Society of Cardiovascular Anesthesiologists

Thoracic epidural versus intercostal nerve catheter plus patient-controlled analgesia: a randomized study.

Luketich JD, Land SR, Sullivan EA, Alvelo-Rivera M, Ward J, Buenaventura PO, Landreneau RJ, Hart LA, Fernando HC. Ann Thorac Surg 2005, 79: 1845-50.

Reviewer: Mark A. Chaney, MD
University of Chicago
Chicago, IL

Abstract: Pain control is an important issue following thoracotomy. Ideal methods should have a high success rate, with easy implementation and minimal complications. Debate exists over the optimal pain control method. This randomized trial was designed to compare epidural (EPI) and intercostal nerve catheter with patient-controlled analgesia (ICN-PCA) for pain control after thoracotomy. This prospective study included 124 randomized patients; 91 had sufficient data for analysis (44 EPI, 47 ICN-PCA). The primary endpoint was pain measurement using a composite of a visual analogue scale, numerical rating, and categorical rating. A second endpoint was the success rate of each method. Pulmonary function tests, antibiotics, intensive care unit, and hospital days, and use of nonprotocol pain medications were also compared. There were twelve pain observations per patient (90% completed on days one to five). The pain composite revealed an average postoperative pain score of 2.4 on a scale from 0 (no pain) to 10 (worst pain). There was no difference between the two groups. Failures of the planned method of analgesia included nine in the EPI group and four in the ICN-PCA group (not significant). Another twenty patients were excluded (no difference between groups) due to unsuspected mediastinal metastases precluding thoracotomy (n=13) and other miscellaneous factors precluding follow-up (n=7). The EPI group had an increased number of urinary catheter days (2.5 days versus 1.7 days, p=0.002) and increased narcotic supplements (p=0.03) compared with the ICN-PCA group. Mean intensive care unit days (0.9) and hospital days (6.2) were similar for both groups, and there were no differences in arrhythmias, pneumonias, transfusions, and antibiotic use. Significant differences were observed (p=0.001) between preoperative and postoperative pulmonary function tests in both groups. However, there were no differences in pulmonary function when the groups were compared with each other. These investigators conclude that satisfactory pain control may be achieved following thoracotomy using either EPI or ICN-PCA. The ICN-PCA method achieves equivalent pain control, compared with EPI, may be placed by the surgeon with no delays in surgery, and decreases postoperative urinary catheter days.

Comments: Pain following thoracotomy is often times intense and difficult to control. Suboptimal analgesia following thoracotomy may lead to prolonged immobility, poor cough and clearance of secretions, atelectasis, pneumonia, deep vein thrombosis, and pulmonary embolism. Thus, adequate pain control is important to achieve following thoracotomy and inadequate analgesia likely leads to increased morbidity. In many centers, EPI anesthesia has emerged as the most common method of obtaining postoperative analgesia following thoracotomy. While this technique has obvious advantages (intense analgesia, enhanced flexibility), disadvantages (patient contraindications, technical difficulties, increased workload, surgical delay, complications) are present as well. Thus, alternative methods of pain control should continue to be evaluated. In this prospective, randomized clinical investigation, EPI was compared to one such alternative method, ICN-PCA. This technique has the advantages of simplicity and lower risk yet has traditionally been associated with decreased quality of postoperative analgesia. These investigators found that postoperative analgesia was equivalent following thoracotomy with EPI or ICN-PCA and EPI patients experienced an increased number of postoperative urinary catheter days. Patients randomized to receive ICN-PCA received a 10 mL bolus of 0.25% bupivacaine injected by percutaneous nerve block before thoracotomy and had an intercostal nerve catheter inserted at conclusion of surgery, through which 0.25% bupivacaine was infused throughout the postoperative period. Not only was postoperative analgesia equivalent with the two techniques, supplemental narcotic medication days were significantly lower (p=0.03) in the ICN-PCA patients compared with EPI patients. Furthermore, other studies have demonstrated the efficacy and safety of intercostal nerve catheters for postoperative analgesia following thoracotomy. While this clinical investigation most certainly does not settle the score between EPI and ICN-PCA regarding post-thoracotomy analgesia, it indicates that in certain circumstances ICN-PCA may offer advantages over the traditional "gold-standard" EPI. Astute clinicians will continue to assess the risk:benefit ratio of the wide variety of techniques available for post-thoracotomy analgesia in each particular patient before deciding on a plan.

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