Thoracic paravertebral block protocols

Indication	Suggested spinal level and type of block
Thoracic surgery
Thoracotomy	Continuous block at the level of the thoracotomy (usually T5) and at level of the chest tube (usually T8)
Video-assisted thoracoscopic surgery (VATS)	Multilevel single injections at T4 to T8
Robot-assisted thoracoscopic surgery (RATS)	Multilevel single injections at T4 to T8
Rib fractures	One continuous TPVB per 4 ribs fractured, centered on the levels of the fractured ribs
Breast surgery*	T2,T4 large volume injections or T2-T6 small volume injection at every level
Upper extremity surgery that extends to the axilla	T2 using large volume single injection
Inguinal hernia repair	T11, T12, L1 multilevel single injections

This table shows the typical placement and type of TPVB typically used for different types of surgery. Important concepts include the following:

TPVB blocks are most effective when placed at the level of desired dermatome coverage due to the variability in the vertical spread, especially when using lower volumes of local anesthetic.
A 4 to 5 mL volume of local anesthetic will usually cover one dermatome.
Continuous blocks (rather than single-injection blocks) are used when the expected duration of severe pain is >8 to 12 hours, which is the expected duration of a single-injection block.

TPVB: thoracic paravertebral block.
* T2 coverage is required for breast surgery that included axillary node dissection.

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