Intrapleural analgesia for post-thoracotomy pain and blood levels of bupivacaine following intrapleural injection

Injection of Bupivacaine into the Pleural and Mediastinal Drains: A Novel Approach for Decreasing Incident Pain After Cardiac Surgery - Montreal Heart Institute Experience

Background

We conducted a chart review of prospectively collected data in order to demonstrate the safety and efficacy of an innovative technique of pleural and mediastinal drain injections.

Methods

Patients who had undergone cardiac surgery and who continued to have pain despite the use of a multimodal pain protocol received injections of 20 mL of 0.25% bupivacaine in pleural and/or mediastinal chest drainage tubes.

Results

Patients were evaluated for the incidence mediastinitis, osteitis, and deep sternal wound infection as well as the speed and intensity of pain relief. The odds ratio of infection in the infused group was 0.955 (CI = 0.4705, 1.9384). The adjusted mean “decrease in pain” was 4.01 (SEM = 0.15 and 95% CI = 3.78, 4.38), using the 11-point Likert Numerical Rating Scale. The mean adjusted “time to maximum pain relief” was 8.33 minutes (SEM = 0.42 and 95% CI = 7.50, 9.15).

Conclusion

This technique is a powerful, safe, and efficient tool in the armamentarium of pain management and its growing use within our institution has provided a substantial benefit in the treatment of early post-operative pain.

Daring discourse: should the ESP block be renamed RIP II block?

During the time period 1984 to the turn of the millennium, interpleural nerve blockade was touted as a very useful regional anesthetic nerve blockade for most procedures or conditions that involved the trunk and was widely practiced despite the lack of proper evidence-based support. However, as an adequate evidence base developed, the interest for this type of nerve block dwindled and very few centers currently use it-thereby to us representing the rest in peace (RIP) I block. Unfortunately, we get a deja-vù sensation when we observe the current fascination with the erector spinae plane block (ESPB), which since 2019 has generated as many as 98 PubMed items. This daring discourse point out the lack of a proper evidence base of the ESPB compared with other established nerve blocking techniques as well as the lack of a proven mechanism of action that explains how this nerve block technique can be effective regarding surgical procedures performed on the front of the trunk. Emerging meta-analysis data also raise concern and give cause to healthy skepticism regarding the use of ESPB for major thoracic or abdominal surgery. Against this background, we foresee that ESPB (and variations on this theme) will end up in a similar fashion as interpleural nerve blockade, thereby soon to be renamed the RIP II block.

Comparative evaluation of effects of intrapleural block with adjuvants on analgesia and pulmonary function after intercostal drainage: A pilot study

Background

Inter-costal chest drain (ICD) used for varied thoracic pathologies causes continuous pain and irritation of the pleura, which limits respiratory efforts and impairs ventilatory function. Intrapleural block deposits local anaesthetic between the layers of pleura and may improve ventilatory function especially in non surgical patients.

Methods

Twenty eight ASA I-III patients treated with ICD, who could perform incentive spirometry, were included for study. They were randomized to 'Group C' (control group); 'Group B' (Bupivacaine); 'Group M' (Bupivacaine + Morphine) and 'Group D' (Bupivacaine + Dexmedetomidine). The drugs were administered via the ICD itself and clamped thereafter for 15 min. The success of the block was assessed by time for first analgesic demand, maximum inspiratory volume generated and Numerical Rating Scale score for pain; by patients.

Results

Effective analgesia was observed in Group B, M and D. Addition of an adjuvant significantly prolonged time for rescue analgesic demand. Patients who received local anaesthetic alone or with an adjuvant had significantly improved maximal inspiratory volume and required lesser rescue analgesics. No significant complications were observed in any group. Pain relief in post-surgical patients using intraplural block is masked by systemic analgesics. However its application in patients with ICD for non surgical indications was explored in this study and was found to improve patient comfort and ventilation.

Conclusion

Intra-pleural blockade is safe and effective in relieving the constant pleural irritation and pain of ICD, thus enabling the patient to improve ventilatory effort and faster recovery of respiratory function.

The effect of bilateral intrapleural infusion of lidocaine with fentanyl versus only lidocaine in relieving pain after coronary artery bypasses surgery

Background and Objective:

Pain control during surgery in order to cause analgesia and reduce the somatic and autonomic response may decrease the morbidity. Intrapleural catheter embedding during surgery under direct vision of surgeon is safe and easy and without potential risk of thoracic epidural block. The aim of this study was to investigate the effect of bilateral intrapleural infusion of lidocaine with fentanyl versus only lidocaine in relieving pain after coronary artery bypass surgery.

Methods:

In this prospective randomized double blind clinical trial,130 adult patients undergoing elective CABG with age range of 20 to 60 years were divided into two groups receiving either lidocaine and fentanyl (group A) or lidocaine (group B). The analgesia was evaluated every two hours in all intubated and non-intubated patients using Visual analog scale (VAS) and data were analyzed using SPSS software package.

Results:

Of all patients, 67 (51.5%) were males and 63 (48.5%) were females. The average age of subjects was 53.49 ± 5.099 years. Mean pain score six hours after the surgery was statistically different between the groups at all times.

Conclusion:

The pain in patients receiving combination of lidocaine and fentanyl is less than patients receiving only lidocaine.

