Small dose of naloxone as an adjuvant to bupivacaine in intrapleural infiltration after thoracotomy surgery: a prospective, controlled study

BACKGROUND: Severe pain always develops after thoracotomy; intrapleural regional analgesia is used as a simple, safe technique to control it. This study was performed to evaluate whether a small dose of naloxone with local anesthetics prolongs sensory blockade. METHODS: A prospective, randomized double-blinded controlled study was conducted on 60 patients of American Society of Anesthesiologists statuses I and II, aged 18 to 60 years, scheduled for unilateral thoracotomy surgery. After surgery, patients were randomly divided into two groups: through the intrapleural catheter, group B received 30 ml of 0.5% bupivacaine, while group N received 30 ml of 0.5% bupivacaine with 100 ng of naloxone. Postoperative pain was assessed using the visual analog pain scale (VAS). Time for the first request for rescue analgesia, total amount consumed, and incidence of postoperative complications were also recorded. RESULTS: The VAS score significantly decreased in group N, at 6 h and 8 h after operation (P < 0.001 for both). At 12 h after injection, the VAS score increased significantly in group N (P < 0.001). The time for the first request of rescue analgesia was significantly longer in group N compared to group B (P < 0.001). The total amount of morphine consumed was significantly lower in group N than in the bupivacaine group (P < 0.001). CONCLUSIONS: Addition of a small dose of naloxone to bupivacaine in intrapleural regional analgesia significantly prolonged pain relief after thoracotomy and delayed the first request for rescue analgesia, without significant adverse effects.

Post-thoracotomy pain relief with subpleural analgesia or thoracic epidural analgesia: randomized clinical trial / Alívio da dor pós-toracotomia com analgesia subpleural ou analgesia epidural torácica: ensaio clínico randomizado

ABSTRACT CONTEXT AND OBJECTIVE: Post-thoracotomy pain is a severe and intense pain caused by trauma to ribs, muscles and peripheral nerves. The current study aimed to compare subpleural analgesia (SPA) with thoracic epidural analgesia (TEA) in patients undergoing thoracotomy. DESIGN AND SETTING: Randomized study at Ankara Numune Education and Research Hospital, in Turkey. METHODS: Thirty patients presenting American Society of Anesthesiologists physical status I-III were scheduled for elective diagnostic thoracotomy. The patients were randomized to receive either patient-controlled SPA or patient-controlled TEA for post-thoracotomy pain control over a 24-hour period. The two groups received a mixture of 3 µg/ml fentanyl along with 0.05% bupivacaine solution through a patient-controlled analgesia pump. Rescue analgesia was administered intravenously, consisting of 100 mg tramadol in both groups. A visual analogue scale was used to assess pain at rest and during coughing over the course of 24 hours postoperatively. RESULTS: In the SPA group, all the patients required rescue analgesia, and five patients (33%) required rescue analgesia in the TEA group (P < 0.05). Patients who received subpleural analgesia exhibited higher visual analogue scores at rest and on coughing than patients who received thoracic epidural analgesia. None of the patients had any side-effects postoperatively, such as hypotension or respiratory depression. CONCLUSION: Thoracic epidural analgesia is superior to subpleural analgesia for relieving post-thoracotomy pain. We suggest that studies on effective drug dosages for providing subpleural analgesia are necessary.

RESUMO CONTEXTO E OBJETIVO: Dor pós-toracotomia é severa e intensa, causada por trauma de nervos periféricos, músculos e costelas. O objetivo foi comparar analgesia subpleural (SPA) com analgesia epidural torácica (TEA) em pacientes submetidos à toracotomia. TIPO DE ESTUDO E LOCAL: Estudo randomizado no Hospital Educação e Pesquisa de Numune, em Ancara, Turquia. MÉTODOS: Trinta pacientes com o estado físico I-III da Sociedade Americana de Anestesiologistas foram agendados para toracotomia diagnóstica eletiva e escolhidos aleatoriamente para receber, num período de 24 horas, SPA ou TEA, ambas controladas pelo próprio paciente, para controle da dor pós-toracotomia. Os dois grupos receberam mistura de 3 ug/ml de fentanil com solução de 0,05% de bupivacaína por meio de bomba de analgesia controlada pelo paciente. Foi administrada analgesia de resgate por via intravenosa, com 100 mg de tramadol, nos dois grupos. No pós-operatório, a escala visual analógica foi utilizada para medir presença de dor durante a tosse ou em repouso, ao longo de 24 horas. RESULTADOS: No grupo SPA, todos os pacientes necessitaram de analgesia de resgate. Cinco pacientes (33%) necessitaram de analgesia de resgate no grupo TEA (P < 0,05). Os pacientes com SPA exibiram pontuações superiores na escala visual analógica, em repouso e ao tossir, em comparação aos que receberam TEA. Nenhum dos pacientes teve quaisquer efeitos secundários no pós-operatório, como hipotensão ou depressão respiratória. CONCLUSÃO: A analgesia peridural torácica é superior à analgesia subpleural no alívio da dor pós-toracotomia. Consideramos que estudos sobre a dosagem de drogas eficazes para proporcionar analgesia subpleural são necessários.

