Toracostomía cerrada bajo sedación en el servicio de urgencias / Thoracostomy under sedation in the emergency service

El trauma es uno de los principales retos en cuanto a salud pública mundial se trata. Según la OMS, causa alrededor de cinco millones de muertes al año, siendo el trauma de tórax uno de los más frecuentes, reportándose hasta 90-96% de lesiones penetrantes con una mortalidad cercana al 30%. La toracotomía es un procedimiento frecuentemente realizado en el servicio de urgencias, pero es una técnica dolorosa e incómoda que puede generar dificultades a la hora de su realización. Se requiere encontrar la información disponible acerca de la seguridad en la intervención bajo sedación y determinar su utilidad en el servicio de urgencias, así como conocer los niveles de sedación para poder realizar las diferentes técnicas y evaluar según el procedimiento a realizar a qué nivel se debe llevar el paciente. La utilización de fármacos para analgesia y sedación en este servicio tiene por objetivo el control efectivo y seguro del dolor, control de la ansiedad, para evitar movimientos del paciente, buscando disminuir las posibles complicaciones. En esta revisión se estudian medicamentos como ketamina, propofol, morfina, hidromorfona, fentanilo, etomidato y midazolam, así como sus posibles combinaciones para implementarlos en el proceso de sedación en la toracostomía de urgencia. No hay una estrategia terapéutica aplicable a todos los pacientes por lo que cada una de ellas debe individualizarse..Au

Trauma constitutes one of the main challenges in terms of public health in the world. According to the WHO, it causes about five million deaths per year, chest trauma is one of the most frequently occurring injuries, reporting up to 90-96% of penetrating injuries with mortality close to 30%. Thoracostomy is a procedure frequently performed in the emergency department, however, it is a painful and uncomfortable procedure, and there could be difficulties while it is done. It is required to find the available information about how safe a thoracostomy is under sedation is and determine its usefulness in the emergency department; learning the levels of sedation, and depending of the procedure the patient needs, determine the level of sedation the patient has to induced into. The use of medications for analgesia and sedation in the emergency room is aimed to the effective and safe control of pain and anxiety as well as to avoid movements of the patient to reduce complications. This review considers medications such as ketamine, propofol, morphine, hydromorphone, fentanyl, etomidate, midazolam and the best combinations of these medications to carry out sedation for emergency thoracostomy. However, there is not a therapeutic strategy applicable to all patients, therefore each patient has to be analyzed individually..Au

Investigation of respiratory disorders in Thoroughbred racehorses training at the Brazilian Jockey Club / Investigação de doenças respiratórias em cavalos de corrida em treinamento no Jockey Club Brasileiro

ABSTRACT: Athletic horses need to maintain healthy airways for optimal performance. This study investigated the presence of respiratory problems in apparently healthy Thoroughbred racehorses in training. According to the Revised Consensus Statement on Inflammatory Airway Diseases of Horses (2016), determining the prevalence of respiratory disorders in different equine populations is fundamental for understanding these diseases. In total, 72 clinically sound Thoroughbred racehorses, in training at the Brazilian Jockey Club (JCB), were initially examined using interpleural pressure measurement by ventigraphy and respiratory endoscopy. When secretions were present in the airways, transendoscopic tracheal aspiration was performed, and the sample was sent for cytology. The main findings included a combination of bronchospasm and tracheal secretions with 61% of the cytology slides showing neutrophil counts ≥20%. Overall, a significant number of the horses displayed signs suggestive of inflammatory airway disease (mild equine asthma), including 47% with increased DPplmax, 11% with tracheal mucus accumulation [mucus score (MS) ≥2] and 18% with carina edema. This was more pronounced in 2-year-old horses within the population studied. These findings are consistent with the literature and reinforce the importance of routine respiratory examination of athletic horses. There is a high incidence of subclinical respiratory disorders in Thoroughbred racehorses in training at the JCB and a significant association between tracheal MS≥2, carina edema, and elevated DPplmax.

