Year : 2008 | Volume
: 52 | Issue : 4 | Page : 432-
Comparison of Interpleural and Thoracic Epidural Bupivacaine with Buprenorphine for Post-Thoracotomy Analgesia
SK Mathur1, Sunil Jain2, D Agrawal1, P Ranjan3, Ankur Jain2,
1 Reader and Head, Division of Cardiothoracic Anaesthesia and Department of Cardiothoracic and Vascular Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005, India
2 P.G.Student, Division of Cardiothoracic Anaesthesia and Department of Cardiothoracic and Vascular Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005, India
3 Reader, Division of Cardiothoracic Anaesthesia and Department of Cardiothoracic and Vascular Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005, India
S K Mathur
Division of Cardiothoracic Anaesthesia, Department of Anaesthesiology Institute of Medical Sciences, Banaras Hindu University, Varanasi- 221005
The study was designed to compare the efficacy of interpleural and thoracic epidural analgesia after thoracotomy with regard to quality of analgesia and complications. Sixty patients undergoing elective thoracotomy were randomly and equally placed into either interpleural (IP) or thoracic epidural (TE) group. In IP group an interpleural catheter was placed in paravertebral space under direct vision during surgery and received 0.25% bupivacaine 20 ml with buprenorphine 150 mcg. In TE group an epidural catheter was inserted in the T6-7 / T7-8 interspace and received 0.25% bupivacaine 10 ml with buprenorphine 150 mcg. Dosage were repeated in both the groups to keep a VAS score <40 for 48 hours post-operatively. Spirometry was done preoperatively and 12, 24 and 36 hours post-operatively. Vital parameters were monitored for 48 hours. The mean analgesia time was 331.73±94.03 min and 567.33±127.33 min in IP and TE groups respectively. The VAS score was significantly reduced within the first 30 minutes of injection in both the groups. Post injection VAS was significantly better in TE group. Mean time taken for interpleural and epidural catheter placement was 5.0±0.0 min and 33.83±3.39 min respectively. Postoperative forced expiratory volume in 1 second(FEV1), forced vital capacity (FVC) and forced expiratory ratio (FER) were similar in both the groups while peak expiratory flow rate (PEFR), maximal expiratory flow (MEF) and F50 were slightly better in TE group. Vital parameters showed similar changes in both the groups. The TE group had more complications. Interpleural analgesia, though of shorter duration, is a safe and effective alternative technique for post-thoracotomy analgesia and has a low complication rate.
|How to cite this article:|
Mathur S K, Jain S, Agrawal D, Ranjan P, Jain A. Comparison of Interpleural and Thoracic Epidural Bupivacaine with Buprenorphine for Post-Thoracotomy Analgesia.Indian J Anaesth 2008;52:432-432
|How to cite this URL:|
Mathur S K, Jain S, Agrawal D, Ranjan P, Jain A. Comparison of Interpleural and Thoracic Epidural Bupivacaine with Buprenorphine for Post-Thoracotomy Analgesia. Indian J Anaesth [serial online] 2008 [cited 2020 Jun 1 ];52:432-432
Available from: http://www.ijaweb.org/text.asp?2008/52/4/432/60658
Post-thoracotomy pain is one of the most severe types of pain during the first 24 hours of the surgery and is responsible for post-operative morbidity and mortality by compromising respiratory functions , . Effective post-operative pain management is one of the most important components of the treatment of patients undergoing thoracic surgery  . Systemic use of non-steroidal anti-inflammatory drugs (NSAIDs) may not relieve moderate to severe post thoracotomy pain and may cause gastrointestinal and renal complications  . Parenteral opioids have an effective potential for reliable pain relief but may cause respiratory depression  . Intercostal nerve blockade requires serial injections and may also lead to long term intercostal neuralgia  . Although thoracic epidural analgesia has been shown as the gold standard method for providing highly effective control of postoperative pain , , it carries a considerable risk of potential serious neurological and hemodynamic complications and may not be suitable in patients suffering from a coagulation disorder ,, . Limitations of various analgesic techniques have evolved a renewed interest in the administration of long acting local anaesthetic agent along with an opioid through an interpleural catheter for post-thoracotomy pain relief ,,, . We intended to compare analgesic efficacy and effects on pulmonary functions of interpleural and thoracic epidural analgesia techniques along with complications.
