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Ann Thorac Surg 2006;81:1522-1523
© 2006 The Society of Thoracic Surgeons

How to do it

Subpleural Catheter Placement for Pain Relief After Thoracoscopic Resection

Frank C. Detterbeck, MD *

Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, North Carolina.

Accepted for publication January 20, 2005.

* Address correspondence to Dr Detterbeck, University of North Carolina, Medical School Wing C, Room 354, CB 7065, Chapel Hill, NC 27599-7065 (Email: fdetter{at}med.unc.edu).


Dr Detterbeck discloses that he has a financial relationship with I-Flow Corp.

 

   Abstract
Top
 Abstract
Introduction
 Technique
 Comment
 Acknowledgments
 References
 
Infusion of local anesthetics into an extrapleural pocket results in excellent postoperative pain relief through a multilevel intercostal nerve blockade. This report describes a simple, rapid technique of subpleural catheter placement that lends itself well to thoracoscopic procedures.

Thoracoscopy is a well-accepted, minimally-invasive method of accomplishing even major resections such as lobectomy or esophagectomy. Although patients return to normal activities somewhat sooner, pain is only slightly diminished initially compared with thoracotomy [1–3]. An epidural catheter can provide excellent pain relief, but is not commonly used for thoracoscopic procedures [4] because of the time required for insertion and frequent side effects.

Multiple studies demonstrate the safety and efficacy of a continuous infusion of local anesthetic through a catheter placed in an extrapleural pocket during thoracotomy, as summarized in a systematic review [5]. Randomized studies consistently demonstrate better pain relief, decreased use of supplemental analgesics, better pulmonary function, and less pulmonary complications with an extrapleural infusion versus narcotics alone, and suggest that this approach is at least as effective as an epidural but without the common side effects. Other methods of post-thoracotomy intercostal nerve blockade are less effective [5].

Thus patients undergoing thoracoscopy require similar initial pain relief compared with thoracotomy, and an alternative to an epidural is needed. Although extrapleural infusion of local anesthetics is an excellent alternative to an epidural after thoracotomy, subpleural catheter placement during thoracoscopy is not intuitive. This article reports a quick and reliable technique to accomplish this during thoracoscopy. In fact, I use this technique during open thoracotomy as well.


   Technique
Top
 Abstract
 Introduction
 Technique
Comment
 Acknowledgments
 References
 
The technique involves an elastomeric system providing a constant infusion of 0.5% bupivicaine at 5 mL/hour through a thin "soaker catheter" with multiple side holes (On-Q Pain-Buster PM026, I-Flow Corp, Lake Forest, CA). The catheter is approximately 1 mm in diameter and has side holes extending 12.5 cm from the tip. This will cover six to seven intercostal nerves and generally provide pain relief for all thoracoscopy access and port sites.

Usually the most posterior port site is the lowest intercostal space entered due to the diagonal course of the ribs. The catheter is passed percutaneously into the deep subcutaneous tissue of this skin incision using a peel-away introducer sheath. Thus the catheter penetrates the skin several centimeters more anteriorly and is brought out through the posterior port site (Fig 1).


Figure 1
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  		Fig 1. The soaker catheter tip is grasped by a long, narrow vascular clamp after it is tunneled to the posterior port site using a peel-away sheath.

 
The catheter tip is grasped (Fig 1) with an 11-inch, narrow, slightly curved DeBakey vascular clamp (Pilling, Fort Washington, PA). An insertion channel is created through the intercostal muscles with a tonsil clamp just posterior to the site of penetration for the thoracoscopic procedure, being careful not to puncture the pleura. The vascular clamp tip is then introduced into the insertion channel, and the parietal pleura is lifted using blunt dissection to create a 1 to 1.5 cm wide extrapleural pocket extending posteriorly and then cephalad in the paravertebral space. The initial posterior direction and curve of the clamp allow the chest wall contour to be followed without undue pressure on the ribs at the insertion site. Creation of the extrapleural pocket is monitored thoracoscopically.

The clamp is advanced until the clamp fulcrum is in the intercostal muscle channel. The jaws of the clamp are approximately the length of six to seven intercostal spaces and also the length of the soaker segment (with side holes) of the catheter. The clamp is opened slightly and withdrawn, leaving the catheter in the extrapleural pocket (Fig 2). Excess catheter emanating from the port site is withdrawn from the percutaneous insertion site.


Figure 2
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  		Fig 2. The soaker catheter is left in the paravertebral extrapleural pocket.

