Ann Thorac Surg 1999;67:825-828
© 1999 The Society of Thoracic Surgeons
Original Articles
Pain control after thoracotomy: bupivacaine versus lidocaine in continuous extrapleural intercostal nerve blockade
Derek S. Watson, MDa,
Steve Panian, MDa,
Vaughan Kendall, MDa,
D. Patrick Maher, MDa,
George Peters, MDa
a Department of Surgical Education, Exempla, St. Joseph Hospital, Denver, Colorado, USA
Accepted for publication September 16, 1998.
Address reprint requests to Dr Panian, Surgical Education, Exempla, St. Joseph Hospital, 1835 Franklin, Denver, CO 80218
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Abstract
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Background. The use of a continuous bupivacaine extrapleural intercostal nerve block after posterolateral thoracotomy has been shown in randomized controlled studies to be effective in reducing postoperative pain and restoring pulmonary function. It is our hypothesis that when using a continuous infusion for nerve block, a long-acting agent (bupivacaine) is unnecessary and a shorter-acting agent (lidocaine) would offer equivalent results with less systemic toxicity. This study was designed to determine whether lidocaine was as effective as bupivacaine in a continuous extrapleural intercostal nerve block after posterolateral thoracotomy because lidocaine is a less toxic analgesic agent. The study was prospectively randomized and double-blinded.
Methods. Forty-six patients undergoing elective posterolateral thoracotomy were randomized to blindly receive bupivacaine (n = 23) or lidocaine (n = 23) by continuous infusion pump through an intraoperatively placed indwelling extrapleural catheter. Postoperative pain was assessed for 48 hours by patient-controlled morphine consumption and by linear visual analog scale. There was no statistically significant difference in age, sex, or type of operation between the two groups.
Results. There was no statistically significant difference between the bupivacaine and lidocaine groups in patient-controlled morphine use or in visual analog scale scores.
Conclusions. Lidocaine offers equivalent pain control to bupivacaine when administered for continuous extrapleural intercostal nerve block after posterolateral thoracotomy, with less risk of systemic toxicity.
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Introduction
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Pain after posterolateral thoracotomy has long been recognized as a cause of postoperative morbidity [1, 2]. Restriction of chest wall motion in response to pain leads to shallow breathing and cough suppression. This deterioration of respiratory mechanics can lead to atelectasis, mucous plugging, hypoxia, ventilation-perfusion mismatch, and pulmonary infections [2, 3]. These problems can be most severe in the obese, the elderly, smokers, and those with existing pulmonary disease [4]. Narcotics are effective in reducing postoperative pain, but are also associated with respiratory depression and suppression of the cough reflex [5–7]. Because of these factors alternative methods of postoperative pain control have been sought. Regional anesthesia by means of intermittent percutaneous intercostal nerve block with a long-acting local anesthetic such as bupivacaine has been shown to be effective in reducing pain, reducing the dosage of narcotics required, and improving pulmonary function [8, 9]. However, this method requires multiple sites of injection and frequent dosing.
In 1988 Sabanathan and colleagues [10] described an intercostal nerve technique using an intraoperatively placed indwelling extrapleural catheter through which a local anesthetic could be continuously infused postoperatively. The catheter was placed percutaneously into an extrapleural pocket created by the surgeon at the time of posterolateral thoracotomy, and then it was infused continuously with 0.5% bupivacaine postoperatively. Multiple prospective randomized studies by several investigators have shown this to be an effective means of reducing postoperative pain and improving postoperative respiratory mechanics [5, 10–15]. When using intermittent dosing for local anesthesia, a long-acting agent such as bupivacaine is advantageous owing to its long half-life. However, with a continuous infusion catheter a short-acting agent such as lidocaine may be a better choice. Bupivacaine is known to have more central nervous system toxicity than lidocaine and causes side effects at lower doses and lower plasma concentrations than lidocaine [16, 17]. A long-acting agent for a continuous infusion locally is probably unnecessary and potentially harmful. This study is designed to compare pain control between 0.5% bupivacaine and 1.0% lidocaine when used for continuous extrapleural intercostal nerve block after posterolateral thoracotomy.
