CASE REPORT. Ultrasound-guided paravertebral block for abdominal pain relief after transcatheter intrarterial chemoembolization of hepatic metastases


BACKGROUND
Transarterial chemoembolization with Irinotecan is an alternative to surgery in patients with metastatic lesions of the liver (1). Up to 90% of patients develop Postembolization Syndrome (abdominal pain, nausea, vomiting and fever), and paravertebral block could minimize these symptoms.

CASE REPORT
A 58 years old woman with colorrectal cancer history, treated with neoadyuvant irinotecan followed by laparoscopic right hemicolectomy, relapsed one year later with a solitary hepatic lesion in the right lobule treated with two hepatic chemoembolization sesions.
For this procedure, we performed a single shot right T8 paravertebral block, using a 21-gauge SonoTAP ® needle guided by ultrasound using 20 ml of ropivacaine 0’75%. Light sedation with propofol infusion was provided, as well as antiemetic profilaxis with 8 mg dexametasone, 1 mg granisetrone and 40mg omeprazole.
We achieved a good analgesic control during the chemoembolization without any incidence. The Visual Analgesic Score was less than 4 during the following 24 hours and no opioids were required.



DISCUSSION
The paravertebral block is commonly used in thoracic anaesthesia and offers a good analgesia after liver trauma or even in percutaneous nephrolitotomy.
We have seen that blockade could be effective with an unilateral single shot technique and offers good pain control during chemoembolization and early postoperative period. Patients with a more extensive hepatic affection  would probably need a bilateral block to provide a good analgesia control.

REFERENCES
1.	Dhand S, Gupta R. Hepatic transcatheter arterial chemoembolization complicated by postembolization syndrome. Semin Intervent Radiol. 2011 Jun;28(2):207-11

LEARNING POINTS
1.	Hepatic chemoembolization with Irinotecan generates acute pain associated with important nausea and vomiting.
2.	Single Shot Paravertebral block provides good analgesia with lower opioid consumption and subsequent lower nausea and vomiting and better patient comfort compared with general anaesthesia.
3.	The use of ultrasound provides feasibility and better efficacy to the technique.