Postoperative analgesia with intrapleural administration of bupivacaine-adrenaline

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.

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.

Interpleural block – part 1

Interpleural blockade is effective in treating unilateral surgical and nonsurgical pain from the chest and upper abdomen in both the acute and chronic settings. It has been shown to provide safe, high-quality analgesia after cholecystectomy, thoracotomy, renal and breast surgery, and for certain invasive radiological procedures of the renal and hepatobiliary systems. It has also been used successfully in the treatment of pain from multiple rib fractures, herpes zoster, complex regional pain syndromes, thoracic and abdominal cancer, and pancreatitis. The technique is simple to learn and has both few contra-indications and a low incidence of complications. In the first of two reviews, the authors cover the history, taxonomy and anatomical considerations, the spread of local anaesthetic, and the mechanism of action, physiological, pharmacological and technical considerations in the performance of the block.

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.

Is there a bilateral block of the thoracic sympathetic chain after unilateral intrapleural analgesia?

This study was designed to ascertain, by telethermography and clinical observation, the effect of injecting anesthetic solutions into the intrapleural space on thoracic sympathetic chains and splanchnic nerves. We studied 15 patients with neoplastic (n = 8) or benign (n = 7) pain, divided into three groups of 5 patients each. The first group received 20 mL of bupivacaine 0.25% in the intrapleural space, the second received 20 mL of bupivacaine 0.5%, and the third received 20 mL of isotonic sodium chloride solution. Each patient was examined telethermographically 30, 60, 90, and 120 min after the blockade. Visceral pain intensity was measured in eight patients using a visual analog scale. Patients receiving bupivacaine had a uniform bilateral increase of cutaneous temperature (+2 degrees C). In those with diffuse visceral pain, the mean value of the pain score decreased from 82 +/- 10 mm at the time of injection to 16 +/- 5 at 120 min. We conclude that intrapleural bupivacaine 0.25% and 0.5% results in bilateral blockade of the thoracic sympathetic chain and also of the splanchnic nerves, which pass in front of the spinal column between the two thoracic sympathetic chains. Our data indicate that intrapleural analgesia can be used in the treatment of not only unilateral visceral and somatic pain, but also diffuse abdominal visceral pain. The bilateral increase of the cutaneous temperature of the trunk (measured telethermographically) and the reduction of the diffuse visceral pain suggest a bilateral block of the sympathetic chain and of the splanchnic nerves.

IMPLICATIONS

We subjected 10 patients to monolateral intrapleural analgesia. Five other patients served as controls. The bilateral increase of the cutaneous temperature of the trunk (measured telethermographically) and the reduction of the diffuse visceral pain suggest a bilateral block of the sympathetic chain and of the splanchnic nerves. Our data indicate that intrapleural analgesia can be used in the treatment of not only unilateral visceral and somatic pain, but also diffuse abdominal visceral pain.

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.

Effective pain relief with continuous intrapleural bupivacaine after thoracotomy in infants and children

The effect of continuous intrapleural bupivacaine on pain relief after lateral thoracotomy was studied in nine infants (< or = 15 kg body weight) and 11 children (> 15 kg body weight). An intrapleural catheter was inserted under direct vision during surgery. After extubation, the patients were transferred to the ICU where vital signs and pain scores were monitored. An intrapleural infusion of bupivacaine 0.25% with adrenaline was given at a loading dose of 0.625 mg.kg-1 body weight followed by a continuous infusion with a starting rate of 1.25 mg.kg-1.h-1. Haemodynamic and respiratory parameters did not differ significantly from control values throughout the study period in either group. The mean infusion rate could be reduced stepwise in both groups to 0.75 +/- 0.32 mg.kg-1.h-1 and 0.73 +/- 0.38 mg.kg-1.h-1 respectively. The pain score indicated a rapid onset of analgesia in both groups and remained low during the study period. The degree of analgesia amongst other factors was position dependent. The lack of any recognizable side effects or complications related to this method has been most encouraging. Only one child required a supplementary dose of an opioid. We conclude that continuous intrapleural access has proved to be a safe and suitable route for pain relief in infants and children following thoracotomy.

