Abstract
This study examined the beneficial effects and potential systemic toxicity from continuous intercostal nerve block by repeated bolus injections of bupivacaine. In this double-blind, randomized study, 20 post-thoracotomy patients were assigned to receive four doses of either: 20 ml 0.5% bupivacaine with epinephrine 5 μg · ml−1 (bupivacaine group, n = 10), or 20 ml preservative-free saline (placebo group, n = 10) through two indwelling intercostal catheters every six hours. Patients receiving intercostal bupivacaine injections had greater decreases in visual analogue pain scores (VAS) (P < 0.05) and lower 24 hr morphine requirements, 16.6 ±4.6 mg vs 35.8 ±7.2 mg, than patients in the placebo group (P < 0.05). Higher post-injection values of forced expiratory volume in one second, forced vital capacity and peaked expiratory flow rate were also observed in the bupivacaine group (P < 0.01). Repeated intercostal bupivacaine administration did lead to systemic accumulation, but the peak bupivacaine level after 400 mg was low at 1.2 ±0.2 μg · ml−1. Thus, the technique of continuous intercostal nerve block described in this study is an effective treatment for the control of post-thoracotomy pain.
Résumé
Cette étude examine les effets bénéfiques et la toxicité systémique potentielle d’un bloc nerveux intercostal continu par des injections répétées de bupivacaïne. Dans cette étude randomisée chaque six heures à double insu, 20 patients posl-thoracotomie ont été divisés afin de recevoir quatre doses de soit: 20 ml 0,5% de bupivacaïne avec épinéphrine 5 μg · ml−1 (groupe bupivacaïne, n = 10), ou 20 ml de soluté physiologique sans préservatif (groupe placébo, n = 10) via un cathéter intercostal chaque six heures. Les patients recevant des injections de bupivacaïne intercostal ont démontré une plus grande diminution dans le test du «Visual analogue pain scores (VAS) (P < 0.05)» et ont requis en 24 heures moins de morphine, 16,6 ±4,6 mg vs 35,8 ±7,2 mg que les patients du groupe placebo (P < 0.05). Les valeurs post-injection plus élevées étaient notées dans le FEV1, la capacité vitale forcée et le flot expiratoire maximal pour le groupe bupivacaïne (P < 0.01). L’administration répétée de bupivacaïne intercostale a amené une accumulation systémique mais le niveau maximal de bupivacaïne après 400 mg était bas à 1,2 ±0,2 μg · ml−1. Ainsi, la technique du bloc nerveux intercostal continu décrite dans cette étude fut un moyen thérapeutique efficace pour le contrôle de la douleur post-thoracotomie.
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References
Moore DC, Bridenbaugh LD. Intercostal nerve block in 4333 patients: indications, technique, and complications. Anesth Analg 1962; 41: 1–11.
Bridenbaugh PO, DuPen SL, Moore DC et al. Postoperative intercostal nerve block analgesia versus narcotic analgesia. Anesth Analg 1973; 52: 81–5.
O’Kelly E, Garry B. Continuous pain relief for multiple fractured ribs. Br J Anaesth 1981; 53: 989–91.
Murphy DF. Continuous intercostal nerve blockade for pain relief following cholecystectomy. Br J Anaesth 1983; 55: 521–4.
Baxter AD, Jennings FO, Harris RS, Flynn JF, Way J. Continuous intercostal blockade after cardiac surgery. Br Anaesth 1987; 59: 162–6.
Murphy DF. Intercostal nerve blockade for fractured ribs and postoperative analgesia: description of a new technique. Regional Anesthesia 1983; 8: 151–3.
Mowbray A, Wong KKS, Murray JM. Intercostal catheterisauon: an alternative approach to the paravertebral space. Anaesthesia 1987; 42: 958–61.
Tucker GT. Determination of bupivacaine (marcaine) and other anilide-type local anesthetics in human blood and plasma by gas chromatography. Anesthesiology 1970; 32: 255–60.
