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Interpleural analgesia in the management of esophageal perforation
Regional Anesthesia 22(2):185-187, 1997
Interpleural Analgesia in the Management of Esophageal Perforation A. Main, M.B., Ch.B.
Background and Objeaives. lnterpleural analgesia was used in a case oI esophageal
perforation due to surgical mishap. The medical literature cites no reference to use of this technique in this condition. Method. Interpleural bupivacaine analgesia was used along with conventional forms of pain relief. Results. Superior analgesia was obtained, and the method proved to be safe and complication free on a general surgical ward over the period of several days that it was used. Conclusion. Interpleural analgesia is safe and eflective for management of pain due to esophageal perforation. Reg Anesth 1997: 22: 185-187. Key words: interpleural analgesia, bupivacaine, pain control, esophageal perforation.
chest radiograph showing mediastinal air and a Gastrografin swallow confirmed the diagnosis of esophageal perforation. Conservative m a n a g e m e n t was instituted, including continuous nasogastric drainage, intravenous fluids, antibiotics, and a cimefidine infusion. Analgesia consisted of meperidine 75 mg intramuscularly every 3-4 hours, which the referring surgeons managed. The patient was referred to the anesthesia d e p a r t m e n t for assessment of pain control, tie was in severe pain, uncontrolled on the present regimen. A regional approach by a continuous interpleural technique was chosen. The block was instituted with patient consent and u n d e r appropriate monitoring (noninvasive blood pressure, electrocardiography, and pulse oximetry). With the patient semirecumbent, the approach into the interpleural space was made through tile seventh left intercostal space in the posterior axillary line. An 8-cm, 16-gauge Tuohy needle (Portex, Hythe, England) was used, through which 15 cm of catheter line was left in sire. A hanging drop technique was used to identify the interpleural space. A dose of 20 mL bupivacaine 0.5% with epinephrine 1:200,000 (Astra Pharmaceuticals, Kings Langley, England) was given over 5 nfinutes, producing rapid onset of analgesia. The pleuritic c o m p o n e n t of the pain was
This case report provides evidence that prolonged interpleural analgesia can be used as part of the balanced analgesic m a n a g e m e n t of esophageal perforation, as in this case was done safely in the setting of a busy general surgical ward.
Case Report A 53-year-old, 80-kg m a n u n d e r w e n t upper digestive endoscopy as part of an investigation of a 6 - m o n t h history of acid reflux symptoms. Six hours after the endoscopy, during which meperidine and diazepam were given intravenously, he complained of left sided pleuritic-type chest pain radiating to the left shoulder and back, along with constant right hypochondrial pain. On examination, he was dyspneic, distressed With pain, and unable to lie flat. He also demonstrated e m p h y sema, tachycardia, and elevated blood pressure. A
From the General Infirmary at Leeds, Leeds, England. The case reported here occurred at the Huddcrsfield Royal Infirmary, Huddersfield, England. Accepted for publication January 19, 1996. Reprint requests: A. Main, M.B., Ch.B., Castle tlill llospital, Castle Road, Coningham, East Yorkshire, HU16 5JQ, U.K.
