38
Intrapleural Bupivacaine for Early Post-Thoracotomy Analgesia - Comparison with Bupivacaine Intercostal Block and Cryofreezing lf. S hafei, M. Chu mberlain. K. N. Natraj an, M. A. R. Khan. and R. G. Gandhi Departmen ts of'Cardio thcracic Surgery and Anaesthesia . Victor ia Hospital. Brackpool. England
54 pat ie nts w ho had pos tcrolate ra l thoracoto my were pros pectively st ud ied 10 compa re the effieaey of intrapl eu ral bupivecaine with tha t of bupivacain e int ercostal block a nd cry oIrecdng. Patients wc ro ra ndomize d into throo gro ups. Th c intra pleural ca theter gro up includc d 16 patlen ts who had intermitten t intra ple ural ins tillatio n of 20 ml of 0.25 % b upivaca ine for for ty-eigh t hours posto pcra tively. Th e sece nd gro up includc d sixteen patient s who were give n perioper ati ve bupivaca ine inte rcos tal block. Thc third grou p inclu ded fiftccn pat ients treated by cryofreez ing or the Intercestal nervcs. Visua l analog ue fou r-hourly pa in scorc was com pared between the th ree gro ups du ring the first for ty-eigh t hou rs post op erativ ely. Th e ana lgesie requ irem ent s during the firs t pos top erati ve week worc also assesse d. Th cr e was no sign ifica nt differcn cc between tho three gro ups in tho avorago pa in score (3.61 ± 1.3 7. 3.54 ± 1. 15 , an d 3.33 ± 1.4 7 resp ect ively). Dur ing the first forty-elght hour s postope ratively. th e percen tage of pati ents w ho requ ire d papaveretum in the intrapleu ral cathcte r gro up (56.3 %) was slg nlflca ntly less than that in th e ot her two groups (both 100 %). Th e averege pap averetum requ irem en t (mg per patientl in th c intr apl eu ra l cat heter grou p (27 .33 ± 25 .27 ) was significan tly lcss tha n tha t in tho sece nd gro u p (52 .66 ± 26 .8 51 but the durcrcn cc was not statist ically sig nifica nt from that in the third gr oup (37.66 ± 20.95). No com plica tio ns relat ed to th e use of the intrapleura l ca thc tc r or to bup ivacai ne toxlcity were encountered. In co nclusion. the tec h niq ue of interm itte nt intr ap leura l bupivacain o is safe a nd com pa rable in efflca cy to bup ivacain e intercostal block a nd cryofreezing. Narco tic requ iremen ts may bc reduced w hc n th is tec hn iquc is use d.
Kcyword s Bupivacain e - Post -thora cotom y pa in cont ro l - Intra pleur a l an a lgesia
Thorac. card iovasc. Surgecn 38 (1990) 38 -41 © Georg Thieme Verlag Siuuga n - New York
Eine prosp ektive random isierte Stud ie zu r Sch merzthe ra pie na ch pester nlat eraler Thorak oto mie bei 54 Patienten wird vorgelegt. Es wird der a na lgetisc he Effekt von Bupiva cai n int rapleural oder a ls Interkostal nerven-Blocka den a ppliziert sowie von Kryothera pie un ter ein a nd er verg liche n. In der e rs te n Gruppe wu rd e bei 16 Pat ienten üb er eine n bei der Oper ati on plaziertcn . mit der Spitze d or sal in der Thora xap ertur intrapleural gelege ne n Kath eter (hande lsüblic he r Epid uralkatheter) während d er ersten 48 Stunde n post oper ativ int erm ittier end 20 ml 0.25 %iges Bupi vaca in {max . 6x pro 24 Std. l instill iert. Der ge na ue Wir kungs mec ha nis mus d ieser Form d er analgetische n The ra pie ist nich t bekannt . In der zweite n Gruppe von 16 Patien ten w urden Blocka den d er 3. bis 8 . Inter kosta lnerven (JCN) mit Bup lvacain (2 ml 0.5 % pro JCN) intraop er at iv gelegt. Die Kryoan algesiegruppe umfaßte 15 Pat ient en . Hier w ur d en die 3. bis 8 . Int erk ost aln erven intraop er ati v wä h rend 30 Se kunden lokal vere ist. Die Sch me rz intensitä t w urd e die ers te n 48 Stunde n post operativ mit eine r visuellen gra ph ische n Meth od e (VAS = visua l linear a nalogue scal e 0 -10) viers tündlich bewe rtet. Gleichz eitig w urde der Ana lget ika beda rf (Papavere tum l in der ers te n postoper at iven Woc he registr iert. Es konnte kein Untersch ied d er du rchsc h nitt lich a ngegebene n Sch merz inte ns itä t in den drei Gru ppe n fest gestellt werd en (3.61 ± 1.3 7. 3.54 ± 1.15 und 3.33 ± 1.47) . Der Bed a rf a n Pap ave retu m zusätzlich wa r in d er Gru ppe mit int rap leu ral em Kathet er signifika nt niedriger (56.3 % der Pati en ten ) als in den beid en a nderen Grupp en nOO % und 100 % der Pat ienten). Der d urc hschnittliche Verbr auch a n Pep ave return (mg pro Pa tient) wa r signifika nt niedrige r in d er Gruppe mit intrapl euralem Kath eter (27 .3 3 ± 25 .27) im Vergleic h zu der 2. Gr uppe (52.66 ± 26 .8 5) a be r nich t im Ve rgleich zu der d ritten Gr uppe (37 .66 ± 20 .9 5), Es tr aten keine kathoter- ode r bup iva cain bedingte Komplikationen a uf. Zusammen fass end ist die Tec h nik mit intermittent intrapleural app lizierte m Bupivacain ge nauso effektiv wie Interko st alne rve n blocka den m it Bup ivaca in oder mit Kryoth er ap ic und stellt eine gute Alternative in de r post op er ativen Sch rnerz beha ndlung d ar. Der Bedarf an na rkotisch en Mitteln kann eingesc hrä nkt werd en .