Postthoracotomy Ipsilateral Shoulder Pain: A Literature Review on Characteristics and Treatment

Context. Postthoracotomy Ipsilateral Shoulder Pain (IPS) is a common and sometimes intractable pain syndrome. IPS is different from chest wall pain in type, origin, and treatments. Various treatments are suggested or applied for it but none of them is regarded as popular accepted effective one. Objectives. To review data and collect all present experiences about postthoracotomy IPS and its management and suggest future research directions. Methods. Search in PubMed database and additional search for specific topics and review them to retrieve relevant articles as data source in a narrative review article. Results. Even in the presence of effective epidural analgesia, ISP is a common cause of severe postthoracotomy pain. The phrenic nerve has an important role in the physiopathology of postthoracotomy ISP. Different treatments have been applied or suggested. Controlling the afferent nociceptive signals conveyed by the phrenic nerve at various levels—from peripheral branches on the diaphragm to its entrance in the cervical spine—could be of therapeutic value. Despite potential concerns about safety, intrapleural or phrenic nerve blocks are tolerated well, at least in a selected group of patient. Conclusion. Further researches could be directed on selective sensory block and motor function preservation of the phrenic nerve. However, the safety and efficacy of temporary loss of phrenic nerve function and intrapleural local anesthetics should be assessed.

Management of Pain in the Critically Ill

Analgesia for critically ill patients can be provided most effectively by the use of modern techniques. Under standing of the anatomical pathways for nociceptive sig nal transmission allows the use of techniques that mod ulate or block nociceptive information at several levels (periphery, spinal cord, and systemic). A comprehen sive discussion of analgesic techniques at each level is presented. Formulation of a treatment plan is discussed. Several examples are presented to show the decision- making process for the use of modern analgesic tech niques in critically ill patients.

Regional anaesthesia in trauma

Regional anaesthesia is very effective in alleviating pain due to trauma, and is also used to provide anaesthesia for trauma surgery. It has the advantage of producing localized but complete pain relief, whilst avoiding the side effects of systemic analgesics or anaesthetics. However, regional anaesthetic drugs and techniques have potentially life-threatening complications, which the practitioner must be able to manage. This article discusses the use of regional anaesthesia, and the benefits and disadvantages of specific regional techniques in various traumatic conditions.

Prospective, comparative study of the On-Q® PainBuster® postoperative pain relief system and thoracic epidural analgesia after thoracic surgery

OBJECTIVE

Pain after thoracotomy is associated with intense discomfort leading to impaired pulmonary function.

DESIGN

Prospective, non-randomized trial from April 2009 to September 2011.

SETTING

Department of Thoracic Surgery, single-center.

PARTICIPANTS

Thoracic surgical patients.

INTERVENTIONS

Comparison of thoracic epidural analgesia (TEA) with the On-Q® PainBuster® system after thoracotomy.

MEASUREMENTS AND MAIN RESULTS

The TEA group (n=30) received TEA with continuous 0.2% ropivacaine at 4 mL-to-8 mL/h, whereas Painbuster® patients (n=32) received 0.75% ropivacaine at 5 mL/h until postoperative day 4 (POD4). Basic and on-demand analgesia were identical in both groups. Pain was measured daily on a numeric analog scale from 0 (no pain) to 10 (worst pain) at rest and at exercise. There were no significant differences regarding demographic and preoperative data between the groups, but PainBuster® patients had a slightly lower relative forced expiratory volume in 1 second (FEV1) (71±20% versus 86±21%; p=0.01). Most common surgical procedures were lobectomies (38.8%) and atypical resections (28.3%) via anterolateral thoracotomy. Most common primary diagnoses were lung cancer (48.3%) and tumor of unknown origin (30%). At POD1, median postoperative pain at rest was 2.1 (1; 2.8) in the TEA group and 2 (1.5; 3.8; p=0.62) in the PainBuster® group. At exercise, median pain was 4.3 (3.5; 3.8) in the TEA group compared to 5.0 (4.0; 6.5; p=0.07). Until POD 5 there were decreases in pain at rest and exercise but without significant differences between the groups.

CONCLUSIONS

Sufficient analgesia after thoracotomy can be achieved with the intercostal PainBuster® system in patients, who cannot receive TEA.

Comparison of paravertebral and interpleural block in patients undergoing modified radical mastectomy

Background:

Paravertebral and inter pleural blocks (IPB) reduce post-operative pain and decrease the effect of post-operative pain on lung functions after breast surgery. This study was designed to determine their effect on lung functions and post-operative pain in patients undergoing modified radical mastectomy.

Materials and Methods:

A total of 120 American Society of Anesthesiologists physical status 1 and 2 patients scheduled to undergo breast surgery were randomly allocated to receive IPB (Group IPB, n = 60) or paravertebral block (PVB) (Group PVB, n = 60) with 20 ml of 0.5% bupivacaine pre-operatively. A standard protocol was used to provide general anesthesia. Lung function tests, visual analog scale (VAS) for pain at rest and movement, analgesic consumption were recorded everyday post-operatively until discharge.

Results:

Lung functions decreased on 1^st post-operative day and returned to baseline value by 4^th post-operative day in both groups. VAS was similar in both groups. There was no significant difference in the consumption of opioids and diclofenac in both groups. Complete block was achieved in 48 patients (80%) in paravertebral group and 42 patients (70%) in inter pleural group.

Conclusion:

To conclude, lung functions are well-preserved in patients undergoing modified radical mastectomy under general anesthesia supplemented with paravertebral or IPB. IPB is as effective as PVB for post-operative pain relief. PVB has the added advantage of achieving a more complete block.

Clinical management of pain in advanced lung cancer

Lung cancer is the most common cancer in the world and pain is its most common symptom. Pain can be brought about by several different causes including local effects of the tumor, regional or distant spread of the tumor, or from anti-cancer treatment. Patients with lung cancer experience more symptom distress than patients with other types of cancer. Symptoms such as pain may be associated with worsening of other symptoms and may affect quality of life. Pain management adheres to the principles set out by the World Health Organization's analgesic ladder along with adjuvant analgesics. As pain can be caused by multiple factors, its treatment requires pharmacological and non-pharmacological measures from a multidisciplinary team linked in with specialist palliative pain management. This review article examines pain management in lung cancer.