RESUMO: Cavalos atletas devem apresentar higidez das vias respiratórias para que obtenham bom desempenho esportivo. Este estudo buscou verificar a incidência de alterações respiratórias em cavalos da raça Puro Sangue Inglês (PSI) de corrida em treinamento, aparentemente sadios. De acordo com o Estatuto do Consenso de Doenças Inflamatórias das Vias Aéreas revisado em 2016, o levantamento das alterações respiratórias em diferentes populações de cavalos é fundamental para o entendimento dessas enfermidades. Nesse sentido, foram examinados 72 equinos PSI em treinamento no Jockey Club Brasileiro (JCB), por meio de mensuração da pressão interpleural através da ventigrafia e endoscopia respiratória. Quando presentes nas vias aéreas, foram coletadas secreções por aspirado traqueal transendoscópico para realização de citologia. Os achados prevalentes foram a combinação de broncoespasmo e secreções traqueais onde, em 61% das lâminas, houve contagem de neutrófilos ≥20%. De um modo geral, um percentual significativo de cavalos apresentou sinais sugestivos de Doença Inflamatória das Vias Aéreas (DIVA), incluindo 47% com elevação na DPplmax, 11% com aumento no muco traqueal (score de muco ≥2) e 18% de edema de carina. Dentro da população estudada, essas alterações foram mais pronunciadas em animais de 2 anos. Esses achados reforçam a importância da investigação respiratória rotineira nos cavalos atletas indo ao encontro do que foi descrito em outras publicações. As alterações respiratórias subclínicas têm alta incidência em cavalos PSI em treinamento no JCB e existe uma associação significativa entre o muco traqueal (score ≥2), edema de carina, e elevação na DPplmax.

The Association of Interpleural Ropivacaine and Epidural Following Major Thoracic Surgery: A Randomised Clinical Trial Investigating Pharmocokinetics and Benefits.

Background: Thoracic surgery is associated with high levels of postoperative pain. Interpleural blockades (IPB) can be effective in reducing this pain, but results after thoracotomy are controversial. The current study investigates the effects of the association of ropivacaine-based IPB and morphine epidurals after posterolateral thoracic surgery. Method: In this prospective, randomised, triple blind, placebo-controlled trial, patients received either intermittent ropivacaine IPB (R-group), (30 mg every 6 hours over 48 hours) or a placebo containing saline serum (P-group). The two groups had a morphine lumbar epidural. Pain was evaluated via patients’ reports and total morphine requirements. Results: 90 patients participated. There were no significant differences between levels of pain reported on mobilisation or morphine consumption between the two groups. For the principal criterion of VAS-A≥70 over the first 48 hours, this corresponds to a RR of 1.3(95%= 0.4-3.8). Patients in the R-group reported higher levels of pain at rest on day 2. The mean peak plasma concentrations of ropivacaine remained inferior to toxic plasma concentration levels. Conclusion: Postoperative interpleural infusions of 30 mg of ropivacaine every 6 hours in association with morphine epidurals are safe and feasible but do not improve postoperative experience of pain.

The Association of Interpleural Ropivacaine and Epidural Following Major Thoracic Surgery: A Randomised Clinical Trial Investigating Pharmocokinetics and Benefits.

Background: Thoracic surgery is associated with high levels of postoperative pain. Interpleural blockades (IPB) can be effective in reducing this pain, but results after thoracotomy are controversial. The current study investigates the effects of the association of ropivacaine-based IPB and morphine epidurals after posterolateral thoracic surgery. Method: In this prospective, randomised, triple blind, placebo-controlled trial, patients received either intermittent ropivacaine IPB (R-group), (30 mg every 6 hours over 48 hours) or a placebo containing saline serum (P-group). The two groups had a morphine lumbar epidural. Pain was evaluated via patients’ reports and total morphine requirements. Results: 90 patients participated. There were no significant differences between levels of pain reported on mobilisation or morphine consumption between the two groups. For the principal criterion of VAS-A≥70 over the first 48 hours, this corresponds to a RR of 1.3(95%= 0.4-3.8). Patients in the R-group reported higher levels of pain at rest on day 2. The mean peak plasma concentrations of ropivacaine remained inferior to toxic plasma concentration levels. Conclusion: Postoperative interpleural infusions of 30 mg of ropivacaine every 6 hours in association with morphine epidurals are safe and feasible but do not improve postoperative experience of pain.

