| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2003;76:978
© 2003 The Society of Thoracic Surgeons
a Bradford Royal Infirmary, Duckworth Lane,Bradford, West Yorkshire BD9 6RJ, UK
To the Editor:
We read with interest the study by Takamori and colleagues [1]. We found the result of interest, although at the same time, it raises concerns about continued research in this area using similar methodology. In their study, epidural analgesia by 1.0% mepivacaine 4 mL/h starting during surgery and maintained for 5 days was successfully supplemented, in terms of pain scores over the first 3 postoperative days, with 8 mL of 0.25% bupivacaine internally injected alongside four intercostal nerves.
A number of points make interpretation difficult. It was not stated that correct epidural catheterization was confirmed, and no local anaesthetic bolus was given. We question, therefore, whether adequate epidural analgesia was in fact used, and this point may be reflected in the marked stress responses, measured with serum ACTH and cortisol, shown in both groups. Questionable quality pain relief in the presence of an acknowledged markedly painful surgical wound [2, 3], does set the scene for observation of the effect of additional analgesia.
For adequate thoracotomy surgical anaesthesia, it is likely that up to seven dermatomes need to be blocked [3]. As only four intercostal nerve blocks were done in these patients, it is likely that dermatomal coverage would have been suboptimal. We also wonder whether the quality of the intercostal block was adequate. This is because only bupivacaine 0.25% was used in a volume of 8 mL. This is a fairly safe amount to use, particularly taking into account the known hazards of direct injection into the neurovascular bundle with internal intercostal blocks in an open chest situation [4–6]. Efficacy would have been compromised not just through the use of a slow-onset local anesthetic and a relatively small volume of a weak solution, but also through initiation of the block well into the surgical procedure, through lack of a preemptive element.
Whatever afferent nerve blocking technique is used, it ought to be optimized, otherwise inherent risks are difficult to justify. The known hazards of cannulation of the thoracic epidural space need to be justified, and that may not have been done in this study.
In our own unit, we strongly recommend the use paravertebral nerve blocks from the points of view of efficacy and safety. We and others have compared paravertebral nerve blocks (using much higher doses of local anesthetic) with epidural nerve blocks and found them to be superior in all measurement parameters [7, 8]. Epidural nerve blocks are therefore reserved for the few situations where paravertebral blocks are contraindicated.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
