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Nikitas J, Yanagawa J, Sacks S, Hui EK, Lee A, Deng J, Abtin F, Suh R, Lee JM, Toste P, Burt BM, Revels SL, Cameron RB, Moghanaki D. Pathophysiology and Management of Chest Wall Pain after Surgical and Non-Surgical Local Therapies for Lung Cancer. JTO Clin Res Rep 2024; 5:100690. [PMID: 39077624 PMCID: PMC11284817 DOI: 10.1016/j.jtocrr.2024.100690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/18/2024] [Accepted: 05/08/2024] [Indexed: 07/31/2024] Open
Abstract
Chest wall pain syndromes can emerge following local therapies for lung cancer and can adversely affect patients' quality-of-life. This can occur after lung surgery, radiation therapy, or percutaneous image-guided thermal ablation. This review describes the multifactorial pathophysiology of chest wall pain syndromes that develop following surgical and non-surgical local therapies for lung cancer and summarizes evidence-based management strategies for inflammatory, neuropathic, myofascial, and osseous pain. It discusses a step-wise approach to treating chest wall pain that begins with non-opioid oral analgesics and includes additional pharmacologic treatments as clinically indicated, such as anticonvulsants, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, and various topical treatments. For myofascial pain, physical medicine techniques, such as acupuncture, trigger point injections, deep tissue massage, and intercostal myofascial release can also offer pain relief. For severe or refractory cases, opioid analgesics, intercostal nerve blocks, or intercostal nerve ablations may be indicated. Fortunately, palliation of treatment-related chest wall pain syndromes can be managed by most clinical providers, regardless of the type of local therapy utilized for a patient's lung cancer treatment. In cases where a patient's pain fails to respond to initial medical management, clinicians can consider referring to a pain specialist who can tailor a more specific pharmacologic approach or perform a procedural intervention to relieve pain.
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Affiliation(s)
- John Nikitas
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Jane Yanagawa
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Sandra Sacks
- Department of Anesthesiology, University of California, Los Angeles, Los Angeles, California
| | - Edward K. Hui
- Center for East-West Medicine, University of California, Los Angeles, Los Angeles, California
| | - Alan Lee
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Jie Deng
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
| | - Fereidoun Abtin
- Thoracic Imaging and Intervention, Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, California
| | - Robert Suh
- Thoracic Imaging and Intervention, Department of Radiological Sciences, University of California, Los Angeles, Los Angeles, California
| | - Jay M. Lee
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Paul Toste
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Bryan M. Burt
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Sha’Shonda L. Revels
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Robert B. Cameron
- Division of Thoracic Surgery, University of California, Los Angeles, Los Angeles, California
| | - Drew Moghanaki
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, California
- Radiation Oncology Service, Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California
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Guerra-Londono CE, Privorotskiy A, Cozowicz C, Hicklen RS, Memtsoudis SG, Mariano ER, Cata JP. Assessment of Intercostal Nerve Block Analgesia for Thoracic Surgery: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2133394. [PMID: 34779845 PMCID: PMC8593761 DOI: 10.1001/jamanetworkopen.2021.33394] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE The use of intercostal nerve block (ICNB) analgesia with local anesthesia is common in thoracic surgery. However, the benefits and safety of ICNB among adult patients undergoing surgery is unknown. OBJECTIVE To evaluate the analgesic benefits and safety of ICNB among adults undergoing thoracic surgery. DATA SOURCES A systematic search was performed in Ovid MEDLINE, Ovid Embase, Scopus, and the Cochrane Library databases