The Annals of thoracic surgery
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Randomized Controlled Trial Comparative Study Clinical Trial
Continuous intercostal nerve block versus epidural morphine for postthoracotomy analgesia.
Twenty patients undergoing elective thoracotomy were randomized into two groups, receiving either lumbar epidural morphine (n = 10) or continuous extrapleural intercostal nerve block (n = 10). Subjective pain relief was assessed on a linear visual analogue scale. Pulmonary function (peak expiratory flow rate, forced expiratory volume in 1 second, and forced vital capacity) was measured on the day before operation and daily for 4 days after operation. ⋯ Vomiting, pruritus, and urinary retention occurred only in the epidural group, whereas nausea occurred significantly less frequently in the extrapleural group. We conclude that after thoracotomy continuous extrapleural intercostal nerve block is as effective as lumbar epidural morphine in reducing postoperative pain and restoring pulmonary mechanics. Because of the significantly lower complication rates we favor continuous extrapleural intercostal nerve block for postthoracotomy analgesia.
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Randomized Controlled Trial Clinical Trial
Continuous intercostal analgesia with 0.5% bupivacaine after thoracotomy: a randomized study.
This study was undertaken to evaluate the effectiveness of 0.5% bupivacaine (360 mg/day) as a continuous infusion through an indwelling intercostal catheter inserted intraoperatively in the management of pain after thoracotomy. Eighty-six patients were randomized into three groups: group 1 = intercostal bupivacaine, group 2 = intercostal saline solution, and group 3 = fixed-schedule intramuscular buprenorphine. Supplementary buprenorphine was given as required. ⋯ No between-group differences in pulmonary function were observed. Respiratory complications occurred in no patients in groups 1 and 3 versus 5 in group 2 (p < 0.05). Continuous intercostal bupivacaine provided similar early pain control as compared with fixed-schedule narcotics but induced better analgesia with fewer complications than on-demand narcotics alone (group 2).
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To assess the clinical manifestations and therapy of secondary spontaneous pneumothorax (SSP), 123 episodes of SSP in 67 patients were retrospectively reviewed and were compared with 254 episodes of primary spontaneous pneumothorax in 130 patients. The major underlying lung diseases associated with SSP were emphysema (22 patients) and tuberculosis (21 patients). ⋯ The recurrence rate of open thoracotomy with pleural abrasion was 12.5% (3 of 24 episodes), which was not lower than that of thoracostomy tube drainage with chemical pleurodesis using tetracycline (recurrence rate, 18.8%) (p > 0.5). We concluded that considering the high age of the patients, the presence of underlying lung diseases, and the increased operative risk, thoracostomy tube drainage rather than open thoracotomy was preferred as the first choice of therapy for SSP.
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Infants with single ventricle and transposition of the great arteries with or without aortic arch obstruction have a poor prognosis due in large part to the development of systemic outflow obstruction, a frequent consequence of pulmonary artery banding. Thus, the initial palliation and long-term treatment options are critical in terms of surgical choices and timing. We report our experience with 9 patients managed by neonatal pulmonary artery banding and early debanding, a Damus-Kaye-Stansel procedure, and either a modified Glenn shunt or a modified Fontan procedure. ⋯ There is trivial or mild pulmonic insufficiency in 5 patients, which is not progressing. One patient had mild to moderate pulmonic insufficiency but died late presumably of an arrhythmia. We conclude that neonatal pulmonary artery banding coupled with planned early debanding, a Damus-Kaye-Stansel procedure, and cavopulmonary anastomosis is a relatively low-risk course for patients with this complex physiology.
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Cardiac operations with cardiopulmonary bypass cause a systemic inflammatory response, which can lead to organ injury and postoperative morbidity. Causative factors include surgical trauma, contact of blood with the extracorporeal circuit, and lung reperfusion injury on discontinuing bypass. ⋯ This includes activation of the complement, coagulation, fibrinolytic, and kallikrein cascades, activation of neutrophils with degranulation and protease enzyme release, oxygen radical production, and the synthesis of various cytokines from mononuclear cells (including tumor necrosis factor, interleukin-1, and interleukin-6). Advances in our understanding of the interactions between these markers of cellular and humoral responses to cardiopulmonary bypass will enable more effective intervention to reduce the deleterious effects and improve the outlook for patients undergoing cardiac operations beyond the 1990s.