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relieved almost completely, which allowed tile patient to breathe more easily. The patient's shoulder and epigastric pain, although still present, was markedly reduced. A chest radiograph taken with a portable machine immediately after insertion showed no evidence of pneumothorax, and the position of the catheter was displayed with the contrast medium, iopamidol (Niopam 200, Merck Pharmaceuticals, Alton Hampshire, U.K.). No adverse effects occurred, although blood pressure and pulse rate were slightly reduced. Arterial oxygen saturation improved from 92% to 97% with the patient breathing oxygen delivered from nasal prongs at 4 L/min. Altered pinprick sensation was found over a 3--4-cm patch of skin about 10 cm below the left nipple, just above the costal margin. Formal pain scoring was not undertaken. After 3 days and five repeat doses at 8- to 12hour-intervals, a continuous 7.5 mL/h infusion of bupivacaine 0.5% with epinephrine 1:200,000 delivered at 7.5 was instituted. This regimen continued for 10 days, during which breakthrough pain was experienced when attempts were made to reduce the infusion rate. The infusion rate was halved after 10 days and stopped completely after 14 days. At no time did the patient develop toxicity to the local anesthetic. Sixteen days after insertion, tile catheter was withdrawn and"sent for bacterial culture, which grew no organisms. During this time, chest radiography showed a developing bilateral basal consolidation and a leftsided pleural effusion due to continued esophageal soiling of the chest cavity. In addition, balanced analgesia consisting of diclofenac and meperidine was used for tile first 2 days. This regimen allowed vigorous c h e s t p h y s i o t h e r a p y to continue, thus avoiding the need for mechanical ventilation due to a worsening venous admixture. Clinical and radiologic resolution progressed thereafter uneventfully, and 3.weeks after the start of his illness the patient was discharged home with a feeding gastrostomy, which had been placed endoscopically 3 days prior to his discharge. Review of chest radiographs subsequent to discharge have shown no abnormality.
Discussion Interpleural analgesia was first described in 1984 in Norway by Reiestad and Stromskag, in a series of 81 patients undergoing cholecystectomy via subcostal incision, unilateral breast surgery, o r renal surgery (1). Since then, it has been used in a number of clinical settings. In the management of chest
trauma, it has obviated the need for opioids and thoracic extradural analgesia (2) and has been used after thoracotomy (3). The severity of this patient's pain, along with impending respiratory complications, demanded an effective analgesic regimen with minimal cost in terms of side effects. Regional block was therefore required, with only the choice of technique open to consideration. Our concern was to provide superior analgesia, perhaps with sparing of opiates and other analgesics, for pleuritic pain with a visceral component. The options considered were paravertebral, epidural, and interpleural analgesic techniques by either bolus or continuous infusion. The spread of injectate in a successful paravertebral block can reach as many as five vertebral levels, with some extension into the epidural space affording visceral analgesia, but it cannot extend across the midline (4). Conversely, interpleural solutions are known to spread throughout the entire pleural cavity (1). Thoracic epidural block gives excellent analgesia and has provided effective in chest injury with rib fractures. Epidural local anesthetics can, however, produce systemic hypotension, urinary retention, and epidural opiates have the potential to cause respiratory depression (5,6). The site of deposition of the drug in the pleural space would seem to suggest that diffusion occurs across the endothoracic fascia, especially through the posterior intercostal membrane, under which the ventral ramus of the mixed spinal nerve and sympathetic ganglia both lie. The generalized spread of the solution can cause a partial or complete phrenic nerve paralysis, as shown in animal studies (7). Unilateral phrenic nerve block has been implicated in failing to improve forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) following cholecystectomy, since these patients are not limited in their breathing by pain(8). However, this cannot be a constant clinical finding, since other studies have proved that the use of interpleural analgesia is associated with a significant improvement in FVC and FEV~ (9). Pulmonary function testing was not undertaken in our case, but vigorous physiotherapy and incentive spirometry were managed easily by our patient. When tested formally, our patient had little altered sensation to pinprick, although subjective pain relief was satisfactory and rapid in onset. In tile literature, a differential effect has been noted between different strengths of anesthetic agent (2). Throughout the duration of anesthetic use in our patient, we administered 0.5% bupivacaine and
