A randomized controlled trial of bupivacaine through intracostal catheters for pain management after thoracotomy.
BACKGROUND
Optimal management of pain after thoracotomy can be challenging. Continuous infusion of local anesthetic into the incision may help reduce the amount of narcotics required to control postoperative pain. To address this issue, we performed a randomized, double-blinded, controlled trial of infusion of bupivacaine versus placebo through intercostal and subcutaneous catheters after thoracotomy.


METHODS
From April 2006 to June 2007, 124 patients had intercostal catheters placed at thoracotomy and connected to continuous infusion pain pumps. Each patient had catheters placed in the intercostal space near the head of the rib and subcutaneously beneath the incision; both were connected to an infusion pump through a Y connector. Patients were randomly assigned to receive placebo (normal saline solution) or 0.25% bupivacaine as a 4 cc per hour infusion for 100 hours after thoracotomy. All personnel caring for the patients were blinded to the content of the infusion. Demographic information, visual analog pain scores, and oral morphine equivalent usage was recorded for each patient. In addition to the infusion catheters, all patients had epidural analgesia that remained in place until postoperative day 3.


RESULTS
There were 60 patients in the bupivacaine arm and 64 in the placebo group. Overall mean age was 64.7 years and 65 (52.4%) were men. Mean body mass index was 28.8 kg/m(2). There were no statistical differences in any demographic parameter except that there were more men in the placebo group. Pulmonary resection was performed in 100 patients, an antireflux procedure in 16, and other miscellaneous procedures in 8. There was no statistical difference in the morphine equivalent usage between the two groups. There was also no difference between the average daily pain scores between the two groups. Length of stay was not significantly different between groups: mean (SD) of 6.2 (3.4) and 6.7 (5.0) for placebo and bupivacaine, respectively (p = 0.51). There was no operative mortality, and complications occurred in 28% of patients (placebo group, 25%; bupivacaine group, 32%; p = 0.41).


CONCLUSIONS
This randomized, double-blinded, controlled trial demonstrated that the infusion of local anesthetic into the subcutaneous area and around the rib fracture site in addition to epidural analgesia did not reduce the amount of narcotic usage after a thoracotomy, nor did it affect visual analog pain scores. Pain control with intercostal catheters infusing local anesthetics did not produce a measurable pain relief beyond that provided by epidural analgesia.
Allen
Mark S
MS
Division of General Thoracic Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota 55905, USA. allen.mark@mayo.edu
Halgren
Lisa
L
Nichols
Francis C
FC
Cassivi
Stephen D
SD
Harmsen
William S
WS
Wigle
Dennis A
DA
Shen
K Robert
KR
Deschamps
Claude
C
D000284:Administration, Oral; D000368:Aged; D015360:Analgesia, Epidural; D016058:Analgesia, Patient-Controlled / Q000379:methods*; D000701:Analgesics, Opioid / Q000008:administration & dosage; D000772:Anesthesia, Local; D002045:Bupivacaine; D002408:Catheters, Indwelling; D004359:Drug Therapy, Combination; D005260:Female; D005764:Gastroesophageal Reflux / Q000601:surgery; D006801:Humans; D007262:Infusions, Intravenous; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy*; D011013:Pneumonectomy; D013908:Thoracotomy
D000701:Analgesics, Opioid; D009020:Morphine; D002045:Bupivacaine
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