Reeeived for I'u bliea tion : Oeto be r 26, 1989
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Sum mary
Postop er ative Ana lges ie na ch Thorak otomie mit Hilfe pleurale r Bupiva cain -Anw cndungen. Bup iva cain-In terkns t ülnerven -Bloekade und Kryotherapie : ei n Vergleic h
Introduction
Instillation ofbu pivacaine into the pleural cavity through an intrapleural catheter ha s been used successfully to relieve pain after abdominal and breast surge ry (2, 4, 5, 7). A few reports described the a pplication ofthis techn ique for postthoracotomy analgesia, with confiicting resu lts (1 , 3, 6). This techniqu e ha s the adva ntage of allowing re peated injection of the local an aesth etic agent during the post operative period with reduced risk of narcotic-ind uced res piratory depression (4). We compared this technique to the most commonly used meth ods of an algesia for thoracotom y, i , e. periop erative bupivacaine inter costal nerve block and cryofreezing before closing the ehest. Patients a nd Meth ods Fifty-four cnnsecutive pat ients scheduled for postero latcral thoracotomy were prospectively ran domized using computer generated tables into three grou ps: - the intrapleural catheter group OPC}: A 16 G nylon catheter (Epidural catheter. Portoxe Ltd.), was placed by the surgcon bctore closing the ehest. The Tuhoy needle was introduced per cutaneously through a convenien t inter costal space above the thoraeoto my incision anteriorly. The cathete r was then advanced until a satis faetory position was ohtained with the tip of the catheter at the dome ofthe pleural cavity poster iorly. Care was taken to avoid siting the tip of the catheter near the ehest drainage tubes. An ad hesive dressing was used to fix the cathete r to the skin. After discont inuati on of genera l anaest hes ia, a 20m l dose of 0.25 % bu pivaeaine without adrenaline was injecte d through the cat heter, and subsequent similar doses were givcn du ring the first 48 postop erative hours to ac hieve pain control (a maximum ofs ix injections da ilyl. The catheter was removed two days after surgery . - the bupivacaine intercostal neroe block group (11) had inflltra tion of about 2 ml of 0.5 % plain bupivacaine in eac h of the 3 rd to the 8 lh inter costal nerves near their postcrior ends.
Ag, (y),rang, mean ± SO Sex malelfemale W,ight(kgl. range mean ± SD Height (ern),range mean ± SD Procedures Lobeetomy Wedge resect. Unresectable tumour Remov. F. S. Pleurectomy Deeortieation Oesophageetomy H. H. repair Remov. Med. Mass. Complications Urin. retention Sputum retention Atrial fibrHlation
TllOrac. cardiovas c. Su rgeofl 38 (1990) - thc cryoanalgesia group (ergo) had a pplication of the cryoprobe to eac h of the 3 ,'d to 8th intercostal nerves , with a freczing time of 30 seconds for eac h nerve. Scven patients were excluded from the stu dy (5 had pneumonectomies , one had signifieant preoper ative ehest pain. an d one had postoperative respiratory failure sccondary to asp iration of gas tr ie contents aftc r oesophagectomyl. In all pati ents, a regime of analgesie med icati on was followed during thc hospital stay to ensure adequate pain control. an d consisted of prescribing pa paveretu m in a dose of 10 to 20 mg (according to the body wcightl as frequent ly as req uired to control pain du ring the first 48 postoperative hours. From tho third day onwa rds , a su blingual or ora l analgesie was presc ribed, hup renorphinc (Temgestcs) . dextropropoxyphine and parace ta mol (Distalgcstcw). or par acctam ol only, depending on the sevcrity of pa in and the patient' s individual tcler unce. Estimatio n ofthe deg ree of pa in during thc first 48 postoper ative hours was recorded four-hourly by patients on a visual lO cm linear ana logue sca le (VAS). (0 :0 No pain, and 10 :0 intolerable pai n). The amo unt ofp ar entcral analgesia during the first two days , and thc nu mber of reques ts for oral analgesia from the 3 ' d to the 7th postoperative days wer c recorded for each patient. All paticnts had at least one daily ehest radiograph during the first postoper ative week. The incidence of eomplieations was recorded. Student t- Test was used to compare results between the three groups. I'robability values below 0.05 were rega rded as significa nt.
