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352. Thoracic paravertebral block (TPVB):

use in managing complications of multiple
rib fractures

381. Intralipid & local anaesthetic toxicity:

audit of knowledge, education and followup

A. Elmowag, A. Niazi
Our Ladys Hospital, Navan, Department of Anaesthesia,
Navan, Ireland

S. Kunnumpurath, A. Riccoboni, G. Kumar, F. Sage

East Surrey Hospital, Anaesthetics, Redhill, UK

Introduction: Rib fractures are common blunt chest injury in

adults1. Pain from the fractured ribs limits the patients ability to
cough and breathe deeply and this leads to sputum retention and
atelectasis1. We present a patient with multiple rib fractures who
was effectively managed with a TPVB.
Case Report: A 50-year-old lady presented after a fall with shortness of breath and left sided chest pain. Chest x-ray revealed
fractures of 5th to 9th ribs on the left side and a collapsed lung with
pnuemothorax. After chest tube insertion, patient was admitted to
the Intensive Care Unit (ICU) and a morphine infusion was commenced. Repeat x-ray revealed no pneumothorax but the affected
lung had not re-expanded. Pain was poorly controlled but as the
morphine infusion was increased, the patient became more sedated. Patients condition deteriorated and her trachea was electively intubated. Bronchial suctioning brought up small amount of
thick secretions. On day two there was no improvement and a
TPVB was performed at T4 level. Morphine infusion was discontinued. Patient was awake, able to cough and thus assist with
suctioning. On day four there was complete re-expansion of her
collapsed lung and her trachea was extubated. She was discharged
from ICU the next day.
Conclusion: This report highlights the benefits of TPVB in reducing pain of multiple fractured ribs and allowing the patient to cough
and remove retained secretions. TPVB is also a safe technique in the
sedated patient.

1. Karmakar MJ. Acute pain management of patients with multiple fractured
ribs. J Trauma. 2003:54:615-625.

Background and Aims: Successful management of local anaesthetic (LA) toxicity depends on the knowledge of safe maximum
dose of LA and appropriate treatment. LA toxicity could effectively
be treated with infusion of Intralipid along with other supportive
measures. Use of Intralipid in the management of toxicity is relatively new and awareness of this information among doctors who
frequently use LA is an important factor in the prevention and
treatment of its toxicity. The aim of our audit was to assess the level
of awareness of LA toxicity and its treatment using Intralipid
among doctors in our hospital and then to run an educational
campaign to improve it.
Methods: A confidential questionnaire was distributed among all
grades of general surgeons, orthopedics and accident and emergency doctors in our hospital. Questions included those on maximum safe doses of LAs and drugs used in treating toxicity. This
questionnaire was followed by an information memo regarding the
maximum safe dose of local anaesthetic drugs and treatment protocol for LA toxicity (AAGBI approved). We then reassed the
effectiveness of this educational campaign using another questionnaire.
Results: In the first survey, 52% of responders knew the correct
dose of bupivacaine and only 1.5% knew that Intralipid could be
used successfully to treat LA toxicity. The second survey conducted
following the educational campaign showed an improvement in
knowledge of the above facts, to 60% and 63% respectively.
Conclusions: There was a significant improvement in the knowledge of responders regarding the use of Intralipid to treat LA
toxicity. This could potentially translate into successful clinical
management of toxicity to local anaesthetic drugs. 40% of the
responders still did not know the maximum safe dose of bupivacaine, which needed further targeted education.