Intrapleural analgesia after endoscopic thoracic sympathectomy

PURPOSE

To compare analgesia traditionally used for thoracic sympathectomy to intrapleural ropivacaine injection in two different doses.

METHODS

Twenty-four patients were divided into three similar groups, and all of them received intravenous dipyrone. Group A received intravenous tramadol and intrapleural injection of saline solution. Group B received intrapleural injection of 0.33% ropivacaine, and Group C 0.5% ropivacaine. The following aspects were analyzed: inspiratory capacity, respiratory rate and pain. Pain was evaluated in the immediate postoperative period by means of the visual analog scale and over a one-week period.

RESULTS

In Groups A and B, reduced inspiratory capacity was observed in the postoperative period. In the first postoperative 12 hours, only 12.5% of the patients in Groups B and C showed intense pain as compared to 25% in Group A. In the subsequent week, only one patient in Group A showed mild pain while the remainder reported intense pain. In Group B, half of the patients showed intense pain, and in Group C, only one presented intense pain.

CONCLUSION

Intrapleural analgesia with ropivacaine resulted in less pain in the late postoperative period with better analgesic outcomes in higher doses, providing a better ventilatory pattern.

Comparison between intermittent intravenous analgesia and intermittent paravertebral subpleural analgesia for pain relief after thoracotomy

OBJECTIVE

In the present prospective double-blind randomized trial, the effects of intermittent paravertebral subpleural bupivacaine and morphine on pain management in patients undergoing thoracotomy were evaluated and compared with intermittent systemic analgesia.

METHODS

Forty-five patients undergoing elective lobectomy were included in the present study. Three randomized groups consisting of 15 patients each were compared. Those in the control group were administered intravenously with tramadol 100 mg plus metamizol 1000 mg every 4 h for 3 days. We placed the catheter just below the parietal pleura along the paravertebral sulcus at the level of T5-T7. At the end of the operation and every 4 h thereafter, the patients received either 1.5 mg kg(-1) bupivacaine (bupivacaine group) or 0.2 mg kg(-1) morphine sulfate (morphine group) with paravertebral subpleural catheter for 3 days. Data regarding demographics, visual analog pain scores, need for supplementary intravenous analgesia, pulmonary function tests, and postoperative pulmonary complications were recorded for each patient.

RESULTS

Visual analog pain scores (visual analog scale (VAS)) were lower in the morphine and bupivacaine groups compared with control group at all postoperative time points. The mean postoperative VAS was significantly different between the control and bupivacaine groups at postoperative hour 12, the control and morphine groups at postoperative hours 6, 12, 48, and 72, and the bupivacaine and morphine groups at postoperative hours 6 and 24 (p<0.05). In the control group, additional analgesic requirement was significantly higher than in the bupivacaine and morphine groups (p<0.05). Postoperative pulmonary complications occurred in three patients (20%) in the control group, in two patients (13%) in the bupivacaine group, and in one (6%) in the morphine group.

CONCLUSIONS

The patients undergoing lung resection through a thoracotomy were observed with reduced postoperative pain and better surgical outcomes with respect to the length of hospital stay, postoperative forced expiratory volume in the first second, pulmonary complications, and need for bronchoscopic management, when paravertebral subpleural analgesia was induced by morphine.

Intrapleural analgesia using ropivacaine for postoperative pain relief after minimally invasive thoracoscopic surgery

PURPOSE

to evaluate the efficacy and safety of intrapleural analgesia (IPA) using ropivacaine after thoracoscopic surgery, compared with thoracic epidural analgesia (TEA) using ropivacaine.

METHODS

forty patients undergoing thoracoscopic bullectomy for spontaneous pneumothorax were randomly assigned to one of two groups. IPA group (n = 20) received intermittent bolus injection of 0.375% ropivacaine into intrapleural space two times; at the end of operation and one more time as the pain increased. TEA group (n = 20) received continuous epidural analgesia with 0.375% ropivacaine. Transrectal diclofenac was administered as an additional analgesic. Pain was assessed on the basis of additional analgesics requirements and by using a visual analog scale (VAS).

RESULTS

the time courses of VAS scores along the postoperative time course were not significantly different (p = 0.175). Consumption of transrectal diclofenac was significantly smaller in IPA group (p = 0.025). No major complications appeared in both groups, and incidence of adverse symptoms was not different.

CONCLUSIONS

in IPA group, pain was managed with less consumption of additional analgesics. IPA could be one of the good choices after thoracoscopic surgery for its efficacy, safety, and benefit of easy placement of the catheter.

Effects of intrapleural analgesia on pulmonary function and postoperative pain in patients with chronic obstructive pulmonary disease undergoing coronary artery bypass graft surgery

OBJECTIVE

Pain after coronary artery bypass graft (CABG) surgery remains a significant problem and may cause serious complications because of restricted breathing and limited early mobilization. The aim of this study was to assess the effects of intrapleural analgesia on the relief of postoperative pain in patients undergoing CABG surgery.

DESIGN

Postoperative pain, pulmonary function tests, and outcomes were compared with a placebo group after CABG surgery in a double-blind randomized clinical trial.

SETTINGS

Cardiovascular surgery clinic.

PARTICIPANTS

One hundred twenty-five patients with decreased lung function were studied.