Paravertebral blockade. Failure rate and complications

The failure rate and complications were studied prospectively in 367 paediatric and adult patients who had received a thoracic or lumbar paravertebral block. The overall failure rate was 10.1%; adults 10.7%; children 6.2%. The frequency of complications were: hypotension: 4.6%; vascular puncture: 3.8%; pleural puncture: 1.1%; pneumothorax: 0.5%. Since these results are similar to those found with alternative methods, e.g. epidural, intrapleural and intercostal blocks, paravertebral block can be recommended as an effective, safe technique for unilateral analgesia in both adults and children.

Clinical management of blunt trauma patients with unilateral rib fractures: a randomized trial

Optimal pain management is essential in blunt trauma patients sustaining significant chest trauma. The purpose of this randomized prospective trial was to measure the difference in pulmonary function in nonintubated patients with unilateral multiple rib fractures receiving two modalities of pain relief: systemic narcotic medications alone or local anesthetics given by intrapleural catheter (IPCs). Forty-two patients were randomized to receive systemic narcotic medications or IPCs for pain control. The patients with IPCs statistically had more compromised pulmonary function as measured by forced vital capacity (FVC) on admission; however, they tended toward a greater objective improvement of FVC on discharge. When analyzing a cohort of severely impaired patients (initial FVC < 20%), half of the systemic medication patients compared to only 10% of the IPC group failed and required another mode of therapy. Catheter complications were minor and did not contribute to overall morbidity. The IPC patients had fewer failures than the systemic medication patients.

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.

Intrapleural analgesia in a child with a mediastinal tumour

A case is presented of an eight-year-old child with a mediastinal tumour, who had developed acute renal failure following the institution of steroid therapy. Intrapleural analgesia was successfully used for the insertion of a peritoneal dialysis catheter so that the considerable risks of general anaesthesia were avoided. Subsequent dialysis allowed chemotherapy to commence and, as a result of the shrinkage in tumour size, general anaesthesia was administered safely two days later. The purpose of this report is to highlight the use of intrapleural analgesia in children as an alternative to general anaesthesia, when the latter is contraindicated. The mechanism of action of intrapleural analgesia and the risks of anaesthesia in the presence of a mediastinal tumour are discussed.

[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.

Measurement of intercostal and pleural pressures by epidural catheter

The pressures in the intercostal and interpleural spaces were measured in 20 patients using an 18 gauge epidural catheter to confirm accurate catheter positioning for continuous intercostal and interpleural local anaesthetic blockade. In the intercostal space the mean (SD) pressure was negative (-1.8 (0.3)) mmHg and positive (+2.1 (0.3)) mmHg at the end of inspiration and expiration respectively. In contrast, in the interpleural space although the pressure varied with the respiratory cycle it remained negative both at the end of inspiration (-8.3 (1.0)) mmHg and expiration (-2.1 (0.8)) mmHg. We conclude that measurement of intercostal and interpleural pressures with an epidural catheter is a straightforward procedure which may be helpful in confirming accurate catheter placement for continuous intercostal or interpleural local anaesthetic blockade.

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.

[Intrapleural analgesia]

Interpleural analgesia, a recently devised method for postoperative analgesia, consists of the injection of a local anaesthetic into the pleural space. The technique of the catheter insertion is simple and derived from the threadening of an epidural catheter, using the same equipment. An unilateral analgesia is obtained with a rapid onset but not efficient enough for a surgical procedure. The area covered by analgesia includes the thorax and the upper part of the abdomen. No haemodynamic adverse effects occur and ventilatory function is rather improved. The main mechanism of analgesia is probably a retrograde intercostal nerve blockade. Although the exact dose and volume of local anaesthetic is still controversial, 20 to 30 mL of 0.5% bupivacaine is very likely the most convenient. Lidocaine may also be administered at the dose of 2 mg.kg-1 of a 2% solution. Main indications of interpleural analgesia are cholecystectomies and thorax trauma patients. Adverse effects and hazards are uncommon and include mainly pneumothorax and toxic effects of a local anaesthetic overdose.