Results Patient cha racteristics, surgical procedures, and complications are summarized in Tab le 1. No compllcations relat ed to the catheter or to bupivacain e toxicity wer e encountered. Ther e was no significant difTer en ce between the ave rage pain scores in the three groups. Nine patients (56 %) in the Il'C group requ ired pap aver etum during the first fort y eight hours. This was significantly less than in the oth ertwo groups in which all pati ent s required pap averetum durin g the sa me perio d. The average papaver etum requirement
IPC (n ~ 16)
B (n ~ 16)
Cryo (n ~ 15)
25- 73 56.1± 13.4
26- 70 50.7± 12.4
25-73 55.1± 15.6
12/4 52-90 69.2±10.6 153- 185 170.1± 9.7
13/3 53 -98 73.4± 11.9 158- 182 171.8± 7.8
5110 40 -81 62.0±1 2.3 148- 176 164.2± 8.4
6 2 3
3 1 3 1 3 3 1 1
6 2 4
2 2
2 1 I
Abbreviations: Wedge Resect.: wedge resection of the lung. Remov. F. S.: removal ot a foreign body(needle) from the lung parenchyma. H. H. Repair: hiatus hernia repair. Remov. Med. Mass: removal of mediastinal mass.
Tabl.1 Patient charactenstics.surgieal procedures, and complications
:!9
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Intrapleural Bupivacainef or Harly Post- thoracotomu Analgesia
Thorac. cardiovasc. Su rgeon 38 (l 990) IPC (n ~ 16) 1.0- 5.67 Average VAS, range 3.61± 1.37 mean ± SO Nu mber of patients needmg papaveretum 9 and pereentage 56.3% (0- 48 h postop.) Papaveretum requirements(mg) per patent (0- 48 h postop.) 00 -75 range mean ± SO 27.33±25.27 Nu mber of patients needing oral 13 analgesia andpereentage 81.3 % (3-7d postop.) Number of requestsfor oral analgesia perpatient (3- 7d postop.) 0-25 range 9.46 ±8. 2 mean ± SO
1I. Shafei. M. Chamberlain. K. N. Natrajan . M. A.
8 (n ~ 16)
Cryo (n ~ 15)
1.42- 5.83 3.54±1.l 5
0.83- 6.08 3.33 ±1. 47'
16 100.0 %
15 100.0 %
20-1 20 52.66 ±26.85
10-90 37.66±20.95··
15 93.8 %
10 66.7 %
1- 29 16.06 ± 8.4
0-32 12.6 ± 7.9···
R. Khan. arid R. G. Ocndhi
Ta bl. 2 2 PainScore (VAS) and analgesic requirernents
n
p-value IPC/8 ~ 0,869 (not significant); IPC/ Cryo ~ 0.581 (not significant); 8/Cryo ~ 0.668 (not significant). (00): p-value IPe/ B = 0.0012(significant); JPC/Cryo = 0.232(not signiflcant), B/Cryo = 0.09 (not significant). (000): p-value IPC/ B = 0.0047 (signifieant);IPC/Cryo = 0.47 (not signiticant): B/Cryo = 0.43 (not signiticant].
per patient in the IPCgroup was significantly less than that in the Bgroup, but the differ ence was not stati stically significant from that in the Cryo group . The average numb er of requests for oral analgesia per patient in the IPC group was significantly less than that in the B group , but the difference was not statistically significant between th e IPC group and the Cryo group . Table 2 summarizes the results of pain score and the analges ie requirements in the three groups. Discussion
The techniqu e of intrapleural catheter for instillation of bupivacaine into the pleural space was initially described for relief of ea rly postop erative pain after unilateral mammary surgery, ren al surgery and choIecystectomy (2. 4, 5, Application of this techniqu e for post-thoracotomy an algesia was then describ ed in few and controversial reports (I , 3, 6). Kambam and co-wor kers (1) reported the use of the intr apleur al catheter with intermittent instillation of bupivacaine in fourteen patients who underwent thora cotomies. and in whom the plasma level of bupivacaine was measured . They found that the method is efTective in patients who underwent lateral and posterior thoracotomies and not effective with anterior thorac otomy. Rosenberg and co-workers (6) used continuous infusion of bupivacain e through an intrapleural catheter for relief of ea rly pain after thora cotomy in fourteen adults. They found that this method produced insufficient pain control, and they reported snapping of the catheter in one pat ient. They did not recomm end the use of intrapleural bupivacain e either as a bolus or as continuous infusion for postoperative pain tr eatm ent after thoracotomy. On the oth er hand, in a recent report by Mcl/vaine and co-workers (3). continuous infusion of bupivacain e via an intrapleural catheter was considered safe and efTective for analgesia after thoracotomy in children. We are not aware ofa ny reports in
n
