Evaluation of Bupivacaine Nerve Blocks in the Modification of Pain and Pulmonary Function Changes after Thoracotomy

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1 Evaluation of Bupivacaine Nerve Blocks in the Modification of Pain and Pulmonary Function Changes after Thoracotomy Eugene A. Woltering, M.D., M. Wayne Flye, M.D., Susan Huntley, B.S., C.R.T., Phillip Kapp, M.D., Andrew Dwyer, M.D., and Byron McLees, M.D., Ph.D. ABSTRACT Thirty-one patients undergoing thoracotomy were prospectively randomized to receive (1) no nerve blocks (n = 12), (2) placement of percutaneous catheters for intermittent nerve blocks with bupivacaine (Marcaine) (n = lo), or (3) bupivacaine nerve blocks intraoperatively (n = 8). One patient refused postoperative evaluation and was not included in this study. All patients received similar preoperative, intraoperative, and postoperative medications. Comparison of preoperative and postoperative arterial blood gases, assessments of pain and alertness, and chest roentgenograms showed no statistical advantage for any group. Analgesic requirements and pulmonary functions (functional residual capacity, tidal volume, minute ventilation peak flow, or forced expiratory volume) did not differ among the groups. Statistically significant differences were seen in mean respiratory rate and forced vital capacity. These differences, however, indicate that bupivacaine either by intraoperative use or by intermittent percutaneous administration did not improve postoperative increases in respiratory rate or decreases in forced vital capacity. Previous reports have differed widely in their conclusions as to the ability of intercostal nerve blocks to prevent postoperative pain and limit pulmonary function changes [2-6, 9, 111. The limited systemic effect of such blocks makes this method of analgesia an attractive alterna- From the Surgery Branch, National Cancer nstitute, the Departments of Critical Care Medicine, Anesthesia, and Diagnostic Radiology, Clinical Center, National nstitutes of Health, Bethesda, MD. Presented at the Twenty-sixth Annual Meeting of the Southern Thoracic Surgical Association, Nov 1-3, 1979, San Antonio, TX. This paper received the President s Award for best paper presented at the Twenty-sixth Annual Meeting of the Southern Thoracic Surgical Association. Address reprint requests to Dr. Woltering, Vanderbilt University, Department of Surgery, Nashville, TN tive to the opiate analgesics. Opiates may have undesirable side-effects such as sedation, nausea, vomiting, decrease in cough frequency, or hypotension. Bupivacaine (Marcaine) is a long-acting local anesthetic, which stabilizes the neuronal membranes and prevents initiation and transmission of nerve impulses, thereby effecting local anesthetic action. Bupivacaine, when used in proper doses, offers a clear-cut advantage in duration of anesthesia. Of patients reported by Moore and colleagues [8], 67.7% experienced relief from pain 10 to 14 hours following bupivacaine administration compared with 10.5%, 11.8%, and 4.2% of patients receiving tetracaine, mepivacaine, or lidocaine, respectively. ntermittent doses of bupivacaine (epidural anesthesia) have been shown to be effective for protracted relief from pain [8]. Nerve block anesthesia utilizing bupivacaine is relatively safe; however, complications such as total spinal anesthesia, shock, allergic reactions, and systemic toxicity do exist [l, 8, 101. The use of paracostal nerve blocks after thoracotomy has been claimed to give objective relief from pain or improvement of pulmonary function or both [2-6, 9, 111. Placement of small polyethylene tubes in the intercostal neurovascular sheath would allow prolonged intermittent administration of local anesthetic agents and should allow a more pain-free recovery. Materials and Methods Thirty-one patients undergoing anterolateral thoracotomy with limited lung resection (wedge excision or lobectomy) at the National nstitutes of Health were randomized at the time of operation into three groups. Group 1 (n = 12) received no nerve blocks. Group 2 (n = 10) had placement of percutaneous catheters in by The Society of Thoracic Surgeons