Atelectasis and oxygenation in major surgery with either propofol with or without nitrous oxide or isoflurane anaesthesia

Forty-two patients undergoing major colonic surgery were assigned at random to receive isoflurane-fentanyl anaesthesia with nitrous oxide in oxygen, propofol-fentanyl anaesthesia with air in oxygen or propofol-fentanyl anaesthesia with nitrous oxide in oxygen. The groups were comparable in demographic data. Atelectases were identified, and the area measured by computerised tomography of the chest 203 +/- 69 min after extubation, and oxygenation was determined by arterial blood gas samples taken during operation at 30, 60, 90 and 120 min after extubation and on postoperative days 1, 2 and 3. Atelectases were seen in all three groups with no differences in the mean area between groups. After operation, the effect of 4 l.min-1 of oxygen by nasal catheter on PaO2 was similar in all groups. A significant decrease in PaO2 was found during the first 3 days after surgery, and was also the same in all groups. There was no correlation between area of atelectasis and postoperative PaO2. We conclude there is no difference in the incidence of postoperative atelectasis or oxygenation when using propofol, with or without nitrous oxide or isoflurane.

Interpleural analgesia and phrenic nerve paralysis

A case of phrenic nerve paralysis following interpleural analgesia for cholecystectomy is reported. The pre-operative chest X ray was normal but chest X ray after cholecystectomy and interpleural analgesia revealed a raised right hemidiaphragm. This resolved after discontinuation of the interpleural analgesia and was probably a result of phrenic nerve paralysis produced by the interpleural local anaesthetic.

Interpleural analgesia with bupivacaine following thoracotomy: ineffective results of a controlled study and pharmacokinetics

STUDY OBJECTIVE

To evaluate intrapleural analgesia with bupivacaine following partial pulmonary resection and to determine pharmacokinetic parameters of bupivacaine with epinephrine.

DESIGN

Prospective, randomized study.

SETTING

Thoracic surgical clinic of a university-affiliated general hospital.

PATIENTS

Eighteen consecutive patients (13 men, 5 women) scheduled for pulmonary surgery by posterolateral thoracotomy.

INTERVENTIONS

Bupivacaine was administered through an intrapleural catheter as a bolus dose of either 40 ml of 0.25% bupivacaine with epinephrine (0.5 mg per 100 ml of solution) (n = 10) or 20 ml of 0.5% bupivacaine with epinephrine (0.5 mg per 100 ml of solution) (n = 8) up to three times daily for a maximum time of 4 days.

MEASUREMENTS AND MAIN RESULTS

Subjective evaluation of pain was performed using the visual analog scale (VAS) before and after each injection by response to spontaneous pain, coughing, deep breathing, and incision palpation. Maximum peak concentration (C Max) and maximum time to reach the peak concentration (T Max) were assessed after the first and last injections. Although VAS pain score decreased significantly, pain relief was not sufficient. C Max and T Max after the first and last injections were not significantly different between the two groups. In each group, C Max after the last injection was significantly higher than after the first injection.

CONCLUSIONS

Intrapleural analgesia conducted with 40 ml of 0.25% bupivacaine with epinephrine or 20 ml of 0.5% bupivacaine with epinephrine was insufficient for pain, despite high plasma bupivacaine concentration.

Interpleural bupivacaine for analgesia during chest drainage treatment for pneumothorax. A randomized double-blind study

The ability of interpleural analgesia to reduce the pain caused by an indwelling chest drain was evaluated in 22 patients treated for spontaneous pneumothorax. Intermittent 8-hourly bolus injections of 20 ml bupivacaine 0.5% with epinephrine were compared with placebo in a randomized double-blind fashion. Visual analogue pain scale (VAS) scores were registered after the 1st, 2nd, 4th, 7th and 10th injections. The scores were significantly lower in the bupivacaine group at 5, 15, 30 and 60 min after the first injection. No significant differences in pain scores were found after 4 or 8 h. Pain scores in the bupivacaine group were also reduced after the 2nd, 4th, 7th and 10th injections, but compared with placebo the differences were significant only after the 2nd and 7th injections. Parenteral morphine consumption was not significantly lower in the bupivacaine group. Arterial blood gases were unaffected by the treatment in both groups. It is concluded that interpleural analgesia using bupivacaine given as bolus injections at 8-h intervals significantly reduces the pain caused by a chest drain within 5 min of injection, but the duration of pain relief is less than 4 h.