using terms for ICNB and thoracic surgery (including thoracic surgery, thoracoscopy, thoracotomy, nerve block, intercostal nerves). The search and results were not limited by date, with the last search conducted on July 24, 2020. STUDY SELECTION Selected studies were experimental or observational and included adult patients undergoing cardiothoracic surgery in which ICNB was administered with local anesthesia via single injection, continuous infusion, or a combination of both techniques in at least 1 group of patients. For comparison with ICNB, studies that examined systemic analgesia and different forms of regional analgesia (such as thoracic epidural analgesia [TEA], paravertebral block [PVB], and other techniques) were included. These criteria were applied independently by 2 authors, and discrepancies were resolved by consensus. A total of 694 records were selected for screening. DATA EXTRACTION AND SYNTHESIS This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data including patient characteristics, type of surgery, intervention analgesia, comparison analgesia, and primary and secondary outcomes were extracted independently by 3 authors. Synthesis was performed using a fixed-effects model. MAIN OUTCOMES AND MEASURES The coprimary outcomes were postoperative pain intensity (measured as the worst static or dynamic pain using a validated 10-point scale, with 0 indicating no pain and 10 indicating severe pain) and opioid consumption (measured in morphine milligram equivalents [MMEs]) at prespecified intervals (0-6 hours, 7-24 hours, 25-48 hours, 49-72 hours, and >72 hours). Clinically relevant analgesia was defined as a 1-point or greater difference in pain intensity score at any interval. Secondary outcomes included 30-day postoperative complications and pulmonary function. RESULTS Of 694 records screened, 608 were excluded based on prespecified exclusion criteria. The remaining 86 full-text articles were assessed for eligibility, and 20 of those articles were excluded. All of the 66 remaining studies (5184 patients; mean [SD] age, 53.9 [10.2] years; approximately 59% men and 41% women) were included in the qualitative analysis, and 59 studies (3325 patients) that provided data for at least 1 outcome were included in the quantitative meta-analysis. Experimental studies had a high risk of bias in multiple domains, including allocation concealment, blinding of participants and personnel, and blinding of outcome assessors. Marked differences (eg, crossover studies, timing of the intervention [intraoperative vs postoperative], blinding, and type of control group) were observed in the design and implementation of studies. The use of ICNB vs systemic analgesia was associated with lower static pain (0-6 hours after surgery: mean score difference, -1.40 points [95% CI, -1.46 to -1.33 points]; 7-24 hours after surgery: mean score difference, -1.27 points [95% CI, -1.40 to -1.13 points]) and lower dynamic pain (0-6 hours after surgery: mean score difference, -1.66 points [95% CI, -1.90 to -1.41 points]; 7-24 hours after surgery: mean score difference, -1.43 points [95% CI, -1.70 to -1.17 points]). Intercostal nerve block analgesia was noninferior to TEA (mean score difference in worst dynamic panic at 7-24 hours after surgery: 0.79 points; 95% CI, 0.28-1.29 points) and marginally inferior to PVB (mean score difference in worst dynamic pain at 7-24 hours after surgery: 1.29 points; 95% CI, 1.16 to 1.41 points). The largest opioid-sparing effect of ICNB vs systemic analgesia occurred at 48 hours after surgery (mean difference, -10.97 MMEs; 95% CI, -12.92 to -9.02 MMEs). The use of ICNB was associated with higher MME values compared with TEA (eg, 48 hours after surgery: mean difference, 48.31 MMEs; 95% CI, 36.11-60.52 MMEs) and PVB (eg, 48 hours after surgery: mean difference, 3.87 MMEs; 95% CI, 2.59-5.15 MMEs). CONCLUSIONS AND RELEVANCE In this study, single-injection ICNB was associated with a reduction in pain during the first 24 hours after thoracic surgery and was clinically noninferior to TEA or PVB. Intercostal nerve block analgesia had opioid-sparing effects; however, TEA and PVB were associated with larger decreases in postoperative MMEs, suggesting that ICNB may be most beneficial for cases in which TEA and PVB are not indicated.