Analgesia pós-operatória: comparação entre bloqueio interpleural e anestesia peridural / Postoperative Analgesia: comparing interpleural block and epidural anesthesia

Modelo: Pesquisa clínica, aleatorizada, prospectiva e duplo-encoberta. Objetivo: Essa pesquisa objetivou comparar a eficácia do bloqueio interpleural e da anestesia peridural, associados à anestesia geral, no controle da dor pós - operatória de cirurgias de abdome superior. Metodologia: Participaram da pesquisa 80 pacientes alocados em 8 grupos(G) (n=10), de ambos os gêneros, idade variando de 18 a 50 anos, peso entre 50 e 100 kg, estado físico ASA P1 e P2, submetidos à colecistectomia por via subcostal, sob bloqueios interpleural(I) ou peridural(P) associados à anestesia geral. Foram administradas: levobupivacaína (L) 0,5% (100 mg) com adrenalina (5 μg.mL-1) ou ropivacaína (R) 0,75% (150 mg), morfina (M) (3 mg) e clonidina (C) (3 μg.kg-1) ou dextrocetamina (K) (0,5 mg.kg-1), por via interpleural, ao nível EIC7, na linha axilar média, com agulha de Tuohy 17G; os mesmos fármacos foram injetados, por via peridural, ao nível T12-L1, com agulha de Tuohy 17G. A indução da anestesia geral foi realizada com a administração de etomidato (0,2 mg.kg-1), alfentanil (30 μg.kg-1) e rocurônio (0,6 mg.kg-1) e a manutenção com oxigênio e isoflurano (0,5vol% a 3,0vol%). A analgesia pós-operatória, analisada pela Escala Verbal Analógica de Dor, foi observada às 6h, 12h, 18h e 24h após o término do ato operatório...

Results: Until six hours after surgery, 14 patients undergoing interpleural block and 7 undergoing epidural anesthesia felt pain. From six to twelve hours, 32 patients undergoing interpleural block and 14 undergoing epidural anesthesia presented pain. Between twelve and eighteen hours, 34 patients undergoing interpleural block and 21 undergoing epidural anesthesia felt pain. From eighteen to twenty-four hours, 36 patients undergoing interpleural block and 25 undergoing epidural anesthesia presented pain. A statistically significant difference was observed comparing the techniques at the period between 6 -12h, 12-18h and 18-24h. Eight patients undergoing interpleural block and three undergoing epidural anesthesia required opioid...

Segurança e eficácia da analgesia interpleural com ropivacaína em simpatectomia torácica videoassistida / The safety and efficacy of the ropivacaine interpleural postoperative analgesia for video-assisted thoracic sympathectomy

Justificativa e objetivos – O bloqueio interpleural foi inicialmente utilizado para analgesia nas cirurgias do abdome superior, colecistectomias abertas, esofagectomias, fraturas costais múltiplas, dor crônica e pancreatites. Esta técnica não se demonstrou satisfatória para analgesia nas toracotomias para pneumonectomia e lobectomia, o que é justificado pela perda da solução anestésica pelo dreno torácico, com consequente má distribuição desta na cavidade pleural. Todavia, nos procedimentos minimamente invasivos, como a simpatectomia torácica videoassistida, se demonstrou satisfatória e duradoura com redução do consumo de opióide no período pós-operatório, nestes procedimentos o anestésico é administrado no espaço interpleural sem riscos de pneumotórax ou injeção intravascular do fármaco. Entretanto, não são encontradas publicações que atestem segurança ou eficácia desta técnica. O objetivo deste estudo foi avaliar a eficácia, as alterações hemodinâmicas e ventilatórias, bem como os riscos de intoxicação por anestésico local decorrentes da analgesia interpleural bilateral com ropivacaína em pacientes com hiper-hidrose palmoaxilar submetidos à simpatectomia torácica videoassistida. Métodos – Estudo duplo-cego, randomizado, incluindo 51 pacientes divididos em três grupos iguais: G1, G2 e G3 que receberam solução interpleural bilateral de solução fisiológica 20mL a 0,9%, de ropivacaína 20mL a 0,35% e de ropivacaína 20mL a 0,5%, respectivamente. Foram avaliados: PAS, PAD, PAM, FC, f, PaO2, PaCO2, SaO2, pH, PImáx, presença de náuseas e vômitos, concentração plasmática da ropivacaína, sinais e sintomas de intoxicação por anestésico local, escore de dor (ENV), localização e fatores desencadeantes da dor, necessidade de analgesia suplementar e satisfação dos pacientes...