Sixty adult patients of both sexes undergoing elective antero-lateral or postero-lateral thoracotomy for various indications were randomly and equally placed into interpleural (IP) and thoracic epidural (TE) groups. Patients having allergy to local anaesthetics and age below 18 years or above 60 years were excluded from the study. The study was approved by the ethics committee of our institution and an informed consent was obtained from the patients. All observational parameters were noted by an independent observer blinded for the post-operative analgesia technique.
Pre-operatively a physical examination and bed side pulmonary function tests by spirometry (Microlab 3300) (forced expiratory volume in 1 second - FEV1, forced vital capacity-FVC, forced expiratory ratio FEV1/FVC - FER, peak expiratory flow rate- PEFR, maximal expiratory flow - MEF and forced expiratory flow at 50% of the forced vital capacity - F50) were done in the evening of day prior to surgery.
After premedication with alprazolam, anaesthesia was induced with fentanyl 3mcg.kg -1 , propofol 2mg.kg -1 and muscle relaxation with vecuronium 0.1mg.kg -1 . The trachea was intubated with appropriate size tracheal tube. Anaesthesia was maintained with isoflurane and 50 % nitrous oxide-oxygen mixture with vecuronium for muscle relaxation. Intraoperative analgesia was provided with fentanyl. At the end of surgery residual muscle paralysis was reversed by neostigmine (0.05 mg.kg -1 ) and glycopyrrolate (0.01 mg.kg 1) and the trachea was extubated following complete recovery of reflexes.
In the IP group, when the chest was still open, surgeon inserted a 16 G radio-opaque nylon epidural catheter (Perifix) in the pleural cavity under direct vision. The tip of the catheter was directed towards the fourth intercostal space on the paravertebral line. The other end of the catheter was taken out by the side of chest drain and fixed to the skin. Before closure of the chest, first dose of 40 ml bupivacaine 0.25% with buprenorphine 150 mcg was given through the catheter. The chest drainage tube was clamped for 30 minutes with the patient still in lateral position with operated side up. In the postoperative period IP group patients received 20 ml bupivacaine 0.25% with buprenorphine 150 mcg through interpleural catheter as and when they complained of pain (VAS >40). Before the injection of interpleural drugs, the patients were positioned semi-lateral with operated side up and the chest tube clamped for 30 minutes after excluding any air leak. The patients were monitored throughout this period to detect any possible intolerance of the procedure.
Patients in the TE group had a 16 G radio-opaque nylon epidural catheter (Perifix) inserted using the median or paramedian approach in the T6-7 / T7-8 interspace before tracheal extubation. The epidural space was identified by the loss of resistance to saline and the catheter was inserted for 3-4 cm beyond the needle tip in cephalic direction. The patients in this group received 10 ml bupivacaine 0.25% with buprenorphine 150 mcg in supine position as and when they complained of pain (VAS >40). Intravenous injection of diclofenac (1.5 mg.kg -1 ) was kept as a rescue analgesic in both the groups.
Pain was assessed with a visual analog scale (VAS) score on a 100 mm scale, with 0 referring to no pain and 100 referring to unbearable pain. Patients were informed about the use of scale preoperatively. Postoperatively, the VAS score was maintained below 40 for 48 hours. Pain intensity was evaluated before and 30 minutes after the injection. Analgesia time was defined as the time interval between two consecutive recordings of the pain. The mean analgesia time was defined as the mean value of such recordings from the first dose to the postoperative 48 hours.
