Santhosh, V (2013) Prospective Randomized Control Trial to compare Continuous Thoracic Epidural Vs Bupivacaine Intercostal Block Plus Intravenous Morphine Infusion for Post Operative Analgesia in Patients Undergoing Elective Thoracotomy. Masters thesis, Christian Medical College, Vellore.
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Abstract
INTRODUCTION: Thoracotomy is widely recognized as being one of the most painful surgical procedures. Respiratory complications like atelectasis, pneumonia are the major cause of post operative complications after lung surgery. Studies have shown that there is a steady decline in the respiratory complications last decade for >10% which is chiefly attributable to improved post operative care especially effective post operative pain management. So, aggressive and well planned pain management is crucial in decreasing morbidity and mortality after thoracic surgery. Despite an increasing array of techniques and new drugs available for post operative analgesia after thoracic surgery, acute pain management after thoracotomy remains a great challenge for the anesthesiologist. No single method is proven to be sufficient for complete pain relief after thoracotomy with minimal side effects. Despite the fact that THORACIC EPIDURAL ANALGESIA is the ‘gold standard’ of post operative care after thoracotomy. Various local and regional techniques especially paravertebral blocks are emerging and seem to be a valid alternative to thoracic epidural. Also in the recent 5 years, a multimodal approach utilizing combined regional and systemic analgesics with different mechanisms of action is found to be promising and beneficial in terms of treating acute pain and preventing chronic pain after thoracotomy. OBJECTIVES: Patients of both genders, >18yrs of age who underwent unilateral thoracotomy for various lung pathologies were included in this study. Randomization was done with Computer generated randomized numbers using Block randomization. It is an open labeled study, since Masking of intervention allocation is not possible. METHOD: Primary Outcome measured was Pain intensity at rest and in doing breathing exercises, during the first post operative day using NUMERICAL RATING SCALE. Secondary Outcomes measured were post operative sedation, frequencies of rescue analgesia, incidence of postoperative side effects like pruritis, nausea or vomiting. Sample Size: 50. Primary outcome variables and secondary outcome variables were compared between two study groups using the MANN WHITNEY U TEST. Group A- Thoracic Epidural group. RESULTS: Group B- Intercostal block with Bupivacaine plus Intravenous Morphine. All the demographic variables were almost similar in both groups. The primary outcome variable- Pain scores were measured using the numerical rating scale during the first post operative day at different time points. Mean pain scores were in the range of 2-2.8 in group A and 2.08-3.2 in group B. Pain scores were significantly less in the epidural group at first (P 0.02)and sixth hours (P 0.05) after surgery, though it is was similar at the end of 24 hours for both at rest and while doing breathing exercises. There was no significant difference in number of times of rescue analgesia or time of first rescue analgesia. Sedation scores were significantly less in group A throughout the first postoperative day (P<0.005). There was no significant difference in the side effect profile in both groups. The results of the study shows a slightly better quality of analgesia with thoracic epidural infusion of 0.1% bupivacaine + 2μ/cc fentanyl for post operative pain relief after thoracotomy when compared with single shot intercostals blockade with bupivacaine +continuous morphine infusion. The fact that this difference is probably not clinically significant makes us to believe that an intercostal blockade with morphine infusion can be considered as a valid alternative to thoracic epidural. This method of intercostals blockade plus morphine infusion, which is practiced in our institution can be considered an easier, safe and reliable alternative to thoracic epidural and is a less time consuming method for post thoracotomy analgesia. CONCLUSION: • Pain scores were less in the epidural group during first 12hrs after surgery and the difference was statistically significant (p0.0505) both during rest and while doing breathing exercises. • There was no statistically significant difference in pain scores between the two groups at the end of first post operative day both during rest (p=0.1090) and while doing breathing exercises (p=0.1642). • There was no statistically significant difference in time for first rescue analgesia (p=0.2340) and incidence of side effects like nausea, vomiting, pruritis, respiratory depression and hypotension (p=1.000) between the two groups. • There was significant difference in sedation scale between the two groups (p=0.0007). Patients in the thoracic epidural group were less sedated. The study results show a slightly better quality of analgesia with thoracic epidural infusion of 0.1%bupivacine +2μ/cc fentanyl for post operative pain relief after thoracotomy when compared with single shot intercostals blockade with bupivacine +continuous morphine infusion. The fact that this difference is probably not clinically significant makes us to believe that an intercostal blockade with morphine infusion can be considered as a valid alternative to thoracic epidural. This method of intercostals blockade plus morphine infusion, which is practiced in our institution can be considered an easier, safe and reliable alternative to thoracic epidural and is a less time consuming method for post thoracotomy analgesia. This study can be used as a pilot study for further extensive studies. A larger case series and a longer follow up plan should be done which will probably give a much more accurate estimation of pain relief. Future trials should take much more detailed consideration of the pulmonary morbidity and mortality and outcome with respect to better post operative analgesia.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Continuous Thoracic Epidural ; Bupivacaine Intercostal Block ; Intravenous Morphine Infusion ; Post Operative Analgesia ; Patients ; Undergoing Elective Thoracotomy ; Prospective Randomized Control Trial. |
| Subjects: | MEDICAL > Anaesthesiology |
| Depositing User: | Subramani R |
| Date Deposited: | 30 Apr 2018 02:55 |
| Last Modified: | 30 Apr 2018 02:55 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/7338 |
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