Background and objectives – The interpleural block was first used for analgesia of upper abdominal surgeries, open cholecystectomy, esophagectomies, multiple rib fractures, chronic pain and pancreatitis. This technique has not proved satisfactory while used in thoracotomy for lobectomy and pneumonectomy which may be justified by the loss of the anesthetic thru the chest tube resulting in poor distribution of it in the pleural cavity. While applied in minimally invasive procedures, such as video-assisted thoracic sympathectomy, the technique has been proved satisfactory and long lasting with postoperatively reduced opioid consumption. In these kinds of procedures the anesthetic is administered in the interpleural space without the risk of pneumothorax and intravascular injection of the drug. However, there are no publications found attesting safety or effectiveness of this technique. The aim of this study was to evaluate the hemodynamic and ventilatory changes, as well as the risks of intoxication by local anesthetic, when bilateral interpleural analgesia with ropivacaine is performed for axillary sympathectomy thoracoscopy due palmar hyperhidrosis. Methods – It is a double-blind study with 51 patients randomized in three groups: G1 (saline), G2 (0.35% ropivacaine) and G3 (0.5% ropivacaine). Each group received bilateral interpleural injection of 20ml of the designed solution. Were evaluated the following parameters: PAS, PAD, PAM, FC, f, PaO2, PaCO2, SaO2, pH, PImáx, presence of nausea and vomiting, plasma concentrations of ropivacaine, signs and symptoms of intoxication by local anesthetic, pain score (VAS), location and triggering factors of pain, need of rescue analgesia and patient satisfaction towards the analgesia technique...

Analgesia em procedimentos cirúrgicos de abdômen superior com bloqueio interpleural / Analgesia in upper abdominal surgery with interpleural block

JUSTIFICATIVA E OBJETIVOS: Pesquisas empregando bloqueio interpleural com anestésico local, opioide e agonista Alfa2-adrenérgico ou bloqueador do receptor N-metil-D-aspartato (NMDA), observaram a ocorrência de analgesia pós-operatória em cirurgias de abdômen superior. O objetivo deste estudo foi observar a presença de dor no pós-operatório de cirurgias de colecistectomia por via subcostal.MÉTODO: Após aprovação pelo Comitê de Ética, participaram do experimento aleatório e prospectivo, 40 pacientes, de ambos os sexos, com idade variando de 18 a 50 anos, peso entre 50 e 100 kg, estado físico ASA I e II, submetidos à colecistectomia por via subcostal, sob anestesia geral associada ao bloqueio interpleural. Foram administradas levobupivacaína a 0,5% (100 mg) com adrenalina 1:200.000 (5 µg.mL-1) ou ropivacaína a 0,75% (150 mg), morfina (3 mg) e clonidina (3 µg.kg-1) ou cetamina (0,5 mg.kg-1), ao nível EIC7, na linha axilar média, com agulha de Tuohy 17G, por via interpleural. A indução da anestesia geral foi realizada com a injeção de etomidato (0,2 mg.kg-1), alfentanil (30 µg.kg-1) e rocurônio (0,6 mg.kg-1) e a manutenção com oxigênio e isoflurano (0,5 vol% a 3,0 vol%). A analgesia pós-operatória, analisada pela escala analógica visual (EAV), foi observada às 6h, 12h, 18h e 24h após o término do ato operatório.RESULTADOS: Apresentaram dor pós-operatória: grupo RMC (ropivacaína, morfina e clonidina), um até 6h, seis entre 6 e 12h e um entre 18 e 24h; grupo RMK (ropivacaína, morfina e cetamina), quatro até 6h, quatro entre 6 e 12h, um entre 12 e 18h e um entre 18 e 24h; grupo LMC (levobupivacaína, morfina e clonidina), quatro até 6h e quatro entre 6 e 12h; grupo LMK (levobupivacaína, morfina e cetamina, cinco até 6h, quatro entre 6 e 12h e um entre 12 e 18h. Aplicando o teste Exato de Fisher observou-se diferença estatística significante entre o tempo de observação até 6h e os demais no grupo RMC; entre o tempo de observação até 6h e os 12-18h e 18-24h nos grupos RMK e LMK. Não ocorreram complicações relacionadas ao bloqueio interpleural.CONCLUSÃO: A necessidade de associar opioide ao analgésico comum para abolir a dor, em cirurgias de colecistectomia por via subcostal, ocorreu em número reduzido de pacientes.

