Comparison of different methods of postoperative analgesia after thoracotomy

Abstract

Fifty-one patients scheduled for thoracotomy were included in a study involving five different methods of postoperative analgesia. Forty patients were randomly divided into: Group C, receiving intramuscular oxycodone on request following an intraoperative intercostal block; Group IC, intercostal blocks with 0.5% bupivacaine performed prior to surgery, 6 h later and on the first postoperative morning: Group EB, epidural bupivacaine as a continuous infusion of 0.25% bupivacaine (5 ml h-1); Group EM4 epidural morphine 4 mg injected prior to surgery and on the first postoperative morning. In addition, a fifth group (Group EM6) of 11 patients received 6 mg of epidural morphine timed as in Group EM4, but these patients were automatically scheduled to be observed in the ICU. Additional intramuscular oxycodone was given on request to all patients. Group EB, EM4 and EM6 had lower numbers of requests than Group C. Pain intensity score was lowest (2.5 on a scale from 0 to 10, 3 h postoperatively) in Group EM6, and there was a statistically significant difference in pain intensity at 3 h between EM4 and EM6. The evaluation of cooperation and pain by the physical therapist revealed no differences between the groups. Postoperative blood-gas analyses contained slightly elevated PCO2 values (6.0-7.3 kPa) in all groups. Postoperatively, only Group EB was devoid of PCO2 values above 7.3 kPa. Urinary retention was a common complication in the patients receiving epidural analgesia, occurring most frequently in Group EM6; 10 of the 11 patients had to be catheterized.

Extradural, paravertebral and intercostal nerve blocks for post-thoracotomy pain

“…Intrathoracic intercostal nerve blocks have been advocated as a reliable method for immediate postoperative pain relief because they are easy to perform during operation [6]. Asantila, Rosenberg and Scheinin [7] compared five methods for postthoracotomy pain treatment. In their study continuous extradural local anaesthetic block seemed to be somewhat better than single intrathoracic intercostal block, but the difference was not statistically significant.…”

“…However, these techniques have not been compared in many randomized, controlled studies after thoracotomy [5]. Intercostal nerve blocks have been described, but repeated blocks may be needed [6,7]. High plasma concentrations of local anaesthetics have been reported after both repeated intercostal nerve blocks and during continuous infusions [8,9].…”

A Comparative Study to Evaluate the Efficacy of Butorphanol as an Adjuvant to Epidural Analgesia for Rib Fractures

“…Epidural analgesia using local anesthetic agents has been proven to be better than systemic opioid analgesics in providing thoracotomy pain management. [11][12][13] Though systematic review and a meta-analysis of randomized controlled trials of epidural analgesia in adult patients with traumatic RFs found no significant benefit on mortality, ICU, and hospital length of stay compared with other analgesic modalities, 14 improved pain management using epidural analgesia in patients with RFs was associated with improved vital capacity and improved inspiratory and expiratory flow rates and better outcome. 9,10 Epidural analgesia increases the patients' compliance and cooperation for pulmonary toileting, thereby improving pulmonary functions and decreasing pulmonary complication.…”

Postoperative pain management

“…By this way, spinal nerves from T1 through T 11 can be blocked effectively decreasing VAS pain scores significantly. Local anesthetics can be infused as a single dose just before closure of the thoracotomy (11,(33)(34)(35)(36), as a single (37) or multiple (38) percutaneous injections or via an indwelling intercostal catheter (39)(40)(41). Intercostal blockade can reduce opioid requirements, however, cannot eliminate them.…”