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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 4  |  Page : 132-139

Post-thoracotomy pain relief in pediatric patients epidural versus inter-pleural analgesia


Department of Anesthesiology and Surgical Intensive Care, Zagazig University, Faculty of Medicine, Zagazig, Egypt

Date of Submission14-May-2015
Date of Acceptance22-Nov-2015
Date of Web Publication17-Mar-2016

Correspondence Address:
Abeer M Elnakera
Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Zagazig University, 44111 Zagazig
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2356-9115.178900

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  Abstract 

Background
For controlling post-thoracotomy pain, thoracic epidural (TE) analgesia is considered a gold standard technique. However, it may be associated with serious complications. Interpleural (IP) analgesia is thought to be a simpler technique. Therefore, the current study aimed to compare the efficacy of simple IP with TE bupivacaine in controlling post-thoracotomy pain in pediatrics.
Patients and methods
A total of 80 pediatric patients undergoing elective thoracotomy were randomly assigned to either the TE or the IP group. In the TE group, epidural catheter was threaded through the caudal space and the tip was placed at the fourth intercostal space. In the IP group, the surgeon inserted the IP catheter through the IP space under direct vision and directed its tip towards the fourth intercostal space on the paravertebral line. Bupivacaine 1.5 mg/kg in 25% concentration was administered through either TE or IP catheters as intermittent boluses every 6 h, starting from the beginning of skin closure, for 24 h postoperatively. Fentanyl 1 mg/kg intravenous bolus was administered as rescue analgesia to keep the pain score less than 0.4. Hemodynamic parameters and pain scores were recorded at 1, 6, 12, 18, and 24 h. In addition, interleukin-6 was measured at 1, 6, and 24 h beginning from the first injected local anesthetic dose. Total postoperative 24 h fentanyl requirements and time to first postoperative rescue analgesia were recorded.
Results
CRIES pain score showed no significant difference between the studied groups. Time to first rescue analgesia was significantly shorter in the IP group (2.75 ± 0.93) compared with the TE group (4.17 ± 1.07). Patients of the IP group required higher doses of intravenous fentanyl than did those in the TE group (12.83 ± 3.83 vs. 8.16 ± 3.4μg) (P<0.05).
Conclusion
For post-thoracotomy pain in pediatrics, equipotent analgesia can be achieved through TE blockade and the simpler IP technique, but with higher postoperative intravenous fentanyl supplementation to the latter technique.

Keywords: analgesia, interpleural, pediatrics, postthoracotomy, thoracic epidural


How to cite this article:
Abd El-Aziz MA, Elnakera AM, Salah AA. Post-thoracotomy pain relief in pediatric patients epidural versus inter-pleural analgesia. Res Opin Anesth Intensive Care 2015;2:132-9

How to cite this URL:
Abd El-Aziz MA, Elnakera AM, Salah AA. Post-thoracotomy pain relief in pediatric patients epidural versus inter-pleural analgesia. Res Opin Anesth Intensive Care [serial online] 2015 [cited 2020 Jun 4];2:132-9. Available from: http://www.roaic.eg.net/text.asp?2015/2/4/132/178900


  Introduction Top


Post-thoracotomy pain is one of the most severe types of pain during the first 24 h of the surgery [1].

In pediatrics, inadequate post-thoracotomy analgesia may lead to adverse circulatory and respiratory events, as well as hypersensitivity to noxious stimuli later in life [2].

Systemic NSAIDs may not relieve severe post-thoracotomy pain and may cause gastrointestinal and renal complications [3]. Parenteral opioids have an effective pain relief but may cause respiratory depression [1].

Regional post-thoracotomy analgesic techniques have been thoroughly investigated in adults [4],[5],[6],[7],[8], but in pediatrics, few clinical trials have investigated interpleural (IP), thoracic epidural (TE), and paravertebral blocks [9],[10],[11].

Although TE analgesia is considered a gold standard technique for providing effective postoperative pain control [12],[13], it carries a considerable risk for potential serious neurological and hemodynamic complications [14].

IP analgesia is thought to be less time-consuming and easy-to-perform technique for post-thoracotomy pain control [7],[13].

Therefore, the current study aimed to compare the efficacy of simple IP with TE bupivacaine in controlling post-thoracotomy pain in pediatrics.


  Patients and methods Top


Study design

The present study was a double-blinded, randomized trial.

Ethics

This study was carried out in Anesthesia and Surgical Intensive Care Department of the Faculty of Medicine, Zagazig University Cardiothoracic Hospital during the period from 14 February 2011 to 9 December 2013 after obtaining Institutional Research Board's (IRB) approval and informed consent from the parents of the patients.

