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Ann Thorac Surg 2002;74:338-341
© 2002 The Society of Thoracic Surgeons

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Original article: general thoracic

Intraoperative intercostal nerve blockade for postthoracotomy pain

^a Department of Surgery, Kurume University School of Medicine, Kurume, Japan

Accepted for publication April 21, 2002.

* Address reprint requests to Dr Takamori, Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan
e-mail: stakam{at}med.kurume-u.ac.jp

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Epidural analgesia is widely employed as a means to control postthoracotomy pain, but is sometimes inadequate. The purpose of this study is to evaluate the effectiveness of intraoperative, temporary, intercostal nerve blockade in addition to epidural analgesia for control of postthoracotomy pain.

Methods. Forty patients undergoing elective lobectomy through antero-axillary thoracotomy were randomized to receive epidural analgesia only (group A, n = 20) or epidural analgesia plus temporary, intraoperative intercostal nerve blockade using 0.25% bupivacaine (group B, n = 20). Postoperative pain was assessed using a subjective analogue visual scale, and with the Prince Henry pain scale. Food intake and nonsteroidal analgesic consumption were also investigated. Serum ACTH and cortisol in each group were measured before and after the operation.

Results. The analogue visual scale scores were significantly higher in group A than group B (p < 0.001), and were significantly higher on the day of operation and postoperative days 1, 2, and 3 (p < 0.001, p < 0.005, p < 0.005, p < 0.05, respectively). Prince Henry pain scale scores were significantly higher on the day of operation and postoperative day 1 (p < 0.05, p < 0.005, respectively). Food intake was significantly lower in group A than in group B (p < 0.05), and nonsteroidal analgesic consumption was not significantly different between groups. There was no significant difference between group A and group B in serum ACTH or in cortisol levels.

Conclusions. Additional intraoperative intercostal nerve blockade provides an additive benefit for postthoracotomy pain relief, especially early after operation.

	Introduction

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Postthoracotomy pain after thoracic surgery has long been recognized as a cause of postoperative morbidity [1], resulting in inadequate ventilation, coughing, atelectasis, mucous plugging, hypoxia, and pulmonary infection [2, 3]. Many treatment modalities have been proposed for postthoracotomy pain. These include systemic use of opioids or nonsteroidal drugs, epidural analgesia, intercostal nerve blockade, cryoanalgesia, and subarachnoid opioid administration. Although parenteral opioids produce reliable pain relief for acute postoperative pain in the majority of patients, these agents are sometimes associated with respiratory depression, nausea, and bowel dysfunction. In patients who present for thoracotomy who already have a compromised pulmonary function, we do not use postoperative opioids either parenterally or epidurally. Epidural analgesia has been widely advocated as a means of controlling postthoracotomy pain [4, 5], but it is sometimes insufficient for pain control. We have used 1% mepivacaine routinely for continuous epidural analgesia without opioid narcotics, because respiratory depression may occur when opioid narcotics are administered epidurally.

The method of extrapleural catheter emplacement was originally described by Sabanathan and associates [6], and continuous intercostal nerve blockade using this technique has been reported to be effective, which might be an alternative to thoracic epidural analgesia [7, 8]. Deneuville and associates described that continuous intercostal bupivacaine provided similar early pain control when compared with fixed-schedule narcotics, but induced better analgesia with fewer complications than on-demand narcotics alone [9]. Intraoperative temporary intercostal nerve blockade with local anesthetic is easy, quick, and safe. We focused on reducing pain awareness as patients recovered from general anesthesia. The present study was designed to compare pain in patients receiving epidural analgesia with or without intraoperative intercostal nerve blockade, and to evaluate the effectiveness of intraoperative intercostal nerve blockade in addition to epidural analgesia for postthoracotomy pain.

	Material and methods

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Patient selection
The study was approved by the institutional Ethics Committee. Informed consent was obtained from each participating patient. Forty patients undergoing elective lobectomy were randomized by permuted block method to receive epidural analgesia (group A, n = 20) or epidural analgesia with intraoperative temporary intercostal nerve blockade (group B, n = 20). The operative procedure was either with or without lymph node dissection. Excluded were: (1) patients less than 40 or more than 70 years old; (2) patients undergoing an operation involving the chest wall; (3) patients with a history of severe hepatic or renal insufficiency; (4) patients with hemorrhagic diathesis or receiving anticoagulants or acetylsalicylic acid; and (5) patients allergic to bupivacaine or with contraindication to epidural techniques.

Techniques
Lobectomy was performed thorough the fourth or fifth intercostal space via an antero-axillar incision between 15 and 25 cm in width. Incision of the parietal pleura inside was within 30 cm in width. Typically, the tip of the epidural catheter was positioned at a thoracic level between T-5 and T-6, before the induction for general anesthesia. Continuous infusion of 1.0% mepivacaine (Fujisawa Pharmaceutical Co., Tokyo, Japan) was administered at 4 mL/h during the operation and was maintained for a minimum of 5 days postoperatively.

Patients assigned to group B received intraoperative intercostal nerve blockade at the end of the surgical procedure, just before chest closure. Intercostal nerve blockade [10] was performed for four intercostal nerves, each of two nerves above and below the level of the thoracotomy, with 8 mL (2 mL per one nerve) of 0.25% bupivacaine (Fujisawa Pharmaceutical Co., Tokyo, Japan) using a 23-gauge needle. The site of the nerve blockade was decided on between the dorsal end of the parietal pleura incision and the costovertebral junction, which is approximately 3 to 4 cm from the spine.