BACKGROUND AND OBJECTIVES: Researches using interpleural block with local anesthetics, opioid and alpha2-adrenergic agonist or N-Methyl-D-aspartate (NMDA) receptor blocker have shown the presence of postoperative analgesia in upper abdominal surgeries. This study aimed at observing the presence of pain in the postoperative period of subcostal cholecystectomies. METHOD: After The Ethics Committee approval, participated in this randomized, prospective study 40 patients of both genders, aged 18 to 50 years, weighing between 50 and 100 kg, physical status ASA I and II, submitted to subcostal cholecystectomy under general anesthesia associated to interpleural block. The following drugs were administered: 0.5% levobupivacaine (100 mg) with 1:200.000 epinephrine (5 µg.mL-1) or 0.75% ropivacaine (150 mg), morphine (3 mg) and clonidine (3 µg.kg-1) or ketamine (0,5 mg.kg-1), at EIC7, in the medium axillary line with 17G Tuohy needle by interpleural route. General anesthesia was induced with etomidate (0.2 mg.kg-1), alfentanil (30 µg.kg-1) and rocuronium (0.6 mg.kg-1) and was maintained with oxygen and isoflurane (0.5 vol% at 3.0 vol%). Postoperative analgesia, evaluated by the visual analog scale (VAS), was observed at 6h, 12h, 18h and 24h after surgery completion.RESULTS: Postoperative pain was observed: one patient up to 6h, six between 6 and 12h and one between 18 and 24h in the RMC group (ropivacaine, morphine and clonidine); four patients up to 6h, four between 6 and 12h, one between 12 and 18h and one between 18 and 24h in the RMK group (ropivacaine, morphine and ketamine); four patients up to 6h, and four between 6 and 12h in the LMC group (levobupivacaine, morphine and clonidine); five patients up to 6h, four between 6 and 12h, and one between 12 and 18h in the LMK group (levobupivacaine, morphine and ketamine). Fisher's Exact test has shown statistically significant difference between 6h observation time and the others in the RMC group; between 6h observation time and 12-18h and 18-24h in RMK and LMK groups. There were no interpleural block-related complications.CONCLUSION: Only a small number of patients needed the association of opioid to normal analgesics to abolish pain in subcostal cholecystectomy surgeries.

Comparison of the Efficacy of Interpleural Block and Paravertebral Block after Video-assisted Endoscopic Thoracic Sympathectomy / 대한마취과학회지

BACKGROUND: Video-assisted thoracic surgery (VATS) is widely used as a less invasive procedure for thoracic surgery. However, there is still significant postoperative pain, although less severe than with conventional thoracic surgery. The aim of this study was to assess the efficacy of an interpleural block and a paravertebral block for postoperative pain control and the recovery of the pulmonary function. METHODS: Fifty-one patients with similar demographic and preoperative physiologic parameters were divided randomly into interpleural or thoracic paravertebral block groups. The visual analogue pain score (VAS) was assessed at 30 min, and 2, 6, 12, and 24 hours after surgery and the forced vital capacity was tested preoperatively, the pulmonary function was evaluated at 30 min, and 2, 6, 12, and 24 hours. RESULTS: The pain scores were significantly lower in the paravertebral block group at 30 min, 2, 6 and 12 hours after surgery during rest (6.4 +/- 1.8, 5.1 +/- 1.1, 4.2 +/- 1.5, 2.8 +/- 0.8 vs 2.9 +/- 1.8, 2.5 +/- 1.6, 2.1 +/- 1.6, 1.9 +/- 1.7, P < 0.05), and only within 2 hours after operation for coughing (7.8 +/- 1.0, 6.4 +/- 0.8 vs 4.7 +/- 2.2, 4.2 +/- 2.1, P < 0.05) than in the interpleural block group. There was significant recovery of the pulmonary function 30 min, 2, and 6 hours after surgery (32%, 43%, 56%, 67%, 75% vs 59%, 59%, 71%, 75%, 84%, P < 0.05) in the paravertebral block group. CONCLUSIONS: A thoracic paravertebral block is more effective in decreasing the level of post-VATS pain, and allows earlier recovery of the forced vital capacity compared with an interpleural block.

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.