Intrapleural bupivacaine in the control of postthoracotomy pain

A randomized, double-blind trial was conducted to determine the effectiveness of intrapleural bupivacaine hydrochloride in the management of pain after thoracotomy. Thirty-three men and 7 women with a mean age of 62 years (range, 21 to 76 years) undergoing elective posterolateral thoracotomy were randomly allocated preoperatively to either a study group receiving 20 mL of 0.25% bupivacaine or a control group receiving 20 mL of 0.9% saline solution through a pleural catheter every 4 hours. Patients received supplementary doses of intramuscular papaveretum as required. Assessment of pain, somnolence, and breathing capacity was performed after the intrapleural injections at 4, 24, 48, and 72 hours postoperatively. Pain assessment, as measured by a linear analog scale, was lower in the bupivacaine group at all times, reaching significance at 4, 24, and 72 hours (p less than 0.05). The forced vital capacity and forced expiratory volume in 1 second at 6 weeks postoperatively remained significantly lower than preoperatively (p less than 0.05). The fall in forced vital capacity from this postoperative level was significantly less in the bupivacaine group at 4, 24, and 48 hours, and the fall in forced expiratory volume in 1 second was significantly less at 4 and 48 hours in the treated group. When used in conjunction with doses of parenteral narcotic, intrapleural bupivacaine gives better pain control with less respiratory depression than intermittent doses of narcotic alone.

Interpleural bupivacaine infusion compared with intravenous pethidine infusion after cholecystectomy

Twenty-six cholecystectomy patients received either an interpleural infusion of bupivacaine (Group B, n = 12) or an intravenous infusion of pethidine (Group P, n = 14) for management of postoperative pain over a three-day period. Patients in Group P experienced a significantly (P less than 0.05) greater incidence of total side-effects (146) than patients in Group B (66). Pain scores (VAS) and responses to a pain questionnaire were similar for both groups; however, within Group B improvement in mean VAS scores at rest with time were more sustained. Similar reductions in FEV1 and FVC from preoperative values occurred for both groups, while for Group P there were significant (P less than 0.05) changes in arterial blood gases (increase in PCO2, decrease in PO2) over two days postoperatively. Patients in Group P recorded longer times to passing flatus and unaided mobilisation (P less than 0.05), and required a significantly greater number of additional medications (anti-emetics and analgesics) over the postoperative period (41 vs 29, P less than 0.05).

Wound infiltration with 0.25% bupivacaine not effective for postoperative analgesia after cholecystectomy

The instillation of local anaesthetic agents into surgical wounds has been reported to be an effective method of reducing pain and narcotic requirements, using both local injection and topical application techniques. We performed a double-blind trial to test the value of the long-acting local anaesthetic, bupivacaine, in this role. Eighty patients undergoing elective cholecystectomy were entered into the study. They were divided into 2 groups of 40 patients to compare a local injection technique with a topical application technique. For each route of application, 20 patients received a test solution containing 0.25% plain bupivacaine, and 20 received 0.9% NaCl as a control. Postoperative analgesia in the form of intramuscular pethidine (1-1.5 mg/kg) was made available to all patients on request. The degree of postoperative pain was assessed using three criteria: the time from operation to the first request for analgesia, the total dose of postoperative pethidine required during the first 3 postoperative days and the patient's rating of pain on a 10 cm linear analogue scale at 24 h and 72 h. There was no statistically significant difference between the degree of postoperative pain experienced by patients receiving bupivacaine and those receiving NaCl, when assessed by any criterion. There was also no significant difference found between patients receiving bupivacaine by local infiltration and those receiving the drug topically. It is concluded that the local application of bupivacaine to the wound is not an effective analgesic technique following laparotomy for cholecystectomy.