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Affiliation(s)
- Carlos E. Guerra-Londono
- Department of Anesthesiology and Perioperative Medicine, MD Anderson Cancer Center, University of Texas, Houston
| | | | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Rachel S. Hicklen
- Research Medical Library, MD Anderson Cancer Center, University of Texas, Houston
| | | | - Edward R. Mariano
- Department of Anesthesia, School of Medicine, Stanford University, Stanford, California
| | - Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, MD Anderson Cancer Center, University of Texas, Houston
- Anesthesiology and Surgical Oncology Research Group, Houston, Texas
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Analgesic effect of intercostal nerve block given preventively or at the end of operation in video-assisted thoracic surgery: a randomized clinical trial. Braz J Anesthesiol 2021; 72:574-578. [PMID: 34324930 PMCID: PMC9515672 DOI: 10.1016/j.bjane.2021.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 07/11/2021] [Accepted: 07/12/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To compare the analgesic effect of intercostal nerve block (INB) with ropivacaine when given preventively or at the end of the operation in patients undergoing video-assisted thoracic surgery (VATS). METHODS A total of 50 patients undergoing VATS were randomly divided into two groups. The patients in the preventive analgesia group (PR group) were given INB with ropivacaine before the intrathoracic manipulation combined with patient-controlled analgesia (PCA). The patients in the post-procedural block group (PO group) were administered INB with ropivacaine at the end of the operation combined with PCA. To evaluate the analgesic effect, postoperative pain was assessed with the visual analogue scale (VAS) at rest and Prince Henry Pain Scale (PHPS) scale at 6, 12, 24, 48, and 72 hours after surgery. RESULTS At 6 h and 12 h post-surgery, the VAS at rest and PHPS scores in the PR group were significantly lower than those in the PO group. There were no significant differences in pain scores between two groups at 24, 48, and 72 hours post-surgery. CONCLUSION In patients undergoing VATS, preventive INB with ropivacaine provided a significantly better analgesic effect in the early postoperative period (at least through 12 h post-surgery) than did INB given at the end of surgery.
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Marciniak DA, Alfirevic A, Hijazi RM, Ramos DJ, Duncan AE, Gillinov AM, Ahmad U, Murthy SC, Raymond DP. Intercostal Blocks with Liposomal Bupivacaine in Thoracic Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2020; 35:1404-1409. [PMID: 33067088 DOI: 10.1053/j.jvca.2020.09.116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Assess the efficacy of adding liposomal bupivacaine (LB) to bupivacaine-containing intercostal nerve blocks (ICNBs) to improve analgesia and decrease opioid consumption and hospital length of stay compared with bupivacaine-only ICNBs. DESIGN This retrospective, observational investigation compared pain intensity scores and cumulative opioid consumption within the first 72 postoperative hours in patients who received ICNBs with bupivacaine plus LB (LB group) versus bupivacaine only (control group) after minimally invasive anatomic pulmonary resection. LB was tested for noninferiority on pain scores and opioid consumption. If LB was noninferior, superiority of LB was tested on both outcomes. SETTING Academic tertiary care medical center. PARTICIPANTS Adult patients undergoing minimally invasive anatomic pulmonary resection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For the secondary analysis, hospital length of stay was compared through the Cox regression model. Of 396 patients, 178 (45%) received LB and 218 (55%) did not. The mean (standard deviation) pain score was three (one) in the LB group and three (one) in the control group, with a difference of -0.10 (97.5% confidence interval [-0.39 to 0.18]; p = 0.41). The mean (standard deviation) cumulative opioid consumption (intravenous morphine equivalents) was 198 (208) mg in the LB group and 195 (162) mg in the control group. Treatment effect in opioid consumption was estimated at a ratio of geometric mean of 0.94 (97.5% confidence interval [0.74-1.20]; p = 0.56). Pain control and opioid consumption were noninferior with LB but not superior. Hospital discharge was not different between groups. CONCLUSIONS LB with bupivacaine in ICNBs did not demonstrate superior postoperative analgesia or affect the rate of hospital discharge.
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Affiliation(s)
- Donn A Marciniak
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH.