Study participants and protocol

Pediatric patients, who underwent elective anterolateral or posterolateral thoracotomy for various indications, were enrolled in the study.

Exclusion criteria were prematurity, age greater than 5 years, emergency operations, parents' refusal, previous thoracotomy, allergy to local anesthetics (LAs), previous unusual response or complications related to anesthesia, pre-existing coagulopathy, severe comorbidity, and local infection in the site of epidural insertion.

Withdrawal criteria included bloody epidural tape, massive air leak after closure of the chest, development of tension pneumothorax after intercostal tube closure, delayed postoperative recovery, or the need for postoperative mechanical ventilation.

Legible patients were randomly assigned into one of the two groups using a computer-generated randomization software:

  1. Group I: the TE group.
  2. Group II: the IP group.


All observational parameters were noted by an independent observer blinded to the postoperative analgesia technique.

After premedication with intravenous atropine (0.01 mg/kg), anesthesia was induced with ketamine 2 mg/kg, endotracheal intubation was facilitated by rocuronium bromide (0.9 mg/kg), and intermittent positive pressure ventilation (IPPV) with FiO 2 100% was initiated (BMI A III Plus ventilator) in a volume-controlled mode. Anesthesia was maintained with isoflurane (1-2 MAC), and rocuronium bromide 0.15 mg/kg was given on a fixed time interval to confirm muscle relaxation. Standard monitoring was carried out through ECG, pulse-oximetry, capnography, non-invasive blood pressure (NIBP), and invasive blood pressure (IBP) (Datex-Ohmeda Cardiocap/5 monitor, GE Healthcare, Phenland). Patients were turned and secured on the lateral decubitus position with the operated side up.

In the TE group, after sterile preparation of the patient's back, a 20-G radio-opaque nylon epidural catheter (B. Braun Melsungen AG - Products - Perifix Complete Set) was threaded through the epidural space through an 18-G intravenous cannula placed through the sacrococcygeal membrane into the caudal space. The epidural catheter tip was placed at the level of fourth thoracic spine (T4). The length of the epidural catheter required was predetermined by measuring the distance on the skin from the caudal space to the desired level for the catheter tip. No LA was given through the catheter until the end of the surgical intervention.

In the IP group, after completion of the planned surgical intervention and when the chest was still open, the surgeon inserted a 6-Fr catheter (Nebro Pharma feeding tube) through the IP space under direct vision. The tip of the catheter was directed toward the fourth intercostal space on the paravertebral line. The other end of the catheter was taken out by the side of the chest drain and was fixed to the skin.

At the beginning of skin closure, an initial bolus dose of 1.5 mg/kg bupivacaine 0.25% was given through the epidural catheter in the TE group and through the IP catheter in the IP group, where the chest drainage tube was clamped for 30 min with the patient still in the lateral position. The patients were monitored throughout this period to detect any possible complications of the procedure. If any patient developed signs of tension pneumothorax (hypoxemia or hypotension), chest tube should be declamped immediately.

At the end of the surgery, residual muscle paralysis was reversed, and the trachea was extubated when extubation criteria were fulfilled.

Patients in both groups received fixed intermittent bolus doses of bupivacaine 1.5 mg/kg in 0.25% concentration through the catheter (either epidural or IP) every 6 h (starting from the first LA dose administered on skin closure) for the first 24 h postoperatively. Before every injection of LA through the catheter, patients in the TE group were kept in the supine position, whereas in the IP group, patients were positioned in the semilateral position, with the operated side up, and the chest tubes were clamped during injection and for 30 min afterwards.

Fentanyl 1 μg/kg intravenous bolus was given as rescue analgesia to keep the pain score less than 0.4.

Measurements

Heart rate (HR) and systolic (SBP) and diastolic arterial blood pressure (DBP) were recorded for baseline values before anesthetic induction.

Pain was assessed with a CRIES pain score [Table 1], where 0 referred to no pain and 10 referred to the most intolerable pain [15]. Pain intensity was evaluated at 1, 6, 12, 18, and 24 h after the first injected LA dose.
Table 1: The parameters of CRIES score [15]

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Blood samples were collected before anesthetic induction, which served as baseline, and then 1, 6, and 24 h after the first injected LA dose for the determination of human interleukin-6 (IL-6) concentrations (Human IL-6 ELISA Kits through Sorin Biomedica ETI-system strip reader instrument).

Time to first rescue analgesia (started from the time of first administration of LA through either TE or IP catheters) was recorded and the total intravenous fentanyl, given in the first postoperative 24 h, was calculated.

