title: Periosteal infusion of bupivacaine/morphine post sternal fracture: a new analgesic technique.
abstract: OBJECTIVE
  Sternal fracture pain is severe and is difficult to alleviate due to the forces acting on the chest wall during respiration. We describe a continuous infusion regional analgesic technique for pain due to sternal fracture.
  
  
  METHODS
  A 47-year-old woman presented with a spontaneous sternal fracture, precluding effective coughing. Diclofenac and increasing doses of opioids did not give adequate pain relief and led to opioid toxicity. Two brief periods of analgesia were achieved with deep subcutaneous infiltration of bupivacaine. An epidural catheter was positioned periosteally, and an infusion of bupivacaine was commenced at 5 mL/h, achieving long-lasting analgesia. The bupivacaine concentration was reduced in a stepwise fashion from 0.5% to 0.25% and was changed to levobupivacaine after 3 days. Adding morphine (5 mg/60 mL levobupivicaine) permitted a reduction in infusion rate. The catheter was removed after 14 days because a local infection developed that resolved uneventfully with antibiotic therapy.
  
  
  CONCLUSIONS
  Continuous infusion of local anesthetic and opioid to a sternal fracture site using a periosteally positioned catheter led to successful analgesia and hence improved respiratory function. Clinicians should consider placing a periosteal catheter when pain associated with sternal fracture cannot be adequately controlled with conventional methods.
authors.affiliation: Department of Anaesthesia and Pain Management, St Vincent's Hospital, Dublin, Ireland. mduncan32@hotmail.com
authors.forename: Michael A
authors.initials: MA
authors.lastname: Duncan
authors.forename: Walter
authors.initials: W
authors.lastname: McNicholas
authors.forename: Declan
authors.initials: D
authors.lastname: O'Keeffe
authors.forename: Maeve
authors.initials: M
authors.lastname: O'Reilly
mesh_terms: D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D002045:Bupivacaine / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D002404:Catheterization; D004646:Emphysema / Q000150:complications; D005260:Female; D005598:Fractures, Spontaneous / Q000150:complications*; D006801:Humans; D007263:Infusions, Parenteral; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D010146:Pain / Q000188:drug therapy* / Q000209:etiology*; D010166:Palliative Care; D010521:Periosteum; D013249:Sternum / Q000293:injuries*
chemical_list: D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D009020:Morphine; D002045:Bupivacaine