- Email: [email protected]
Pain Control With Bupivacaine After Lung Resections
1360
CORRESPONDENCE
Selimiye Mh. Tibbiye Cd. No. 13, Uskudar Istanbul, Turkey email: [email protected]
References 1. Manenti A, Melegari G, Zizzo M, Barbieri A. Contemporary thoracic aortic and abdominal injuries: an emergency strategy (letter). Ann Thorac Surg 2017;103:1359. 2. Topcu AC, Ciloglu U, Bolukcu A, Dagsali S. Management of traumatic aortic and splenic rupture in a patient with ascending aortic aneurysm. Ann Thorac Surg 2016;102: e81–2. 3. Roselli EE, Idrees J, Greenberg RK, Johnston DR, Lytle BW. Endovascular stent grafting for ascending aorta repair in highrisk patients. J Thorac Cardiovasc Surg 2015;149:144–5. 4. Lu Q, Feng J, Zhou J, et al. Endovascular repair of ascending aortic dissection: a novel treatment option for patients judged unfit for direct surgical repair. J Am Coll Cardiol 2013;61: 1917–24. 5. Estrera AL, Miller CC, 3rd, Guajardo-Salinas G, Coogan S, Charlton-Ouw K, Safi HJ. Update on blunt thoracic aortic injury: fifteen-year single-institution experience. J Thorac Cardiovasc Surg 2013;145:154–8. 6. Santaniello JM, Miller PR, Croce MA. Blunt aortic injury with concomitant intra-abdominal solid organ injury: treatment priorities revisited. J Trauma 2002;53:442–5.
MISCELLANEOUS
Pain Control With Bupivacaine After Lung Resections To the Editor: We read with interest the article by Khalil and colleagues [1] regarding pain control after thoracotomy. Lung resections have been performed with video-assisted thoracic surgery in our clinic. In these surgeries, we use two port incisions and one 3-cmlong utility thoracotomy incision. When we started the operation, we first use bupivacaine for the port incision of thoracoscopy into the intercostal area. We plan the incision level according to the lobe or segment to be resected. Next, the bupivacaine is injected to the branch of intercostal nerve for utility and other port incisions. This procedure provides advantages for the early postoperative period. After the blockage of intercostal nerves, the patients mobilize and start the respiratory exercises early. As a result, hospitalization time is reduced. Generally, we use tramadol hydrochloride on the first day. This material is well tolerated, and it accelerates the mobilization of the patients. The use of bupivacaine repetitively is excellent for the patients who have undergone thoracotomy. The blockage of intercostal nerves decreases the risk of atelectasis and complications. Our aim is mobilize the patient and remove the chest tubes earlier than with other methods. Sometimes we use additional bupivacaine directly into the chest tube incision if any pain occurs. We do not prefer using opioid analgesics for the patients who have to make respiratory exercises for the lung expansion generally, because these drugs have sedative and somniferous effects. We are of the opinion that the use of smaller incisions as a minimally invasive surgery, bupivacaine, and the use of one chest tube reduces acute and chronic postoperative pain. The injection of bupivacaine as a blockage into the intercostal nerve is safe, and it helps to reduce the use of postoperative analgesics.
Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier Inc.
Ann Thorac Surg 2017;103:1359–62
Murat Oncel, MD Guven Sadi Sunam, MD Huseyin Yildiran, MD Selcuk University Medical Faculty Department of Thoracic Surgery Alaeddin Keykubat Kamp€ us€ u, 42000 Konya, Turkey email: [email protected]
Reference 1. Khalil KG, Boutrous ML, Irani AD, et al. Operative intercostal nerve blocks with long-acting bupivacaine liposome for pain control after thoracotomy. Ann Thorac Surg 2015;100:2013–8.
