Eur J Cardiothorac Surg 2002;21:1115-1119
© 2002 Elsevier Science NL
Is intercostal block for pain management in thoracic surgery more successful than epidural anaesthesia?
P.N. Wurnig*,
H. Lackner,
C. Teiner,
P.H. Hollaus,
M. Pospisil,
B. Fohsl-Grande,
M. Osarowsky,
N.S. Pridun
Department of Thoracic Surgery, Otto-Wagner Hospital, Sanatoriumstrasse 2, 1140 Vienna, Austria
Received 18 September 2001;
received in revised form 15 February 2002;
accepted 18 February 2002.
* Corresponding author. Tel.: +43-1-91060-44008; fax: +43-1-91060-49824
e-mail: peter.wurnig{at}pul.magwien.gv.at
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Abstract
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Objective: Currently epidural anesthesia is the gold standard for postoperative pain management in thoracic surgery. In a prospective randomised study, the effect of an intercostal nerve block applied at the end of the operation was compared to that of epidural anesthesia. Methods: Thirty patients undergoing thoracotomy were randomised to each group. Patients with resection of the parietal pleura, rib resection and rethoracotomy were excluded from the study. Both groups received non-steroidal anti-inflammatory drugs every 8 h as a baseline analgesic medication and were allowed to ask for supplemental subcutaneous opiate injection, limited to four injections per day. The patients in the epidural catheter group (group I) were provided with a motor pump allowing continuous infusion of bupivacain 0.125% and 2 mg fentanyl/ml at a dosage of 6–10 ml per hour, dependent on the pain level over a period of 5 days. The patients of the second group (group II) received an intercostal nerve block at the end of the operation reaching from the third to the ninth intercostal space with 20 ml 0.5% bubivacaine. Pain was evaluated with a pain score ranging from 1 (no pain) to 10 (worst pain) twice daily in relaxed position and during physical activity like coughing. On the fifth postoperative day, the patients were asked specific questions concerning the subjective pain experience. Costs of both treatments were calculated. Mean pain values and costs of both groups were compared by t-tests for independent samples. A P value of less than 0.05 was considered significant. Results: Eighteen male and 12 female patients, aged between 35 and 71 years (mean 59) were included in the study. Nineteen patients had lobectomy, five bilobectomy, two decortication and three wedge resection. There were 22 right sided and eight left sided procedures. In group I, the mean pain score on the operation day was 3.95 in relaxed position and 6.33 during physical activity like coughing. The mean pain score during the following 4 days was 2.19 in relaxed position and 4.28 with activity. Three patients required additional subcutaneous opiate injection. In group II, the mean score on the operation day was 2.0 in relaxed position and 3.5 during activity. The mean pain score during the next 4 days was 2.84 in relaxed position and 5.65 with activity. Twelve patients received subcutaneous opiates. In both groups, no complications were observed. Costs: The costs for treatment of one patient was €105 in group I and €33 in group II. Patients' satisfaction was equal in both groups, there were no differences in terms of outcome and recovery. Conclusion: Pain management by intercostal block was superior during the first 24 h after surgery whereas on the second day after surgery pain control was significantly better achieved by the epidural catheter in relaxed position. A combination of both forms of anaesthesia seems to be an ideal pain management in patients undergoing thoracic surgery.
Key Words: Pain • Intercostal block • Epidural anaesthesia • Thoracic surgery
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1. Introduction
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Postoperative morbidity and even mortality is dependent on postoperative pain management. Functionally, pain results in lung restriction; adequate ventilation and coughing are compromised. Airway secretion is cleared out insufficiently and may be followed by bronchial obstruction, subsequently by atelectasis and finally may result in bacterial colonisation and parenchymal lung infection.
Currently, various methods are used for pain management after thoracic surgery. Systemic use of narcotics or anti-inflammatory drugs administered either alone or in combination do not result in satisfactory pain relief [1]. Non-steroidal anti-inflammatory drugs may cause gastrointestinal problems like bleeding. Pain management by local administration of drugs to the pain causing anatomic region is therefore an optimum strategy with minor side effects by which the risk of morbidity may be reduced. This method proved to be a gold standard for pain control after thoracic operations [2]. There are two possibilities: analgesia through an epidural catether or neuronal blockade. Epidural catheter management is not suitable for all patients and is associated with potential risks like dural perforation, bleeding, infection, hypotension, bradycardia and urinary infection [3]. Intercostal neuronal blockade has been reported to be very effective [4] and may be an alternative to epidural analgesia.
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2. Material and methods
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Thirty patients undergoing elective anterolateral thoracotomy (fourth intercostal space) for lobectomy, bilobectomy, open decortication or wedge resection without pleural or rib resection were randomly assigned to receive either epidural catheter analgesia (EPC, group I) or intercostal block (ICB, group II) for postoperative pain management. Patients undergoing resection or decortication in combination with resection of the pleura and or rib, patients with a history of severe heart disease, hepatic or renal insufficiency (as determined by preoperative blood tests), patients with hemorrhagic diathesis or medication of anticoagulants or acetylsalicylic acid within the last 10 days before admission to hospital and patients with a known allergy to local anaesthesia or with an other contraindication to epidural techniques were excluded from the study. Informed consent was obtained from every participating patient [1]. Patients of either group received a baseline analgesic medication with non-steroidal anti-inflammatory drugs and were allowed to ask for supplemental subcutaneous opiate injections (nicomorphine; maximal dose 0.1 mg/kg every 4–6 h) if required.
