 at rest to 3/10 with movement, with decreased sensation to cold from the 5th to the 9th thoracic dermatome on the left. In the first 48 hours of hospitalization prior to catheter placement she required a total of 41 milligrams of morphine and 3.9milligrams of dilaudid for pain, and after catheter placement she received no narcotics. Also, prior to her paravertebral catheter she had increased oxygen requirements to 4 liters per minute oximask with corresponding oxygen saturations between 92 and 97%. After PV catheter she no longer needed supplemental oxygen. The catheter was removed after 7 days and the patient was discharged home. The remainder of her pregnancy was uneventful and she delivered via spontaneous vaginal route at 38 weeks 5 days.
Discussion: This case illustrates the potential role of paravertebral catheters for acute costal pain in cystic fibrosis patients with exacerbations during pregnancy. By improving pulmonary function this could theoretically lead to improved maternal-fetal outcomes.