which the efficacy of th is techniqu e has been compared to other techniques of analgesia for thoracotomy, In this study, intermittent doses of 20 ml bupivacaine of 0.25 % up to six tim es a day were used. This dosage was pr eviously shown to be effective (5. 7) and weil below the dosage which may produce bupivacain e toxic plasma concentration (2-4 jLg/ml) (8). Kambam and co-workers (I ) measured lower peak plasma levels of bupivacain e when used with adrena line. Therefore they suggested using bupivacaine with adrenaline. However, we elected to use plain bupivacaine to avoid the possible probl em from the systemie absorption of adrenaline. in particular cardiac arrhythmias. Unlike Rosenberg and co-workers (6) who used this technique in two pneumon ectomy patients , we excluded such pati ents from the stud y becau se of the poten tial ha zards of leaving an intrapleural catheter in the pn eumonectomy space. In addition. the distribution of the local anaesthetic agent in the pneumonectomy spa ce is unpredictable. The mechanism ofintrapleural analgesia is not c1ear. It has been suggested that the instilled bupivacain e produ ces multiple intercostal blockade (4). and block of the nerve endings in the pleura (6). It see ms from the above theories that the most appropriate position of the catheter tip should be at the dome of the pleural space posteriorl y. so that the injected local anaesth etic agent triekles over the posterio r ends of the intercostal nerves. The advantage of insertin g the catheter at operation is to allow its prop er positioning , and the whoie procedure of inse rtion should not consume more than a few minut es ofthe operating time . We took the pr ecautions ofplacing the catheter tip away from the ehest dr ainage tub es and disconnecting any suction applied to the ehes t drains during and for 15 minutes after injections in the postop erative period. From the results ofthis stud y, the sa fety ofthis technique is evident from the absence ofa ny complications related
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40
Thorac. cardiovasc. S u rgeo1l 38 (1990)
IntrapleurallJupivacaine j or Ear ly Post -Thoracotomy Analqesia
Ackno w ledgements Wc wish to th a nk Dr . D. R. Kelly. Dr. A. Lockhart fram the Depa rtm e nt of Anaesthesia, Dr. ll. P. Tulloh fro m th e Departm e nt of Hadiology, Mrs. Boothe from the Libra ry, a nd our Nu rs ing a nd Secr etaria l Staff for th eir assistance in pr ep aring thi s re po rt .
Re feren ces 1
2 3
4
5
6
7
8
Kambam. 1. H.• R. E. Handte. J. Flanagan, M. Lupinetti, a nd J. lI ammon: Intrap leural anaesth esia for post -tho racotom y pain rellef Iabstractl . Anes th. Ana lg. 66 (198 7) S90 Kvalheim. L.. a nd F. Reiestad: Intra pleural cat heter in the man agemen t of postoperative pa in . Anest hesi ology 6 1 (19 84) A23 1 Mclloaine, W B.. H. F. Knox. P. V. Fennessey . a nd M. Goldstein: Continuous infusion of bupivacai ne via a n int rap leural catheter für a nalgesia after thoracotomy in children. Anest hes iology 69 (1988) 26 1-264 Reiest ad. F., a nd K. B. St remskaq: Intrap leu ral cathet er in the ma nagem ent of postoperative pain . A prelimin a ry rcp cr t. Reg. Anest h . 11 (1986 ) 89 - 91 Reies tad. F.. K. B. St remsk aq. a nd F.. Ifolmqvist: Intrap leural administra tion of bupivacain e in postoperative management of pain . Anesthes iology 65 (1986) A204 Rosenberg. P. H . B. M. A. Schein in. M. 1. A. Lepiintalo. and O. Lindf ors: Contin uous intra pleural infusion of bupivacal ne for a na lgesia afte r thoractomy. Anest hesio logy 67 (1987) 8 11- 8 13 Se tteer. J. L.. G. E. Larijani, M. E. Goldberg. A. T. Marr. and M. L. Rocci: A kinetic an d dynamic eva luation ofintrapleura l buplvacain e for subcostal incisional pain . Anest hes iology 65 (1986) A213 Tucker. G. T.: Pharmacokinetics of local anaesthotics. Br. J. Anaest h . 58 (9 86) 717 - 73 1
/I . Shafei. MS FRCS
Na tional Hea rt Hospital Weste rmo reland Street Lond on Wl M 8BA England
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to clinical hupivacaine toxicity or the use of the catheter . Ther e was no significant differenc e between the average pain scores in the three groups, and the numher of patients who required narcotic injections and the average na rcotic requ irem ent per patient during the first forty-eight postoperativ e hours in the intr ap leural catheter group wa s less than that in the other groups. Intrapleural hupivacaine is a simpie technique when compared to epidural analgesia, which has its own complications and requires high-dependency postoperative care . It is efficient in pain control and it has the advantage that repeat injection of the local anaesthetic agent is feasible. ohviating the need for narcotic injections. From our experience, we believe that an intrapleural catheter with intermittent instillation of bup ivacaine is a safe and effective technique for early post -thoracotomy pain relief, and we recommend this meth od, either as an alternative to, or in conjunction with , other methods of an algesia for thoracotomy.