InterpleuralAnalgesia for Esophageal Perforation
w e r e unable to m a t c h subjective relief to the cutan e o u s extent of the block. Since we w e r e unable to care for this patient in the intensive care unit, i n t e r m i t t e n t bolus dosing was selected as being less "nurse intensive" on a b u s y general ward. However, after b r e a k t h r o u g h pain occurred m o r e frequently t h a n was desirable, a c o n t i n u o u s infusion was c o m m e n c e d . Interpleural bupivacaine infusion has p r o d u c e d analgesia superior to that p r o d u c e d by bolus dosing in the postoperative setting (10). The rate of bupivacaine given was within the r e c o m m e n d e d limits for the patient's weight. However, studies on interpleural b u p i v a c a i n e kinetics h a v e s h o w n that 0.25% bupivacaine at 8 - 1 0 m L / h can give effective postoperative analgesia (11,12). Regional techniques provide superior analgesia as c o m p a r e d with "as needed" intramuscular opiates, especially w h e n part of a balanced analgesic regimen (13). Nonsteroidal a n t i i n f l a m m a tory drugs (NSAIDs) given i n t r a v e n o u s l y to postt h o r a c o t o m y patients reduce opiate c o n s u m p t i o n and i m p r o v e gas e x c h a n g e values in c o m p a r i s o n with patients given opiates alone (14). We used a n NSAID in o u r patient's t r e a t m e n t and n o t e d it to be well accepted and a useful adjunct to the regional approach. In s u m m a r y , the use of interpleural analgesia in the m a n a g e m e n t of pain due to esophageal perforation has b e e n f o u n d to be a safe and effective m e a n s of providing analgesia. It proved to be well tolerated by the patient, easy to m a n a g e o n a general surgical ward, a n d free f r o m a n y of the reported complications of the technique.
References 1. Reiestad F, Stromskag KE. Interpleural catheter in the management of post-operative pain. Reg Anesth 1985:11: 89-91. 2. Rocco A, Reiestad F, Gudman J, McKay W. Interpleural administration of local anesthetics for pain relief in patients with multiple rib fractures. Preliminary report. Reg Anesth 1987: 12: 10-14.
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3. Ferrante FM, Chan VWS, Arthur GR, Rocco AG. Interplcural analgesia after thoracotomy. Anesth Analg 1991: 72: 105-109. 4. Conacher ID, Kokri M. Post-operative paravertebral blocks f o r thoracic surgery--a radiological appraisal. Br J Anaesth 1987: 59: 155-161. 5. Griffiths DPG, Diamond AW, Cameron JD. Postoperative extradural analgesia following thoracic surgery: A feasibility study. Br J Anaesth 1975: 47: 48-55. 6. Bromage PR, Camporesi E, Chestnut D. Epidural narcotics for post-operative analgesia. Anesth Analg 1980: 59: 473-480. 7. Kowalski SE, Bradley BD, Greengrass RA, Freedman J, Younes MK. Effects of interpleural bupivacaine (0.5%) on canine diaphragmatic function. Anesth Analg 1992: 75: 400-404. 8. Oxorn DC, Whatley GS. Post-cholecystectomy pulmonary function following interpleural bupivacaine and intramuscular pethidine. Anaesth Intensive Care 1989: 17: 440-443. 9. Vadeboncouer TR, Reigler FX, Gautt RS, Weinberg GL. A randomised, double-blind comparison of the effects of interpleural bupivacaine and saline on morphine requirements and pulmonary function after cholecystectomy. Anesthesiology 1989: 71: 339-343. 10. Aquilar JL, Montes A, Montero A, Vidal E F-Llamazares J, Pastor C. Continuous pleural infusion of bupivacaine offers better post-operative pain relief than does bolus administration. Reg Anesth 1992: 17: 12-14. 11. Kastrissios H, Triggs EJ, Mogg GAG, Higbie JW. The disposition of bupivacaine following a 72 hr interpleural infusion in cholecystectomy patients. Br J Clin Pharmacol 1991: 32: 251254. 12. Seltzer JL, Larijani GE, Goldberg ME, Marr AT. Imrapleural bupivacaine--a kinetic and dynamic evaluation. Anesthesiology 1987: 67: 798800. 13. Dahl JB, Kehlet H. Non-steroidal anti-flammatory drugs: Rationale for use in severe postoperative pain. Br J Anaesth 1991: 66: 703712. 14. Pertuuen K, Kalso E, Heinonen J, Salo J. IV diclofenac in post-thoracotomy pain. Br J Anaesth 1992: 68: 474-480.