 
Injection of 10 to 20 mL of 0.5% bupivacaine fills the extrapleural pocket, after which the catheter is connected to the elastomeric system. The 400 mL device can be overfilled to 500 mL, providing an infusion of local anesthetic for approximately 4 days. The catheter is looped slightly at the insertion site and covered with an occlusive dressing.


   Comment
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 Abstract
 Introduction
 Technique
 Comment
Acknowledgments
 References
 
Continuous infusion of bupivacaine through a subpleural catheter has become standard in my practice for patients undergoing major resection via thoracoscopy. It is also routine after open thoracotomy whenever there are concerns or difficulty inserting an epidural catheter (in this case a small skin incision is made for clamp insertion). The entire process of extrapleural pocket creation, placement, and securing of the subpleural catheter takes approximately 5 minutes on average and can consistently be accomplished in less than 10 minutes. In my experience, alternative techniques for the placement of a catheter during thoracoscopy, such as percutaneously through a Tuohy needle [6], are difficult, often unsuccessful, and require more time, despite several months of effort to learn this skill.

No complications have been noted with this insertion technique. There has been no leakage of local anesthetic through the skin incision after closure or into the subcutaneous tissues during initial filling of the extrapleural pocket. No kinking of the catheter or injury to intercostal vessels have occurred. In approximately 10% of patients, a 2 to 3 mm pleural tear occurred during creation of the extrapleural pocket, but did not prevent filling of the pocket and was not of clinical consequence. Catheter removal is easy and painless, and patients who have gone home are able to remove it themselves.

Extrapleural bupivacaine has resulted in good pain relief in the vast majority of patients, consistent with the published literature [5, 7, 8]. The infusion rate using the system described here is consistent with that shown to be both safe and effective in other studies (5 to 7 mL/hr of 0.5% bupivacaine) [5, 7, 8].

A subpleural catheter avoids the side effects of nausea, itching, and urinary retention commonly seen with an epidural catheter, and it can be placed much more quickly and reliably. The subpleural catheter also provides intercostal nerve blockade over a wider area than insertion of a soaker catheter just above and just below a thoracotomy incision. This technique of subpleural catheter placement is simple, rapid, and should be used more widely, particularly for patients undergoing thoracoscopic resection.


   Acknowledgments
Top
 Abstract
 Introduction
 Technique
 Comment
 Acknowledgments
References
 
The author thanks Edwin Staples of the Medical Illustration and Photography Department at the University of North Carolina School of Medicine for creating the illustrations for this article. The author acknowledges financial support from I-Flow Corp, which covered the cost of illustrations for this article and provided remuneration for the author's participation in educational programs regarding the technique described here.


   References
Top
 Abstract
 Introduction
 Technique
 Comment
 Acknowledgments
 References
 

  1. Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Lobectomy—video-assisted thoracic surgery versus muscle-sparing thoracotomya randomized trial. J Thorac Cardiovasc Surg 1995;109:997-1001discussion 1001–2.[Abstract]
  2. Giudicelli R, Thomas P, Lonjon T, et al. Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy Ann Thorac Surg 1994;58:712-717discussion 717–8.[Abstract]
  3. Tschernko EM, Hofer S, Bieglmayer C, Wisser W, Haider W. Early postoperative stressvideo-assisted wedge resection/lobectomy vs conventional axillary thoracotomy. Chest 1996;109:1636-1642.[Abstract/Free Full Text]
  4. Yim AP, Landreneau RJ, Izzat MB, Fung AL, Wan S. Is video-assisted thoracoscopic lobectomy a unified approach? Ann Thorac Surg 1998;66:1155-1158.[Abstract/Free Full Text]
  5. Detterbeck FC. Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy Ann Thorac Surg 2005;80:1550-1559.[Abstract/Free Full Text]
  6. Soni AK, Conacher ID, Waller DA, Hilton CJ. Video-assisted thoracoscopic placement of paravertebral cathetersa technique for postoperative analgesia for bilateral thoracoscopic surgery. Br J Anaesth 1994;72:462-464.[Abstract/Free Full Text]
  7. Richardson J, Sabanathan S, Jones J, Shah RD, Cheema S, Mearns AJ. A prospective, randomized comparison of preoperative and continuous balanced epidural or paravertebral bupivicaine on post-thoracotomy pain, pulmonary function and stress responses Br J Anaesth 1999;83:387-392.[Abstract/Free Full Text]
  8. Sabanathan S, Smith PJ, Pradhan GN, Hashimi H, Eng JB, Mearns AJ. Continuous intercostal nerve block for pain relief after thoracotomy Ann Thorac Surg 1988;46:425-426.[Abstract]



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This Article
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