41
Intrapleural Bupivacaine for Early Post-Thoracotomy Analgesia - Comparison with Bupivacaine Intercostal Block and Cryofreezing lf. S hafei, M. Chu mberlain. K. N. Natraj an, M. A. R. Khan. and R. G. Gandhi Departmen ts of'Cardio thcracic Surgery and Anaesthesia . Victor ia Hospital. Brackpool. England
54 pat ie nts w ho had pos tcrolate ra l thoracoto my were pros pectively st ud ied 10 compa re the effieaey of intrapl eu ral bupivecaine with tha t of bupivacain e int ercostal block a nd cry oIrecdng. Patients wc ro ra ndomize d into throo gro ups. Th c intra pleural ca theter gro up includc d 16 patlen ts who had intermitten t intra ple ural ins tillatio n of 20 ml of 0.25 % b upivaca ine for for ty-eigh t hours posto pcra tively. Th e sece nd gro up includc d sixteen patient s who were give n perioper ati ve bupivaca ine inte rcos tal block. Thc third grou p inclu ded fiftccn pat ients treated by cryofreez ing or the Intercestal nervcs. Visua l analog ue fou r-hourly pa in scorc was com pared between the th ree gro ups du ring the first for ty-eigh t hou rs post op erativ ely. Th e ana lgesie requ irem ent s during the firs t pos top erati ve week worc also assesse d. Th cr e was no sign ifica nt differcn cc between tho three gro ups in tho avorago pa in score (3.61 ± 1.3 7. 3.54 ± 1. 15 , an d 3.33 ± 1.4 7 resp ect ively). Dur ing the first forty-elght hour s postope ratively. th e percen tage of pati ents w ho requ ire d papaveretum in the intrapleu ral cathcte r gro up (56.3 %) was slg nlflca ntly less than that in th e ot her two groups (both 100 %). Th e averege pap averetum requ irem en t (mg per patientl in th c intr apl eu ra l cat heter grou p (27 .33 ± 25 .27 ) was significan tly lcss tha n tha t in tho sece nd gro u p (52 .66 ± 26 .8 51 but the durcrcn cc was not statist ically sig nifica nt from that in the third gr oup (37.66 ± 20.95). No com plica tio ns relat ed to th e use of the intrapleura l ca thc tc r or to bup ivacai ne toxlcity were encountered. In co nclusion. the tec h niq ue of interm itte nt intr ap leura l bupivacain o is safe a nd com pa rable in efflca cy to bup ivacain e intercostal block a nd cryofreezing. Narco tic requ iremen ts may bc reduced w hc n th is tec hn iquc is use d.
Kcyword s Bupivacain e - Post -thora cotom y pa in cont ro l - Intra pleur a l an a lgesia
Thorac. card iovasc. Surgecn 38 (1990) 38 -41 © Georg Thieme Verlag Siuuga n - New York
Eine prosp ektive random isierte Stud ie zu r Sch merzthe ra pie na ch pester nlat eraler Thorak oto mie bei 54 Patienten wird vorgelegt. Es wird der a na lgetisc he Effekt von Bupiva cai n int rapleural oder a ls Interkostal nerven-Blocka den a ppliziert sowie von Kryothera pie un ter ein a nd er verg liche n. In der e rs te n Gruppe wu rd e bei 16 Pat ienten üb er eine n bei der Oper ati on plaziertcn . mit der Spitze d or sal in der Thora xap ertur intrapleural gelege ne n Kath eter (hande lsüblic he r Epid uralkatheter) während d er ersten 48 Stunde n post oper ativ int erm ittier end 20 ml 0.25 %iges Bupi vaca in {max . 6x pro 24 Std. l instill iert. Der ge na ue Wir kungs mec ha nis mus d ieser Form d er analgetische n The ra pie ist nich t bekannt . In der zweite n Gruppe von 16 Patien ten w urden Blocka den d er 3. bis 8 . Inter kosta lnerven (JCN) mit Bup lvacain (2 ml 0.5 % pro JCN) intraop er at iv gelegt. Die Kryoan algesiegruppe umfaßte 15 Pat ient en . Hier w ur d en die 3. bis 8 . Int erk ost aln erven intraop er ati v wä h rend 30 Se kunden lokal vere ist. Die Sch me rz intensitä t w urd e die ers te n 48 Stunde n post operativ mit eine r visuellen gra ph ische n Meth od e (VAS = visua l linear a nalogue scal e 0 -10) viers tündlich bewe rtet. Gleichz eitig w urde der Ana lget ika beda rf (Papavere tum l in der ers te n postoper at iven Woc he registr iert. Es konnte kein Untersch ied d er du rchsc h nitt lich a ngegebene n Sch merz inte ns itä t in den drei Gru ppe n fest gestellt werd en (3.61 ± 1.3 7. 3.54 ± 1.15 und 3.33 ± 1.47) . Der Bed a rf a n Pap ave retu m zusätzlich wa r in d er Gru ppe mit int rap leu ral em Kathet er signifika nt niedriger (56.3 % der Pati en ten ) als in den beid en a nderen Grupp en nOO % und 100 % der Pat ienten). Der d urc hschnittliche Verbr auch a n Pep ave return (mg pro Pa tient) wa r signifika nt niedrige r in d er Gruppe mit intrapl euralem Kath eter (27 .3 3 ± 25 .27) im Vergleic h zu der 2. Gr uppe (52.66 ± 26 .8 5) a be r nich t im Ve rgleich zu der d ritten Gr uppe (37 .66 ± 20 .9 5), Es tr aten keine kathoter- ode r bup iva cain bedingte Komplikationen a uf. Zusammen fass end ist die Tec h nik mit intermittent intrapleural app lizierte m Bupivacain ge nauso effektiv wie Interko st alne rve n blocka den m it Bup ivaca in oder mit Kryoth er ap ic und stellt eine gute Alternative in de r post op er ativen Sch rnerz beha ndlung d ar. Der Bedarf an na rkotisch en Mitteln kann eingesc hrä nkt werd en .
