Effect of preincisional epidural fentanyl and bupivacaine on postthoracotomy pain and pulmonary function.
BACKGROUND
This study attempts to determine whether preemptive thoracic epidural analgesia (TEA) initiated before surgical incision would reduce the severity of acute post-thoracotomy pain, its effects on pulmonary function and stress response.


METHODS
Forty patients undergoing posterolateral thoracotomy received TEA either before (preoperative-TEA group) or after (postoperative-TEA group) surgery. Postoperative analgesia was maintained with epidural infusion of bupivacaine and fentanyl. Pain scores, pulmonary functions, arterial blood gases, plasma glucose, cortisol levels and epidural fentanyl consumption were compared for 48 hours after surgery.


RESULTS
The preoperative-TEA group demonstrated significantly reduced pain scores at 2, 4, 8, 12, 24, and 48 hours at rest (p = 0.001, p = 0.002, p = 0.004, p = < 0.001, p = 0.006, and p = 0.001, respectively) and at 4, 8, 12, 24, 48 hours on coughing (p = 0.001, p = 0.001, p = 0.001, p = 0.001, p = 0.004, respectively), and a significant reduction in epidural fentanyl consumption (208.6 +/- 49.3 mL, versus 260 +/- 28.8 mL, p = 0.001). The preoperative-TEA group showed significant improvement in pulmonary functions as compared with the postoperative-TEA group (p < 0.05), except forced expiratory volume in one second at 24 hours (p = 0.061) and peak expiratory flow rate at 48 hours (p = 0.188). The postoperative-TEA treated patients were more likely to have a higher arterial carbon dioxide pressure at 4, 8, 12, and 24 hours (p = 0.017, p = 0.001, p = 0.003, p = 0.001), respectively. However, we could not demonstrate a statistical difference in oxygenation, cortisol, or glucose level.


CONCLUSIONS
Though preemptive TEA appeared to reduce the severity of acute pain, preserve pulmonary function, and reduce analgesic requirements, these statistically significant differences were not enough to conclude a clinical significant difference between groups.
Amr
Yasser Mohamed
YM
Department of Anesthesiology, Faculty of Medicine, Tanta University Hospital, Tanta, Egypt. yasser.amr@gmail.com
Yousef
Ayman Abd Al-Maksoud
AA
Alzeftawy
Ashraf E
AE
Messbah
Wail I
WI
Saber
Ahmed Mohamed
AM
D000328:Adult; D000368:Aged; D015360:Analgesia, Epidural / Q000379:methods*; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D001786:Blood Glucose / Q000378:metabolism; D002045:Bupivacaine / Q000008:administration & dosage* / Q000009:adverse effects; D002245:Carbon Dioxide / Q000097:blood; D004311:Double-Blind Method; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D008171:Lung Diseases / Q000601:surgery*; D008176:Lung Volume Measurements; D008297:Male; D008875:Middle Aged; D010100:Oxygen / Q000097:blood; D010147:Pain Measurement / Q000187:drug effects; D010149:Postoperative Pain / Q000097:blood / Q000175:diagnosis / Q000517:prevention & control*; D011182:Postoperative Care; D011292:Premedication; D011446:Prospective Studies; D011659:Pulmonary Gas Exchange / Q000187:drug effects; D013908:Thoracotomy
D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D001786:Blood Glucose; D002245:Carbon Dioxide; D010100:Oxygen; D005283:Fentanyl; D006854:Hydrocortisone; D002045:Bupivacaine