The use of bupivacaine to relieve pain at iliac graft donor sites

We report a prospective study to test the hypothesis that infiltrating the wound with bupivacaine during operations for the removal of iliac bone grafts will lead to a significant reduction of pain. Pain was assessed by a visual analogue scale applied at regular intervals. Bupivacaine infiltration appears to reduce pain for 24 hours, but only to a significant degree during the first 4 hours after operation.

Effects of interpleurally administered bupivacaine 0.5% on opioid analgesic requirements and endocrine response during and after cholecystectomy: a randomized double-blind controlled study

In 30 patients undergoing cholecystectomy, a randomized double-blind saline-controlled study was performed using interpleural 0.5% bupivacaine with or without epinephrine (5 micrograms.ml-1) in combination with 0.8% halothane inspired concentration in oxygen. The aim of the study was to investigate whether interpleural 0.5% bupivacaine could decrease the intraoperative opioid requirements and attenuate the metabolic endocrine response to surgical stress. Patients were randomly allocated to one of three groups: Group 1: 0.5% bupivacaine; Group 2: 0.5% bupivacaine with epinephrine (5 micrograms.ml-1); and Group 3: saline. The interpleural catheter was inserted after induction of anesthesia in the spontaneously breathing patient. The study drug was injected 30 min prior to surgery. Peak plasma bupivacaine concentrations in the respective groups were 1.30 +/- 0.78 and 1.16 +/- 0.48 micrograms.ml-1. In all patients concentrations were below suggested convulsive level. Two patients in Group 1 and two in Group 2 required intraoperative fentanyl (0.1 mg each). In contrast, eight patients in the saline group received an average of 0.21 mg (range 0.1 +/- 0.4 mg) fentanyl (P less than 0.05). Postoperatively, a second dose of the study drug was given. Subsequently, pain was assessed using a visual analog score and a verbal rating scale. Pain scores decreased significantly 30 min after the interpleural injection in both bupivacaine groups and remained unchanged in the saline group (P less than 0.05). Pain management by means of interpleural bupivacaine was successful in 17 of the 20 patients. In the saline group seven out of ten patients needed additional analgesics (P less than 0.05). Cortisol levels increased in response to surgery in all groups: maximum levels in Groups 1, 2 and 3 were: 1.09 +/- 0.29, 1.11 +/- 0.20 and 1.19 +/- 0.16 mumol.l-1, respectively. Plasma glucose concentrations increased significantly in all groups: maximum levels in Groups 1, 2 and 3 were: 7.6 +/- 1.3, 7.3 +/- 1.7 and 8.3 +/- 1.7 mmol.l-1, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Pleural anesthetics given through an epidural catheter secured inside a chest tube

Pain management after thoracic surgical procedures is a difficult clinical problem. A variety of pain management methods are used with variable efficacy. This paper presents an effective method of pleural anesthetic administration using a pleural catheter inserted through a chest tube.

Interpleural analgesia improves pulmonary function after cholecystectomy

The purpose of this study was to examine the effects of interpleural bupivacaine on analgesia and ventilatory capacity after cholecystectomy. Forty-two patients undergoing elective cholecystectomy were randomly assigned to two groups: one to receive interpleural administration of bupivacaine-adrenaline mixture (Group 1 = 22 patients) and the other standard administration of intramuscular meperidine (Group 2 = 20 patients) for postoperative pain relief. The intensity of pain was evaluated by a visual analogue scale (VAS) preoperatively as well as at 2, 8, 24 and 48 hr postoperatively. At the same time, FVC and FEV1.0 measurements were obtained for all patients. The group given interpleural bupivacaine had better pain relief with mean VAS of 0.6 +/- 0.9 (mean +/- SD) 1.1 +/- 1.4, 0.6 +/- 0.9 and 0.8 +/- 1.2 compared with 5.2 +/- 2.2, 5.8 +/- 2.7, 5.5 +/- 2.2 and 4.5 +/- 1.8 for patients receiving meperidine (P less than 0.001). The patients in Group 1 also had larger FVC and FEV than those in Group 2: FVC 22 +/- 14.5 per cent vs 32 +/- 15.2 per cent (P less than 0.005), FEV1.0 25 +/- 15.5 vs 38 +/- 14.8 per cent (P less than 0.001) (mean +/- SD). We conclude that the interpleural analgesia can achieve better pain relief with greater ventilatory capacity than a standard analgesic regimen in the first two days after cholecystectomy.