Reeeived for I'u bliea tion : Oeto be r 26, 1989
Downloaded by: University of British Columbia. Copyrighted material.
Sum mary
Postop er ative Ana lges ie na ch Thorak otomie mit Hilfe pleurale r Bupiva cain -Anw cndungen. Bup iva cain-In terkns t ülnerven -Bloekade und Kryotherapie : ei n Vergleic h
Introduction
Instillation ofbu pivacaine into the pleural cavity through an intrapleural catheter ha s been used successfully to relieve pain after abdominal and breast surge ry (2, 4, 5, 7). A few reports described the a pplication ofthis techn ique for postthoracotomy analgesia, with confiicting resu lts (1 , 3, 6). This techniqu e ha s the adva ntage of allowing re peated injection of the local an aesth etic agent during the post operative period with reduced risk of narcotic-ind uced res piratory depression (4). We compared this technique to the most commonly used meth ods of an algesia for thoracotom y, i , e. periop erative bupivacaine inter costal nerve block and cryofreezing before closing the ehest. Patients a nd Meth ods Fifty-four cnnsecutive pat ients scheduled for postero latcral thoracotomy were prospectively ran domized using computer generated tables into three grou ps: - the intrapleural catheter group OPC}: A 16 G nylon catheter (Epidural catheter. Portoxe Ltd.), was placed by the surgcon bctore closing the ehest. The Tuhoy needle was introduced per cutaneously through a convenien t inter costal space above the thoraeoto my incision anteriorly. The cathete r was then advanced until a satis faetory position was ohtained with the tip of the catheter at the dome ofthe pleural cavity poster iorly. Care was taken to avoid siting the tip of the catheter near the ehest drainage tubes. An ad hesive dressing was used to fix the cathete r to the skin. After discont inuati on of genera l anaest hes ia, a 20m l dose of 0.25 % bu pivaeaine without adrenaline was injecte d through the cat heter, and subsequent similar doses were givcn du ring the first 48 postop erative hours to ac hieve pain control (a maximum ofs ix injections da ilyl. The catheter was removed two days after surgery . - the bupivacaine intercostal neroe block group (11) had inflltra tion of about 2 ml of 0.5 % plain bupivacaine in eac h of the 3 rd to the 8 lh inter costal nerves near their postcrior ends.
Ag, (y),rang, mean ± SO Sex malelfemale W,ight(kgl. range mean ± SD Height (ern),range mean ± SD Procedures Lobeetomy Wedge resect. Unresectable tumour Remov. F. S. Pleurectomy Deeortieation Oesophageetomy H. H. repair Remov. Med. Mass. Complications Urin. retention Sputum retention Atrial fibrHlation
TllOrac. cardiovas c. Su rgeofl 38 (1990) - thc cryoanalgesia group (ergo) had a pplication of the cryoprobe to eac h of the 3 ,'d to 8th intercostal nerves , with a freczing time of 30 seconds for eac h nerve. Scven patients were excluded from the stu dy (5 had pneumonectomies , one had signifieant preoper ative ehest pain. an d one had postoperative respiratory failure sccondary to asp iration of gas tr ie contents aftc r oesophagectomyl. In all pati ents, a regime of analgesie med icati on was followed during thc hospital stay to ensure adequate pain control. an d consisted of prescribing pa paveretu m in a dose of 10 to 20 mg (according to the body wcightl as frequent ly as req uired to control pain du ring the first 48 postoperative hours. From tho third day onwa rds , a su blingual or ora l analgesie was presc ribed, hup renorphinc (Temgestcs) . dextropropoxyphine and parace ta mol (Distalgcstcw). or par acctam ol only, depending on the sevcrity of pa in and the patient' s individual tcler unce. Estimatio n ofthe deg ree of pa in during thc first 48 postoper ative hours was recorded four-hourly by patients on a visual lO cm linear ana logue sca le (VAS). (0 :0 No pain, and 10 :0 intolerable pai n). The amo unt ofp ar entcral analgesia during the first two days , and thc nu mber of reques ts for oral analgesia from the 3 ' d to the 7th postoperative days wer c recorded for each patient. All paticnts had at least one daily ehest radiograph during the first postoper ative week. The incidence of eomplieations was recorded. Student t- Test was used to compare results between the three groups. I'robability values below 0.05 were rega rded as significa nt.
