Interpleural Analgesia After Thoracotomy

Abstract

We examined the effects of the following variables on interpleural analgesia after thoracotomy: addition of epinephrine to local anesthetic, thoracostomy drainage, two-catheter placement, and location of catheter tips. Twenty patients were randomized to have one catheter (paravertebral tip location) or two catheters (paravertebral and lateral thoracic wall tip locations). Interpleural catheters were sutured to the parietal pleura by the surgeon at time of wound closure. Patients were then randomly assigned to receive 20 mL of 0.5% bupivacaine with 1:200,000 epinephrine through the single catheter or 10 mL of 0.5% bupivacaine with or without 1:200,000 epinephrine through each of the two catheters while supine. Bupivacaine concentrations in whole blood and in thoracostomy drainage fluid were assayed by gas chromatography. Actual content of bupivacaine in the drainage fluid was calculated. Degree of analgesia was assessed by verbal numerical pain scores over the first 4 h and opioid demand thereafter. Addition of epinephrine to bupivacaine did not influence the degree of analgesia. Approximately 30%-40% of any administered dose of bupivacaine was lost via the thoracostomy tube over a 4-h period. There was no correlation between the true initial dose (100 mg minus thoracostomy drainage) and Cmax. Use of two catheters resulted in significantly less opioid requirements after an initial 8-h period. Failure to achieve adequate interpleural analgesia in postthoracotomy patients may be related to loss of anesthetic via thoracostomy drainage, presence of extravasated blood and tissue fluid in the pleural space, and possibly sequestration and channeling of flow of local anesthetic by restricted motion of an operated lung.(ABSTRACT TRUNCATED AT 250 WORDS)

Intrapleural Analgesia Using Ropivacaine for Postoperative Pain Relief after Minimally Invasive Thoracoscopic Surgery

“…Several reports have described effectiveness of IPA as postoperative pain relief for thoracic surgery, [5][6][7][8] but some reports have been only mildly positive 9) or frankly negative. 10,11) These conflicting results may be due to a variety of the applications and the study settings.…”

Bloqueio pleural bilateral: analgesia e funções pulmonares em pós-operatório de laparotomias medianas

“…Torna-se relevante, portanto, o posicionamento do paciente para o êxito farmacológico. Com o hemitórax alvo para cima, o decúbito lateral de 90º resulta na embebição da cadeia simpática paravertebral, enquanto que o decúbito lateral em 45º, na embebição dos nervos intercostais (Figura 1) 10 .…”

“…Patients' positioning is then relevant for the pharmacological success. With the target hemithorax facing upwards, 90º lateral position results in the soaking of the paravertebral sympathetic chain while 45º lateral position determines the soaking of intercostal nerves (Figure 1) 10 .…”

Combined chest drain and intrapleural catheter

“…Variability of response is caused by loss of up to 40% of anaesthetic solution through chest drains [6], (60% in the paper by Broome etal. ), mixing of the local anaesthetic with blood and fluid in the pleural space [3,6] and size mismatch between the postoperative lung and chest cavity producing an unimpeded gravitational pooling of solution in the dependent parts of the chest, which is thereby lost to analgesia.…”

“…), mixing of the local anaesthetic with blood and fluid in the pleural space [3,6] and size mismatch between the postoperative lung and chest cavity producing an unimpeded gravitational pooling of solution in the dependent parts of the chest, which is thereby lost to analgesia. This last problem can be somewhat countered by keeping the immediate postoperative patient supine as in this study, but an additional and possibly irreversible decline in postoperative pulmonary function would be expected [I.…”