Spirometry (FEV1, FVC, FER, PEFR, MEF and F50) were done 12 hours, 24 hours and 36 hours postoperatively with the same portable pulmonary function test machine. Heart rate, systemic arterial blood pressure, central venous pressure, respiratory rate, oxygen saturation by pulse oximetry (SpO 2 ) and VAS score were monitored before the injection, through the first 30 minutes after the injection and at hourly intervals through the 48 hours postoperatively. A note was made of any side effects like nausea, vomiting, hypotension, respiratory depression, urinary retention, local anaesthetic toxicity, etc. All patients received oxygen at the rate of 4 L/min with a face mask in the recovery room for 12 hours postoperatively.
The mean and standard deviation of the parameters observed in two groups were calculated and compared using Student's 't' test. The critical value of 'p' indicating the probability of significant difference was taken as  . However, Scheinin et al failed to find such a duration of analgesia and may probably be because of positioning and clamping of chest drainage tube for 10 minutes only which may be inadequate for appropriate fixation of the drugs. The mean duration of analgesia (567.33±127.33 minutes) achieved in TE group was significantly longer as compared to IP group [Table 2].
The mean duration of pain relief in the IP group was approximately same with each of the initial five doses which all together constituted the first 24 hours of postoperative period. The subsequent doses had longer duration of analgesia which was significantly higher when compared to first dose [Table 2]. The possible reason for lesser duration of analgesia in the first 24 hours postoperatively may be due to high degree of pain in the first 24 hours, more dilution of drugs by pleural exudation and blood and more loss of drugs in the chest drain. Tissue fluid, tissue edema and blood from freshly operated lung may setup diffusion barrier preventing drugs from reaching intercostal nerves. The increase in duration of analgesia after 24 hours of surgery may be due to decreased intensity of pain and accumulation of drugs after repeated doses.
In TE group the mean duration of analgesia after first dose was 438.0±32.63 minutes which increased with each subsequent dose, which was statistically significant as compared to first dose, to reach a maximum of 736.33±20.42 minutes with the last dose in 48 hours postoperatively [Table 2]. The duration of analgesia in TE group remained significantly higher (about 1.5 times) as compared to IP group all through the study period. The possible reasons may be that the drugs in epidural space act more precisely on intercostal nerve roots, no loss of drugs into the chest drain and no diffusion barrier for drugs to reach to intercostal nerves. A maximum of six doses were required to maintain the desired level of analgesia in the first 48 hours in TE group while a maximum of nine doses were required to maintain the analgesia in IP group.
We used the method of intermittent administration of drugs in both the groups to maintain the similarity of drug administration. The use of continuous infusion for interpleural analgesia would probably have resulted in excessive loss of drugs in the drainage tube because it can not be kept clamped during the entire period of infusion. Continuous infusion can also lead to central nervous system toxicity . Though we used the similar concentration of bupivacaine in both the groups, its volume was higher in the interpleural group as pleural cavity is a large space and requires larger volume to block intercostal nerves.
A disadvantage of chest tube clamping is the risk of pneumothorax in the patient with large air leaks. In our study the chest drain tube was clamped for 30 minutes after drug administration and we did not observe any complications. However, unclamping chest tube results in more rapid removal of injected solution from the pleural cavity . It is reported in several studies that interpleural bupivacaine provides sufficient analgesia after cholecystectomy when loss of drugs does not occur ,, . We did not use epinephrine with bupivacaine as it has not been shown conclusively to result in lower plasma bupivacaine level after interpleural injection . Also, it has got undesirable arrhythmogenic potential.
The analgesic effect of interpleural local anaesthetics is believed to be related primarily to its diffusion through parietal pleura and intercostalis intimus muscle to block paravertebral nerves as well as nerves innervating the viscera . The intercostalis intimus muscle is poorly developed or essentially absent in the upper intercostal spaces and may therefore be optimal site for catheter tip location.
We combined buprenorphine with bupivacaine to block opioid receptors demonstrated in the peripheral nervous system for better pain relief ,, .