Measurements
The patients, two times per day on a simplified visual analogue scale, subjectively self-assessed pain with scores ranging from 0 (no pain) to 10 (worst imaginable pain) [11]. Using the Prince Henry pain scale (0, no pain while coughing; 1, pain while coughing but not during deep breathing; 2, pain during deep breathing but not at rest; 3, pain at rest, slight; 4, pain at rest, severe), patients were also asked their perceived level of pain [12]. Food intake was investigated using a score from 0 (no intake) to 3 (full intake) for total daily food intake. Nonsteroidal analgesic (diclofenac sodium per rectum or per os) was administered whenever any patient complained of pain, and the timing and frequency of these administrations were investigated. These four parameters were recorded from the day before the operation through day 5 after the operation.

Blood samples were collected from an antecubital vein in intervals as follows: before surgery, within 3 hours after surgery, and on days 1, 3, and 5 after surgery. The serum concentration of ACTH was determined by radioimunoassay (Alegro ACTH kit; Nippon Medics Inc., Tokyo, Japan), and cortisol was measured by a gamma coat cortisol kit (Baxter Travenol, Inc., Tokyo, Japan).

Statistical analysis
All values are expressed as means ± the standard deviation. Repeated-measures analysis of variance was performed for comparison between groups, and Wilcoxon signed-rank test between groups at each time point, using a Stat View software package J-4.5 (Abacus Concept, Berkeley, CA). Values of p less than 0.05 were considered significant.

	Results

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There were 11 males and 9 females in group A (mean age, 60.1 years), and 13 males and 7 females in group B (mean age, 62.7 years). The reasons for lobectomy were benign disease (hemoptysis) in 1 patient, and lung cancer in each of the other 39 patients. The mean duration of the operation was 209 ± 67 and 210 ± 76 minutes, and the mean duration of drainage was 4.4 ± 1.6 and 4.6 ± 1.3 days in group A and in group B, respectively. There was no significant difference in the patient characteristics between group A and group B (Table 1). The analogue visual scale scores were significantly higher in group A than group B (p < 0.001), and were significantly higher on the day of operation and postoperative days 1, 2, and 3 day at each time point (p < 0.001, p < 0.005, p < 0.005, p < 0.05, respectively) (Fig 1). Prince Henry pain scale scores were significantly higher on the day of operation and postoperative day 1 at each time point (p < 0.05, p < 0.005, respectively) (Fig 2). The food intake was significantly lower in group A than in group B (p < 0.05) (Fig 3), and nonsteroidal analgesic consumption was not significantly different between groups (Fig 4). There was no significant difference between group A and group B in serum ACTH or in cortisol levels (Figs 5 and 6). There was no complication from the epidural catheter emplacement and infusion of mepivacaine or intercostal nerve blockade with bupivacaine in any patient.

View larger version (24K): [in this window] [in a new window]   Fig 1. Scores on the visual analogue pain scale were significantly higher in group A than group B (* = p < 0.001), and were significantly higher on the day of operation, and on postoperative days 1, 2, and 3 at each time point ( = p < 0.001, = p < 0.005, = p < 0.005, ¶ = p < 0.05, respectively). (Op = day of operation.)

View larger version (23K): [in this window] [in a new window]   Fig 2. Scores on the Prince Henry pain scale were significantly higher on the day of operation and on postoperative day 1 at each time point (* = p < 0.05, = p < 0.005, respectively). (Op = day of operation.)

View larger version (32K): [in this window] [in a new window]   Fig 3. The food intake was significantly lower in group A than that in group B (* = p < 0.05). (Op = day of operation.)

View larger version (29K): [in this window] [in a new window]   Fig 4. The analgesic consumption in each group showed no significant difference. (Op = day of operation.)

View larger version (18K): [in this window] [in a new window]   Fig 5. The serum ACTH levels in each group showed no significant difference. (Op = day of operation.)

View larger version (17K): [in this window] [in a new window]   Fig 6. The serum cortisol levels in each group showed no significant difference. (Op = day of operation.)

	Comment

Top Abstract Introduction Material and methods Results Comment References

Interestingly, the food intake in group A was significantly less than in group B. Food intake, an indicator of postoperative quality of life, should be inversely correlated with postoperative pain. We found no significantly difference in nonsteroidal analgesic consumption between groups. That may have been because the requirement for nonsteroidal analgesic depended on each patient’s character, and the number of the patients of this study was relatively small.

There was no significant difference in serum ACTH or in cortisol levels between group A and group B, which indicated that the additional intercostal nerve blockade did not affect the basic surgical stress.

Watson and associates reported that lidocaine is equivalent pain control to bupivacaine when administered for continuous extrapleural intercostal nerve block after posterolateral thoracotomy, with less risk of systemic toxicity [13]. The dosage of intercostal nerve blockade in our study was only 8 mL of 0.25% bupivacaine, which had a low risk for systemic toxicity. In our preliminary experience, additional intraoperative intercostal nerve blockade with 1% mepivacaine was also effective, although controlling the timing of awareness from general anesthesia was difficult because its pharmacological half-life is so short. Ropivacaine, a relatively newly developed local anesthetic, is more suitable because it is longer acting and less toxic in the central nervous system and cardiovascular system than bupivacaine [14]. In conclusion, we found that additional intraoperative temporary intercostal nerve blockade with local anesthetic showed an additive benefit for postthoracotomy pain relief.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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