INTERVENTIONS

Group A (62 patients) received 20 mL of 0.5% bupivacaine bilaterally in the intrapleural spaces every 6 hours for 4 days, and group B (63 placebo patients) received sterile saline solution.

MEASUREMENTS AND MAIN RESULTS

Group A had a significantly shorter extubation time than the placebo group (8 +/- 1 h v 10 +/- 4 hours, p < 0.001). Blood gas analysis showed higher PaO2 and lower PaCO2 levels in group A. The patients receiving bupivicaine had significantly higher FEV1, FCV, VC, MVV, PEF, and FEF 25-75% values postoperatively when compared with the placebo group. Postoperative analgesic requirements and visual analog pain scales were significantly lower in group A. The intensive care unit stay in group A was shorter (1.2 +/- 0.7 v 1.4 +/- 0.6 days, p = 0.04); however, the hospital stay did not differ between groups.

CONCLUSIONS

Improvement in lung function parameters correlating with decreased postoperative pain with intrapleural bupivacaine was observed. Intrapleural analgesia provided a good level of analgesia, improved respiratory performance, and allowed rapid mobilization, which led to a reduction of postoperative respiratory complications.

Efficacy of Methods of Intercostal Nerve Blockade for Pain Relief After Thoracotomy

Intercostal nerve blockade for postthoracotomy pain relief can be accomplished by continuous infusion of local anesthetics through a catheter in the subpleural space or through an interpleural catheter, by cryoanalgesia, and by a direct intercostal nerve block. A systematic review of randomized studies indicates that an extrapleural infusion is at least as effective as an epidural and significantly better than narcotics alone. The other techniques of intercostal blockade do not offer an advantage over narcotics alone.

Double-blind comparison of intrapleural saline and 0.25% bupivacaine for ipsilateral shoulder pain after thoracotomy in patients receiving thoracic epidural analgesia

BACKGROUND

The aim of this prospective double-blind randomized placebo-controlled study was to investigate the effect of intrapleural bupivacaine on ipsilateral post-thoracotomy shoulder pain in patients receiving thoracic epidural analgesia.

METHODS

Of the 68 patients recruited to the study, 41(60%) developed ipsilateral shoulder pain within 2 h of surgery. These patients were randomly assigned to receive either 40 ml of intrapleural bupivacaine 0.25% with epinephrine 1:200 000 or 40 ml of intrapleural saline. The study solution was injected into the tube of a basal drain that had been clamped distal to the site of administration. Shoulder pain at rest and on coughing was assessed using a visual analogue scale (VAS) and an observer verbal rating score (OVRS) immediately before and 30 min, 1 h, 2 h, 3 h and 4 h after intrapleural bupivacaine/saline. The total volume of epidural solution administered was recorded.

RESULTS

Thirty-nine patients completed the study and were included in the analysis. There were no significant differences in baseline characteristics between the two groups. There were no significant differences between groups for VAS or OVRS pain scores at rest or with cough at any of the six assessment times. The total volumes of epidural solution administered to the bupivacaine and saline groups were 56 ml and 48 ml, respectively. This difference was not significant.

CONCLUSION

Intrapleural administration of 40 ml of bupivacaine 0.25% does not provide effective pain relief for ipsilateral post-thoracotomy shoulder pain.

Intermittent infusion of 0.25% bupivacaine through an intrapleural catheter for post-thoracotomy pain relief

BACKGROUND

The present study was designed to evaluate the effectiveness of intrapleural 0.25% bupivacaine delivered by intermittent infusions for post-thoracotomy pain relief.

METHODS

Forty patients undergoing elective lobectomy were randomly, but equally, placed into two groups. An intrapleural catheter was inserted under direct vision during surgery. Group I received intrapleural 40 mL of 0.25% bupivacaine, group II was administered 40 mL of saline solution as a control group. Diclofenac sodium was administered as an additional analgesic, if required. Postoperative pain was evaluated using a visual analog scale (VAS), and Prince Henry pain scale. Arterial oxygen saturation, heart rate, and systemic arterial pressures were monitored. All observations were recorded 5, 10, 15, 20, 25, and 30 minutes after the injection, and thereafter at hourly intervals through the postoperative 24 hours.

RESULTS

The mean analgesia times were 5 hours and 2 hours in group I and group II, respectively. Therefore, bupivacaine administrations were repeated every 6 hours in group I, and saline with additional analgesic were administered every 4 hours in group II. The heart rate and arterial pressures did not show a significant difference. While the additional analgesic requirement was 180 +/- 10 mg/d in group II, there was no need for additional analgesic administration in the group I patients. Arterial oxygen was significantly higher in group I than in group II. Arterial carbon dioxide tension of group II was significantly higher than that of group I. While the postoperative atelectasis and pneumonia developed in four patients and one, respectively, in group II, no such complication was observed in group I.

CONCLUSIONS

The easy placement of an intrapleural catheter and better pain relief observed in the present study suggest that intermittent pleural infusion of 0.25% bupivacaine has proven to be a safe and effective method for relief of post-thoracotomy pain.

Acute pain management for patients undergoing thoracotomy

Management of thoracotomy pain can be difficult, but the benefits of effective pain control are significant. A variety of modalities for treating postoperative pain after thoracotomy are available, including systemic opiates, regional analgesics, and new oral and parenteral agents. This work provides a review of the literature and recommendations for the clinician.