Interpleural Analgesia in the Management of Esophageal Perforation A. Main, M.B., Ch.B.
Background and Objeaives. lnterpleural analgesia was used in a case oI esophageal
perforation due to surgical mishap. The medical literature cites no reference to use of this technique in this condition. Method. Interpleural bupivacaine analgesia was used along with conventional forms of pain relief. Results. Superior analgesia was obtained, and the method proved to be safe and complication free on a general surgical ward over the period of several days that it was used. Conclusion. Interpleural analgesia is safe and eflective for management of pain due to esophageal perforation. Reg Anesth 1997: 22: 185-187. Key words: interpleural analgesia, bupivacaine, pain control, esophageal perforation.
chest radiograph showing mediastinal air and a Gastrografin swallow confirmed the diagnosis of esophageal perforation. Conservative m a n a g e m e n t was instituted, including continuous nasogastric drainage, intravenous fluids, antibiotics, and a cimefidine infusion. Analgesia consisted of meperidine 75 mg intramuscularly every 3-4 hours, which the referring surgeons managed. The patient was referred to the anesthesia d e p a r t m e n t for assessment of pain control, tie was in severe pain, uncontrolled on the present regimen. A regional approach by a continuous interpleural technique was chosen. The block was instituted with patient consent and u n d e r appropriate monitoring (noninvasive blood pressure, electrocardiography, and pulse oximetry). With the patient semirecumbent, the approach into the interpleural space was made through tile seventh left intercostal space in the posterior axillary line. An 8-cm, 16-gauge Tuohy needle (Portex, Hythe, England) was used, through which 15 cm of catheter line was left in sire. A hanging drop technique was used to identify the interpleural space. A dose of 20 mL bupivacaine 0.5% with epinephrine 1:200,000 (Astra Pharmaceuticals, Kings Langley, England) was given over 5 nfinutes, producing rapid onset of analgesia. The pleuritic c o m p o n e n t of the pain was
This case report provides evidence that prolonged interpleural analgesia can be used as part of the balanced analgesic m a n a g e m e n t of esophageal perforation, as in this case was done safely in the setting of a busy general surgical ward.
Case Report A 53-year-old, 80-kg m a n u n d e r w e n t upper digestive endoscopy as part of an investigation of a 6 - m o n t h history of acid reflux symptoms. Six hours after the endoscopy, during which meperidine and diazepam were given intravenously, he complained of left sided pleuritic-type chest pain radiating to the left shoulder and back, along with constant right hypochondrial pain. On examination, he was dyspneic, distressed With pain, and unable to lie flat. He also demonstrated e m p h y sema, tachycardia, and elevated blood pressure. A
From the General Infirmary at Leeds, Leeds, England. The case reported here occurred at the Huddcrsfield Royal Infirmary, Huddersfield, England. Accepted for publication January 19, 1996. Reprint requests: A. Main, M.B., Ch.B., Castle tlill llospital, Castle Road, Coningham, East Yorkshire, HU16 5JQ, U.K.