2 123 Woltering et al: Bupivacaine Nerve Blocks fl Neurovascular A "" ji [--. Fig 1. (A and B) Method of placement of percutaneous catheters for administration of intermittent bupivacaine intercostal nerve blocks. three interspaces around the incision. Five milliliters of 0.5% bupivacaine was placed into each catheter intraoperatively and every 6 hours for 3 days postoperatively (Fig 1). Group 3 (n = 8) received only intraoperative nerve blocks with 5 ml of 0.5% bupivacaine in each of the three interspaces around the incision. One patient, a 12-year-old girl, was not included in this analysis because her family refused to participate in the postoperative evaluation, after randomization. All groups received atropine, 0.4 mg, and hydroxyzine, 1.5 mg per kilogram of body weight, preoperatively, no narcotics intraoperatively, and morphine sulfate on a per-weight basis every 2 hours as needed postoperatively. Patients were excluded from this study for the following reasons: they were less than 12 years old or older than 65 years; they had a history of drug abuse or dependence; they had a B history of allergy to local anesthetic agents; or they had impaired hepatic or renal function (bilirubin greater than 1.5 mglloo ml; creatinine greater than 1.5 mglloo ml; blood urea nitrogen greater than 20 mglloo ml). Preoperative evaluation included chest roentgenograms, pulmonary function testing, arterial blood gases, and patient pain assessment. Pulmonary function testing included rate, tidal volume, minute ventilation, peak flow, forced expiratory volume, forced vital capacity, and functional residual capacity. Patient pain assessments were done using 100 mm scales on which the patient was asked to mark his ability to tolerate any pain (general) and the pain of a toothache, headache, and stomachache (Fig 2). The patients were also evaluated preoperatively by a modification of the Melzack-McGill pain questionnaire [7]. ntraoperatively, if the patient had met the criteria of limited pulmonary resection (single or multiple wedge excisions of nodules, or lobectomy), a numbered card (generated by a random numbers table) directed the operating

3 124 The Annals of Thoracic Surgery Vol 30 No 2 August Rate Your General Ability to Tolerate Pain: 1. How alert feel: pain at all. an extreme amount of pain. feel sleepy, quite unresponsive. feel quite alert and responsive. 2. Rate Your Ability to Tolerate the Pain of a Toothache: the pain of a toothache. an extremely painful toothache. 3. Rate Your Ability to Tolerate the Pain of a Headache: the pain of a headache. an extremely painful headache. 4. Rate Your Ability to Tolerate the Pain of a Stomachache: the pain of a stomachache. an extremely painful stomachache. Fig 2. Scales used for assessment of preoperative pain tolerance. All scales are 100 mm long. surgeon (M. W. F.) to do one of three things: (1) perform no nerve blocks; (2) place polyethylene catheters in the posterior paracostal neurovascular sheath in the interspace opened and in the interspace above and below the incision, through which 5 ml of 0.5% bupivacaine was placed at the termination of anesthesia and every 6 hours for 3 days postoperatively; or (3) perform intraoperative nerve blocks with 5 ml of 0.5% bupivacaine in the interspace opened as well as the interspace above and below. At 2, 24, 48, and 72 hours postoperatively, patients were evaluated by the same criteria as preoperatively. Arterial blood gases were drawn 24 hours postoperatively. All patients received morphine sulfate, 0.04 or 0.08 mg per kilogram, intravenously every 2 hours as needed for pain. Pain medication was supplied only on patient request, and the nursing staff was instructed not to suggest or offer analgesics at any time. All patients initially received 0.04 mg per kilogram of morphine sulfate but could, at their request, increase the dose to 0.08 mg per kilogram if the lower dose did not provide 2. How much pain feel: feel quite comfortable, no apparent pain. am in extreme pain. Fig 3. Scales used for patient assessment of postoperative pain and alertness. All scales are 100 mm long. adequate pain control. No other hypnotics, sedatives, or pain medications were allowed. Chest roentgenograms were evaluated blindly at the termination of this study by a radiologist (A. D.), and were rated on the presence of ipsilateral or contralateral pulmonary atelectasis or consolidation and by the percent change (from preoperative) in the apicaldiaphragmatic distance in an inspiratory roentgenogram. Pulmonary function tests preoperatively and postoperatively were obtained using a portable electronic spirometer, and results were expressed as the change from preoperative values for each category. Arterial blood gases obtained postoperatively were compared with preoperative measurements, and values were expressed as the change from preoperative values. Pain and alertness assessments postoperatively were performed using a 100 mm scale (Fig 3). For each patient, preoperative pain tolerance was computed and postoperative pain assessment value (in millimeters) was subtracted from the preoperative pain tolerance value to arrive at a value we considered representative of the patient s pain, adjusted for tolerance. Observer ratings of pain and alertness were done on simiar scales by the respiratory therapist (S. H.) performing the pulmonary function tests. Regional anesthesia was evaluated daily by pinpricks about the wound and along the chest wall anteriorly, laterally, and posteriorly. n evaluating pain and changes in chest roentgenogram, pulmonary function tests, and arterial blood gases, each patient served as his own control, i.e., postoperative values were compared with preoperative values. Group