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Material and methods
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Forty-six patients scheduled to undergo elective posterolateral thoracotomy for pulmonary procedures were blindly randomized into two groups. Group A (n = 23) received 0.5% bupivacaine, and group B (n = 23) received 1.0% lidocaine. Both groups at the time of posterolateral thoracotomy underwent placement of an extrapleural catheter as originally described by Sabanathan and coworkers [10]. An extrapleural pocket was developed posteriorly for two to three interspaces above and below the level of the thoracotomy (Fig 1). A 20-gauge Teflon catheter was then placed percutaneously into this space by direct visualization (Fig 2). The final position of the catheter is with the lower portion in the inferior part of the pocket and the tip in the superior portion of the pocket (Fig 3). At the conclusion of the procedure, the catheter was injected with a 10-mL loading dose of the blinded study medication. In the postanesthetic care unit, patients were started on a continuous infusion of the study medication given by an infusion pump. Group A received 0.1 mL · kg-1 · h-1 of 0.5% bupivacaine (0.5 mg · kg-1 · h-1). Group B received 0.1 mL · kg-1 · h-1 of 1.0% lidocaine (1 mg · kg-1 · h-1). The patients were then monitored for 48 hours postoperatively. Pain was assessed by patient-controlled morphine (PCM) consumption and by a linear visual analog scale (VAS). Patients viewed a 10-cm scale graduated from 0 (no pain) to 10 (worst imaginable pain) and were asked to rate their perceived level of pain daily.
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Fig 2. Twenty-gauge Teflon catheter placed by direct vision percutaneously through a needle into the extrapleural space. The catheter is placed in the most inferior part of the created space and then directed superiorly.
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Fig 3. Final position of the catheter with the lower portion in the inferior part of the pocket and the tip in the most superior part of the pocket.
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Results
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The patients underwent posterolateral thoracotomy for the following procedures: wedge resection, 10; lobectomy, 28; bilobectomy, 3; pneumonectomy, 4; and thoracotomy alone, 1 (Table 1). There were 24 men and 22 women. The average age was 65 years, and the average weight was 74 kg. There were no statistically significant differences between groups A and B in age, sex, or weight (Table 2).
There was no statistically significant difference in the amount of morphine consumed by the two groups at 24 or 48 hours after posterolateral thoracotomy. Group A PCM consumption was 23.1 mg on postoperative day 1, and 19.4 mg on postoperative day 2. Group B PCM consumption was 26.2 mg on postoperative day 1 and 19.2 mg on postoperative day 2. Also there was no statistically significant difference in VAS scores between the bupivacaine and lidocaine groups. The average VAS score for group A was 4.5 on day 1 and 3.6 on day 2. The average VAS score for group B was 3.3 on day 1 and 2.4 on day 2 (Table 3). There were no complications noted in either group from catheter placement or infusion of bupivacaine or lidocaine.
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Comment
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The posterolateral thoracotomy incision can produce severe pain in the postoperative patient [18, 19]. This pain can prolong patient stay in the intensive care unit and the hospital, as well as increase morbidity and mortality by impairing pulmonary function. Effective postthoracotomy analgesia has been shown to improve patient outcome and decrease patient intensive care unit and hospital stays. Multiple prospective randomized controlled studies have shown that the use of an indwelling extrapleural catheter for continuous infusion of regional anesthesia is an effective way of decreasing postoperative pain and decreasing narcotic requirements [5, 10–15, 20]. Many of these studies have used bupivacaine as the analgesic of choice. Although there have been no serious complications reported in the literature to date, bupivacaine is known to have more serious side effects than lidocaine (Table 4). Accidental intravascular administration of bupivacaine has been associated with severe myocardial suppression and prolonged asystole. Because of its long half-life, bupivacaine is slowly cleared when toxic serum levels do occur, even after cessation of the medication. Lidocaine must be present at much higher plasma concentrations than effective levels for pain control before toxicity is seen, and it is more rapidly cleared once the medication is discontinued. Because of this, when using a continuous infusion catheter, lidocaine should be a safer, more logical choice for intercostal nerve block. There have been studies indicating that lidocaine is preferred with extrapleural catheters for these reasons [20]. However, to date we have found no studies comparing the efficacy of lidocaine and bupivacaine.
This study has demonstrated that lidocaine offers equivalent pain control to bupivacaine when administered for continuous extrapleural intercostal nerve blockade after thoracotomy, with less risk of systemic toxicity.
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Abstract
Introduction
