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Use of continuous retropleural bupivacaine in postoperative pain management for pediatric thoracotomy
Use of Continuous Retropleural Bupivacaine in Postoperative Management for Pediatric Thoracotomy By Michael
I? Gibson,
Thomas Akron,
Background/Purpose: The aim of this study the use of a continuous bupivacaine infusion pleural space as an adjunct for postoperative ment in pediatric thoracotomy.
was to evaluate into the retropain manage-
Metbods:A retrospective chart review was performed on 13 pediatric patients undergoing thoracotomy over a 3-year period (April 1995 through July 1997). In seven patients, insertion of a retropleural catheter was accomplished before closure of the thoracotomy by placing an epidural catheter posterior to the parietal pleura. This potential space was entered two intercostal levels below the incision and advanced superiorly four intercostal spaces. Bupivacaine (0.125% or 0.25%) was infused at 0.5 ml/kg/h. Postoperative intravenous narcotic requirement was compared between the study population (n = 7) and the control population (n = 6). Statistical analysis was conducted using the “separate” Student’s ttest. Resulfs:Thirteen were evaluated
pediatric for total
patients morphine
(age range, use after
7 to 18 years) thoracotomy.
P
OSTOPERATIVE PAIN MANAGEMENT in thoracotomy patients often is diffkult. The pediatric population presents an even greater challenge secondary to their inability to effectively communicate their pain intensity. A multitude of alternative modalities have been investigated to provide relief from thoracotomy pain, while also lessening the possible morbidity of parental therapy. However. little has been published on postoperative thoracotomy pain management in the pediatric population. The aim of this study was to evaluate the use of a continuous bupivacaine infusion into the retropleural space as an adjunct for postoperative pain management in pediatric thoracotomy. MATERIALS
AND
METHODS
Vetter,
and
John
Pain
P. Crow
Ohio
Seven patients had anterior spinal five had mediastinal operations, lobectomy. The two groups were and type of operation. Infusion catheter continued for an average days). The total mean postoperative was 2.32 mg/kg (0.544 mg/kg/day) and 0.88 mgikg 10.204 mgikgiday) retropleural catheter (P < ,001).
release and fusion, whereas and one patient had a comparable in age, weight, through the retropleural of 3.8 days (range, 3 to 6 morphine requirement in the control population for the patients with a
Conclusion: A continuous infusion of bupivacaine through a unique retropleural technique decreases the postoperative need for morphine in postoperative pediatric thoracotomy patients. J Pediatr Surg 34:199-201. Copyright o 1999 by W.B. Saunders Company. INDEX WORDS: management,
Retropleural postthoracotomy
bupivacaine, pain.
postoperative
pain
catheter was passed four intercostal spaces cephalad. A stairstep incision in the pleum was needed on occasion and then wah closed. The catheter was secured loosely to the pleura with an absorbable suture and conventionally dressed on the skin surface. A bolus of bupivacaine was given before emergence from anesthesia (0.15 mL/kg of 025% bupivacaine with I :7OOOOO epinephrine). Bupivacaine (0.135% or 0.15%) mith or without 1:700000 epinephrine was infused at 0.5 ml/kg/h beginning on admission to the recovery room. Postoperative intravenous morphine (0.1 mglkg) was given on an every-z-hour as-needed barih per patient request or when deemed necessary by the nursing staff. Cumulative postoperative morphine use was I-ecorded. The postoperative intravenous morphine requirement (milligrams per kilogram per hour) was then compared between the study population (n = 7) and the control population (n = 6). Statistical analysis was conducted using a “separate” Student’s I test, with a P less than .05 considered indicative of a significant population difference. RESULTS
A rermspectivr chart review was performed on I3 pediatric patient\ undergoIng thoracotomy from April 1995 through July 1997. In \evrn patients, insertion of a rodiopaque polyamide XI-gauge epidural catheter (B. Braun Medical Inc. Bethlehem. PA) wa< accomplished before thoracoromy closure.
Thirteen pediatric patients (age range, 7 to 18 years) were evaluated for total morphine use after thoracotomy.
Before closure of the thoracotomy. the epidural catheter was introduced pel-cutaneously into the hemithorax through an 18.gauge Touhy Schliff epidural needle (B. Braun Medical Inc) used essentially as an Introducer (Fig 1). The retropleural space was developed through a mull incision in the parietal pleura. IO cm lateral to the costovertebral Junction. two intercostal spaces below the incision. The epidural Journaf
of Pediatric
Surgery.
