Research Protocols

Investigators:
M.J. Grennan Jr., M.D., M.A.
Lynn R. Johnson, M.D., M.S.
Jack Kabazie, M.D.
Peter Kaplan, M.D.

The post-thoracotomy patient will typically experience several postoperative pain unless aggressive pain management techniques are employed. The traditional approach to managing this class of patients is to use parental opioids, by either the intramuscular or intravenous route. Theparenteral approach often results in inadequate pain control due to the pharmacokinetics of the drugs, routes employed and frequent delays between a patients report of pain and the administration of the analgesic. Patient-controlled analgesia (PCA) had been an advance in that it minimizes the effect of treatment delay; however, it does not entirely eliminate parental opioidside effects which include: respiratory depression, suppression of the cough reflex, nausea,sedation, dizziness, vomiting, puritis, constipation, dry mouth, diaphoresis, weakness and headache.

Regional anesthesia techniques allow a reduction in opioid use with a concomitant reduction in systemic opiod side effects. Percutaneous intercostal nerve blocks with local anesthetic have been used for years in an effort to treat post-thoracotomy pain. Satisfactory levels of analgesia are achieved but are limited by the duration of the action of the local anesthetic employed.Bupivicaine, for example, will provide good pain relief for only about six hours. In recent years,thoracic epidural analgesia has been frequently employed at major centers for treating post-thoracotomy pain. An alternative to the thoracic epidural is the extrapleural catheter. This catheteris placed under direct vision intraoperatively and functions as a multilevel intercostal nerve block. The extrapleural catheter exits percutaneously allowing access for intermittent blousing or continuous infusions postoperatively. A potential problem with the percutaneous catheter is the development of relatively high levels of local anesthetic owing to the rapid uptake of this drug in the intercostal spaces.

This study will evaluate the relative efficacy of the extrapleural catheter infusion technique as compared to the epidural catheter infusion technique in managing post-thoracotomy pain.

Ninety adults will be divided into three study groups:
Group A will receive intial bolus of local anesthetic intraoperatively and continuous infusion of local anesthetic postoperatively, supplemented with parenteral morphine or meperidine via PCAdevice.

Group B will have thoracic epidural catheters placed preoperatively in either the holding area or operating room. After epidural catheter placement and prior to induction of general anesthesia, preservative-free morphine will be administered via epidural catheter. Local anestheticbupivicaine will be bolused during the last hour of the case, supplemented with parenteralmorphine or meperidine via PCA device.

Group C will be the control group with parenteral morphine or meperidine via PCA device. A visual analog scale, McGill pain questionnaire, Pain Fellow questionnaire and Satisfaction questionnaire will be utilized to assess pain.

The primary outcomes being measured are pain, analgesic requirements and patient satisfaction. Secondary outcomes being measured are complications, respiratory functions, perioperative cost, change in limb strength and mobility and length of hospital stay.

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