Patients assigned to the ICB group received an intercostal block with 20 ml 0.5% levobupivacain from the third to the ninth intercostal space just around the intercostal bundle at the end of the operation, just before chest closure.
In patients assigned to the EPC group, a catheter was placed into the epidural space at a thoracic level (between T5 and T6 ) before induction of general anesthesia. A continuous infusion by motor pump beginning with 6–10 ml/h of bubivacain 0.125% with additional 2 µg fentanyl/ml was administered for 5 days depending on the level of anesthesia. During the study period, the patients assessed pain severity twice a day (at 8 am and at 8 pm) in relaxed position and during physical activity like coughing using the visual pain analogue scale of El-Baz et al. [5] (1=no pain, 10=most severe pain). This visual pain analogue scale shows five visual expressions for different degrees of pain positioned near the appropriate score on the scale. On the fifth postoperative day, the patients were asked specific questions concerning the subjective pain experience.
Chest drains were removed if the drainage volume was less than 150 ml/4 h. Physiotherapy started on day of surgery with coughing under assistance of a physiotherapist and is continued by mobilisation sitting in the bed and small activity on first postoperative day and beginning of complete mobilisation on second operative day by standing up and walking around. Patients in both groups were able to attend this program to avoid respiratory problems.
The costs were calculated for both groups. Mean pain value and costs of both groups were compared by t-test for independent samples. A P-value of less than 0.05 was considered significant.
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3. Results
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We treated 30 patients (12 females and 18 males) and each group consisted of 15 patients. The underlying disease is shown in Table 1. Both groups were comparable with respect to age and surgical procedure (Table 2). Duration of chest tube drainage ranged from 3 to 8 days (median 4 days). The complete mobilisation (walking around and leaving the room) was prolonged for 1 day in two patients in group I and one patient in group II.
3.1. Pain relief
Both techniques provided good postoperative analgesia as demonstrated by the low pain score. The highest scores were 3.9 in relaxed position and 6.0 during activity in group I and 4.1 in and 5.1, respectively, in group II. No patient reached the maximum pain score of 10. On the day of surgery, no statistically significant difference could be observed between the two groups. However, on the first, second and third postoperative day, the ICB group (group II) showed a higher pain score in relaxed position than those in the EPC group (group II) (t-test for independent samples, P<0.05). There were no differences between pain scores during activity and relaxed position in both groups (Fig. 1
, P>0.05). In group II, the additional pain medication was prevalent.
3.2. Complications
Patients who received an epidural catheter more frequently complained of nausea than those in the ICB group, although this was not a statistically significant difference. Pruritus occurred in two patients in the EPC group (group 1). No periods of excessive somnolence were detected in either of the groups. All patients had a urinary catheter through the second day after surgery, and no voiding problems were observed.
3.3. Additional pain medication
In the ICB group, altogether 12 patients needed additional opiate injections. Two received opiates on the day of surgery, eight on the first postoperative day, six on the second, four on the third day after surgery. Opiate therapy could be stopped in all patients on day 5. Opiate consumption ranged from 0.5 mg nicomorphine to 8 mg a day. The median dosage applied was 1 mg on day 1, 1.5 mg on day 2 and 1 mg on day 3.
In the EPC group, three patients required additional opiate injection on the operation day, two on the first postoperative day and one patient on third. The median opiate consumption was 2 mg on day of surgery, 1 mg on first and 1.5 mg on third postoperative day.
3.4. Costs (Table 3)
Doubtlessly, intercostal block therapy is much cheaper than epidural anaesthesia because of the equipment required for epidural anaesthesia. However, neither of these therapies can be referred to as an expensive treatment.
3.5. Specific questions
There was no statistical difference between both the groups (Table 4). The most important answer, in our opinion, was that only one patient in group I was, if necessary, against another surgery because of his bad memory due to pain.