Vol 34, No 1 (January),
1999: pp 199.201
199
200
GIBSON,
Retropleural
VETTER,
AND
CROW
day) in the control population versus 0.88 mg/kg (0.204 mg/kg/day) for the patients with a retropleural catheter (P < .OOl, Table 1).
Catheter
DISCUSSION
ion 7”,XI”‘rfintercostal
Fig 1.
Retropleural
catheter
Nerve
location.
Three patients underwent left thoracotomies, whereas 10 patients received right thoracotomies. Seven patients had anterior spinal release and fusion, and five had mediastinal operations, and one patient had a lobectomy. These two groups were comparable with respect to age, weight, and type of operation. Infusion through the retropleural catheter was maintained for an average of 3.8 days (range, 3 to 6 days). Three patients received 0.125% bupivacaine with 1:200000 epinephrine, two patients received 0.125% bupivacaine without epinephrine, one patient received 0.25% bupivacaine with 1:200000 epinephrine, and one patient received 0.25% bupivacaine without epinephrine. The total morphine use for those patients receiving the retropleural bupivacaine ranged from 0.02 mg/kg (0.008 mg/kg/day) to 1.98 mg/kg (0.367 mg/kg/day), whereas total morphine use without the catheter varied from 1.41 mg/kg (0.353 mg/kg/day ) to 2.79 mg/kg (0.697 mg/kg/day). The total mean postoperative morphine requirement was 2.32 mg/kg (0.544 mg/kg/
Multiple modalities have been investigated to effect improved postoperative thoracotomy pain management, however, little attention has been focused on the pediatric population.‘-6 Local measures such as discrete intercostal nerve blocks and intrapleural delivery of local anesthetics have been evaluated in the adult and pediatric populations.1.3-sUnlike discrete nerve blocks, which provide no more than 6 hours of analgesia, the retropleural catheter technique presented here allows for sustained analgesia. Moreover, acute changes in local anesthetic blood concentrations are essentially avoided, thus lessening the likelihood of toxicity. Furthermore, our retropleural catheter technique provides for a more precise anatomic delivery of local anesthesia. By developing a potential space, the local anesthetic solution delivered via the retropleural catheter directly bathes the intercostal nerves. The entire volume of local anesthetic, dispersed from the tip. impacts all four intercostal nerves before dissipating into the markedly larger interpleural space. It is the high concentration of drug delivered into a limited area that provides effective regional pain control. The use of bupivacaine as an anesthetic has been well established in both pediatric and adult populations.‘,3,1 The concentration of bupivacaine of 0.125% or 0.25% with or without epinephrine at an infusion rate of 0.5 ml/kg/h was chosen because of previous research findings that have recommended an infusion rate not to exceed 0.5 ml/kg/h of 0.25% bupivacaine with 1:200000 epinephrine.’ It should be noted that more recent recommendations have admonished the delivery of no more than 0.5 mg/kgih of bupivacaine via either an intrapleural or epidural route of administration in children.’ Thus, the use of 0.125% bupivacaine should be considered if bupivacaine infusion rates of more than 0.5 ml/kg/h are used. During the period reviewed, varying attending anesthesiologists preferences resulted in varying local anesthetic concentrations. The study will be continued in a prospective fashion using standardized drug dosage protocols. In our study, the use of a retropleural catheter as an adjunct in postoperative thoracotomy pain management with respect to quantity of morphine use showed a statistically significant difference with an observed P value of less than .OOl. It would thus appear that placement of such a catheter is useful in pediatric postoperative thoracotomy pain management.
RETROPLEURAL
BUPIVACAINE
AFTER
THORACOTOMY
201
Table 1. Comparison Patient NO.