Results Patient cha racteristics, surgical procedures, and complications are summarized in Tab le 1. No compllcations relat ed to the catheter or to bupivacain e toxicity wer e encountered. Ther e was no significant difTer en ce between the ave rage pain scores in the three groups. Nine patients (56 %) in the Il'C group requ ired pap aver etum during the first fort y eight hours. This was significantly less than in the oth ertwo groups in which all pati ent s required pap averetum durin g the sa me perio d. The average papaver etum requirement
IPC (n ~ 16)
B (n ~ 16)
Cryo (n ~ 15)
25- 73 56.1± 13.4
26- 70 50.7± 12.4
25-73 55.1± 15.6
12/4 52-90 69.2±10.6 153- 185 170.1± 9.7
13/3 53 -98 73.4± 11.9 158- 182 171.8± 7.8
5110 40 -81 62.0±1 2.3 148- 176 164.2± 8.4
6 2 3
3 1 3 1 3 3 1 1
6 2 4
2 2
2 1 I
Abbreviations: Wedge Resect.: wedge resection of the lung. Remov. F. S.: removal ot a foreign body(needle) from the lung parenchyma. H. H. Repair: hiatus hernia repair. Remov. Med. Mass: removal of mediastinal mass.
Tabl.1 Patient charactenstics.surgieal procedures, and complications
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Intrapleural Bupivacainef or Harly Post- thoracotomu Analgesia
Thorac. cardiovasc. Su rgeon 38 (l 990) IPC (n ~ 16) 1.0- 5.67 Average VAS, range 3.61± 1.37 mean ± SO Nu mber of patients needmg papaveretum 9 and pereentage 56.3% (0- 48 h postop.) Papaveretum requirements(mg) per patent (0- 48 h postop.) 00 -75 range mean ± SO 27.33±25.27 Nu mber of patients needing oral 13 analgesia andpereentage 81.3 % (3-7d postop.) Number of requestsfor oral analgesia perpatient (3- 7d postop.) 0-25 range 9.46 ±8. 2 mean ± SO
1I. Shafei. M. Chamberlain. K. N. Natrajan . M. A.
8 (n ~ 16)
Cryo (n ~ 15)
1.42- 5.83 3.54±1.l 5
0.83- 6.08 3.33 ±1. 47'
16 100.0 %
15 100.0 %
20-1 20 52.66 ±26.85
10-90 37.66±20.95··
15 93.8 %
10 66.7 %
1- 29 16.06 ± 8.4
0-32 12.6 ± 7.9···
R. Khan. arid R. G. Ocndhi
Ta bl. 2 2 PainScore (VAS) and analgesic requirernents
n
p-value IPC/8 ~ 0,869 (not significant); IPC/ Cryo ~ 0.581 (not significant); 8/Cryo ~ 0.668 (not significant). (00): p-value IPe/ B = 0.0012(significant); JPC/Cryo = 0.232(not signiflcant), B/Cryo = 0.09 (not significant). (000): p-value IPC/ B = 0.0047 (signifieant);IPC/Cryo = 0.47 (not signiticant): B/Cryo = 0.43 (not signiticant].
per patient in the IPCgroup was significantly less than that in the Bgroup, but the differ ence was not stati stically significant from that in the Cryo group . The average numb er of requests for oral analgesia per patient in the IPC group was significantly less than that in the B group , but the difference was not statistically significant between th e IPC group and the Cryo group . Table 2 summarizes the results of pain score and the analges ie requirements in the three groups. Discussion
The techniqu e of intrapleural catheter for instillation of bupivacaine into the pleural space was initially described for relief of ea rly postop erative pain after unilateral mammary surgery, ren al surgery and choIecystectomy (2. 4, 5, Application of this techniqu e for post-thoracotomy an algesia was then describ ed in few and controversial reports (I , 3, 6). Kambam and co-wor kers (1) reported the use of the intr apleur al catheter with intermittent instillation of bupivacaine in fourteen patients who underwent thora cotomies. and in whom the plasma level of bupivacaine was measured . They found that the method is efTective in patients who underwent lateral and posterior thoracotomies and not effective with anterior thorac otomy. Rosenberg and co-workers (6) used continuous infusion of bupivacain e through an intrapleural catheter for relief of ea rly pain after thora cotomy in fourteen adults. They found that this method produced insufficient pain control, and they reported snapping of the catheter in one pat ient. They did not recomm end the use of intrapleural bupivacain e either as a bolus or as continuous infusion for postoperative pain tr eatm ent after thoracotomy. On the oth er hand, in a recent report by Mcl/vaine and co-workers (3). continuous infusion of bupivacain e via an intrapleural catheter was considered safe and efTective for analgesia after thoracotomy in children. We are not aware ofa ny reports in
n