| | - Andrej Alfirevic
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Ryan M Hijazi
- Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Daniel J Ramos
- Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Andra E Duncan
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH
| | - A Marc Gillinov
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
| | - Usman Ahmad
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
| | - Sudish C Murthy
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
| | - Daniel P Raymond
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
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Atrial septal defect closure via mini-thoracotomy in pediatric patients: Postoperative analgesic effect of intercostal nerve block. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:257-263. [PMID: 32551155 DOI: 10.5606/tgkdc.dergisi.2020.19104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/22/2020] [Indexed: 02/06/2023]
Abstract
Background In this study, we evaluated the efficacy of intercostal nerve block for postoperative pain management in pediatric patients undergoing atrial septal defect closure through a right lateral mini-thoracotomy. Methods Between January 2016 and January 2019, a total of 63 pediatric patients (37 males, 26 females; mean age 34.8±26.8 months; range, 2 to 96 months) who underwent corrective congenital heart surgery for atrial septal defect closure through a right lateral mini-thoracotomy were retrospectively reviewed. The patients were divided into two groups as those (Group 1, n=33) receiving intercostal nerve block and general anesthesia and those (Group 2, n=30) receiving general anesthesia alone. Intravenous morphine at a dose of 0.03 mg/kg was applied as rescue analgesia to the patients with a Ramsay Sedation Scale score of >4 and Children"s Hospital of Eastern Ontario Pain Scale score of >7. The total analgesic requirement, adverse effects, duration of mechanical ventilation and length of stay in the intensive care unit were recorded. Results The mean duration of mechanical ventilation and intensive care unit stay was shorter in Group 1 compared to Group 2 (3.6±1.3 vs. 9.4±2.1 h; 23±2.6 vs. 30±7.2 h, respectively) (p<0.0001). The need for postoperative rescue analgesia was statistically significantly lower in Group 1 compared to Group 2 (0.3±0.5 mg vs. 1.1±0.9 mg, respectively) (p=0.003). The mean total morphine consumption was also lower in Group 1 compared to Group 2 (4.0±2.2 mg vs. 9.0±3.4 mg, respectively) (p<0.0001). Conclusion Intercostal nerve block before thoracotomy closure in pediatric patients undergoing atrial septal defect repair under mini-thoracotomy provides early extubation, shorter mechanical ventilation duration and intensive care unit stay, and reduced analgesic requirements.
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Ranganathan P, Tadvi A, Jiwnani S, Karimundackal G, Pramesh CS. A randomised evaluation of intercostal block as an adjunct to epidural analgesia for post-thoracotomy pain. Indian J Anaesth 2020; 64:280-285. [PMID: 32489201 PMCID: PMC7259421 DOI: 10.4103/ija.ija_714_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 12/20/2019] [Accepted: 02/17/2020] [Indexed: 12/31/2022] Open
Abstract
Background and Aims: Post-thoracotomy pain can be severe and disabling. The aim of this study was to examine the efficacy of intercostal nerve block when used as adjunct to thoracic epidural analgesia in patients undergoing posterolateral thoracotomy. Methods: This was a parallel-group randomised patient and assessor-blinded study carried out at a tertiary-referral cancer center. We included 60 adult patients undergoing elective lung resection under general anaesthesia with thoracic epidural analgesia. In addition, the intervention arm received single-shot intercostal blocks with 10 ml of 0.25% bupivacaine at the level of and two levels above and below the thoracotomy. We assessed post-operative pain scores at 2 to 4 hours and 18 to 24 hours after surgery, peri-operative fentanyl requirement, percentage of patients who needed fentanyl PCA and maximum volume achieved on bedside spirometry 18 to 24 hours after surgery. Groups were compared using the unpaired t-test for continuous data and the chi square test for categorical data at a 5% level of significance. Results: 2 to 4 hours post-operatively, mean pain scores at rest were 3.0 in both groups (difference 0.04, 95% CI -1.1 to + 1.1) and on coughing were 4.6 (ICB group) and 4.9 (C group) (difference 0.32, 95% CI -1.0 to + 1.6). There were no differences between the groups for any of the other outcomes. Conclusion: Addition of intercostal block to epidural analgesia does not confer any benefit in terms of post-operative pain, fentanyl requirements or volume achieved on spirometry.