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4. Discussion
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Pain management is one of the main issues during the perioperative period to avoid complications. Especially pain following thoracic surgery is accompanied by mal-ventilation of the lung and all the problems arising therefrom. Thoracic epidural analgesia combining local anaesthetics and opiate analgesia has been shown to be highly effective in the control of postoperative pain after thoracic operations. It may thus currently be considered the gold standard method to which other modalities should be compared. Catheter insertion requires considerable experience [6] and in some patients it may even be technically impossible for anatomic or resurgery reasons. Potential complications such as dural puncture, bleeding, hematoma and infection at the catheter implantation site need to be taken into consideration [3]. Side effects such as urinary retention, hypotension, bradycardia, opiate induced pruritus, weakness of the upper extremities and other neurological sensations are rather uncomfortable than dangerous [7]. Recently, intercostal nerve blockade as a potential alternative became focus of interest. Selective blockade of the intercostal nerves at the level of the surgical incision has been shown to be effective for pain relief, either by means of serial injections, cryoanalgesia, or continuous intercostal infusion. Especially cryoanalgesia is associated with long-term intercostal neuralgia [8]. Oliver et al. [9] abandoned the cryolesion technique because long-term follow up revealed a disturbingly high number of patients who developed chest wall pain several months after the procedure. This disadvantage is avoided when intercostal blockade is achieved by means of an indwelling catheter positioned intraoperatively in the extrapleural space. This method of pain management is reported to be favourable as compared to the administration of parenteral opiates. One study could show that lumbar epidural morphine application is less effective than continuous intercostal blockade [10]. Another study comparing extradural infusion at the thoracic level with continuous administration of a paravertebral block and single intrathoracic block did not show any difference between the two methods. These studies show that the pain symptoms have a large individual variation [11]. Another alternative procedure of pain management in patients with thoracic surgery is intrapleural administration of bupivacaine. The advantage of this method is the simple administration of the drug by catheter which can also be performed by the nurse [12] although a failure rate of 20% has been reported for the placement of the cannula in the intercostal space [13].
In this study, it was investigated if epidural catheter analgesia is superior to an intercostal block administered intraoperatively. The aim was to verify the subjective pain and the subjective postoperative well-being. Therefore lung function and other functional parameters are not of interest by this specific question. Open and minimally invasive approaches have different pain sensations, therefore only a standard incision was included in this study. Preliminary results showed that intercostal block is free of side effects and is more effective in pain management than epidural anaesthesia. It could be shown that on day of surgery, an intercostal block was associated with a lower pain score as compared to epidural anaesthesia. Intercostal block did not show any complications whereas epidural anaesthesia was accompanied by mild side effects like nausea or pruritus. In our opinion, a malposition of the catheter in 20% is not acceptable and needs more supplemental systemic analgesia with all the side effects and risks. Therefore, we performed intercostal block without catheter application. The method of application used in this study is so simple and safe that it can be executed with little experience and can be extended over six intercostal spaces.
The intercostal block allows good nerve and pain blockage on the day of surgery. On the following day, pain increases much slower due to the slowly decreasing effect of the nerve blockage. However, these differences did not reach statistical significance except in-between the two groups on the days after surgery in relaxed position. It was not surprising that after the day of surgery, epidural anaesthesia was superior to intercostal block.
From these results, we conclude that epidural anaesthesia still remains the gold standard for pain management during thoracic surgery. Without any risk of complication, an intercostal block administered at the end of surgery is a good alternative with a satisfactorily low level of pain and should be taken into consideration. Especially the type of administration of the block described above is easy to do, precise for anatomical reasons and complications can be avoided.
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5. Conclusion
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In conclusion, this study strongly confirms the opinion expressed in the respective literature: epidural anaesthesia is the golden standard for postoperative management of pain after thoracic surgery. Intercostal nerve blockade should be considered as a good alternative therapy if epidural catheter pain relief is not possible for other reasons.
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Footnotes
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Presented at the joint 15th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 9th Annual Meeting of the European Society of Thoracic Surgeons, Lisbon, Portugal, September 16–19, 2001.
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Appendix A. Conference discussion
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Mr A. Mearns (Bradford, UK): I am in despair. We presented to the EACTS in 1988–89 with Richard Berrisford paravertebral analgesia, and we presented paper after paper at these meetings. The last one I gave was in Poland. And I thought you had all been convinced and I thought the show was over, and, quite clearly, I will have to come back again next year with more statistics. Please do use the paravertebral analgesia, because you are halfway there. It took you five injections.
My anesthetist preoperatively passes a paravertebral catheter, not epidural, a paravertebral catheter, the same catheter, into the paravertebral space nine times out of 10, 100% successfully, a preoperative block, and that runs for four or five days, however, length of time you have. You have to put five injections in there and carefully manage them. Your paravertebral could have been in already before you open the chest. I would stay there.
You used a very long-acting local anesthetic.
Dr Wurnig: Yes, we used a local anesthetic only.
Mr Mearns: Yes, but it is a very long-acting one because you are saying you have still got an effect at five days, or are you putting an injection in every day?
Dr Wurnig: No, no. We use it only during surgery, and after surgery on the second and third, and what we find out is that the intercostal block was not as good as epidural anesthesia. We used only baseline analgesics and subcutaneous opiate.
Mr Mearns: With paravertebral analgesia you don't use anything when it is a question of weaning off. Did you actually repeat the injections after the operating day or was it just as you came off the table before you closed the chest?
Dr Wurnig: Only during surgery.
Mr Mearns: And you felt it was still working five days later?
Dr Wurnig: No, no. I am especially convinced that it is not still working five days later.
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Top
Abstract
1. Introduction