Group 1
Age (vr)
Group
and Study
Group
Retropleural Agent
Morphine Requirement (mgikgidav)
SW
Weight (kg)
M
29.1
Anterior
None
No
0.644
spinal release Esophageal repair Resection of paraspinal
None
No No
0.425
None
exposure release
and
None
No
0.546
exposure
and
No
0.353
None
No
0.601
and
0.125% bupivacaine with I:200000 epinephrine
Yes
0.082
and
0.125% bupivacaine with I:200000 epinephrine 0.125% bupivacaine with
Yes
0.367
Yes
0.119
0.25% bupivacaine with I:200000 epinephrine
Yes
0.156
0.25%
Surgical Procedure
Retropleural Catheter
1 (Control)
2
M
27.7
3
M
33
4 5
17 18
6
exposure
and
F
46.7
mass Anterior spinal
M
51.5
Anterior
57.6
spinal release Resection of broncho-
F
genie Group 7
of Control
0.697
cyst
2 (Study)
8 3 10
14
F
63
19
M
59
Anterior spinal Anterior
26
spinal release Resection of broncho-
72
genie Anterior
8
F F
spinal
exposure release exposure
cyst exposure
I:200000 and
release
epinephrine
11
F
23
0.364
M
60
Lobectomy Anterior exposure
Yes
12
and
0.125%
bupivacaine
Yes
0.331
63
spinal Anterior
and
0.125%
bupivacaine
Yes
0.008
13
F
spinal
release exposure
bupivacaine
release
REFERENCES WB. Knox RF. Fennessey PV. et al: Continuous of bupivacaine via intrapleural catheter for analgesia after thoracotomy in children, Anesthesiology 69:X-264, 1988 2. Safran D. Kuhlman G, Orhant EE. et al: Continuous intercostal blockade with lidocaine after thoracic surgery. Anesth Analg 70:3453-19. 1990 3. Seltzer JL. Larijani GE. Goldberg ME. et al: lntrapleural bupivacaine-.A kinetic and dynamic evaluation. Anesthesiology 67:798-800. 1987 4, Rosenberg PH. Scheimn BM. Lepantalo MJ. et al: Continuous I. Mcllvaine
infusion
intrapleural infusion of bupivacaine Anesthesiology 67:X I I-8 13. 1987
for analgesia
after
thoracotomy.
5. Aykac B. Erolcay H. Dikmen Y, et al: Comparison of intrapleural versus intravenous morphine for postthoracotomy pain management. J Cardiothorac Vast Anesthesia 9538.540, 1995 6. Covino
BG: Inter-pleural
regional
Analgesia.
Anesth
Analg
67:427-
419, 1988 7. Berde CB: Convulsions associated with pediatric sia. Anesth Analg 1992:75: 164-l 66 (editorial)
regional
aneuthe-
I? Gibson,
Thomas Akron,
Background/Purpose: The aim of this study the use of a continuous bupivacaine infusion pleural space as an adjunct for postoperative ment in pediatric thoracotomy.
was to evaluate into the retropain manage-
Metbods:A retrospective chart review was performed on 13 pediatric patients undergoing thoracotomy over a 3-year period (April 1995 through July 1997). In seven patients, insertion of a retropleural catheter was accomplished before closure of the thoracotomy by placing an epidural catheter posterior to the parietal pleura. This potential space was entered two intercostal levels below the incision and advanced superiorly four intercostal spaces. Bupivacaine (0.125% or 0.25%) was infused at 0.5 ml/kg/h. Postoperative intravenous narcotic requirement was compared between the study population (n = 7) and the control population (n = 6). Statistical analysis was conducted using the “separate” Student’s ttest. Resulfs:Thirteen were evaluated
pediatric for total
patients morphine
(age range, use after
7 to 18 years) thoracotomy.
P
OSTOPERATIVE PAIN MANAGEMENT in thoracotomy patients often is diffkult. The pediatric population presents an even greater challenge secondary to their inability to effectively communicate their pain intensity. A multitude of alternative modalities have been investigated to provide relief from thoracotomy pain, while also lessening the possible morbidity of parental therapy. However. little has been published on postoperative thoracotomy pain management in the pediatric population. The aim of this study was to evaluate the use of a continuous bupivacaine infusion into the retropleural space as an adjunct for postoperative pain management in pediatric thoracotomy. MATERIALS
AND
METHODS
Vetter,
and
John
Pain
P. Crow
Ohio
Seven patients had anterior spinal five had mediastinal operations, lobectomy. The two groups were and type of operation. Infusion catheter continued for an average days). The total mean postoperative was 2.32 mg/kg (0.544 mg/kg/day) and 0.88 mgikg 10.204 mgikgiday) retropleural catheter (P < ,001).
