|Year : 2008 | Volume
| Issue : 4 | Page : 404
Intrapleural Bupivacaine Analgesia: Bolus Versus Continuous Infusion Technique for Postoperative Pain Relief in Children
Hassan S Al-Khayat1, Abhay Patwari1, Mohamed S El-Khatib2, Hassan Osman3, Khairy Naguib4
1 Consultant, Fraqhar (W.Germany) and Consultant, Department of Anaesthesia and Intensive Care, Farwania Hospital, Kuwait., Kuwait
2 Senior Registrar, (Egypt), Department of Anaesthesia and Intensive Care, Farwania Hospital, Kuwait., Kuwait
3 Consultant, (Egypt), Department of Anaesthesia and Intensive Care, Farwania Hospital Kuwait and Professor, Department of Anaesthesia and Intensive Care, Faculty of Medicine, Alexandria University, Egypt., Kuwait
4 Chairman and HOD, Department of Anaesthesia and Intensive Care, Farwania Hospital, Kuwait., Kuwait
|Date of Acceptance||15-Jun-2008|
|Date of Web Publication||19-Mar-2010|
P.O.Box 26228, Safat 13123, State of Kuwait.
Source of Support: None, Conflict of Interest: None
Many serious problems can occur in children due to unrelieved postoperative pain. Intrapleural regional analgesia is a new postoperative pain relief technique. The aim of the present study was to evaluate the efficacy of intrapleural bupivacaine administration either by bolus or by continuous infusion method for providing postoperative pain relief in children following upper abdominal surgery. The study was carried out on 30 children scheduled for upper abdominal operations and randomly divided into two equal groups. Group A received a single dose of 1.5 mg. kg - 1 of 0.25% bupivacaine while the other Group B received 0.125 mg. kg - 1 . hour - 1 of 0.25% bupivacaine infusion after an initial bolus dose of 0.4 mg. kg - 1 of 0.25% bupivacaine. The results showed a significant decrease in haemodynamic parameters under designed techniques with significant improvement of respiratory functions. Pain relief score and Prince Henry scale were significantly decreased in both groups with longer periods of postoperative analgesia in Group B. Both techniques proved to be convenient and safe postoperative pain-relief methods in children following upper abdominal surgical interventions. Either method had its own advantages and disadvantages.
Keywords: Intrapleural analgesia, Bupivacaine, Bolus, Continuous infusion, Pain relief, Children.
|How to cite this article:|
Al-Khayat HS, Patwari A, El-Khatib MS, Osman H, Naguib K. Intrapleural Bupivacaine Analgesia: Bolus Versus Continuous Infusion Technique for Postoperative Pain Relief in Children. Indian J Anaesth 2008;52:404
|How to cite this URL:|
Al-Khayat HS, Patwari A, El-Khatib MS, Osman H, Naguib K. Intrapleural Bupivacaine Analgesia: Bolus Versus Continuous Infusion Technique for Postoperative Pain Relief in Children. Indian J Anaesth [serial online] 2008 [cited 2019 Oct 19];52:404. Available from: http://www.ijaweb.org/text.asp?2008/52/4/404/60654
| Introduction|| |
The adverse sequelae of postoperative pain are numerous. Children with significant postoperative pain may demonstrate anxiety, fright, insomnia which often exacerbate their pain perception rendering the postoperative recovery period an unpleasant and ominous experience.  Other pain related stress responses include activation of the coagulation system, platelet aggregation and altered fibrinolysis which may enhance clotting leading to deep venous thrombosis and pulmonary embolism.  Pain increases the sympatho-adrenal outflow of catecholamines resulting in dysrhythmias, tachycardia and hypertension.  Reports have underlined the need to pay more meticulous attention to postoperative pain relief in paediatric patients. 
Postoperative pain plays a significant role in the pathogenesis of postoperative pulmonary complication especially after upper abdominal and thoracic operations. Diminishing lung volumes due to acute restrictive pulmonary dysfunction secondary to pain may result in relative hypoxaemia, major atelectasis and pulmonary consolidation. 
A good postoperative pain-relief technique is one that can eliminate or diminish the incidence of postoperative complications and shorten recovery room and intensive care unit stays, the length of hospitalization and overall cost by applying new approaches to pain management. 
Intrapleural regional analgesia is a recent method of postoperative pain relief reported by Reiestad and Stromskug.  This technique may provide a unique form of regional analgesia that has proven advantageous for upper abdominal surgical interventions.
Postoperative pain assessment in the child is very difficult because of the inability of the child to provide verbal self report, his limited behavioral expression and his few previous experiences of pain. 