4 125 Woltering et al: Bupivacaine Nerve Blocks means for these evaluations except pain were based on the average of the group s individual values. All statistics were performed using the Student t test. Results Comparisons of preoperative and postoperative arterial blood gases, chest roentgenograms, and pain assessments showed no statistical advantage for any group. Arterial blood gases obtained 24 hours postoperatively showed a mean decrease in partial pressure of arterial oxygen (PaO,) of 22.2, 13.0, and 9.3 mm Hg and a change in partial pressure of arterial carbon dioxide (PaCO,) of -4.1, + 1.0, and +2.8 mm Hg in Groups 1, 2, and 3, respectively. There was no statistical difference among the groups when comparing preoperative and postoperative changes in PaO,, PaC02, or ph. Chest roentgenograms showed a mean maximal apical/ diaphragmatic diameter decrease of i0.4 /o, 14.0 /0, and 16.3% in Groups 1, 2, and 3, respectively. These values, as well as the incidence of ipsilateral or contralateral atelectasis, did not differ statistically. Patients in Group 1 experienced a mild degree of hypoesthesia immediately around the surgical wound for all 3 days. Group 2 patients were anesthetic to pinprick in the three interspaces blocked. This anesthesia gradually decreased to hypoesthesia of an area one more interspace above and below the incision, and these changes persisted for up to 24 hours after the last injected dose of bupivacaine. Group 3 patients had a similar distribution of anesthesia, but it markedly diminished by 24 hours postoperatively. There were no paresthesias in the operative site in the three-tosix-month follow-up period of these patients to Table 2. Morphine Sulfate Usage Morphine Sulfate (mgidayy Group Day1 Day 2 Day (0.45) 17.7 (0.30) 14.2 (0.24) (0.45) 22.0 (0.31) 25.4 (0.36) (0.30) 25.8 (0.32) 12.9 (0.16) avaues in parenthesis are usage in milligrams per kilogram of body weight per day. indicate long-term nerve inflammation or damage. Postoperatively, there were no differences, on any day, in any group, in the absolute amount of pain experienced or in the patients perception of alertness (Table 1). When correction for preoperative pain tolerance was done, there again was no difference among the groups on any of the 3 postoperative days. There were also no statistical differences in observed ratings of pain and alertness on any day. Although it could not be documented objectively, during the first few hours postoperatively, patients receiving intraoperative bupivacaine by either approach subjectively appeared to have less pain. This was not supported by analgesic usage or pulmonary function data. The amount of morphine sulfate used by these patients daily or cumulatively shows no advantage for nerve block anesthesia. When comparing absolute amount of morphine sulfate used in each group or the amount of morphine sulfate used per kilogram of patient weight per day, there is no statistical difference between any two groups on any day (Table 2). Pulmonary function changes in the postoperative period are greatest for those tests that are effort dependent. n our series there were Table 1. Patient Rating of Postoperative Pain and Alertnessa Alertness Pain Groupk) Day 1 Day 2 Day 3 Day 1 Day 2 Day t f f t t f f f f f f f f t f f f t 30 avalues shown are in mm k standard deviation and are derived from 100 mm rating scales shown in Figure 2. bgroup 1, no block; Group 2, block by catheter; Group 3, single bupivacaine injection.

5 126 The Annals of Thoracic Surgery Vol 30 No 2 August 1980 Table 3. Change in Respiratory Rate from Preoperative Value Respiratory Rate (breathsimin) Group Day 1 Day 2 Day sc +7.9h ZC f p < hp < p = Table 4. Change in Forced Vital Capacity from Preoperative Values Forced Vital Capacity (cc) Group Day 1 Day 2 Day 3 1-1,513-1,251-1,028C*d 2-2,140-1,819-2,005d 3-2,420a -2,242-2,110c p < Dp < p < dp < no statistical differences in the change from preoperative values in any group, on any day in tidal volume, minute ventilation, peak flow, forced expiratory volume, or functional residual capacity, an effort-independent variable. ncreases in respiratory rate were seen in all groups postoperatively (Table 3). However, the greatest increases over preoperative values were seen in Group 2 (mean increase of 13.4, 7.9, and 7.75 breaths per minute on days 1, 2, and 3, respectively). This was a significant increase over the change in the control group (4.3, 2.9, and 3.5 breaths per minute on days 1, 2, and3, respectively) ( p < 0.005, < 0.03, and < 0.05, respectively). n addition, Group 2 and Group 3 were significantly different on day 1 ( p = 0.05). There was also a significantly greater decrease in forced vital capacity on days 1, 2, and 3 in Group 3 (intraoperative injections), i.e., a decrease of 2,420, 2,242, and 2,110 cc on days 1,2, and3, respectively ( p < 0.003, < 0.003, and < 0.005, respectively) (Table 4). The difference on day 3 between the control group and Group 2 (intermittent block by catheter) (mean decrease, 2,005 cc) was also statistically significant (p < 0.01). Comment Effort-dependent pulmonary functions such as tidal volume, inspiratory force capacity, minute ventilation, vital capacity, and forced expiratory volume when utilized in conjunction with objective assessment of local anesthesia, subjective ratings of pain and alertness, changes in arterial blood gases, analgesic usage, and the development of roentgenographic evidence of atelectasis should reflect a patient s postoperative pain and alertness accurately. Other investigators have showed changes in vital capacity [2, 4, 6, 111, analgesic usage [3, 6, 9, 111, PaO, [61, PaCO, [2,6], and forced expiratory flow [6], or in subjective relief from pain [4-6, 9, 111, when intercostal nerve blocks were utilized. n some studies, patients had subcostal or flank incisions [5,9] and thus are not directly comparable to this series. Other series were either not randomized or did not attempt to define analgesic usage by patient weight or to control for variance in dosage or frequency [2-5, 9, 111. Toledo-Pereyra and DeMeester [ll] demonstrated significant improvements in forced expiratory volume and forced vital capacity, as well as a decrease in analgesic requirement and subjective pain. These improvements lasted for approximately 7 days, far longer than would have been expected from the usual activity of bupivacaine. Kaplan and colleagues [6], in a well-defined, randomized, controlled series of 18 patients, compared the use of bupivacaine and saline solution, bupivacaine and low molecular weight dextran, and saline solution and dextran as nerve blocks. They showed significantly less decrease in PaOz, less carbon dioxide retention, and less decrease in forced vital capacity, forced expiratory flow, and analgesic requirements for both groups using bupivacaine than for the saline solution and dextran nerve block. n contrast, in a study of 138 patients undergoing anterolateral or posterolateral thoracotomy, Galway and co-workers [41 could find no statistically significant differences in patients subjective relief from pain, changes in pulmonary functions, arterial blood gases, or analge-