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Affiliation(s)
- Priya Ranganathan
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Asharab Tadvi
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sabita Jiwnani
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - George Karimundackal
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - C S Pramesh
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Amer AF, Omara AF. Small dose of naloxone as an adjuvant to bupivacaine in intrapleural infiltration after thoracotomy surgery: a prospective, controlled study. Korean J Pain 2019; 32:105-112. [PMID: 31091509 PMCID: PMC6549584 DOI: 10.3344/kjp.2019.32.2.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/02/2019] [Accepted: 02/03/2019] [Indexed: 11/30/2022] Open
Abstract
Background Severe pain always develops after thoracotomy; intrapleural regional analgesia is used as a simple, safe technique to control it. This study was performed to evaluate whether a small dose of naloxone with local anesthetics prolongs sensory blockade. Methods A prospective, randomized double-blinded controlled study was conducted on 60 patients of American Society of Anesthesiologists statuses I and II, aged 18 to 60 years, scheduled for unilateral thoracotomy surgery. After surgery, patients were randomly divided into two groups: through the intrapleural catheter, group B received 30 ml of 0.5% bupivacaine, while group N received 30 ml of 0.5% bupivacaine with 100 ng of naloxone. Postoperative pain was assessed using the visual analog pain scale (VAS). Time for the first request for rescue analgesia, total amount consumed, and incidence of postoperative complications were also recorded. Results The VAS score significantly decreased in group N, at 6 h and 8 h after operation (P < 0.001 for both). At 12 h after injection, the VAS score increased significantly in group N (P < 0.001). The time for the first request of rescue analgesia was significantly longer in group N compared to group B (P < 0.001). The total amount of morphine consumed was significantly lower in group N than in the bupivacaine group (P < 0.001). Conclusions Addition of a small dose of naloxone to bupivacaine in intrapleural regional analgesia significantly prolonged pain relief after thoracotomy and delayed the first request for rescue analgesia, without significant adverse effects.
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Affiliation(s)
- Asmaa Fawzy Amer
- Department of Anesthesiology, Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amany Faheem Omara
- Department of Anesthesiology, Surgical Intensive Care and Pain Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
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Comparison of intravenous morphine, epidural morphine with/without bupivacaine or ropivacaine in postthoracotomy pain management with patient controlled analgesia technique. Braz J Anesthesiol 2013; 63:213-9. [PMID: 24565129 DOI: 10.1016/j.bjane.2012.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 05/22/2012] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The aim of this randomized, double-blinded, prospective study was to determine the effectiveness and side effects of intravenous or epidural use of morphine, bupivacaine or ropivacaine on post-thoracotomy pain management. METHODS Sixty patients undergoing elective thoracotomy procedure were randomly allocated into 4 groups by the sealed envelope technique. Group IVM, EM, EMB and EMR received patient controlled intravenous morphine, and epidural morphine, morphine-bupivacaine and morphine-ropivacaine, respectively. Perioperative heart rate, blood pressure and oxygen saturation and postoperative pain at rest and during cough, side effects and rescue analgesic requirements were recorded at the 30(th) and 60(th) minutes and the 2(nd), 4(th), 6(th), 12(th), 24(th), 36(th), 48(th), and 72(nd) hour. RESULTS Diclofenac sodium requirement during the study was lower in Group EM. Area under VAS-time curve was lower in Group EM compared to Group IVM, but similar to Group EMB and EMR. Pain scores at rest were higher at the 12, 24, 36, and 48(th) hour in Group IVM compared to Group EM. Pain scores at rest were higher at the 30(th) and 60(th) minutes in Group EM and Group IVM compared to Group EMB. Pain scores during cough at the 30(th) minute were higher in Group EM compared to Group EMB. There was no difference between Group IVM and Group EMR. CONCLUSIONS Morphine used at the epidural route was found more effective than the intravenous route. While Group EM was more effective in the late period of postoperative, Group EMB was more effective in the early period. We concluded that epidural morphine was the most effective and preferred one.
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Comparison of Intravenous Morphine, Epidural Morphine With/ Without Bupivacaine or Ropivacaine in Postthoracotomy Pain Management With Patient Controlled Analgesia Technique. Braz J Anesthesiol 2013; 63:213-9. [DOI: 10.1016/s0034-7094(13)70218-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 05/22/2012] [Indexed: 11/21/2022] Open
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Esme H, Apiliogullari B, Duran FM, Yoldas B, Bekci TT. Comparison between intermittent intravenous analgesia and intermittent paravertebral subpleural analgesia for pain relief after thoracotomy. Eur J Cardiothorac Surg 2012; 41:10-3. [PMID: 21596578 DOI: 10.1016/j.ejcts.2011.03.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Hidir Esme
- Department of Thoracic Surgery, Konya Education and Research Hospital, Konya, Turkey.