The quality of analgesia in both the groups was assessed by VAS score 30 minutes after the administration of drugs. The mean VAS after all the doses of drugs in IP group was 7.88±2.47 which was significantly higher than the mean VAS score of 5.72±1.76 attained in TE group [Table 3]. This significant difference of better analgesia attained in TE group was with all the doses and not only in the first 24 hours [Table 3]. It shows that thoracic epidural analgesia gives better pain relief as compared to interpleural analgesia. None of the patients in both the groups required rescue analgesic.
The mean time taken by the surgeon for interpleural catheter placement was 5.0±0.0 minutes while epidural catheter placement technique required 33.83±3.39 minutes. In TE group this time was used in positioning of the patients, painting and draping, localization of epidural space, catheter placement and its fixation. In IP group catheter could be positioned properly under vision as the thorax was open and its fixation along with chest drainage tube was much easier. This saved the precious operating room time in the IP group.
The decrease in heart rate, systolic and diastolic blood pressure and respiratory rate from pre-analgesic values were significant in both the groups and was due to adequate analgesia provided by both the techniques [Table 4]. In the TE group, two patients developed single episode of significant fall of blood pressure (>20%) which was not associated with excessive blood loss and was controlled by intravenous fluids and vasopressure.
In our study we did spirometry preoperatively and then 12, 24 and 36 hours after surgery. Postoperative spirometry was done only when patients were comfortable with a VAS score of  , J. Richardson , B. Brismar and Kaiser . The postoperative PEFR, MEF and F50 were also decreased in both the groups. This decrease was lesser in TE group reflecting better pain relief and higher airflow in medium and small airways.
In our study two patients of IP group and four patients of TE group developed nausea and vomiting. These episodes were not related with episodes of hypotension. Two patients in TE group had developed significant hypotension and required intravenous fluids and vasopressure. One patient in IP group and two patients in TE group developed urinary retention. However, none of them required bladder catheterization. Two patients in TE group had epidural catheter blockade which was relieved by withdrawing the catheter 1 cm outside. Two patients in the TE group had dural puncture during the catheter placement. However, none of them developed postdural puncture headache and neurological complications. One patient in the TE group developed paraparesis after 72 hours of surgery. This patient had an episode of hypotension in the immediate postoperative period. The MRI report was normal. Patient recovered fully following next 48 hours.
There are some limitations to this study. Estimation of serum levels of bupivacaine and buprenorphine to assess the systemic absorption of these drugs were not done. The arterial blood gas analysis was also not done to assess the gaseous exchange as there were no clinical indications to that.
We can conclude that interpleural analgesia, though gives shorter duration of analgesia, is a safe and effective alternative technique for postoperative analgesia after thoracotomy and has a low complication rate compared with thoracic epidural analgesia.
|1||Takamori S, Yoshida S, Hatashi A. Intraoperative intercostal nerve blockade for post-thoracotomy pain. Ann Thorac Surg 2002;74:338-41.|
|2||Kaiser AM, Zollinger A, Lorenzi D. Prospective, randomized comparison of extrapleural versus epidural analgesia for post-thoracotomy pain. Ann Thorac Surg 1998;66:367-72.|
|3||Dryden CM, McMenemin I, Duthie DJR. Efficacy of continuous intercostal bupivacaine for pain relief after thoracotomy. Br J Anaesth 1993;70:508-10.|
