Thoracic epidural versus intercostal nerve catheter plus patient-controlled analgesia: a randomized study.
BACKGROUND
Pain control is an important issue after thoracotomy. Ideal methods should have a high success rate, with easy implementation and minimal complications. Debate exists over the optimal pain control method. This randomized trial was designed to compare epidural (EPI) and intercostal nerve catheter with patient-controlled analgesia (ICN-PCA) for pain control after thoracotomy.


METHODS
The study included 124 randomized patients; 91 had sufficient data for analysis (44 EPI, 47 ICN-PCA). The primary endpoint was pain measurement using a composite of a visual analogue scale, numerical rating, and categorical rating. A second endpoint was the success rate of each method. Pulmonary function tests, antibiotics, intensive care unit (ICU), and hospital days, and use of nonprotocol pain medications were also compared.


RESULTS
There were 12 pain observations per patient (90% completed on days 1 to 5). The pain composite revealed an average postoperative pain score of 2.4 on a scale from 0 (no pain) to 10 (worst pain). There was no difference between the groups. Failures of the planned method of analgesia included 9 in the EPI group and 4 in the ICN group (p = 0.23). Another 20 patients were excluded (no difference between groups) due to unsuspected mediastinal metastases precluding thoracotomy (n = 13), and other miscellaneous factors precluding follow-up (n = 7). The EPI group had an increased number of urinary catheter days (2.5 days vs 1.7, p = 0.002) and increased narcotic supplements (p = 0.03) compared with ICN. Mean ICU days (0.9) and hospital days (6.2) were similar for both groups, and there were no differences in arrhythmias, pneumonias, transfusions, and antibiotic use. Significant differences were seen (p = 0.001) between preoperative and postoperative pulmonary function tests in both groups. However, there were no differences in pulmonary function when the groups were compared with each other.


CONCLUSIONS
Satisfactory pain control was achieved after thoracotomy using either EPI or ICN-PCA. The ICN-PCA achieved equivalent pain control compared with EPI, and was placed by the surgeon with no delays in surgery, and demonstrated a decreased requirement for Foley catheter duration.
Luketich
James D
JD
Division of Thoracic and Foregut Surgery, Cancer Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA. luketichjd@upmc.edu
Land
Stephanie R
SR
Sullivan
Erin A
EA
Alvelo-Rivera
Miguel
M
Ward
Julie
J
Buenaventura
Percival O
PO
Landreneau
Rodney J
RJ
Hart
Lee A
LA
Fernando
Hiran C
HC
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016058:Analgesia, Patient-Controlled; D000767:Anesthesia, Epidural / Q000379:methods*; D000779:Anesthetics, Local / Q000008:administration & dosage; D002045:Bupivacaine / Q000008:administration & dosage; D005260:Female; D006801:Humans; D007367:Intercostal Nerves; D007902:Length of Stay; D008012:Lidocaine / Q000009:adverse effects; D008175:Lung Neoplasms / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009407:Nerve Block / Q000379:methods*; D010147:Pain Measurement; D003074:Solitary Pulmonary Nodule / Q000601:surgery; D013908:Thoracotomy / Q000009:adverse effects*; D016896:Treatment Outcome
D000779:Anesthetics, Local; D008012:Lidocaine; D002045:Bupivacaine