Pain Management in Chest Trauma

Patients continue to report inadequate or poor pain control in the hospital setting following thoracic trauma. Moderate-to-severe pain is a potent activator of the “stress response”. Ongoing stimulation of this response can have a detrimental effect on many physiologic functions. Cardiovascular, pulmonary, gastrointestinal, and hemostatic functions may all be negatively affected by poorly controlled pain. Postoperative pain due to elective surgery is often used as a model for thoracic trauma pain management. This approach has limitations. Trauma pain is experienced without the benefits of anesthesia or preemptive analgesia. Thoracic trauma pain management seeks to limit the secondary effects of an initially painful stimulus. Resuscitation and neurological assessment may delay definitive pain control. A multimodal approach to the management of thoracic trauma pain may include combinations of systemic narcotics, nonsteroidal anti-inflammatory medications, epidural narcotics, epidural local anesthetic combinations, pleural catheters as well as peripheral nerve blocks. Carefully titrated systemic narcotics continue to be the most commonly applied pain management treatment either by fixed dosing or patient controlled techniques. This treatment approach alone often does not provide adequate pain control and is not without unwanted adverse effects. When appropriate, the addition of regional analgesic techniques can improve patient satisfaction, attenuate the detrimental stress response, and lead to improved patient outcome. An individualized, physician-derived pain management plan is required in order to provide adequate pain management to the thoracic trauma patient.

Postthoracotomy Pain Management

In modern medicine, postoperative analgesia is consid ered an integral part of the anesthetic management. Thoracotomy has been reported to be among the most intense clinical postoperative pain experiences. If pain is poorly controlled in the postoperative period, respira tory excursions, movements, and coughing may result in muscle splinting, atelectasis and postoperative pulmo nary dysfunction. This article focuses on the various analgesic modalities that are available for altering the flow of nociceptive information from the periphery to cortex: (1) the transduction of nociceptive information at the peripheral receptor (local anesthetics, nonsteroi dal anti-inflammatory drugs); (2) the transmission of nociceptive information along the afferent sensory neu ral pathways (intercostal, intrapleural, or epidural local anesthetics); and finally, (3) the modulation of nocicep tive input at the level of the dorsal horn of the spinal cord (lumbar or thoracic epidural and intrathecal opi oids) or the brain (systemic opioids). Finally, the role of preemptive analgesia in thoracic surgery is discussed.

The Pharmacology of New Drugs and New Uses for Older Drugs Used for Thoracic Pain Relief

Thoracotomy results in severe pain and deleterious changes in pulmonary physiology. These alterations are inevitable and can be minimized by effective analgesia. There are many options available for the treatment of postthoracotomy pain. Systemic opioids have been extensively used in this context but their side effects have led to the development of various routes of administration; the epidural route in combination with local anesthetics is the most effective. Other techniques include intercostal nerve block and intrapleural analge sia. Drugs such as clonidine, nonsteroidal anti-inflamma tory drugs, and ketamine are promising for the relief of pain after thoracotomy but further investigations are still warranted.

Management of pain in intensive care settings

An organized treatment plan for providing analgesia in ICU settings can make a significant difference in patient comfort and outcome. Advanced analgesic techniques are available for use at each level of the "pain pathway." These include agents and methods that act at the periphery, at the spinal cord level, and through a systemic approach. Consultation with specialists in pain management can help achieve optimum therapy for patients in the ICU setting.

Pain management in cardiothoracic practice

All analgesia regimens have benefits and side effects, and personal expertise can greatly influence the efficacy of regional techniques. A multimodal approach to analgesic management allows physicians to achieve maximum analgesic efficacy while limiting side effects. An appropriate analgesic plan takes into account the extent of pain associated with the type of incision and adjusts this according to each patient's individual needs. As we enter the new millennium, thoracic and cardiac surgery is becoming more innovative, and the life expectancy of people in the first world is constantly increasing. Older people with less physiologic reserve and more multisystem dysfunction are undergoing more major surgical procedures, and adequate pain control in the postoperative period is becoming increasingly important.

The use of interpleural analgesia using bupivacaine for pain relief in advanced cancer

The use of interpleural analgesia is described in six patients with a variety of advanced malignancies suffering from pain uncontrolled by opioids. The benefits and complications of the technique are discussed including management of the catheters at home and the measurement of plasma bupivacaine concentrations. Interpleural analgesia can provide good analgesia in a small, selected population of patients with otherwise uncontrolled pain of malignant origin.

Pleural bupivacaine placement for optimal postthoracotomy pulmonary function: a prospective, randomized study

OBJECTIVE

To determine dependent chest tube losses of bupivacaine with paravertebral versus interpleural administration, thereby helping to explain the significant differences in pulmonary function that exist between these two techniques.

DESIGN

A prospective, randomized study.

SETTING

A single hospital.

PARTICIPANTS

Twelve adult patients undergoing posterolateral thoracotomies.

INTERVENTIONS

Paravertebral or interpleural administration of bupivacaine.

MEASUREMENTS AND MAIN RESULTS

Analgesia, as assessed by visual analog pain scores and patient-controlled morphine requirements, was similar in both groups. Postoperative spirometric values were significantly better at most times with the paravertebral route of administration. Dependent chest tube bupivacaine losses were approximately four times higher in the interpleural group.

CONCLUSION

Local anesthetic on the diaphragm might actively impair respiratory function through diaphragmatic and abdominal muscle weakness, while failing to contribute to pain relief.

A comparative evaluation of intrapleural and thoracic epidural analgesia for postoperative pain relief after minimally invasive direct coronary artery bypass surgery

OBJECTIVE

To compare the efficacy of thoracic epidural analgesia (TEA) and intrapleural analgesia (IPA) after minimally invasive direct coronary artery bypass (MIDCAB) surgery with regard to quality of analgesia and complications.

DESIGN

A prospective, randomized study.

SETTING

A specialty research hospital.