Reply To the Editor: We read with considerable interest the comments made by Oncel and colleagues [1] on our article [2], regarding their experience with intercostal nerve blocks for pain relief, after mostly videoassisted thoracic surgery (VATS) pulmonary resections using bupivacaine. Their favorable experience generally duplicates our own experience using the long-acting liposomal bupivacaine. After our initial experience comparing intercostal blocks (IBs) in 53 patients with thoracic epidural analgesia in 35 patients, we observed statistically significant better pain control in day 1 and 3, fewer pulmonary complications, and shorter length of stay in favor of the IB group. We have used this approach exclusively in the last 2 years for all pulmonary resections. We agree with the authors that smaller incisions not requiring forcible rib spreading, and one chest tube, combined with a single-shot IB with standard bupivacaine HCl, generally result in adequate pain control after VATS. However, this particular bupivacaine formulation is effective for only 6 to 8 hours. We note that for their patients who had thoracotomy, they required repetitive injections to achieve satisfactory pain control. The long-acting bupivacaine liposome used in our study is effective for 3 days or more in reported series [3]; therefore, it has been successful for conventional “open” thoracotomy when compared with continuous epidural analgesia, which we generally used for the first 3 days postoperatively in our earlier series. We also agree that bupivacaine intercostal nerve blocks at multiple levels during thoracotomy have decreased both acute and chronic postoperative pain, by blocking the noxious peripheral nerve stimuli from reaching the posterior column of the spinal cord. The mechanism is thought to be related to blocking both peripheral sensitization of the of the pain transmitting fibers of peripheral nerves and central sensitization of the posterior column neurons, that now perceive ordinary innocuous stimuli, such as light touch and heat as pain [4]. Indeed, we have noted dramatic decrease in the incidence of prolonged postthoracotomy intercostal neuralgia (pathologic pain) in the last 5 years since we adopted this modality for routine pain control after thoracotomy. Our group is now in the final stages of a large randomized controlled study comparing ordinary bupivacaine with liposomal formulation for pain control after thoracotomy, median sternotomy, and thoracoabdominal incisions. The results will be analyzed later this year and will be published in due course.
0003-4975/$36.00
CORRESPONDENCE
Selimiye Mh. Tibbiye Cd. No. 13, Uskudar Istanbul, Turkey email: [email protected]
References 1. Manenti A, Melegari G, Zizzo M, Barbieri A. Contemporary thoracic aortic and abdominal injuries: an emergency strategy (letter). Ann Thorac Surg 2017;103:1359. 2. Topcu AC, Ciloglu U, Bolukcu A, Dagsali S. Management of traumatic aortic and splenic rupture in a patient with ascending aortic aneurysm. Ann Thorac Surg 2016;102: e81–2. 3. Roselli EE, Idrees J, Greenberg RK, Johnston DR, Lytle BW. Endovascular stent grafting for ascending aorta repair in highrisk patients. J Thorac Cardiovasc Surg 2015;149:144–5. 4. Lu Q, Feng J, Zhou J, et al. Endovascular repair of ascending aortic dissection: a novel treatment option for patients judged unfit for direct surgical repair. J Am Coll Cardiol 2013;61: 1917–24. 5. Estrera AL, Miller CC, 3rd, Guajardo-Salinas G, Coogan S, Charlton-Ouw K, Safi HJ. Update on blunt thoracic aortic injury: fifteen-year single-institution experience. J Thorac Cardiovasc Surg 2013;145:154–8. 6. Santaniello JM, Miller PR, Croce MA. Blunt aortic injury with concomitant intra-abdominal solid organ injury: treatment priorities revisited. J Trauma 2002;53:442–5.