Postoperative complications

Bradypnea [respiratory rate<30 breaths/min (0-1 year), 24 breaths/min (1-3 years), or 22 breaths/min (3-5 years)], hypoxemia (SaO 2 <92% on room air), bradycardia [HR<100 beats/min (0-1 year), 90 beats/min (1-3 years), 80 beats/min (3-5 years), or rapidly decreasing HR], hypotension [SBP<60 mmHg (0-1 year), 70 mmHg (1-3 years), or 75 mmHg (3-5 years)], TE or IP catheter blockade, urinary retention, and vomiting were recorded and considered for statistical analysis.

Sample size calculation

With a statistical test power of 80%, confidence interval of 95% and the expected difference in time to first postoperative rescue analgesia of 60% according to a study by Mathur et al. [7], The accepted sample size was 72 patients, 36 patients for each group. A total of 80 patients were included in the study to compensate for the dropouts.

Statistical analysis

Continuous parametric data were expressed as mean ± SD. Student's t-test was used for comparing the means of both groups, whereas the paired t-test was used for intragroup comparison. Nonparametric data were expressed as median and range, and compared using the Mann-Whitney U-test. Nominal data were expressed as number and percentage, and compared using the χ2 -test. The critical value of P less than 0.05 was considered significant.


  Results Top


Out of 92 consecutive pediatric patients scheduled for thoracotomy during the study period, 12 patients were excluded from the study either because of prematurity, age >5 years or parents' refusal to intervention. Therefore, 80 patients were enrolled in the study and randomly allocated into two equal groups. Further, four patients were withdrawn from the study: three of them from the TE group because of intraoperative cardiopulmonary arrest (either due to resistant hypoxia or uncontrolled bleeding) and one patient from the IP group because of delayed recovery and the need for postoperative mechanical ventilation. Thus, data from 76 patients (37 patients in the TE group and 39 patients in the IP group) were considered for statistical analysis [Figure 1].
Figure 1: Flow chart for patients' distribution. IO, intraoperative; N, number of patients.

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Patients' characteristics, type of surgical intervention, and operative time showed no statistical significant difference between the two studied groups [Table 2].
Table 2: Patient's characteristics, type of surgical intervention, and operative time

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There was no statistically significant difference between the two studied groups as regards baseline HR, SBP, DBP values, and IL-6 level.

In both groups, the average HR was significantly reduced at 6, 12, 18, and 24 h postoperatively when compared with the baseline values. The average HR was significantly higher in the IP group compared with the TE group at 1, 6, and 18 h postoperatively [Figure 2].
Figure 2: Average heart rate variation during the first postoperative 24 h. Data were presented as mean ± SD; Student's t-test was used. Paired t-test was used for intragroup comparison. *Statistically significant difference between the two studied groups (P < 0.05). #Statistically significant difference in comparison with baseline (P < 0.05). HR, heart rate; IP, interpleural; TE, thoracic epidural.

Click here to view


The average SBP was significantly reduced at 6 and 12 h postoperatively in the TE group and in the IP group, respectively, when compared with the baseline values. The average SBP was significantly higher in the IP group compared with the TE group at 1 and 6 h postoperatively [Figure 3].
Figure 3: Average systolic blood pressure (SBP) variation during the first postoperative 24 h. Data were presented as mean ± SD; Student's t-test was used. Paired t-test was used for intragroup comparison. *Statistically significant difference between the two studied groups (P < 0.05). #Statistically significant difference in comparison with baseline (P < 0.05). IP, interpleural; TE, thoracic epidural.

Click here to view


Compared with the baseline values, the average DBP was significantly reduced at 12 and significantly elevated at 24 h postoperatively in the IP group and the TE group, respectively. The average DBP was significantly higher in the IP group compared with the TE group at 1 and 6 h postoperatively [Figure 4].
Figure 4: Average diastolic blood pressure (DBP) variation during the first postoperative 24 h. Data were presented as mean ± SD; Student's t-test was used. Paired t-test was used for intragroup comparison. *Statistically significant difference between the two studied groups (P < 0.05). #Statistically significant difference in comparison with baseline (P < 0.05). IP, interpleural; TE, thoracic epidural.