PARTICIPANTS

Fifty consenting adults scheduled for MIDCAB surgery.

INTERVENTIONS

All patients underwent elective MIDCAB surgery. Patients in the TEA group (n=25) had an epidural catheter inserted in the fourth to fifth thoracic interspace and those in the IPA group (n=25) had an intrapleural catheter inserted in the sixth to seventh intercostal space intraoperatively under vision.

MEASUREMENTS AND MAIN RESULTS

Parameters evaluated after administration of bupivacaine (8 mL of 0.25% in the TEA group and 20 mL of 0.25% in the IPA group) on first demand included visual analog scale (VAS) pain scores, cardiovascular and respiratory (clinical, blood gases) function, wakefulness, supplemental analgesic requirement, and complications. Measurements were made at 2-hour intervals for the next 12 hours. VAS scores were significantly lower at 2, 6, 8, and 12 hours in the IPA group (TEA = 3.5, 4.5, 4.9, 4.6; IPA = 2.2, 3.6, 3.5, 3.7). There were no significant differences in hemodynamic or respiratory parameters or postoperative requirement for supplemental analgesia. In the TEA group, three patients had catheter migration and four had severe backache.

CONCLUSION

IPA is a safe and effective technique for postoperative analgesia after MIDCAB surgery and has a low complication rate compared with TEA. Careful positioning, chest tube clamping, and anchoring of the catheter are mandatory for IPA to be effective.

Local and regional anesthesia and analgesia

Many benefits can be obtained from the use of drugs applied locally or regionally when treating dogs and cats that are in pain or will be in pain because of surgical trauma. These techniques often use less medication than for systemic administration with a reduction in the likelihood of toxic effects from these compounds. Complete relief of pain can be achieved by blocking nerves originating from the site of injury by using local anesthetics, but this may entail loss of all sensation and motor paralysis. Other drugs, such as the opioids, may decrease the nociceptive input with minimal effect on motor activity. This report discusses the use of local anesthetics and other drugs for analgesia of the skin, mucous membranes, joints, pleura, and peritoneum, and the application of these drugs for regional blocks of peripheral nerves and epidural/intrathecal injection.

Intrapleural Analgesia before Pleurodesis

Intrapleural injection of local anesthetics has proved effective in managing pain caused by various conditions. We used this technique prior to pleurodesis and monitored the effect. Twenty consecutive patients suffering from severe unilateral pleural effusion were included. The investigation was performed double blind. Ten patients received bupivacaine intrapleurally and ten patients received sodium chloride prior to pleurodesis with tetracycline. Pain was scored using the visual analog scale before, and at various intervals after the pleurodesis. The patients in the placebo group had high pain scores and needed supplemental morphine injections. The patients in the bupivacaine group had low pain scores and did not need supplemental morphine. We found that intrapleural injection of bupivacaine prior to pleurodesis with tetracycline was effective in abolishing the pain.

Central nervous system toxicity in a patient receiving continuous intrapleural bupivacaine

A patient developed signs of central nervous system (CNS) toxicity during treatment of postthoracotomy pain with a continuous intrapleural bupivacaine infusion. This incident occurred after the patient's chest tube was clamped, without any decrease in the bupivacaine infusion rate. This is the first reported case of CNS toxicity in a patient receiving a continuous intrapleural bupivacaine infusion. Possible etiologies of this complication are discussed, as are ways to avoid such a complication in the future.

Review of the technique and complications of median sternotomy in the dog and cat

The surgical and medical records of 67 dogs and nine cats which underwent median sternotomy over a five-year period were reviewed. The indication for median sternotomy and the short and longer term complications were recorded. Twenty-six of the dogs died or were euthanased within 48 hours of the surgery as a consequence of the pre-existing disease or complications of the intrathoracic surgical procedure. A further four dogs were enthanased between 48 hours and 14 days following confirmation of neoplastic processes. Thirty-seven dogs were alive at 14 days: of these, seven dogs (19 per cent) experienced short-term wound complications, including haemorrhage, wound infection, thoracic limb neurological deficits and excessive postoperative discomfort. Of the 37 dogs alive for longer term follow-up, eight dogs (22 per cent) experienced wound complications, including haemorrhage, sternal fracture, sternal osteomyelitis and delayed wound healing. No complications were noted in the cats.

A double-blinded evaluation of intraperitoneal bupivacaine vs saline for the reduction of postoperative pain and nausea after laparoscopic cholecystectomy

BACKGROUND

Intraperitoneal local anesthesia has been reported to reduce postoperative pain after laparoscopy for gynecologic procedures that do not require a great deal of dissection or manipulation of viscera. This study was performed to determine the efficacy of intraperitoneal bupivacaine in laparoscopic cholecystectomy (LC).

METHODS

Fifty-five patients were evaluable in this randomized, double-blind, placebo-controlled study. Twenty-six patients received bupivacaine (0.1%) and 29 patients received placebo (saline). Prior to any dissection of the gallbladder, the surgeon irrigated 100 ml of experimental solution under the right hemidiaphragm, over Glisson's capsule, over the gallbladder serosa, and into the subhepatic space. The operation was then performed as usual. Postoperatively, analgesic medication usage, nausea, vomiting, and pain scores were determined during hospitalization. A questionnaire was given to each patient upon discharge from the hospital in order to continue monitoring medications and pain for the first 48 h at home.

RESULTS

Postoperative pain was reduced significantly (P < 0.05) in the patients who received bupivacaine, but the effect was modest and observable only during the first 6 h after surgery. Despite this difference, there was no significant reduction in the amount of analgesic medication used by the patients who received bupivacaine, nor was there any reduction in nausea, vomiting, or shoulder pain when queried specifically.