Comparison of Interpleural Block and Paravertebral Block with Bupivacaine for Pain Relief after Cholecystectomy / 대한마취과학회지

The adverse effects of pain in post-surgery or trauma patients are well documented. A reliable, safe approach to achieving unilateral analgesia in multiple contiguous thoracic dermatomes would be of great benefit to anesthesiologists in acute pain setting following thoracic or upper abdominal surgery. The aim of this study of post-cholecystectomy pain was to compare two methods of postoperative analgesia with interpleural block and paravertebral block with bupivacaine. Thirty otherwise healthy patients who had undergone elective cholecystectomy through a subcostal incision were randomly allocated to two groups of fifteen patients each and given either interpleural block(group 1) or paravertebral block(group 2) with 20 ml 0.5% bupivacaine mixed with 1:200,000 epinephrine through a single catheter. The degree of analgesia was assessed by a verbal rating scale, Prince Henry pain score and a visual analogue scale(VAS 1-10 cm ; O=no pain, 10=worst pain). These pain scores and vital signs were assessed just before and 10, 20, 30, 60 and 120 minutes after injection of bupivacaine. The onset time of analgesia was similar in both groups(6.6+/-3.74 minutes in group 1 and 5.5+/-2.88 minutes in group 2), but the duration of analgesia was significantly longer in group 1(6.5+/-1.92 hours) than group 2(4.5+/-2.17 hours)(p<0.05). In both groups Prince Henry pain scores significantly decreased 10 minutes after injection of bupivacaine and VAS also significantly decreased 10 and 20 minutes after injection(p<0.05), but there was no significant difference between two groups. The systolic blood pressure decreased 10 minutes after the injection of bupivacaine in both groups(Group 1-3.7%, Group 2-6.5%) and the diastolic blood pressure decreased 10 minutes after the injection of bupivacaine only in group 1(2.5%), (p<0.05), however, these changes in arterial blood pressure were of minimal clinical significance. There is no complication in group 1, but 2 out of 15 patients in group 2 showed bilateral blockade without any serious hemodynamic derangement clinically. In conclusion, both techniques showed similarity in the onset and the degree of analgesia except the duration of analgesia, and presented only a few minor complications. Therefore, we feel that paravertebral block can be used in case that coexisting pulmonary or pleural pathology limits the use of interpleural block for post-cholecystectomy pain management. Furthermore, either of the two techniques may be used alternatively in management of thoracic or upper abdominal pain according to technical skill and preference of anesthesiologists.

Analgesic Effect of Interpleural Block with 0.25 % and 0.375 % Bupivacaine Hydrochloride after Thoracotomy / 대한마취과학회지

Postoperative pain may be associated with shallow breathing, inability to cough, and reduction in spirometric values which lead to restrictive pattern of ventiltion with hypoxemia and/or hypercapnea. Therfore postoperative pain should be maneged by using appropriate methods. To investigate the analgesic effect of interpleural block with 0.25% or 0.375% bupivacaine hydrochloride, 30 patients were randomly divided into one of three groups(saline group, 0.25% bupivacaine group and 0.375% bupivacaine group). In the saline group, 0.9% saline with 1: 200, 000 epinephrine(0.5 ml/kg) was injected into the pleural cavity via the chest drainage tube, either 0.25% or 0.375% bupivacaine with 1: 200,000 epinephrine(0.5 ml/kg) was injected with the same manner of the saline group in the bupivacaine groups, respectively. Respiratory parameters(minute volume, tidal volume, respiratory rate, forced vital capacity, incentive spirometric volume, cough score, deep inspiratory score), numeric pain rating score and hemodynamic changes were measured before anesthetic induction, 10 minutes before the study drug injection, 30 and 60 minutes after the study drug administration, respectively. Postoperative respiratory parameters were decreased at l0 minutes before the drug injection compared to the preanesthetic values in all groups. There were no statistically significant differences of all parameters after the drug administration among three groups. There was a tendency of improvement in the respiratory parameters after the drug injection in saline and 0.25 % bupivacaine groups and a greater tendency of improvement of respiratory parameters and numeric pain rating score in 0.375% bupivacaine group than the other groups. Only one case of tachycardia was developed in the saline group. These results suggest that the postoperative pain after thoracotomy is not appropriately manged by using the interpleural block with 0.25% or 0.375% bupivacaine hydrochloride (0.5 ml/kg) administrated via the drainage tube of the chest.