Click here to view


In both groups, IL-6 plasma level was significantly elevated at 1, 6, and 24 h postoperatively when compared with the baseline values. IL-6 plasma level was significantly higher in the IP group compared with the TE group at 6 h postoperatively [Table 3].
Table 3: Interleukin-6 level variation during the first postoperative 24 h

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There was no statistically significant difference between the two studied groups as regards CRIES pain score at all measuring points during the first 24 h postoperatively [Table 4].
Table 4: CRIES pain score variation during the first postoperative 24 h

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Time to first postoperative rescue analgesia in the IP group was significantly shorter than that in the TE group (2.75 ± 0.93 vs 4.17 ± 1.07 hrs.) [Figure 5].
Figure 5: Time to first postoperative rescue analgesia. Data were presented as mean ± SD; Student's t-test was used. *Statistically significant difference between the two studied groups (P < 0.05). IP, interpleural; TE, thoracic epidural.

Click here to view


The number of patients who did not need postoperative rescue analgesia showed no statistical difference (P = 0.43) between the TE group [25/37 (67.6%)] and the IP group [23/39 (59%)].

In the TE group, the number of patients who did not need postoperative rescue analgesia (25/37, 67.6%) was significantly higher (P = 0.0004) than that of patients who needed (12/37, 32.4%) it.

The average intravenous fentanyl administered during the first postoperative 24 h was significantly higher in the IP group compared with the TE group [Table 5].
Table 5: Average intravenous fentanyl administered during the first postoperative 24 h

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No significant difference was found between the two groups as regards postoperative complications except for catheter blockade, which occurred in four patients of the TE group versus no patient in the IP group (P = 0.004). The blockade was relieved by withdrawing the catheter by 0.5 cm.

Two patients developed hypoxia, one in the TE group and the other in the IP group. Oxygenation improved in both patients by increasing FiO 2 with nasotracheal suction for the former and supplemental fentanyl administration for the latter. One patient in the TE group developed bradycardia and hypotension, which responded to intravenous fluids, atropine, and ephedrine. One patient in the TE group and three patients in the IP group developed vomiting, which responded to intravenous administration of ondansetron hydrochloride (0.1 mg/kg) over 5 min. Two patients in the IP group developed urinary retention, which was relieved by catheterization.

There was no inadvertent dural puncture during the caudal epidural catheter placement. No patient showed neurological signs or symptoms of epidural hematoma. In the IP group, no patient developed adverse events after clamping the chest tube.


  Discussion Top


On administration of intermittent boluses of bupivacaine 1.5 mg/kg, the current study revealed the superiority of TE over IP analgesia for the control of post-thoracotomy pain in pediatrics. However, with significantly earlier and higher postoperative intravenous fentanyl supplementation, IP blockade can provide equipotent analgesia to TE blockade, as shown by similar postoperative CRIES pain scores and number of patients who did not need postoperative rescue analgesia in the two groups. The superiority of TE over IP analgesia was still supported by lower HR (1, 6, and 18 h postoperatively), SBP and DBP (1 and 6 h postoperatively), and IL-6 plasma level (6 h postoperatively) in patients of the TE group compared with those of the IP group. Moreover, the majority of the patients in the TE group did not need supplemental analgesia.

As regional analgesic modalities for post-thoracotomy pain control in pediatrics were investigated only in few clinical trials [9],[10],[11], we aimed to compare a gold standard technique, epidural blockade, with a simple and easily performed technique, IP analgesia, using the same LA agent.

In our study, the postoperative CRIES pain score was similar in both groups, which was in contrast to the findings of a study by Mathur et al. [7], who proved that visual analogue scale (VAS) values in the TE group were significantly lower than that attained in the IP group. However, a study by Mehta et al. [16] showed that VAS score was significantly lower in the IP group compared with the TE group after minimally invasive direct coronary artery bypass surgery. This difference between our study and the other two studies may be due to different age group studied (pediatric vs. adult), different pain assessment tool used (CRIES vs. VAS), different pain score measurement points, and the entire dependence on regional anesthetic blocks for post-thoracotomy pain in the study by Mathur and colleagues.

In the current study, the time to first postoperative rescue analgesia was significantly shorter in the IP group compared with the TE group. This finding was in agreement with those obtained in the study by Mathur et al. [7], who reported a longer duration of analgesia in the TE group compared with the IP group (about 1.5 times) during the first 24 h postoperatively, and suggested that a shorter duration of IP analgesia may be due to a large IP space, dilution of drugs by pleural exudation and blood, loss of drugs in the chest drain and diffusion barrier formed by tissue fluid, edema and blood preventing drugs from reaching intercostal nerves; meanwhile, in TE analgesia, the epidural space is potential, directly surrounding the intercostal nerve roots, and thus there is no loss of drug or diffusion barrier.