CONCLUSIONS

Intraperitoneal bupivacaine offered a detectable, albeit subtle benefit to patients undergoing LC. However, the effect was transient and had little impact upon the patient's convalescence.

Thoracic paravertebral analgesia

Thoracic paravertebral nerve blockade, although once widely practised, has now only a few centres which contribute to the literature. Data production has, however, continued and this review correlates this new information with existing knowledge. Its history, taxonomy, anatomy, indications, techniques, mechanisms of analgesia, efficacy, contraindications, toxicity, side effects and complications are reviewed. Thoracic paravertebral analgesia is advocated for surgical procedures of the thorax and abdomen, especially wherever the afferent input is predominantly unilateral eg. thoracotomy, cholecystectomy and nephrectomy. It is also of benefit in the prevention and management of chronic pain. It is a simple undertaking with impressive efficacy. Plasma local anaesthetic levels are acceptable and its side effect and complication rates are low. No mortality has been reported. For unilateral surgery of the chest or truck, thoracic paravertebral analgesia should be considered as the afferent block of choice. For bilateral surgery, its efficacy may be limited by the doses of local anaesthetic which could safely be used and further study in this area in particular is required. This form of afferent blockade deserves greater consideration and investigation.

Pain outcomes after thoracotomy: lumbar epidural hydromorphone versus intrapleural bupivacaine

OBJECTIVE

To evaluate postthoractomy analgesia in patients receiving lumbar epidural hydromorphone versus intrapleural bupivacaine.

DESIGN

A randomized, prospective, double-blind study.

SETTING

A university-affiliated medical center.

PARTICIPANTS

Twenty patients undergoing lateral thoracotomy for either pulmonary wedge resection, lobectomy, or pneumonectomy.

INTERVENTION

Nine patients received epidural hydromorphone, and 11 patients received intrapleural bupivacaine in the postoperative period.

MEASUREMENTS AND MAIN RESULTS

Severity of pain was assessed using a visual analog pain scale (VAPS) (0 to 100 mm) at 1, 3, and 5 hours. Patients receiving epidural hydromorphone had a statistically significant improvement in VAPS scores. Patients who received intrapleural bupivacaine did not achieve a significant reduction in pain scores. Nine of 11 patients in the intrapleural bupivacaine group had "failed" postoperative analgesia as defined by a VAPS greater than 30. Only 3 of 9 patients in the continuous epidural hydromorphone group had "failed" analgesia.

CONCLUSION

Epidural hydromorphone is superior to intrapleural bupivacaine in achieving satisfactory pain outcomes during the first 5 hours after thoracotomy.

Effect of interpleural administration of bupivacaine or lidocaine on pain and morphine requirement after esophagectomy with thoracotomy: a randomized, double-blind and controlled study

The purpose of the present study was to investigate the efficacy of interpleural (IP) analgesia with bupivacaine or lidocaine after esophageal surgery and to measure the plasma concentrations of bupivacaine and lidocaine after intermittent IP administrations. Two IP catheters were inserted percutaneously in the seventh intercostal space during operation. Patients in the bupivacaine group (Gr B) received 1 mg/kg of 0.5% bupivacaine with epinephrine 1:200000 in 20 mL of saline 0.9%, patients in the lidocaine group (Gr L) received 3 mg/kg of 2% lidocaine with epinephrine in 20 mL of saline 0.9%, and patients in the placebo group (Gr P) received 20 mL of saline 0.9% every 4 h during 2 days. Pain was assessed by visual analog scale (VAS) every 4 h at rest (VASR), after a deep breath or cough (VASC), at the thoracotomy (VAST), and at the laparotomy (VASL). Morphine consumption using a patient-controlled analgesia (PCA) device was recorded. There was no significant difference in the mean VASR, VASC, and VASL scores among the three groups. VAST scores were significantly lower in Gr B at 12, 16, 28, and 32 h when compared with Gr P and Gr L (P < 0.05). There was no statistical difference in mean VAST between Gr L and Gr P. Total consumption of morphine was lower in Gr B than in Gr P and Gr L (41.2 +/- 13 mg vs 66.1 +/- 21 mg in Gr P (P < 0.02) and 75.5 +/- 27 mg in Gr L (P < 0.01)), but were similar in Gr L when compared with Gr P.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of the hemodynamic effects of interpleural bupivacaine in dogs

The hemodynamic effects of interpleural (IP) bupivacaine were studied in six halothane-anesthetized dogs. On four separate occasions, each dog received IP saline (S), or bupivacaine at a low dosage of 1.5 mg/kg (L), high dosage of 3.0 mg/kg (H), or high dosage of 3.0 mg/kg with epinephrine 5 micrograms/mL (HE). Heart rate, systolic and mean arterial pressures, and base excess were significantly lower in the H dosage group than in the other treatment groups. Cardiac output, expressed as a percentage of change from baseline, was significantly higher in the L group than in the H and S groups. Pulmonary arterial pressure and respiratory rate were significantly higher in the HE group than in the other three groups. Mean plasma concentrations of bupivacaine peaked between 5 and 15 minutes after IP injection. Maximum plasma concentrations in individual dogs were variable; however, mean maximum plasma concentrations in the H and HE groups were not significantly different. Clinically significant hypotension occurred in one dog in the H group and in one dog in the HE group. No pulmonary complications were detected.

[Comparison of extrapleural and intrapleural analgesia with bupivacaine after thoracotomy]

OBJECTIVE

To compare the analgesic and the ventilatory effects as well as blood concentrations of bupivacaine, administered either in the extrapleural or interpleural space after posterolateral thoracotomy.