release and fusion, whereas and one patient had a comparable in age, weight, through the retropleural of 3.8 days (range, 3 to 6 morphine requirement in the control population for the patients with a
Conclusion: A continuous infusion of bupivacaine through a unique retropleural technique decreases the postoperative need for morphine in postoperative pediatric thoracotomy patients. J Pediatr Surg 34:199-201. Copyright o 1999 by W.B. Saunders Company. INDEX WORDS: management,
Retropleural postthoracotomy
bupivacaine, pain.
postoperative
pain
catheter was passed four intercostal spaces cephalad. A stairstep incision in the pleum was needed on occasion and then wah closed. The catheter was secured loosely to the pleura with an absorbable suture and conventionally dressed on the skin surface. A bolus of bupivacaine was given before emergence from anesthesia (0.15 mL/kg of 025% bupivacaine with I :7OOOOO epinephrine). Bupivacaine (0.135% or 0.15%) mith or without 1:700000 epinephrine was infused at 0.5 ml/kg/h beginning on admission to the recovery room. Postoperative intravenous morphine (0.1 mglkg) was given on an every-z-hour as-needed barih per patient request or when deemed necessary by the nursing staff. Cumulative postoperative morphine use was I-ecorded. The postoperative intravenous morphine requirement (milligrams per kilogram per hour) was then compared between the study population (n = 7) and the control population (n = 6). Statistical analysis was conducted using a “separate” Student’s I test, with a P less than .05 considered indicative of a significant population difference. RESULTS
A rermspectivr chart review was performed on I3 pediatric patient\ undergoIng thoracotomy from April 1995 through July 1997. In \evrn patients, insertion of a rodiopaque polyamide XI-gauge epidural catheter (B. Braun Medical Inc. Bethlehem. PA) wa< accomplished before thoracoromy closure.
Thirteen pediatric patients (age range, 7 to 18 years) were evaluated for total morphine use after thoracotomy.
Before closure of the thoracotomy. the epidural catheter was introduced pel-cutaneously into the hemithorax through an 18.gauge Touhy Schliff epidural needle (B. Braun Medical Inc) used essentially as an Introducer (Fig 1). The retropleural space was developed through a mull incision in the parietal pleura. IO cm lateral to the costovertebral Junction. two intercostal spaces below the incision. The epidural Journaf
of Pediatric
Surgery.
Vol 34, No 1 (January),
1999: pp 199.201
199
200
GIBSON,
Retropleural
VETTER,
AND
CROW
day) in the control population versus 0.88 mg/kg (0.204 mg/kg/day) for the patients with a retropleural catheter (P < .OOl, Table 1).
Catheter
DISCUSSION
ion 7”,XI”‘rfintercostal
Fig 1.
Retropleural
catheter
Nerve
location.
Three patients underwent left thoracotomies, whereas 10 patients received right thoracotomies. Seven patients had anterior spinal release and fusion, and five had mediastinal operations, and one patient had a lobectomy. These two groups were comparable with respect to age, weight, and type of operation. Infusion through the retropleural catheter was maintained for an average of 3.8 days (range, 3 to 6 days). Three patients received 0.125% bupivacaine with 1:200000 epinephrine, two patients received 0.125% bupivacaine without epinephrine, one patient received 0.25% bupivacaine with 1:200000 epinephrine, and one patient received 0.25% bupivacaine without epinephrine. The total morphine use for those patients receiving the retropleural bupivacaine ranged from 0.02 mg/kg (0.008 mg/kg/day) to 1.98 mg/kg (0.367 mg/kg/day), whereas total morphine use without the catheter varied from 1.41 mg/kg (0.353 mg/kg/day ) to 2.79 mg/kg (0.697 mg/kg/day). The total mean postoperative morphine requirement was 2.32 mg/kg (0.544 mg/kg/