In our study, the average fentanyl requirements during the first postoperative 24 h to maintain the CRIES pain score below 0.4 was significantly higher in the IP group compared with the TE group. In their study, Tobias et al. [17] found that eight of the 14 children (57%) who received IP analgesia for post-thoracotomy pain required no postoperative rescue analgesia, whereas, in our study, 23 of the 39 pediatric patients (59%) in the IP group required no postoperative rescue analgesia. The majority of the patients in the TE group in the current study (25 from 37, 67.5%) received no postoperative rescue analgesia, whereas a study by Lubenow et al. [12] found that 96.2% of the 1324 patients with TE analgesia, using opioid with or without a LA agent, required no postoperative rescue analgesia. This difference between our study and that of Lubenow and colleagues may be due to different age group studied (pediatric vs. adult), different sample size (37 vs. 1324), and different agents used (bupivacaine vs. opioid with or without LA).

The average HR (1, 6, and 18 h postoperatively) and SBP and DBP (1 and 6 h postoperatively) were significantly higher in the IP group compared with the TE group. However, other studies showed no significant differences in hemodynamic parameters between the TE and IP groups [16],[18].

IL-6 plasma level, in the current study, was significantly elevated in both groups at 1, 6, and 24 h postoperatively when compared with the baseline values. Similar results were found in a study by Kim and Hahm [19], who reported that IL-6 plasma level increased immediately after abdominal hysterectomy and remained consistent for 24 h with lower IL-6 response when ketorolac was added to morphine in patient controlled analgesia (PCA). In addition, a study by Esme et al. [20] showed that the serum IL-6 level was significantly high in all patients at third hour after thoracotomy and that elevation was significantly less pronounced when using an anti-inflammatory drug. In their study, Fiorellia et al. [21] reported lesser increase in postoperative IL-6 on using transcutaneous nerve stimulation for controlling acute post-thoracotomy pain. In the current study, we found that serum IL-6 level was significantly lower in the TE group than that in the IP group at 6 h postoperatively.

It has been shown that bupivacaine acts by producing a reversible blockade of sodium channels in the nervous tissue [22]. Epidural blockade of spinal nerve roots attenuates the surgical stress-induced increase in proinflammatory cytokine production, including IL-6 through sympathetic nerve block, thus improving the overall immune response [23].

Following its IP administration, bupivacaine diffuses through the parietal pleura blocking the intercostal nerves. This diffusion is limited by the uptake of LAs by the visceral pleura [24]. In their study, Strømskag and Kleiven [25] suggested that using a larger volume of LAs could extend up to five adjacent intercostal spaces. Failure to clamp the chest tube before administration of LAs can lead to inadequate post-thoracotomy analgesia [5]. Less supplemental opioid requirements was shown in a study by Ferrante et al. [26], who used multiple IP catheters for more even distribution of LAs over the pleura. We used the method of intermittent administration of drugs in both groups as continuous infusion can lead to central nervous system toxicity and excessive loss of drugs in the chest tube because it cannot be kept clamped during the entire period of infusion [27]. In their study, Scheinin et al. [28] clamped the chest tube for 10 min only and failed to prove effective analgesia. In our study, we clamped the chest tube in patients of group IP for 30 min after each LA injection to allow appropriate fixation of LAs. Chest tube clamping can be a risk factor for the development of tension pneumothorax, especially in patients with massive air leaks [29]. Thus, from the start, if massive air leak was present after the chest closure, the technique was aborted and the patient was excluded from the study. Fortunately, intercostal tube was clamped safely during the study.

IP analgesia was investigated for pain control in pediatrics but for upper abdominal surgery [30]. Moreover, epidural analgesia was reported as an excellent modality for pediatric post-thoracotomy pain control in a retrospective, single-center audit by Kotzé et al. [10]. The current study was a randomized trial comparing both techniques for the control of post-thoracotomy pain in pediatrics and revealed that the simple technique of IP analgesia results in post-thoracotomy pain relief equipotent to that of TE analgesia when earlier rescue systemic fentanyl is used.

Limitations

The current study was limited because of a small sample size, lack of measurement of serum bupivacaine level, and gaseous exchange parameters.

Recommendations

Further studies, that may include larger sample sizes, are required to measure LA blood level, identify the optimum safe dose, add adjuvants to maximize the efficacy of regional blocks, and relate the pain control modality to gaseous exchange parameters.


  Conclusion Top


For post-thoracotomy pain in pediatrics (aged from 1.5 - 60 months), equipotent analgesia can be achieved through TE blockade and the simpler, IP technique, but with a higher postoperative intravenous fentanyl supplementation to the latter technique.


  Acknowledgements Top


Conflicts of interest

None declared.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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