The aim of the present work was to evaluate the efficacy of intrapleural bupivacaine administration, either by bolus or continuous infusion technique for postoperative pain relief following upper abdominal surgery in children.
| Patients and Methods|| |
This prospective double-blind study was carried out on 30 children of either sex in the age group 6-12 years, with a mean age and weight of 9.2 ± 1.47 years and 23.27 ± 2.71 kg respectively. Children were randomly selected from those admitted to the surgical department of Farwania Hospital, Kuwait and the surgical department of Alexandria Main University Hospital, Egypt (only four cases) and were scheduled for upper abdominal operations. The sample size was determined by consensus based upon the frequency of upper abdominal surgery in paediatric patients conducted at our hospital and a reasonable time frame in which to complete the study (about two years) All patients were free from any previous history of respiratory or cardiovascular diseases. A history of traumatic or spontaneous pneumothorax, haemothorax, pleuritis or pneumonia was considered a contraindication for the technique.
Patients were randomly divided into two equal groups (A and B) comprising of 15 patients each. In every child, an epidural catheter G20 was placed through a Tuohy needle into the pleural space after completion of surgery while the patient was still anaesthetized but breathing spontaneously. Each author performed the catheter placement and acted as a blinded observer in different patients. The patient was left in the supine position and the arm abducted to 90°. The epidural needle was passed over the upper border of the 5 th or 6 th rib in the midaxillary line at the angle of 30-40° in a medial direction under complete aseptic technique. The intrapleural space was identified by loss of resistance and transmitted respiratory movements of the plunger of a well-lubricated low resistance syringe.
Group A patients received a single dose of 1.5 mg.kg -1 of 0.25% bupivacaine via the catheter, which was left in place. Group B patients received 0.125 mg.kg 1.hour -1 of 0.25% bupivacaine infusion via a syringe pump after an initial bolus dose of 0.4 mg.kg -1 of 0.25% bupivacaine. In the ward, Group A and B patients had a syringe pump connected to the intrapleural catheter. However, Group A patients received an infusion of normal saline at the same rate as Group B patients
All children were premedicated and anaesthetized using the same technique and drugs. The surgical interventions included: nephrolithotomy, post-traumatic splenectomy and upper abdominal exploration.
The intrapleural technique used was explained to the parents and informed consent was taken but the children themselves were unaware that this was a painrelieving method and considered it as a part of routine surgical management.
| Measurments and Timing:|| |
The following parameters were measured:
A) Respiratory function tests: tidal volume (ml/breath), minute volume (L/minute), vital capacity (L) and forced expiratory volume in one second (FEV1%)
B) Arterial blood gas analysis using ABL 300 blood gas analyzer. Capillary blood was withdrawn from a warm ear lobule. The sample was delivered using heparinized capillary tubes
C) Cardiovascular: heart rate and mean arterial blood pressure.
D) Pain grading using the Visual Analog Scale (10 cm line with 0 signifying no pain and 10 signifying maximum imaginable pain)  and Prince Henry pain scale  (verbal rating scale using a score of 0-3 where 0 signifies no pain, 1-pain on coughing, 2-pain on deep breathing and 3-pain at rest). All parameters (A, B, C, and D) were measured immediately postoperatively before the child complained of pain and 3, 6 and 12 hours after injection of the analgesic drug.
E) X ray chest: plain X-ray chest, posterio-anterior and lateral views were done preoperatively and immediately post-operatively after intrapleural catheter fixation and if needed later on whenever any complication had occurred.
F) Time of analgesia (in minutes) was recorded from the beginning of pain relief after drug injection till the patient started to feel pain again.
All patients were closely observed and any complications were recorded and measured.
Range and mean (X+ SD) were plotted for every para meter.
Data were analyzed using Student's t test and t 1 and t 2 were calculated for comparisons within the group and between the two groups respectively. A p-value of 0.05 was considered statistically significant.
| Results|| |
[Table 1] shows changes in pulse rate and MAP in the two groups. The change in pulse rate (reduction) was significant at 3 hours in Group A whereas it was significant and sustained in Group B for the entire period. There is a reduction in MAP in both groups but it was significant and sustained in Group B. There was a significant improvement in tidal volume, minute volume and vital capacity in both groups (increase) but it was more significant and sustained in Group B. Significant changes (increase) in Vt and VC can be seen in Group A at 3 hours following a bolus injection. No significant changes in FEV1 % could be demonstrated [Table 2].
When the effect of the two techniques on arterial blood gases were compared there was significant and sustained increase in PaO2 in Group B and in Group A at 3 hrs. A significant change in PaCO2 (decrease) could only be demonstrated in Group B at 6 hrs. There was no appreciable change in pH in both groups [Table 3].
There was a significant and sustained reduction in both the pain scores in Group B. Significant reduction in pain scores could be seen at 3 hours in Group A [Table 4].
