Exploring Extrapleural Hematoma After Ultrasound-Guided Paravertebral Block: A Clinical Case Report

BACKGROUND This report describes the case of a 61-year-old man with extrapleural hematoma after ultrasound-guided thoracic paravertebral block following right upper-lobectomy. Extrapleural hematoma results from bleeding between the parietal pleura and the internal thoracic fascia. The hematoma was likely due to an unintentional puncture of an intercostal artery, exacerbated by postoperative low-molecular-weight heparin use. The causes and early treatment strategies are discussed. CASE REPORT A 61-year-old man scheduled for video-assisted right upper-lobectomy received an ultrasound-guided thoracic paravertebral block before surgery. The needle was clearly visualized during the puncture, and no blood was aspirated intermittently. The block was confirmed to be effective by thermal sensation testing. The patient underwent routine anesthesia induction and intubation, and after the thoracoscope was inserted into the chest cavity, a local hematoma of approximately 4×5 cm at the T6-T7 paravertebral area was found. The surgeon proceeded with the right upper-lobectomy without addressing the hematoma. Prophylactic low-molecular-weight heparin (4000 IU) was administered at 14 h and 40 h postoperatively. At 49 h after surgery, the patient developed signs of hypovolemic shock. Re-exploration revealed a massive hematoma extending from T1 to T12 in the right paravertebral space, which was evacuated thoracoscopically. CONCLUSIONS After detecting local hematoma or bleeding caused by paravertebral nerve block, use of anticoagulant drugs should be avoided as much as possible after surgery. Moreover, biochemical tests and imaging examinations should be actively used to assess whether there is ongoing bleeding. If the bleeding worsens, surgical intervention should be considered as early as possible.