Absence of an early pre-emptive effect after thoracic extradural bupivacaine in thoracic surgery

Abstract

We have determined if thoracic extradural block before surgical incision for thoracotomy produces pre-emptive analgesia. Using a double-blind, placebo-controlled, crossover design, 45 patients (ASA II-III) undergoing posterolateral thoracotomy for lung resection were randomized to one of three groups: group 1 received 0.5% bupivacaine and adrenaline 1/200,000 (B+E) 8 ml through a thoracic extradural catheter (tip T3-T5) 30 min before skin incision and saline 8 ml 15 min after skin incision; group 2 received saline 8 ml extradurally before incision and B+E 8 ml after incision; group 3 received saline 8 ml extradurally before and after incision. General anaesthesia was induced and maintained with propofol, alfentanil and atracurium. The alfentanil infusion was stopped before chest closure and fentanyl 50 micrograms in saline 10 ml was given extradurally. Patient-controlled extradural analgesia (PCEA) was commenced with 0.125% bupivacaine, adrenaline 1/400,000 and fentanyl 6 micrograms ml-1 (continuous rate of 2 ml h-1 and supplementary doses of 0.5 ml per 6 min). Visual analogue scale (VAS) scores (recorded at rest, on mobilization and after cough), verbal rating scale (VRS) (recorded at rest), number of successful PCEA demands and complications were measured during the first 48 h after operation. There was no significant difference between groups, either in PCEA requirements (P > 0.21) or in VAS scores (either at rest, during mobilization of the ipsilateral arm of surgery or after cough). No significant differences between groups were found in the VRS. Thoracic extradural block with bupivacaine did not produce an early preemptive effect after thoracotomy.

Pre- and intraoperative epidural ropivacaine have no early preemptive analgesic effect in major gynecological tumour surgery

“…[1][2][3][4] However, the results of the intraoperative use of TEA in combination with general anesthesia are still controversial with respect to a reduction of postoperative pain perception or postoperative analgesic consumption. [5][6][7][8][9][10] This can be explained in part by the variety of types and sites of surgery, 11 or by the presence or absence of pain before surgery. 12 In a recently published review Moiniche et al pointed out that preemptive continuous epidural treatment extending into the postoperative period might have an improved capacity to reduce nociceptive input and thereby central neuroplasticity caused not only by incision and ongoing surgery but also by postsurgical inflammation.…”

Effects of Preoperatively or Postoperatively Initiated Thoracic Epidural Analgesia in Patients Undergoing Elective Lung Surgery

“…Our da ta are not in ag re e ment with the stu di es reporting no ad van ta ge of the se drugs in com bi na ti on fol lo wing tho ra co tomy. 12,26 In the se stu di es that Oc hroch et al administered 6 ml of a mix tu re of 0.375% bu pi va ca i ne and 3 µg ml -1 of fen tanyl cit ra te fol lo wed by an in fu si on of the sa me mix tu re at a rate of 8 ml h -1 . 26 Drugs were admi nis te red in tra o pe ra ti vely thro ugh the epi du ral cat he ter.…”

“…10,11 Sin ce the va li dity and cli ni cal re le van ce of pre emp ti ve anal ge si a has be en qu es tio ned and sta ted that any ef fects of pre emp ti ve analge si a may not trans la te in to cli ni cally re le vant long term im pro ve ments in pa ti ent sa tis fac ti on or out co me, [12][13][14] the ob jec ti ve of the pre sent study was to eva lu a te the con tri bu ti on of pre o pe ra ti vely initi a ted TE A on tho ra cic epi du ral pa in re li ef af ter elec ti ve lung sur gery. Alt ho ugh it has be en sug gested that oxi da ti ve stress may oc cur fol lo wing pulmo nary re sec ti on, 15 chan ges in plas ma and bronc ho al ve o lar li pid pe ro xi da ti on and nit ric oxide (NO) le vels are not stu di ed in pa ti ents un der goning lung sur gery.…”

“…Du ring the first 48 h af ter the ope ra ti on, pa tients used the epi du ral PCA as des cri bed in the proto col and they we re qu es ti o ned abo ut the ir pa in at 1, 2,4,8,12,16,20,24,36 and 48 h at rest and coug hing by an ob ser ver blin ded to tre at ment gro ups using VAS and the re sults we re re cor ded. The to tal amo unt of anal ge sics the pa ti ent re ce i ved and the num ber of re qu ests for anal ge si a from the pump we re re cor ded.…”

Analgesia preemptiva

“…However, when administering 15 ml of epidural 0.5% bupivacaine in patients submitted to abdominal surgeries, Katz et al 54 observed that pain scores using McGill's questionnaire and morphine consumption were lower for the group medicated before surgical incision. Aguilar et al 55 administered 0.5% thoracic epidural bupivacaine with epinephrine in patients submitted to pulmonary resection without differences between groups receiving medication before or after incision as to analgesic consumption, VAS and verbal scale and the preemptive effect could not be demonstrated.…”