Cousins MJ, Bridenbaugh PO. Neural blockade in clinical anesthesia and management of pain. Philadelphia: Lippincott, 1988; 122.
Moore DC. Intercostal nerve block: spread of india ink injected to the rib’s costal groove. Br J Anaesth 1981; 53: 325–9.
Murphy DF. Continuous intercostal nerve blockade: an anatomical study to elucidate its mode of action. Br J Anaesth 1984; 56: 627–9.
Middaugh RE, Menk EJ, Reynolds WJ, Bauman JM, Cawthon MA, Hartshorne MF. Epidural block using large volumes of local anesthetic solution for intercostal nerve block. Anesthesiology 1985; 63: 214–6.
Crossley AWA, Hosie HE. Radiographic study of intercostal nerve blockade in healthy volunteers. Br J Anaesth 1987; 59: 149–54.
Sabanathan S, Bickford Smith PJ, Pradhan GN, Hashimi H, Eng JB, Mearns AJ. Continuous intercostal nerve block for pain relief after thoracotomy. Ann Thorac Surg 1988; 46: 425–6.
Olivet RT, Nauss LA, Payne WS. A technique for continuous intercostal nerve block analgesia following thoracotomy. Thorac Cardiovasc Surg 1980; 80: 308–11.
Safran D, Kuhlman G, Orhant EE, Castelain MH, Journois D. Continuous intercostal blockade with lidocaine after thoracic surgery. Anesth Analg 1990; 70: 345–9.
Conacher ID. Pain relief after thoracotomy. Br J Anaesth 1990; 65: 806–12.
Shulman M, Sandler AN, Bradley JW, Young PS, Brebner J. Postthoracotomy pain and pulmonary function following epidural and systemic morphine. Anesthesiology 1984; 61: 569–75.
Johnson WC. Postoperative ventilatory performance: dependence upon surgical incision. Am Surg 1975; Oct.: 615–9.
Craig DB. Postoperative recovery of pulmonary function. Anesth Analg 1981; 60: 46–52.
Berend N, Woolcock AJ, Marlin GE. Effects of lobectomy on lung function. Thorax 1980; 35: 145–50.
Toledo-Pereyra LH, DeMeester TR. Prospective randomized evaluation of intrathoracic intercostal nerve block with bupivacaine on postoperative ventilatory function. Ann Thorac Surg 1979; 27: 203–5.
Delilkan AE, Lee CK, Yong NK, Ong SC, Ganendran A. Postoperative local analgesia for thoracotomy with direct bupivacaine intercostal blocks. Anaesthesia 1973; 28: 561–7.
Kaplan JA, Miller ED, Gallagher EG. Postoperative analgesia for thoracotomy patients. Anesth Analg 1975; 54: 773–7.
Faust RJ, Nauss LA. Post-thoracotomy intercostal block: comparison of its effects on pulmonary function with those of intramuscular meperidine. Anesth Analg 1976; 55: 542–6.
Bergh NP, Dottori O, Lof BA, Simonsson BG, Ygge H. Effect of intercostal block on lung function after thoracotomy. Acta Anaesthesiol Scand, Suppl 1966; 24: 85–95.
Lyles R, Skurdal D, Stene J, Jaberi M. Continuous intercostal catheter techniques for treatment of posttraumatic thoracic pain. Anesthesiology 1986; 65: A205.
Moore DC, Mather LE, Bridenbaugh LD, Balfour RI, Lysons DF, Horton WG. Arterial and venous plasma levels of bupivacaine following peripheral nerve blocks. Anesth Analg 1976; 55: 763–8.
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Chan, V.W.S., Chung, F., Cheng, D.C.H. et al. Analgesic and pulmonary effects of continuous intercostal nerve block following thoracotomy. Can J Anaesth 38, 733–739 (1991). https://doi.org/10.1007/BF03008451
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DOI: https://doi.org/10.1007/BF03008451