Multiple modalities have been investigated to effect improved postoperative thoracotomy pain management, however, little attention has been focused on the pediatric population.‘-6 Local measures such as discrete intercostal nerve blocks and intrapleural delivery of local anesthetics have been evaluated in the adult and pediatric populations.1.3-sUnlike discrete nerve blocks, which provide no more than 6 hours of analgesia, the retropleural catheter technique presented here allows for sustained analgesia. Moreover, acute changes in local anesthetic blood concentrations are essentially avoided, thus lessening the likelihood of toxicity. Furthermore, our retropleural catheter technique provides for a more precise anatomic delivery of local anesthesia. By developing a potential space, the local anesthetic solution delivered via the retropleural catheter directly bathes the intercostal nerves. The entire volume of local anesthetic, dispersed from the tip. impacts all four intercostal nerves before dissipating into the markedly larger interpleural space. It is the high concentration of drug delivered into a limited area that provides effective regional pain control. The use of bupivacaine as an anesthetic has been well established in both pediatric and adult populations.‘,3,1 The concentration of bupivacaine of 0.125% or 0.25% with or without epinephrine at an infusion rate of 0.5 ml/kg/h was chosen because of previous research findings that have recommended an infusion rate not to exceed 0.5 ml/kg/h of 0.25% bupivacaine with 1:200000 epinephrine.’ It should be noted that more recent recommendations have admonished the delivery of no more than 0.5 mg/kgih of bupivacaine via either an intrapleural or epidural route of administration in children.’ Thus, the use of 0.125% bupivacaine should be considered if bupivacaine infusion rates of more than 0.5 ml/kg/h are used. During the period reviewed, varying attending anesthesiologists preferences resulted in varying local anesthetic concentrations. The study will be continued in a prospective fashion using standardized drug dosage protocols. In our study, the use of a retropleural catheter as an adjunct in postoperative thoracotomy pain management with respect to quantity of morphine use showed a statistically significant difference with an observed P value of less than .OOl. It would thus appear that placement of such a catheter is useful in pediatric postoperative thoracotomy pain management.
RETROPLEURAL
BUPIVACAINE
AFTER
THORACOTOMY
201
Table 1. Comparison Patient NO.
Group 1
Age (vr)
Group
and Study
Group
Retropleural Agent
Morphine Requirement (mgikgidav)
SW
Weight (kg)
M
29.1
Anterior
None
No
0.644
spinal release Esophageal repair Resection of paraspinal
None
No No
0.425
None
exposure release
and
None
No
0.546
exposure
and
No
0.353
None
No
0.601
and
0.125% bupivacaine with I:200000 epinephrine
Yes
0.082
and
0.125% bupivacaine with I:200000 epinephrine 0.125% bupivacaine with
Yes
0.367
Yes
0.119
0.25% bupivacaine with I:200000 epinephrine
Yes
0.156
0.25%
Surgical Procedure
Retropleural Catheter
1 (Control)
2
M
27.7
3
M
33
4 5
17 18
6
exposure
and
F
46.7
mass Anterior spinal
M
51.5
Anterior
57.6
spinal release Resection of broncho-
F
genie Group 7
of Control
0.697
cyst
2 (Study)
8 3 10
14
F
63
19
M
59
Anterior spinal Anterior
26
spinal release Resection of broncho-
72
genie Anterior
8
F F
spinal
exposure release exposure
cyst exposure
I:200000 and
release
epinephrine
11
F
23
0.364
M
60
Lobectomy Anterior exposure
Yes
12
and
0.125%
bupivacaine
Yes
0.331
63
spinal Anterior
and
0.125%
bupivacaine
Yes
0.008
13
F
spinal
release exposure
bupivacaine
release
REFERENCES WB. Knox RF. Fennessey PV. et al: Continuous of bupivacaine via intrapleural catheter for analgesia after thoracotomy in children, Anesthesiology 69:X-264, 1988 2. Safran D. Kuhlman G, Orhant EE. et al: Continuous intercostal blockade with lidocaine after thoracic surgery. Anesth Analg 70:3453-19. 1990 3. Seltzer JL. Larijani GE. Goldberg ME. et al: lntrapleural bupivacaine-.A kinetic and dynamic evaluation. Anesthesiology 67:798-800. 1987 4, Rosenberg PH. Scheimn BM. Lepantalo MJ. et al: Continuous I. Mcllvaine
infusion
intrapleural infusion of bupivacaine Anesthesiology 67:X I I-8 13. 1987
for analgesia
after
thoracotomy.
5. Aykac B. Erolcay H. Dikmen Y, et al: Comparison of intrapleural versus intravenous morphine for postthoracotomy pain management. J Cardiothorac Vast Anesthesia 9538.540, 1995 6. Covino
BG: Inter-pleural
regional
Analgesia.
Anesth
Analg
67:427-
419, 1988 7. Berde CB: Convulsions associated with pediatric sia. Anesth Analg 1992:75: 164-l 66 (editorial)
regional
aneuthe-