which the efficacy of th is techniqu e has been compared to other techniques of analgesia for thoracotomy, In this study, intermittent doses of 20 ml bupivacaine of 0.25 % up to six tim es a day were used. This dosage was pr eviously shown to be effective (5. 7) and weil below the dosage which may produce bupivacain e toxic plasma concentration (2-4 jLg/ml) (8). Kambam and co-workers (I ) measured lower peak plasma levels of bupivacain e when used with adrena line. Therefore they suggested using bupivacaine with adrenaline. However, we elected to use plain bupivacaine to avoid the possible probl em from the systemie absorption of adrenaline. in particular cardiac arrhythmias. Unlike Rosenberg and co-workers (6) who used this technique in two pneumon ectomy patients , we excluded such pati ents from the stud y becau se of the poten tial ha zards of leaving an intrapleural catheter in the pn eumonectomy space. In addition. the distribution of the local anaesthetic agent in the pneumonectomy spa ce is unpredictable. The mechanism ofintrapleural analgesia is not c1ear. It has been suggested that the instilled bupivacain e produ ces multiple intercostal blockade (4). and block of the nerve endings in the pleura (6). It see ms from the above theories that the most appropriate position of the catheter tip should be at the dome of the pleural space posteriorl y. so that the injected local anaesth etic agent triekles over the posterio r ends of the intercostal nerves. The advantage of insertin g the catheter at operation is to allow its prop er positioning , and the whoie procedure of inse rtion should not consume more than a few minut es ofthe operating time . We took the pr ecautions ofplacing the catheter tip away from the ehest dr ainage tub es and disconnecting any suction applied to the ehes t drains during and for 15 minutes after injections in the postop erative period. From the results ofthis stud y, the sa fety ofthis technique is evident from the absence ofa ny complications related
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Thorac. cardiovasc. S u rgeo1l 38 (1990)
IntrapleurallJupivacaine j or Ear ly Post -Thoracotomy Analqesia
Ackno w ledgements Wc wish to th a nk Dr . D. R. Kelly. Dr. A. Lockhart fram the Depa rtm e nt of Anaesthesia, Dr. ll. P. Tulloh fro m th e Departm e nt of Hadiology, Mrs. Boothe from the Libra ry, a nd our Nu rs ing a nd Secr etaria l Staff for th eir assistance in pr ep aring thi s re po rt .
Re feren ces 1
2 3
4
5
6
7
8
Kambam. 1. H.• R. E. Handte. J. Flanagan, M. Lupinetti, a nd J. lI ammon: Intrap leural anaesth esia for post -tho racotom y pain rellef Iabstractl . Anes th. Ana lg. 66 (198 7) S90 Kvalheim. L.. a nd F. Reiestad: Intra pleural cat heter in the man agemen t of postoperative pa in . Anest hesi ology 6 1 (19 84) A23 1 Mclloaine, W B.. H. F. Knox. P. V. Fennessey . a nd M. Goldstein: Continuous infusion of bupivacai ne via a n int rap leural catheter für a nalgesia after thoracotomy in children. Anest hes iology 69 (1988) 26 1-264 Reiest ad. F., a nd K. B. St remskaq: Intrap leu ral cathet er in the ma nagem ent of postoperative pain . A prelimin a ry rcp cr t. Reg. Anest h . 11 (1986 ) 89 - 91 Reies tad. F.. K. B. St remsk aq. a nd F.. Ifolmqvist: Intrap leural administra tion of bupivacain e in postoperative management of pain . Anesthes iology 65 (1986) A204 Rosenberg. P. H . B. M. A. Schein in. M. 1. A. Lepiintalo. and O. Lindf ors: Contin uous intra pleural infusion of bupivacal ne for a na lgesia afte r thoractomy. Anest hesio logy 67 (1987) 8 11- 8 13 Se tteer. J. L.. G. E. Larijani, M. E. Goldberg. A. T. Marr. and M. L. Rocci: A kinetic an d dynamic eva luation ofintrapleura l buplvacain e for subcostal incisional pain . Anest hes iology 65 (1986) A213 Tucker. G. T.: Pharmacokinetics of local anaesthotics. Br. J. Anaest h . 58 (9 86) 717 - 73 1
/I . Shafei. MS FRCS
Na tional Hea rt Hospital Weste rmo reland Street Lond on Wl M 8BA England
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to clinical hupivacaine toxicity or the use of the catheter . Ther e was no significant differenc e between the average pain scores in the three groups, and the numher of patients who required narcotic injections and the average na rcotic requ irem ent per patient during the first forty-eight postoperativ e hours in the intr ap leural catheter group wa s less than that in the other groups. Intrapleural hupivacaine is a simpie technique when compared to epidural analgesia, which has its own complications and requires high-dependency postoperative care . It is efficient in pain control and it has the advantage that repeat injection of the local anaesthetic agent is feasible. ohviating the need for narcotic injections. From our experience, we believe that an intrapleural catheter with intermittent instillation of bup ivacaine is a safe and effective technique for early post -thoracotomy pain relief, and we recommend this meth od, either as an alternative to, or in conjunction with , other methods of an algesia for thoracotomy.
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