MISCELLANEOUS
Pain Control With Bupivacaine After Lung Resections To the Editor: We read with interest the article by Khalil and colleagues [1] regarding pain control after thoracotomy. Lung resections have been performed with video-assisted thoracic surgery in our clinic. In these surgeries, we use two port incisions and one 3-cmlong utility thoracotomy incision. When we started the operation, we first use bupivacaine for the port incision of thoracoscopy into the intercostal area. We plan the incision level according to the lobe or segment to be resected. Next, the bupivacaine is injected to the branch of intercostal nerve for utility and other port incisions. This procedure provides advantages for the early postoperative period. After the blockage of intercostal nerves, the patients mobilize and start the respiratory exercises early. As a result, hospitalization time is reduced. Generally, we use tramadol hydrochloride on the first day. This material is well tolerated, and it accelerates the mobilization of the patients. The use of bupivacaine repetitively is excellent for the patients who have undergone thoracotomy. The blockage of intercostal nerves decreases the risk of atelectasis and complications. Our aim is mobilize the patient and remove the chest tubes earlier than with other methods. Sometimes we use additional bupivacaine directly into the chest tube incision if any pain occurs. We do not prefer using opioid analgesics for the patients who have to make respiratory exercises for the lung expansion generally, because these drugs have sedative and somniferous effects. We are of the opinion that the use of smaller incisions as a minimally invasive surgery, bupivacaine, and the use of one chest tube reduces acute and chronic postoperative pain. The injection of bupivacaine as a blockage into the intercostal nerve is safe, and it helps to reduce the use of postoperative analgesics.
Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier Inc.
Ann Thorac Surg 2017;103:1359–62
Murat Oncel, MD Guven Sadi Sunam, MD Huseyin Yildiran, MD Selcuk University Medical Faculty Department of Thoracic Surgery Alaeddin Keykubat Kamp€ us€ u, 42000 Konya, Turkey email: [email protected]
Reference 1. Khalil KG, Boutrous ML, Irani AD, et al. Operative intercostal nerve blocks with long-acting bupivacaine liposome for pain control after thoracotomy. Ann Thorac Surg 2015;100:2013–8.
Reply To the Editor: We read with considerable interest the comments made by Oncel and colleagues [1] on our article [2], regarding their experience with intercostal nerve blocks for pain relief, after mostly videoassisted thoracic surgery (VATS) pulmonary resections using bupivacaine. Their favorable experience generally duplicates our own experience using the long-acting liposomal bupivacaine. After our initial experience comparing intercostal blocks (IBs) in 53 patients with thoracic epidural analgesia in 35 patients, we observed statistically significant better pain control in day 1 and 3, fewer pulmonary complications, and shorter length of stay in favor of the IB group. We have used this approach exclusively in the last 2 years for all pulmonary resections. We agree with the authors that smaller incisions not requiring forcible rib spreading, and one chest tube, combined with a single-shot IB with standard bupivacaine HCl, generally result in adequate pain control after VATS. However, this particular bupivacaine formulation is effective for only 6 to 8 hours. We note that for their patients who had thoracotomy, they required repetitive injections to achieve satisfactory pain control. The long-acting bupivacaine liposome used in our study is effective for 3 days or more in reported series [3]; therefore, it has been successful for conventional “open” thoracotomy when compared with continuous epidural analgesia, which we generally used for the first 3 days postoperatively in our earlier series. We also agree that bupivacaine intercostal nerve blocks at multiple levels during thoracotomy have decreased both acute and chronic postoperative pain, by blocking the noxious peripheral nerve stimuli from reaching the posterior column of the spinal cord. The mechanism is thought to be related to blocking both peripheral sensitization of the of the pain transmitting fibers of peripheral nerves and central sensitization of the posterior column neurons, that now perceive ordinary innocuous stimuli, such as light touch and heat as pain [4]. Indeed, we have noted dramatic decrease in the incidence of prolonged postthoracotomy intercostal neuralgia (pathologic pain) in the last 5 years since we adopted this modality for routine pain control after thoracotomy. Our group is now in the final stages of a large randomized controlled study comparing ordinary bupivacaine with liposomal formulation for pain control after thoracotomy, median sternotomy, and thoracoabdominal incisions. The results will be analyzed later this year and will be published in due course.
0003-4975/$36.00