A randomised double-blind study of interpleural analgesia after cholecystectomy

Continuous interpleural analgesia provided by 4 hourly injections of 20 ml bupivacaine 0.5% with adrenaline 5 micrograms/ml was compared with placebo in a randomised, double-blind study after cholecystectomy. All patients self-administered intravenous morphine using a patient-controlled analgesia device. There was a highly significant difference in mean morphine consumption between the groups (72 mg as compared with 22 mg). Visual analogue pain scores tended to be lower in the bupivacaine group throughout and this was significant at 2 hours. Respiratory function measurements were not significantly different between the groups. The mean peak venous plasma bupivacaine concentration after the sixth dose was 3.03 micrograms/ml and no symptoms suggestive of local anaesthetic toxicity occurred. It is concluded that this regimen can provide effective and continuous analgesia after cholecystectomy and that combined administration of interpleural bupivacaine and systemic morphine is more effective than morphine alone in the immediate postoperative period. The doses of bupivacaine required for optimal use of the technique lead to significant total plasma bupivacaine concentrations within 24 hours.

Side effects and complications related to interpleural analgesia: an update

Interpleural analgesia has been successfully used for pain relief after cholecystectomy, renal surgery, breast surgery and thoracotomy. Little has been reported about side effects and complications. This article summarizes available information about adverse events collected from the literature. The survey comprises a total of 703 cases. Pneumothorax was the most frequently registered complication followed by signs of systemic toxicity and pleural effusion. Horner's syndrome, pleural infections and catheter rupture have also been reported.

Hemodynamic effects of interpleural analgesia in pigs

Six anesthetized pigs received bupivacaine 2 mg/kg with epinephrine 2 micrograms/kg interpleurally while six saline injected animals served as controls. The animals were monitored hemodynamically for 120 min after injection. There were no significant changes in hemodynamic variables in the control group. In the group receiving bupivacaine with epihephrine there was a pattern of increase in mean arterial blood pressure, systemic vascular resistance and mean pulmonary arterial blood pressure after 60 min of observation. There were no other significant changes in pulmonary or systemic hemodynamics or gas exchange as evaluated by blood gases or whole body oxygen consumption. It is speculated that the increased systemic vascular resistance was an effect of the epinephrine added to the anesthetic. Interpleural analgesia may be a safe pain-relieving method even in slightly hypovolemic individuals.

Steady-state pharmacokinetics of interpleural bupivacaine in patients after cholecystectomy

Venous plasma concentrations of bupivacaine were determined in eight cholecystectomy patients following multiple interpleural bolus instillations of bupivacaine 20 ml 0.5% with adrenaline (5 mg/l) administered at six- to eight-hour intervals. The mean steady-state peak plasma concentration was 2.3 mg/l (range 1.2-3.1 mg/l); however, in three of the eight patients peak plasma concentrations were greater than 3 mg/l. The mean accumulation ratio was found to be 1.6 (range 0.99-2.49), with steady-state occurring within the first 24 hours of drug administration. Mean apparent systemic plasma clearance was 0.16 +/- 0.07 l/kg/h with a mean terminal half-life of 5.8 +/- 2.3 hours measured at steady-state, values which were not significantly different (P greater than 0.05) from those values obtained following single interpleural bolus dose administration.