STUDY DESIGN

Randomized clinical trial.

PATIENTS

Twenty ASA class I and II patients, scheduled for elective thoracic surgery were randomly allocated either in the IP group (catheter inserted into the interpleural space) or the EP group (catheter inserted in extrapleural position, paravertebrally above the posterior parietal pleura).

METHODS

In the catheter, inserted at the Th4 level at the end of the surgical procedure, 20 mL of 0.5% bupivacaine were injected after full recovery from anaesthesia, with the thoracic drains clamped for 30 min. The injection was repeated every six hours. Pain was evaluated after a deep inspiration with a visual analog scale (VAS), before and 1.3 and 6 hours after the injection. Analgesia was considered as effective if the VAS score at the end of the first hour was less than 30 mm. Otherwise 0.1 mg.kg-1 of morphine was administered subcutaneously. The forced vital capacity (FVC) and the forced expiratory volume one second (FEV1) were measured preoperatively and on 1st (D1) and 2nd postoperative Day (D2). Blood samples for measurements of plasma bupivacaine concentrations were obtained at 5, 10, 20, 30, 60, 90, 120, 150, 180 and 250 min respectively after the first injection.

RESULTS

Bupivacaine provided a more rapid, deep and prolonged analgesia by extrapleural than by interpleural route. Analgesia was effective in 9 patients in EP group vs 4 patients in IP group (P < 0.05). Morphine requirements were 4 +/- 8 mg in EP group vs 17 +/- 10 mg in the IP group (P < 0.05). The FVC and FEV1 values were similarly decreased on D1, but recovery was better in EP group on D2 (P < 0.05). Bupivacaine peak concentrations in plasma were lower in EP group (0.86 +/- 0.42 microgram.mL-1) than in IP group (1.63 +/- 1.44 micrograms.mL-1), however the difference was not significant.

CONCLUSIONS

Extrapleural administration of bupivacaine provides better analgesia as the anaesthetic agent comes in closer contact with intercostal nerves and with lower risk of loss of agent through the pleural drainage. Therefore its use is recommended preferentially over the interpleural route for analgesia after posterolateral thoracotomy.

Interpleural or thoracic epidural analgesia for pain after thoracotomy. A double blind study

The analgetic effect of bupivacaine given epidurally or interpleurally after thoracotomy was investigated in a randomized, double blind, placebo controlled study. 32 patients with both an epidural and an interpleural catheter, were randomized to receive either interpleural or epidural analgesia. The interpleural group was given bupivacaine 5 mg.ml-1 with 5 microgram epinephrine as a 30 ml interpleural bolus, followed by a continuous infusion starting at a rate of 7 ml per hour and epidurally a bolus of 0.9% NaCl followed by a continuous infusion of 0.9% NaCl. The epidural group was given bupivacaine 3.75 mg.ml-1 with 5 microgram epinephrine as a 5 ml epidural bolus, followed by a continuous infusion starting at a rate of 5 ml per hour and interpleurally a bolus of 0.9% NaCl followed by a continuous infusion of 0.9% NaCl. The draining tubes were clamped during the injection of the interpleural bolus and 15 min afterwards. Adequacy of pain relief was evaluated with the Prins-Henry pain scale. Morphine requirement was registered, there was no difference between the groups in pain scores or need for additional morphine.

[Interpleural analgesia : A topical review.]

Interpleural analgesia is a method of postoperative analgesia that was developed by Kvalheim and Reiestad in 1984. The main indication is postoperative pain after unilateral thoracic and upper abdominal surgery. Many authors report good analgesic effects and better postoperative lung function following cholecystectomy. There is some controversy on the effectiveness of this method after thoracic surgery. Further indications are post-traumatic pain after multiple rib fractures and chronic pain in the upper abdomen (carcinoma of the pancreas, chronic pancreatitis). The local anaesthetic of choice is bupivacaine (in concentrations of 0.25-0.75%, injection volumes of 10-40 ml, with or without epinephrine, applied as bolus or infusion), but others, such as lidocaine or morphine, are also being tested. Risks involved in this method are pneumothorax when the catheter is placed blind and the systemic toxicity of the local anaesthetic. This review provides information on the mechanism of action, the technique, the clinical use to date and possible risks.

Interpleural analgesia for postoperative pain relief in renal surgery patients

The feasibility of interpleural analgesia for postoperative pain relief after renal surgery using anterior intercostal incision was studied in 16 adult patients. 20 ml bupivacaine plain 5 mg/ml in ten patients, and the same dose of bupivacaine with epinephrine 5 micrograms/ml in six patients, was injected through epidural catheter into the pleural space of the operated side, maximally three times per 24 hours. As additional pain medication, oxycodone i.m. was given if needed. In ten control patients, oxycodone was the only pain medication. Postoperative pain relief in patients who received interpleural bupivacaine plain was excellent in four, moderate in four and poor in two cases. For supplemental pain relief the patients were given 2.1 +/- 1.1 (SEM) injections of oxycodone during the three days. Control patients received, respectively. 11.6 +/- 0.7 injections of oxycodone, and they considered the pain relief excellent in six and moderate in four cases. Median duration of interpleural analgesia was in bupivacaine plain cases 6 h (range 2-14 h) and in bupivacaine with epinephrine 7 h (range 4-15 h). The mean peak serum concentration of bupivacaine plain was 1868 +/- 168 ng/ml, and that of bupivacaine with epinephrine 1312 +/- 273 ng/ml. No complications were seen. The results suggest that interpleural analgesia obtained by 20 ml bupivacaine 5 mg/ml three times a day gives most patients good pain relief.