|4||Tetik O, Islamoglu F, Ayan E, Duran M. Intermittent infusion of 0.25% bupivacaine through an intrapleural catheter for post-thoracotomy pain relief. Ann Thorac Surg 2004;77:284-288.|
|5||Anesthesia for thoracic surgery: Wilson WC, Benumot JL. In Miller RD, ed. Miller´s Anesthesia, 6 th ed. Philadelphia, Pennsylvania: Churchill Livingstone 2005:18471940.|
|6||Christopher L, Sapirstein A, Herbert R. Effect of postoperative epidural analgesia on morbidity and mortality after lung resection in medicare patients. J of Clinical Anesth 2006;18:515-20.|
|7||Liu S, Carpentier RL, Neal JM. Epidural anesthesia and analgesia.Anesthesiology 1995;82:1474-506.|
|8||James EC, Kolberg BS, Iwen GW, Gellatly TA. Epidural analgesia for post-thoracotomy patients. J Thorac Cardio Vasc Surg 1981;82:898-903.|
|9||Kambam JR, Handte RE, Flanagan J, Fisher K, et al. Intrapleural anesthesia for post-thoracotomy pain relief. Reg Anesth 1987;12:106-107.|
|10||McIlvaine WB, Knox RF, Fennessey PV, Goldstein M. Continuous infusion of bupivacaine via intrapleural catheter for analgesia after thoracotomy in children. Anaesthesiology 1988;69:261-264.|
|11||Rosenberg PH, Scheinin BM-A, Lepantalo MJA, Lindfors O. Continuous intrapleural infusion of bupivacaine for analgesia after thoracotomy. Anesthesiology 1987;67:811-813.|
|12||Scheinin B, Lindgren L, Rosenberg PH. Treatment of post-thoracotomy pain with intermittent instillations of intrapleural bupivacaine. Acta Anaesthesiol Scand 1989;33:156-159.|
|13||Kreitzer JM, Reuben SS. Central nervous system toxicity in a patient receiving continuous intrapleural bupivacaine. J Clin Anesth 1996;8:666-68.|
|14||Ferrante FM, Chan VWS, Arthur GR, Rocco AG. Interpleural analgesia after thoracotomy. Anesth Analg 1991;72:105-109.|
|15||Vade Boncouer TR. Interpleural regional analgesia. In Ferrante FM and Vade Boncouer TR, Editors, Postoperative pain management, Churchill Livingstone, New York 1993; 383-402.|
|16||Laurito CE, Kirz LI, Vade Bancouer TR, et al. Continuous infusion of interpleural bupivacaine maintains effective analgesia after cholecystectomy. Anesth Analg 1991;72:516-521.|
|17||Stomskag KE, Reiestad F Holmqvist EL. Intrapleural administration of 0.25%, 0.375% and 0.5% bupivacaine with epinephrine after cholecystectomy. Anesth Analg 1988;67:427-29.|
|18||Rademaker BMP, Sih IL, Kalkman CJ, et al. Effects of interpleurally administered bupivacaine 0.5% on opioid analgesic requirements and endocrine response during and after cholecystectomy. Acta Anaesthesiol Scand 1991;35:108-112.|
|19||Riegler FX, Vade Boncouer TR, Pelligrino DA. Interpleural anesthetics in the dog: differential somatic neural blockade. Anesthesiology 1989;71:744-50.|
|20||Stein C. Peripheral mechanisms of opioid analgesia. Anesth Analg 1993;76: 182-191.|
|21||Karakaya D, Buyukgoz F, Baris S, et al. Addition of fentanyl to bupivacaine prolongs anesthesia and analgesia in axillary branchial plexus blocks. Reg Anesth Pain Med 2001;26:434-438.|
|22||Aykac B, Erolcay H, Dikmen Y, et al. Comparison of intrapleural versus intravenous morphine for post thoracotomy pain management. J Cardiothorac Vasc Anesth 1995;9:538-540.|
|23||Tommy S, Mark N, Nicholas R. Intrapleural bupivacaine versus saline after thoracotomy - effects on pain and lung function. J Cardiothorac Anesth 1989;3:144-149.|
|24||Richardson J, Sabanathan S, Mearns AJ. A prospective, randomized comparison of interpleural and paravertebral analgesia in thoracic surgery. BrJAnaesth 1995;75:405-408.|
|25||Brismar B, Pettersson N, Tokics L, Strandberg A, Hedenstierna G. Postoperative analgesia with intrapleural administration of bupivacaine - adrenaline. Acta Anaesthesiol Scand 1987;31:515-20.|
|26||Kaiser Am, Zollinger A, Lorenzi D. Prospective, randomized comparison of extrapleural versus epidural analgesia for post-thoracotomy pain. Ann Thorac Surg 1998;66:367-72.|