Ann Thorac Surg 2005;79:1828-1829
© 2005 The Society of Thoracic Surgeons
Correspondence
Intrapleural Bupivacine for Postthoracotomy Analgesia
C.S. Pramesh, MS, FRCS,
Rajesh C. Mistry, MS,
Gouri H. Pantvaidya, MS, MRCS,
Vikram R. Ghanekar, MS
Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai 400012, India
(E-mail: cspramesh{at}vsnl.net).
To the Editor:
We read with interest the article by Tetik and associates [1] on the efficacy of intrapleural administration of bupivacaine hydrochloride for postthoracotomy analgesia. We were perplexed by the design of the trial and wonder what the aim of the study was. Any intervention that is to be tested in a randomized trial needs to be compared with the existing "standard" treatment. If the aim of the authors was to evaluate whether analgesia with an intermittent infusion of 0.25% bupivacaine through an intrapleural catheter gives acceptable pain relief after thoracotomy, it is logical that this method be compared with the accepted standard followed in most centers in the world, ie, epidural analgesia with local analgesics or opiates. The authors admitted that epidural analgesia is the gold standard for postthoracotomy pain relief and that systemic nonsteroidal antiinflammatory drugs do not provide satisfactory analgesia.
To study intrapleural administration of a specific drug with an intrapleural placebo as the "control" arm is not only unscientific but also inconsiderate. We wonder how the patients who enrolled for the trial gave informed consent when half of them would not receive effective analgesia and would be given "salvage analgesia" with intramuscular administration of diclofenac sodium when they complained of pain! Did Tetik and coauthors really expect the patients who received intrapleural bupivacaine to experience anything other than significantly reduced pain compared with the group given the intrapleural placebo? It is hardly surprising that the patients in the placebo group requested and received additional analgesic administration, which was also one of the variables evaluated to establish the superiority of intrapleural bupivacaine. A disturbing point is that the only analgesic the placebo group received was intramuscular diclofenac, and this cannot be considered an "additional" analgesic.
At best, this trial establishes that bupivacaine is a good local anesthetic and acts when administered intrapleurally. In no way does the study establish the superiority of the intrapleural procedure itself, as was claimed by the authors. If their aim had been to suggest that intrapleural bupivacaine offers effective analgesia, the design of the study should have been to compare that method with epidural analgesia with respect to ease of the procedure, complications, and efficacy of the analgesic.
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References
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- Tetik O,
slamo
lu F, Ayan E, Duran M, Buket S, Çekirdekçi A. Intermittent infusion of 0.25% bupivacaine through an intrapleural catheter for post-thoracotomy pain relief Ann Thorac Surg 2004;77:284-288.[Abstract/Free Full Text]
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