6 127 Woltering et al: Bupivacaine Nerve Blocks sic usage when nerve blocks were utilized. As we found in the present study, they noted some beneficial effects of nerve block anesthesia in the subjective relief from pain in the initial recovery period (sixty minutes) [4]. The adequacy of the chest wall block in our study appeared to be confirmed by a transient subjective sensation of diminished pain in the area of the incision upon injection of bupivacaine by catheter and the objective anesthesia to pinprick of the chest wall surrounding the incision, in the Group 2 patients. Two of the previous groups who reported an improvement in postoperative pain also blocked three intercostal nerves [5, 91. Of the four studies in which five interspaces were blocked, postoperative pain was diminished in three [2, 3, 111 but was not statistically influenced in the study of Galway and associates [4]. n order to adequately control for subjective pain experiences and preoperative patient differences, each patient in this series served as his own control for pulmonary function testing, chest roentgenograms, arterial blood gases, and subjective pain tolerance and assessment ratings. The entry criterion was limited to those patients undergoing limited pulmonary resection, and the patients were given medications in a similar manner. n an effort to define a possible prolonged effect of bupivacaine intercostal nerve blocks, the intermittent percutaneous administration of bupivacaine for 3 days, as well as a single injection was studied. n this series we have seen no improvement in analgesic usage, arterial blood gases, pulmonary function testing, chest roentgenograms, patient s subjective rating of pain and alertness, or in observer s subjective rating of pain and alertness. Thus we were unable to define any objective short-term or long-term benefits from bupivacaine nerve block anesthesia in patients undergoing thoracotomy. References Cottrell W, Shick LM, Perkins HM, et al: Hemodynamic changes after intercostal nerve block with bupivacaine-epinephrine solution. Anesth Analg (Cleve) 57:492, 1978 Faust, RJ, Nauss LA: Post thoracotomy intercostal block: comparison of its effects on pulmonary function with those of intramuscular meperidine. Anesth Analg (Cleve) 55:542, 1976 Fleming WH, Sarafian LB: Kindness pays dividends: the medical benefits of intercostal nerve block following thoracotomy. J Thorac Cardiovasc Surg 74:273, 1977 Galway JE, Caves PK, Dundee JW: Effect of intercostal nerve blockage during operation on lung function and the relief of pain following thoracotomy. Br J Anaesth 47:730, Humphreys CF, Kay H: The control of postoperative wound pain with the use of bupivacaine injections. J Urol 116:618, Kaplan JA, Miller ED, Gallagher ED: Postoperative analgesia for thoracotomy patients. Anesth Analg (Cleve) 54:773, Melzack R: The McGill pain questionnaire: major properties and scoring methods. Pain 1:277, Moore DC, Bridenbaugh LD, Thompson GE, et al: Bupivacaine: a review of 11,080 cases. Anesth Analg (Cleve) 57:42, Noller CW, Gillenwater JY, Howards SS, et al: ntercostal nerve block with flank incision. J Urol 117:759, Otto CW, Wall CL: Total spinal anesthesia: a rare complication of intrathoracic intercostal nerve block. Ann Thorac Surg 22:289, Toledo-Pereyra LH, DeMeester TR: Prospective randomized evaluation of intrathoracic intercostal nerve block with bupivacaine on postoperative ventilatory function. Ann Thorac Surg 27:203, 1979

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