A randomized controlled trial of bupivacaine through intracostal catheters for pain management after thoracotomy

Kinesiotaping for isolated rib fractures in emergency department

INTRODUCTION

Rib fractures, which are among the most common injuries in blunt thoracic trauma, are usually encountered in Emergency Departments. Kinesiotape (KT) is a drug-free elastic therapeutic tape used for treating various musculoskeletal problems such as injury, dysfunction and pain. We aimed to investigate whether kinesotaping should be used safely and effectively in rib fractures in emergency setting.

MATERIALS AND METHODS

This was a prospective, randomized controlled study conducted in an Emergency Department of a University Hospital. Patients diagnosed with isolated rib fractures were included in the study. Pain severity of patients assessed with 0-10 cm visual analog scale (VAS), then patients assigned into 2 treatment groups. One of them received treatment with flurbiprofen 200 mg/day and the other group received kinesiotaping in addition to the same oral therapy. On the 4th day of the procedure, both groups were assessed with VAS in the followup visit.

RESULTS

Total of 82 patients presented with rib fractures, 52 of them were excluded. Remaining 30 constituted the study group and randomly allocated to kinesiotaping (n = 16) or control group (n = 14). In both groups, pain intensity on the 4th day was significantly reduced when compared with baseline (p for both<0.01). Additionally, considering the reducing the pain intensity on 4th day, kinesiotaping was significantly superior than the control group (p < 0.01).

CONCLUSION

This study investigated the use of kinesiotaping in emergency departments. When compared to NSAID therapy alone, combined kinesiotaping and NSAID therapy appears to be more effective in terms of pain reduction in rib fractures.

Optimizing health before elective thoracic surgery: systematic review of modifiable risk factors and opportunities for health services research

Despite progress in many different domains of surgical care, we are still striving toward practices which will consistently lead to the best care for an increasingly complex surgical population. Thoracic surgical patients, as a group, have multiple medical co-morbidities and are at increased risk for developing complications after surgical intervention. Our healthcare systems have been focused on treating complications as they occur in the hopes of minimizing their impact, as well as aiding in recovery. In recent years there has emerged a body of evidence outlining opportunities to optimize patients and likely prevent or decrease the impact of many complications. The purpose of this review article is to summarize four major domains-optimal pain control, nutritional status, functional fitness, and smoking cessation-all of which can have a substantial impact on the thoracic surgical patient's course in the hospital-as well as to describe opportunities for improvement, and areas for future research efforts.

Effects of flurbiprofen on CRP, TNF-α, IL-6, and postoperative pain of thoracotomy

OBJECTIVE

The aims of this study were to evaluate serum levels of acute phase reactants, such as CRP and cytokines (TNF-α and IL-6) in patients who have undergone thoracotomy and to investigate the effects of flurbiprofen on postoperative inflammatory response.

METHODS

Forty patients undergoing posterolateral thoracotomy were randomly divided into 2 groups of 20 each. Control group received tramadol (4 x 100 mg) intravenously for four days, and flurbiprofen group received both tramadol (4 x 100 mg) and flurbiprofen (2 x 100 mg). Blood samples were collected before surgery and at the 3th and 168th hours after surgical procedure to measure serum CRP, IL-6, and TNF-α. Pain visual analog scales were recorded daily during the first four postoperative days. Spirometric measurement of forced expiratory volume in the first second (FEV 1) was done before and four days after the operation.

RESULTS

The serum CRP, IL-6, and TNF-α levels in both groups increased significantly at 3th hour after thoracotomy. Serum TNF-α levels did not differ significantly between the groups at postoperative 4th day. However, IL-6 and CRP were significantly lower in flurbiprofen group than in control group at the same day (p < 0.05). Visual analog scale was significantly lower in flurbiprofen group at 6th, 12th, 48th, 72th, and 96th hours postoperatively (p < 0.05). The patients receiving flurbiprofen had higher FEV 1 values when compared with control group at postoperative 4th day.

CONCLUSIONS

Patients undergoing thoracotomy showed reduced postoperative pain, mean additional analgesic consumption, and serum IL-6 and CRP levels, when flurbiprofen was added to systemic analgesic therapy. Analgesia with anti-inflammatory drug may contribute to the attenuation of the postoperative inflammatory response and prevent postoperative pain in patients undergoing thoracotomy.

A systematic review of comparative studies indicates that paravertebral block is neither superior nor safer than epidural analgesia for pain after thoracotomy

Background

The “gold standard” for pain relief after thoracotomy has been thoracic epidural analgesia (TEA). The studies comparing TEA with paravertebral block (PVB) and recent reviews recommend PVB as a novel, safer method than TEA.

Methods

A systematic search of the Cochrane and PubMed databases for prospective, randomized trials (RCTs) comparing TEA and PVB for post-thoracotomy analgesia was done. We assessed how TEA and PVB were performed, methods of randomization, assessment of pain relief, and complications. Abstracts only were excluded.

Results

Ten studies were included, comprising 224 patients randomized to TEA, 243 to PVB. The studies were heterogeneous. Therefore, a systematic narrative review with our evaluations is presented.

Only 3/10 trials reported the method of randomization. Pain during coughing was reported in only 5/10, pain assessment not specified in 5/10. Only 1/10 trials found PVB superior to TEA, but placed TEA catheters too low (<T7). TEA was superior to PVB in 1/10, during first 1.5 days. PVB and TEA were equally effective in 8/10. 5/10 trials found PVB had less hypotension or urinary retention. None of the studies used appropriate and optimal TEA: TEA was started after end of surgery in half, catheters placed too low (2/10), too high (1/10), not reported in (1/10). 7/10 infused local anaesthetic only, 2/10 added fentanyl, 1/10 added morphine, and none added adrenaline. PVB infusions had higher concentration of bupivacaine (5 mg/ml) in 2/10, 1/10 added fentanyl, 1/10 added ornipressin. Loading doses were higher in 5/10, and with more concentrated solutions in 5/10 of PVB than in the TEA group.

Conclusions

10 heterogeneous, mostly small, studies comparing TEA and PVB for post-thoracotomy analgesia do not allow conclusions on which method has superior analgesic efficacy and safety. The main methodological problem was that none of the studies use optimal thoracic epidural analgesia, with siting of catheters inappropriate in some and the epidural infusion containing too concentrated local anaesthetic because opioid and adrenaline were not added. Anatomical considerations (the paravertebral space comprises parts of the epidural space and contains spinal cord arteries) and personally experienced complications with PVB (paraplegia) convince us that PVB must have higher risk of, infrequent but serious, spinal cord complications than TEA. Percutaneous PVB may puncture pleura and lung.

Some surgeons expressed satisfaction with PVB because the method omits costly acute pain services for monitoring on surgical wards and saves time in the operating room. They are, however, bound to experience serious complications from PVB, sooner or later.

To our knowledge, optimally conducted epidural analgesia has not been compared with PVB. Current literature and our experience with both techniques for up to four decades, indicate that PVB may be an alternative for post-thoracotomy pain when TEA is infeasible for various patient-related reasons (Breivik et al., 2009). Severely disturbed haemostasis is a contraindication for PVB and TEA. Higher concentrations of local anaesthetics are needed to obtain intercostal nerve blocks and epidural analgesia with PVB, risking local anaesthetic intoxication. Robust monitoring regimen for effects and adverse effects is as important for PVB as for TEA.