185
186
RegionalAnesthesia Vol. 22 No. 2 March-April 1997
relieved almost completely, which allowed tile patient to breathe more easily. The patient's shoulder and epigastric pain, although still present, was markedly reduced. A chest radiograph taken with a portable machine immediately after insertion showed no evidence of pneumothorax, and the position of the catheter was displayed with the contrast medium, iopamidol (Niopam 200, Merck Pharmaceuticals, Alton Hampshire, U.K.). No adverse effects occurred, although blood pressure and pulse rate were slightly reduced. Arterial oxygen saturation improved from 92% to 97% with the patient breathing oxygen delivered from nasal prongs at 4 L/min. Altered pinprick sensation was found over a 3--4-cm patch of skin about 10 cm below the left nipple, just above the costal margin. Formal pain scoring was not undertaken. After 3 days and five repeat doses at 8- to 12hour-intervals, a continuous 7.5 mL/h infusion of bupivacaine 0.5% with epinephrine 1:200,000 delivered at 7.5 was instituted. This regimen continued for 10 days, during which breakthrough pain was experienced when attempts were made to reduce the infusion rate. The infusion rate was halved after 10 days and stopped completely after 14 days. At no time did the patient develop toxicity to the local anesthetic. Sixteen days after insertion, tile catheter was withdrawn and"sent for bacterial culture, which grew no organisms. During this time, chest radiography showed a developing bilateral basal consolidation and a leftsided pleural effusion due to continued esophageal soiling of the chest cavity. In addition, balanced analgesia consisting of diclofenac and meperidine was used for tile first 2 days. This regimen allowed vigorous c h e s t p h y s i o t h e r a p y to continue, thus avoiding the need for mechanical ventilation due to a worsening venous admixture. Clinical and radiologic resolution progressed thereafter uneventfully, and 3.weeks after the start of his illness the patient was discharged home with a feeding gastrostomy, which had been placed endoscopically 3 days prior to his discharge. Review of chest radiographs subsequent to discharge have shown no abnormality.
Discussion Interpleural analgesia was first described in 1984 in Norway by Reiestad and Stromskag, in a series of 81 patients undergoing cholecystectomy via subcostal incision, unilateral breast surgery, o r renal surgery (1). Since then, it has been used in a number of clinical settings. In the management of chest
trauma, it has obviated the need for opioids and thoracic extradural analgesia (2) and has been used after thoracotomy (3). The severity of this patient's pain, along with impending respiratory complications, demanded an effective analgesic regimen with minimal cost in terms of side effects. Regional block was therefore required, with only the choice of technique open to consideration. Our concern was to provide superior analgesia, perhaps with sparing of opiates and other analgesics, for pleuritic pain with a visceral component. The options considered were paravertebral, epidural, and interpleural analgesic techniques by either bolus or continuous infusion. The spread of injectate in a successful paravertebral block can reach as many as five vertebral levels, with some extension into the epidural space affording visceral analgesia, but it cannot extend across the midline (4). Conversely, interpleural solutions are known to spread throughout the entire pleural cavity (1). Thoracic epidural block gives excellent analgesia and has provided effective in chest injury with rib fractures. Epidural local anesthetics can, however, produce systemic hypotension, urinary retention, and epidural opiates have the potential to cause respiratory depression (5,6). The site of deposition of the drug in the pleural space would seem to suggest that diffusion occurs across the endothoracic fascia, especially through the posterior intercostal membrane, under which the ventral ramus of the mixed spinal nerve and sympathetic ganglia both lie. The generalized spread of the solution can cause a partial or complete phrenic nerve paralysis, as shown in animal studies (7). Unilateral phrenic nerve block has been implicated in failing to improve forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) following cholecystectomy, since these patients are not limited in their breathing by pain(8). However, this cannot be a constant clinical finding, since other studies have proved that the use of interpleural analgesia is associated with a significant improvement in FVC and FEV~ (9). Pulmonary function testing was not undertaken in our case, but vigorous physiotherapy and incentive spirometry were managed easily by our patient. When tested formally, our patient had little altered sensation to pinprick, although subjective pain relief was satisfactory and rapid in onset. In tile literature, a differential effect has been noted between different strengths of anesthetic agent (2). Throughout the duration of anesthetic use in our patient, we administered 0.5% bupivacaine and
InterpleuralAnalgesia for Esophageal Perforation
w e r e unable to m a t c h subjective relief to the cutan e o u s extent of the block. Since we w e r e unable to care for this patient in the intensive care unit, i n t e r m i t t e n t bolus dosing was selected as being less "nurse intensive" on a b u s y general ward. However, after b r e a k t h r o u g h pain occurred m o r e frequently t h a n was desirable, a c o n t i n u o u s infusion was c o m m e n c e d . Interpleural bupivacaine infusion has p r o d u c e d analgesia superior to that p r o d u c e d by bolus dosing in the postoperative setting (10). The rate of bupivacaine given was within the r e c o m m e n d e d limits for the patient's weight. However, studies on interpleural b u p i v a c a i n e kinetics h a v e s h o w n that 0.25% bupivacaine at 8 - 1 0 m L / h can give effective postoperative analgesia (11,12). Regional techniques provide superior analgesia as c o m p a r e d with "as needed" intramuscular opiates, especially w h e n part of a balanced analgesic regimen (13). Nonsteroidal a n t i i n f l a m m a tory drugs (NSAIDs) given i n t r a v e n o u s l y to postt h o r a c o t o m y patients reduce opiate c o n s u m p t i o n and i m p r o v e gas e x c h a n g e values in c o m p a r i s o n with patients given opiates alone (14). We used a n NSAID in o u r patient's t r e a t m e n t and n o t e d it to be well accepted and a useful adjunct to the regional approach. In s u m m a r y , the use of interpleural analgesia in the m a n a g e m e n t of pain due to esophageal perforation has b e e n f o u n d to be a safe and effective m e a n s of providing analgesia. It proved to be well tolerated by the patient, easy to m a n a g e o n a general surgical ward, a n d free f r o m a n y of the reported complications of the technique.