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Meierhenrich R, Hock D, Kühn S, Baltes E, Muehling B, Muche R, Georgieff M, Gorsewski G. Analgesia and pulmonary function after lung surgery: is a single intercostal nerve block plus patient-controlled intravenous morphine as effective as patient-controlled epidural anaesthesia? A randomized non-inferiority clinical trial. Br J Anaesth 2011; 106:580-9. [DOI: 10.1093/bja/aeq418] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Mustola ST, Lempinen J, Saimanen E, Vilkko P. Efficacy of Thoracic Epidural Analgesia With or Without Intercostal Nerve Cryoanalgesia for Postthoracotomy Pain. Ann Thorac Surg 2011; 91:869-73. [DOI: 10.1016/j.athoracsur.2010.11.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 11/09/2010] [Accepted: 11/10/2010] [Indexed: 11/17/2022]
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Kang JH, Lee SK, Seo MB, Na JY, Jang JH, Kim KY. A Clinical Study of Intercostal Neuropathy after Rib Fracture. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2010. [DOI: 10.5090/kjtcs.2010.43.1.53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jung-Hun Kang
- Department of Rehabilitation Medicine, College of Medicine, Chosun University
| | - Seog-Ki Lee
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Chosun University
| | - Min-Bum Seo
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Chosun University
| | - Jeong-Yeop Na
- Department of Rehabilitation Medicine, College of Medicine, Chosun University
| | - Jae-Hyouk Jang
- Department of Rehabilitation Medicine, College of Medicine, Chosun University
| | - Kweon-Young Kim
- Department of Rehabilitation Medicine, College of Medicine, Chosun University
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Geiger F, Kessler P, Rauschmann M. [Pain therapy after spinal surgery]. DER ORTHOPADE 2008; 37:977-83. [PMID: 18797843 DOI: 10.1007/s00132-008-1333-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A dorsal approach during spinal surgery offers the possibility to distribute drugs directly to the nerve root or epidurally. This can be done via a single intraoperative dose or by placing an epidural catheter. A safe and effective analgesia can thereby be achieved. As placement is done under visual control, no major complications are to be expected. In nerve root compressions, additional local application of steroids and preoperative gabapentin seems sensible. No advantage of preemptive administration of other analgesics can be determined. Another problem, especially of ventral fusions, is the commonly needed autologous pelvic bone grafts. Here the local application of local anesthetics or opioids makes sense. In transthoracic approaches epidural analgesia is recommended by thoracic surgeons, but this is difficult to perform especially in children with deformities. Furthermore it is generally important not to compromise neuralgic controls by analgesic measures.
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Affiliation(s)
- F Geiger
- Abteilung für Wirbelsäulenchirurgie, Orthopädische Universitätsklinik Friedrichsheim gGmbH, Marienburgstrasse 2, 60528, Frankfurt/M., Deutschland.
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16
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Joshi GP, Bonnet F, Shah R, Wilkinson RC, Camu F, Fischer B, Neugebauer EAM, Rawal N, Schug SA, Simanski C, Kehlet H. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008; 107:1026-40. [PMID: 18713924 DOI: 10.1213/01.ane.0000333274.63501.ff] [Citation(s) in RCA: 394] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Thoracotomy induces severe postoperative pain and impairment of pulmonary function, and therefore regional analgesia has been intensively studied in this procedure. Thoracic epidural analgesia is commonly considered the "gold standard" in this setting; however, evaluation of the evidence is needed to assess the comparative benefits of alternative techniques, guide clinical practice and identify areas requiring further research. METHODS In this systematic review of randomized trials we evaluated thoracic epidural, paravertebral, intrathecal, intercostal, and interpleural analgesic techniques, compared to each other and to systemic opioid analgesia, in adult thoracotomy. Postoperative pain, analgesic use, and complications were analyzed. RESULTS Continuous paravertebral block was as effective as thoracic epidural analgesia with local anesthetic (LA) but was associated with a reduced incidence of hypotension. Paravertebral block reduced the incidence of pulmonary complications compared with systemic analgesia, whereas thoracic epidural analgesia did not. Thoracic epidural analgesia was superior to intrathecal and intercostal techniques, although these were superior to systemic analgesia; interpleural analgesia was inadequate. CONCLUSIONS Either thoracic epidural analgesia with LA plus opioid or continuous paravertebral block with LA can be recommended. Where these techniques are not possible, or are contraindicated, intrathecal opioid or intercostal nerve block are recommended despite insufficient duration of analgesia, which requires the use of supplementary systemic analgesia. Quantitative meta-analyses were limited by heterogeneity in study design, and subject numbers were small. Further well designed studies are required to investigate the optimum components of the epidural solution and to rigorously evaluate the risks/benefits of continuous infusion paravertebral and intercostal techniques compared with thoracic epidural analgesia.