The duration was prolonged in both groups but significantly so in group B [Table 5].
| Discussion|| |
Intrapleural analgesia has proven advantageous for postoperative pain management in children subjected to upper abdominal surgical procedures.  Its mechanism of action has not been firmly established. It may produce its analgesic effect by backward diffusion from the intrapleural space to the intercostal space resulting in an intercostal nerve block.  Stromskug et al  studied the injected local analgesic distribution intrapleurally by computerized tomography and found that, the intrapleural technique can block sympathetic chain and splanchnic nerves.
Haemodynamic changes in the two groups showed significant decrease in both heart rate and mean arterial pressure and this may be due to relief of pain, anxiety and distress by the effective intrapleural analgesia. In the present study, continuous infusion technique provided more haemodynamic stability than single bolus procedure. The fall in MAP was more following the bolus dose administration. Stromskug and Lindeberg  detected significant decrease in haemodynamics following intrapleural bupivacaine, using single bolus technique.
Adequate pain relief may promote an effective breathing pattern and improve respiratory function postoperatively.  In the present study, respiratory functions significantly improved immediately after analgesic infusion. Minute ventilation, vital capacity and FEV1% changes showed better pulmonary functions under the continuous catheter technique than the single bolus dose. Scott et al  in their study on pulmonary function parameters using the continuous intrapleural administration of bupivacaine 0.5% following cholecystectomy showed 20 - 50% improvement as compared to the immediate postoperative values.
In our study, administration of intrapleural analgesic lead to improvement of postoperative blood gases. The significant increase in the PaO 2 lasted for twelve hours after starting infusion and for as long as it continued. Nashins et al  in their study showed no significant changes in arterial pH and significantly improved arterial blood gases.
No patients in the present study had apparent complications. There was no evidence of pneumothorax, haemothorax, empyema, systemic analgesic toxicity, infection or Horner's syndrome. Symreng et al  noted that some catheters could be placed extrapleurally or inside the lung parenchyma. Semsroth et al  used intrapleural bupivacaine infusion in infants and children after thoracotomy and found it to be a safe and effective method of pain relief.
The clinical assessment of the analgesic effect of any technique is difficult in children during the immediate postoperative period because of its quantitative nature and subjectivity. That is why in the present study two previously validated pain scales were used.
Pain relief scores and Prince Henry scores were significantly decreased in both the study groups. However, different values were obtained in the bolus and continuous infusion technique. Data revealed that all patients had satisfactory analgesia within three hours of drug administration.
Mcilvaine et al  in their work using single bolus dose of intrapleural bupivacaine found that all their patients had adequate analgesia and none of them required narcotic analgesic medication. On the contrary, Rosenberg et al  failed to get adequate analgesia after intrapleural bupivacaine for management of thoracotomy pain. This may be due to loss of a major portion of the bupivacaine dose by infusion through the intercostal tube. However, this was not the case in our study. The significantly longer duration of analgesia in Group B than Group A was mainly attributed to the use of larger doses and a stable steady state level of bupivacaine concentration.
Both intrapleural bupivacaine techniques proved to be convenient postoperative pain relief methods in children following upper abdominal surgical interventions. Trivedi et al found it useful during percutaneous nephrectomy.  Chawla et al used intrapleural bupivacaine for pain relief after nephrectomy.  Intrapleural anaesthesia was used as a sole anaesthetic technique for mastectomy in a ASA IV patient unfit for GA. The catheter was kept for 48 hours postoperatively and bupivacaine infusion was used for analgesia.  Intrapleural technique is also useful in the management of acute pain in patients with multiple fractured ribs.  The infusion technique avoided the hazards of repeated injections and the nursing staff was free from the tedious protocol of drawing up regular doses of the drug.  At the same time, it abolished the problem of fluctuating analgesic response and if any adverse effects occurred, cessation of infusion lead to immediate decay of the serum drug concentration.  Symreng et al  found that serum levels of bupivacaine reached 0.44-1.5 mcg.ml-1 after a bolus dose of 20 ml of 0.25% bupivacaine. This is much below the toxic level of 2-4 mcg.ml -1 . Kambam et al  in their study found that addition of adrenaline to the bupivacaine bolus reduced serum levels to 0.32 ± 0.02 mcg.ml -1 instead of 1.28 ± 0.48 mcg.ml-1 . There is a significant decrease in peak plasma concentration with the addition of adrenaline. Plasma bupivacaine levels reach their peak usually within 20 minutes of injection. 
The continuous intrapleural analgesic infusion needs a delivery system (pump) and patient monitoring is mandatory. The bolus dose technique of intrapleural analgesia is simple, inexpensive and eliminates the need of a syringe pump.
In conclusion, it can be said that intrapleural bupivacaine, either as a bolus single dose or continuous infusion is a safe and reliable technique of providing adequate analgesia for upper abdominal surgery in children. However the continuous infusion technique provides better analgesia for a longer duration, stable haemodynamics, improvement in respiratory function and arterial blood gases and reduction in the incidence of postoperative pulmonary complications. It also frees the nursing staff from repeated interventions.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]