Distribution of local anesthetics injected into the interpleural space, studied by computerized tomography

Twenty-one patients were given interpleural analgesia for postoperative pain relief after cholecystectomy, or renal or breast surgery. The patients were classified randomly into two groups: an interpleural injection of 20 ml of 0.375% bupivacaine mixed with 10 ml contrast medium was given to 11 patients in the supine position, and 10 in the lateral position. The patients remained in this position for 1 h. There was no significant difference in the rostrocaudal distribution of the contrast on computerized tomography taken 20 min later: Th3-L1 in the supine group vs. Th5-L1 in the lateral group. In the supine group the mean level of contrast medium reached significantly higher medially along the mediastinum (51 +/- 11 mm) than laterally (27 +/- 11 mm).

Analgesia and respiratory function following intrapleural bupivacaine after cholecystectomy

Analgesia and pulmonary function following intrapleural bupivacaine were compared with those following intramuscular pethidine in thirty-four patients after cholecystectomy. The patients were randomly allocated to two groups of seventeen patients each to receive either intrapleural bupivacaine or intramuscular pethidine. The positions of seventeen intrapleural catheters inserted were confirmed by chest radiography. Two out of seventeen catheters were found to be located in the extrapleural space. It was also recognized by fluoroscopy that phrenic nerve palsy did not develop on patients given intrapleural bupivacaine. The subjective quality of analgesia following intrapleural bupivacaine was significantly better than that following intramuscular pethidine. The mean duration of analgesia obtained after each injection of bupivacaine was 4.68 hr (range 3.5-6.1 hr). Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV 1), which decreased markedly in the postoperative period improved significantly after being given bupivacaine or pethidine. But there was no significant difference in the improvement of FVC and FEV 1, between both groups in spite of the higher percentage of pain relief in the intrapleural bupivacaine group. All respiratory function tests studied thirty days after surgery were not significantly different when compared with those before surgery.

Successful treatment of chronic pancreatitis pain with interpleural analgesia

Interpleural analgesia has recently been shown to be effective in the management of various chronic pain syndromes. We have used interpleural analgesia successfully in 11 patients with severe chronic pancreatitis of 24-38 months' duration. Daily injections of 30 ml of 0.5 per cent bupivacaine with epinephrine 5 mu.ml-1, were given through a percutaneously inserted pleural catheter over a five- to ten-day period. Patients have remained pain-free during follow up which ranges from 24 to 40 weeks. This method of providing analgesia for the patient suffering from the pain of chronic pancreatitis is simple, safe, effective and can be provided on an outpatient basis.

Comparison of the effects of continuous intrapleural vs epidural administration of 0.5% bupivacaine on pain, metabolic response and pulmonary function following cholecystectomy

Twenty patients undergoing elective cholecystectomy were prospectively randomised to receive either intrapleural (bolus 20 ml followed by 10 ml/h) or thoracic epidural (bolus 9 ml followed by 5 ml/h) bupivacaine 0.5% for 8 h postoperatively to assess the effect of these two techniques on pain, pulmonary function and the surgical stress response. As assessed by the visual analogue scale (VAS), both groups received good but not total pain relief. Both groups had a 50% reduction in forced expiratory volume (FEV1), forced vital capacity (FVC) and peak expiratory flow rate (PEFR) after operation, and there was no observed effect on the stress response as measured by plasma glucose and cortisol. It is concluded that while both techniques provide good analgesia, the degree and extent of nerve blockade are not sufficient to affect the afferent neurogenic stimuli responsible for the observed effects on pulmonary function and the stress response.

Lung function during anesthesia and respiratory insufficiency in the postoperative period: physiological and clinical implications

This review covers the physiological and clinical implications of lung function during anesthesia and respiratory insufficiency in the postoperative period. We have divided it into 3 main sections: 1) lung function changes induced by anesthesia and surgery, in which the impact on pulmonary mechanics, ventilation/perfusion changes and gas exchange are examined; 2) physiological implications of postoperative respiratory function secondary to decreased alveolar ventilation, development of atelectasis, and interstitial lung edema; and 3) clinical implications of postoperative respiratory failure. In this last section we analyze the current therapeutic modalities available to reduce the incidence of postoperative respiratory failure, as well as related morbidity and mortality.