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Affiliation(s)
- Girish P Joshi
- Department of Anesthesiology and Pain Management, University of TX Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9068, USA.
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Yildirim V, Akay HT, Bingol H, Bolcal C, Oz K, Kaya E, Demirkilic U, Tatar H. Interpleural versus epidural analgesia with ropivacaine for postthoracotomy pain and respiratory function. J Clin Anesth 2007; 19:506-11. [DOI: 10.1016/j.jclinane.2007.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Revised: 03/28/2007] [Accepted: 04/11/2007] [Indexed: 11/29/2022]
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Ogus H, Selimoglu O, Basaran M, Ozcelebi C, Ugurlucan M, Sayin OA, Kafali E, Ogus TN. Effects of intrapleural analgesia on pulmonary function and postoperative pain in patients with chronic obstructive pulmonary disease undergoing coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2007; 21:816-9. [PMID: 18068058 DOI: 10.1053/j.jvca.2007.05.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2006] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Halide Ogus
- Cardiovascular Surgery Clinic, Goztepe Safak Hospital, Istanbul, Turkey
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19
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Pourseidi B, Khorram-Manesh A. Effect of intercostals neural blockade with Marcaine (bupivacaine) on postoperative pain after laparoscopic cholecystectomy. Surg Endosc 2007; 21:1557-9. [PMID: 17342558 DOI: 10.1007/s00464-006-9181-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2006] [Revised: 09/10/2006] [Accepted: 09/18/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Postoperative pain experienced by patients who undergo laparoscopic cholecystectomy may aggravate surgical complications, prevent early discharge, and cause readmission. This study aimed to evaluate the effectiveness of an intraoperative intercostals neural blockade for the control of postoperative pain after laparoscopic cholecystectomy. METHODS In a prospective, double-blinded, clinical trial, 61 patients classified as American Society of Anesthesiology (ASA) 1 and 2 undergoing laparoscopic cholecystectomy were randomized to receive only general anesthesia (control group, n = 30) or general anesthesia plus intraoperative intercostals neural blockade using 0.5% bupivacaine-adrenaline at the right side (intercostals group, n = 31). Postoperative pain was assessed according to a pain severity score using a subjective analog visual scale (VAS) 6, 12, and 24 h after the surgery. Systemic narcotic injection was available to all surgically treated patients postoperatively according to their demand. The history, pain severity score, and all postoperative data were recorded for each patient. RESULTS The pain severity score was significantly higher in control group than in the intercostals group (p < 0.001), suggesting that patients who received intercostals neural blockade had less pain postoperatively than the control group. CONCLUSION Intercostals neural blockade may safely be used to reduce the postoperative pain after laparoscopic cholecystectomy.
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Affiliation(s)
- B Pourseidi
- Department of Surgery, Kerman University of Medical Science, Kerman, Iran
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Abstract
PURPOSE OF REVIEW Creating the fine details of the ear in a patient with a congenital absent ear is extremely challenging. Each component of the multidisciplinary team that manages the ear reconstruction, hearing restoration, and associated craniofacial anomalies of these patients has seen recent progress. RECENT FINDINGS Population studies have provided new insights into the etiology of microtia. Novel techniques for costal cartilage harvest, implantation, and positioning add to the techniques of Brent and Nagata, which remain the gold standard for microtia repair. Advances in the use of alloplasts and tissue-engineered cartilage appear promising. SUMMARY Technical advances in combined aural atresia/microtia reconstruction, bone-anchored prosthetics, bone-anchored hearing aides, and use of alloplastic implants provide numerous options to patients and practitioners. Implantable, tissue-engineered auricular frameworks appear to be a promising option for the future.