Intrapleural analgesia after endoscopic thoracic sympathectomy / Analgesia intrapleural após simpatectomia videotoracoscópica

PURPOSE: To compare analgesia traditionally used for thoracic sympathectomy to intrapleural ropivacaine injection in two different doses. METHODS: Twenty-four patients were divided into three similar groups, and all of them received intravenous dipyrone. Group A received intravenous tramadol and intrapleural injection of saline solution. Group B received intrapleural injection of 0.33 percent ropivacaine, and Group C 0.5 percent ropivacaine. The following aspects were analyzed: inspiratory capacity, respiratory rate and pain. Pain was evaluated in the immediate postoperative period by means of the visual analog scale and over a one-week period. RESULTS: In Groups A and B, reduced inspiratory capacity was observed in the postoperative period. In the first postoperative 12 hours, only 12.5 percent of the patients in Groups B and C showed intense pain as compared to 25 percent in Group A. In the subsequent week, only one patient in Group A showed mild pain while the remainder reported intense pain. In Group B, half of the patients showed intense pain, and in Group C, only one presented intense pain. CONCLUSION: Intrapleural analgesia with ropivacaine resulted in less pain in the late postoperative period with better analgesic outcomes in higher doses, providing a better ventilatory pattern.

OBJETIVO: Comparar a analgesia tradicionalmente utilizada para simpatectomia videotoracoscópica à injeção intrapleural de ropivacaína em duas doses diferentes. MÉTODOS: Vinte e quatro pacientes foram distribuídos em três grupos semelhantes, e todos eles receberam dipirona endovenosa. O grupo A recebeu tramadol endovenoso e injeção intrapleural de solução salina. O grupo B recebeu injeção intrapleural de ropivacaína a 0,33 por cento, e Grupo C ropivacaína a 0,5 por cento. Os aspectos analisados foram: capacidade inspiratória, freqüência respiratória e dor. A dor foi avaliada no período pós-operatório por meio da escala visual analógica e durante o período de uma semana. RESULTADOS: Nos grupos A e B, a redução da capacidade inspiratória foi observada no período pós-operatório. Nas primeiras 12 horas de pós-operatório, apenas 12,5 por cento dos pacientes nos grupos B e C apresentaram dor intensa em comparação a 25 por cento no Grupo A. Na semana seguinte, apenas um paciente do grupo A apresentou dor leve, enquanto o restante relatou dor intensa. No Grupo B, metade dos pacientes apresentou dor intensa, e no Grupo C, apenas um apresentou intensa dor. CONCLUSÃO: A analgesia intrapleural com ropivacaína resultou em menos dor no pós-operatório tardio com os melhores resultados analgésicos nas doses mais altas, proporcionando um melhor padrão ventilatório.

Comparison of the role of intrapleural bupivacaine injection with intravenous morphine in the management of post-operative pain after open cholecystectomy

Post-operative pain after open cholecystectomy can result in increased oxygen consumption, increased risk of myocardial ischemia, atelectasis, pneumonia, decreased vital capacity, and increased morbidity and mortality. In this study we compared the analgesic effects of intrapleural bupivacaine with intravenous morphine post-operatively. Sixty patients who were candidates for elective open cholecystectomy were randomly divided into two groups based on randomized numbers for a double-blinded randomized clinical trial. Anesthesia technique was precisely the same for all patients. At the end of surgery, 20 cc of 0.5% bupivacaine and epinephrine with a concentration of 1/200, 000 was injected intrapleurally for group B patients; whereas, 0.1 mg/kg intravenous morphine and 20cc normal saline was injected intrapleurally for group M cases. In order to obtain a visual analog scale[VAS] <3, morphine consumption up to 12 hours post-op was 10.5 +/- 3.2 mg in group M which was much more than that of group B, in which this amount was 4.3 +/- 1.5 mg. This difference was statistically significant [P<0.05]. The mean frequency of morphine injection was 3.7 +/- 1.3 times in group M and 1.2 +/- 0.7 times in group B and the difference in this regard was statistically significant. The patients' first demand for morphine was 1.8 +/- 0.6 and 4.2 +/- 0.3 hours postoperatively for groups M and B respectively. The difference in this regard was statistically significant [P<0.05]. In this study we realized that a single shot of intrapleural bupivacaine can provide an almost favorable analgesia for the management of post-operative pain due to open cholecystectomy compared to other current analgesic methods. It may reduce the related complications as well. We observed no complication due to the single shot of intrapleural bupivacaine

Pain relief following thoracoscopic sympathectomy for palmar hyperhidrosis: a prospective randomised double-blind study