References 1. Reiestad F, Stromskag KE. Interpleural catheter in the management of post-operative pain. Reg Anesth 1985:11: 89-91. 2. Rocco A, Reiestad F, Gudman J, McKay W. Interpleural administration of local anesthetics for pain relief in patients with multiple rib fractures. Preliminary report. Reg Anesth 1987: 12: 10-14.
9
Main
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3. Ferrante FM, Chan VWS, Arthur GR, Rocco AG. Interplcural analgesia after thoracotomy. Anesth Analg 1991: 72: 105-109. 4. Conacher ID, Kokri M. Post-operative paravertebral blocks f o r thoracic surgery--a radiological appraisal. Br J Anaesth 1987: 59: 155-161. 5. Griffiths DPG, Diamond AW, Cameron JD. Postoperative extradural analgesia following thoracic surgery: A feasibility study. Br J Anaesth 1975: 47: 48-55. 6. Bromage PR, Camporesi E, Chestnut D. Epidural narcotics for post-operative analgesia. Anesth Analg 1980: 59: 473-480. 7. Kowalski SE, Bradley BD, Greengrass RA, Freedman J, Younes MK. Effects of interpleural bupivacaine (0.5%) on canine diaphragmatic function. Anesth Analg 1992: 75: 400-404. 8. Oxorn DC, Whatley GS. Post-cholecystectomy pulmonary function following interpleural bupivacaine and intramuscular pethidine. Anaesth Intensive Care 1989: 17: 440-443. 9. Vadeboncouer TR, Reigler FX, Gautt RS, Weinberg GL. A randomised, double-blind comparison of the effects of interpleural bupivacaine and saline on morphine requirements and pulmonary function after cholecystectomy. Anesthesiology 1989: 71: 339-343. 10. Aquilar JL, Montes A, Montero A, Vidal E F-Llamazares J, Pastor C. Continuous pleural infusion of bupivacaine offers better post-operative pain relief than does bolus administration. Reg Anesth 1992: 17: 12-14. 11. Kastrissios H, Triggs EJ, Mogg GAG, Higbie JW. The disposition of bupivacaine following a 72 hr interpleural infusion in cholecystectomy patients. Br J Clin Pharmacol 1991: 32: 251254. 12. Seltzer JL, Larijani GE, Goldberg ME, Marr AT. Imrapleural bupivacaine--a kinetic and dynamic evaluation. Anesthesiology 1987: 67: 798800. 13. Dahl JB, Kehlet H. Non-steroidal anti-flammatory drugs: Rationale for use in severe postoperative pain. Br J Anaesth 1991: 66: 703712. 14. Pertuuen K, Kalso E, Heinonen J, Salo J. IV diclofenac in post-thoracotomy pain. Br J Anaesth 1992: 68: 474-480.