Post-thoracotomy pain relief with subpleural analgesia or thoracic epidural analgesia
randomized clinical trial
Keywords:
Pain, postoperative, Analgesia, epidural, Pleura, Thoracotomy, Analgesia, patient-controlledAbstract
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 patientcontrolled 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 patientcontrolled 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 postthoracotomy pain. We suggest that studies on effective drug dosages for providing subpleural analgesia are necessary.
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References
Gulbahar G, Kocer B, Muratli SN, et al. A comparison of epidural and paravertebral catheterisation techniques in post-thoracotomy pain management. Eur J Cardiothorac Surg. 2010;37(2):467-72.
Behera BK, Puri GD, Ghai B. Patient-controlled epidural analgesia with fentanyl and bupivacaine provides better analgesia than intravenous morphine patient-controlled analgesia for early thoracotomy pain. J Postgrad Med. 2008;54(2):86-90.
Sentürk M, Ozcan PE, Talu GK, et al. The effects of three different analgesia techniques on long-term postthoracotomy pain. Anesth Analg. 2002;94(1):11-5.
Kanazi GE, Ayoub CM, Aouad M, et al. Subpleural block is less effective than thoracic epidural analgesia for post-thoracotomy pain: a randomised controlled study. Eur J Anaesthesiol. 2012;29(4):186-91.
Joshi GP, Bonnet F, Shah R, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg. 2008;107(3):1026-40.
Bachmann-Mennenga B, Biscoping J, Kuhn DF, et al. Intercostal nerve block, interpleural analgesia, thoracic epidural block or systemic opioid application for pain relief after thoracotomy? Eur J Cardiothorac Surg. 1993;7(1):12-8.
Helms O, Mariano J, Hentz JG, et al. Intra-operative paravertebral block for postoperative analgesia in thoracotomy patients: a randomized, double-blind, placebo-controlled study. Eur J Cardiothorac Surg. 2011;40(4):902-6.
Richardson J, Lönnqvist PA, Naja Z. Bilateral thoracic paravertebral block: potential and practice. Br J Anaesth. 2011;106(2):164-71.
Karmakar MK. Thoracic paravertebral block. Anesthesiology. 2001;95(3):771-80.
McKenzie AG, Mathe S. Interpleural local anaesthesia: anatomical basis for mechanism of action. Br J Anaesth. 1996;76(2):297-9.
Macias A, Monedero P, Adame M, et al. A randomized, double-blinded comparison of thoracic epidural ropivacaine, ropivacaine/fentanyl, or bupivacaine/fentanyl for postthoracotomy analgesia. Anesth Analg. 2002;95(5):1344-50.
Concha M, Dagnino J, Cariaga M, et al. Analgesia after thoracotomy: epidural fentanyl/bupivacaine compared with intercostal nerve block plus intravenous morphine. J Cardiothorac Vasc Anesth. 2004;18(3):322-6.
Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2014;18(5):626-35.
Ginosar Y, Riley ET, Angst MS. The site of action of epidural fentanyl in humans: the difference between infusion and bolus administration. Anesth Analg. 2003;97(5):1428-38.
Kanai A, Osawa S, Suzuki A, et al. Regression of sensory and motor blockade, and analgesia during continuous epidural infusion of ropivacaine and fentanyl in comparison with other local anesthetics. Pain Med. 2007;8(7):546-53.