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Affiliation(s)
- Travis T Tollefson
- Cleft and Craniofacial Program, Department of Otolaryngology Head and Neck Surgery, Facial Plastic Surgery, University of California Davis, Sacramento, California 95817, USA.
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Detterbeck FC. Efficacy of Methods of Intercostal Nerve Blockade for Pain Relief After Thoracotomy. Ann Thorac Surg 2005; 80:1550-9. [PMID: 16181921 DOI: 10.1016/j.athoracsur.2004.11.051] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2004] [Revised: 11/22/2004] [Accepted: 11/24/2004] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Frank C Detterbeck
- Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, North Carolina 27599-7065, USA.
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Santos PSSD, Resende LAL, Fonseca RG, Lemônica L, Ruiz RL, Catâneo AJM. Intercostal nerve mononeuropathy: study of 14 cases. ARQUIVOS DE NEURO-PSIQUIATRIA 2005; 63:776-8. [PMID: 16258655 DOI: 10.1590/s0004-282x2005000500011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This retrospective study describes 14 cases of intercostal nerve mononeuropathy (INM) found in 5,560 electromyography (EMG) exams performed between January 1991 and June 2004 in our University Hospital. Medical charts of all patients with history of thoracic pain and EMG diagnosis of intercostal mononeuropathy were reviewed. INM was detected in 14 patients; etiology was thoracic surgery in 6 (43%), post-herpetic neuropathy in 4 (28%), probable intercostal neuritis in 2 (14%), lung neoplasia in 1 (7%), and radiculopathy in 1 (7%). From this study, trauma and infection were the main etiologies in intercostal neuropathic pain development. Tricyclic antidepressants and anticonvulsants were the most common therapeutic drugs used.
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Tetik O, Islamoglu F, Ayan E, Duran M, Buket S, Cekirdekçi A. Intermittent infusion of 0.25% bupivacaine through an intrapleural catheter for post-thoracotomy pain relief. Ann Thorac Surg 2004; 77:284-8. [PMID: 14726080 DOI: 10.1016/s0003-4975(03)01338-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Omer Tetik
- Department of Cardiovascular Surgery, Atatürk Medical Research Hospital, Izmir, Turkey
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Bilgin M, Akcali Y, Oguzkaya F. Extrapleural regional versus systemic analgesia for relieving postthoracotomy pain: a clinical study of bupivacaine compared with metamizol. J Thorac Cardiovasc Surg 2003; 126:1580-3. [PMID: 14666036 DOI: 10.1016/s0022-5223(03)00701-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The effects of a local anesthetic delivered through a catheter inserted in the extrapleural region by a surgeon and an analgesic agent given systemically on pain after thoracotomy were assessed. METHODS The patients in group I (n = 25) had a catheter inserted between the parietal pleura and the endothoracic fascia by a surgeon, and 0.5% bupivacaine was given through this catheter. Another 25 patients (group II) had metamizol given intravenously. Respiratory function tests, arterial blood gases, range of shoulder motion, and postoperative pain were evaluated for each group. Bupivacaine and metamizol were given just before finishing the thoracotomy and then repeated every 4 hours for 3 days. RESULTS There was no statistical difference in arterial blood gases between the groups (P >.05). There were statistically significant differences in the respiratory function tests, range of shoulder motion, and visual analogue scale (P <.05) between the groups. Group I had fewer complications than group II. There was no mortality in either group. CONCLUSIONS Bupivacaine given through a catheter to the extrapleural region before finishing thoracotomy is substantially beneficial for the prevention of postoperative pain and reduction of postoperative complications.
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Affiliation(s)
- Mehmet Bilgin
- Department of Thoracic Surgery, Erciyes University Medical Facility, Kayseri, Turkey.
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Richardson JA, Anikin VA. Optimal thoracotomy analgesia. Ann Thorac Surg 2003; 76:978; author reply 978-9. [PMID: 12963258 DOI: 10.1016/s0003-4975(03)00312-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Intercostal nerve blockade versus thoracic epidural analgesia for post thoracotomy pain relief. Indian J Thorac Cardiovasc Surg 2003. [DOI: 10.1007/s12055-003-0003-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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