Acute pain management following thoracoscopic sympathectomy [TS] has been described in the literature. The combination of interpleural [IP] injection of bupivacaine and intramuscular injection. [I.M] NSAIDs has not been reported. Therefore we conducted this randomized controlled trial to compare this technique to other reported techniques described for postoperative analgesia following TS. 40 patients scheduled to have TS under general anesthesia for the treatment of hyperhidrosis were randomly allocated into 4 groups. Group 1 received 1.5 mg/kg b.w I.M pethidine at end of surgery. Group 2 received ketoprofen 100 mg I.M at end of surgery. Group 3 received 0.4 ml/kg b.w interpleural bupivacaine 0.5%. Group 4 received a combination of I.M ketoprofen [100 mg] in addition to interpleural bupivacaine [0.4 ml/kg]. Postoperative pain was assessed using the 11 point numeric rating score [NRS] at 7 different intervals. First, immediately on admission to PACU, every 2 hours for the next 8 hours then at 12 and at 24 hours. Pain was assessed at rest, during deep inspiration and while coughing. ANOVA was used for statistical analysis and Chi-square test for comparing of the data where P values <0.05 were considered significant. The NRS at rest was 3.2 [1.9], 2.4 [1.6], 3 [1.9] and 0.7 [0.9] at Groups 1, 2, 3 and 4 respectively with significant difference in Group 4 versus other Group [P<0.05] at 2 hours postoperatively and up to 24 hours postoperatively. The same trend was also found during maximal inspiration and while coughing. Opioid consumption in 24 hours was significantly reduced in Group 4 compared to other Groups. Combination of IP bupivacaine and I.M ketoprofen provided superior analgesia when compared to each modality alone and was better than intramuscular pethidine injection in terms of NRS and the consumption of rescue morphine postoperatively. Further studies are needed on large sample size to confirm our results

Three modalitis of postoperative pain management for transthoracic endoscopic sympathectomy

Transthoracic endoscopic sympathectomy [TES] has been already a standard method for the treatment of primary hyperhydrosis. Postoperative pain is a problem that usually encountered during TES. Although the surgical procedure is simple and short, the pain is usually severe [Failor and Capell, 2003]. This study was performed in 57 patients of both sex, aged 11-48 years old, divided randomly into three groups. All patients were premedicated with intravenous midazolam 0.02mg/kg. Anesthesia was induced with sleeping dose of thiopentone sodium, lug/kg fentanyl and atracurium 0.5mg/kg to facilitate endotracheal intubation. We evaluated the effect of three methods of management of postoperative pain. I [n=20] was treated by IV pethidine starting with 1mg/kg pethidine with top up doses of pethidine when needed. Group II [n=19] was treated by intrapleural plain bupivacaine 0.25% 1mg/kg. Group III [n=18] was treated by local infiltration of 0,5% plain bupivacaine 2 ml at both sides of cut ends of the sympathetic chain. In conclusion, we found that the systemic use of pethidine was least satisfactory and the intrapleural of injection bupivacaine was the best. However the time to discharge from hospital was the same for all groups

A Comparison of the Effect between Intravenous Fentanyl and Interpleural Bupivacaine Following Thoracoscopic Surgery / 대한마취과학회지

BACKGROUND: Epidural and intravenous administration of opioids had been commonly used for postoperative pain management in thoracoscopic surgery. Recently, interpleural analgesia was frequently used. The aim of this study was to compare the effect of an intravenous continuous infusion of fentanyl (F-IV) with interpleural bupivacaine (B-IP) using a continuous infusion system in the management of post-thoracoscopic pain. METHODS: An interpleural continuous infusion of bupivacaine (B-IP group: basal infusion 7(ng/kg/min) was compared with an intravenous continuous infusion of fentanyl (F-IV group: basal infusion 0.33ng/ kg/hr) in forty patients who had undergone elective thoracoscopic surgery. During the postoperative 48 hours, the visual analogue scale (VAS), Prince-Henry score (PHS), heart rate, respiratory rate and peripheral oxygen saturation were measured. RESULTS: The postoperative heart rate in both groups was significantly higher than the preoperative value (P < 0.05 1 h and 4 h after operation), but there were no differences in the respiratory rate and peripheral oxygen saturation between the two groups. There were significant improvement of the degree of pain in VAS and PHS after administration of the analgesic, but there was no significant differences in the two groups during 48 hours. The incidence of adverse effects such as nausea, vomiting, dizziness, urinary difficulty and respiratory depression was higher in the F-IV than the B-IP group. CONCLUSIONS: The interpleural continuous infusion of local anesthetics and intravenous continuous infusion of fentanyl provided effective analgesia in this study. The side effects were significantly lower in the interpleural continuous infusion of local anesthetics than intravenous continuous infusion of fentanyl. Therefore, interpleural continuous infusion of local anesthetics could be a useful alternative for postoperative analgesia after thoracoscopic surgery.

Analgesia por catéter interpleural en pacientes despues de toracotomía / Analgesia by catheter interpleural in patients after of thoracotomy

El dolor trás la cirugía toráxica plantea un reto al anestesiólogo ya que los movimientos toráxicos están limitados por el dolor.