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REGIONAL ANESTHESIA AND PAIN MANAGEMENT

Pleural Bupivacaine for Pain Treatment After Nephrectomy

Robert Greif, MD^*,, Thomas Wasinger, MD, Kurt Reiter, MD, Michael Chwala, MD, and Julius Neumark, MD

*Department of Anesthesia and Perioperative Care and Outcomes Research^TM Group, University of California-San Francisco, San Francisco, California; and Departments of Anesthesiology and Intensive Care Medicine and Urology, Donauspital, Vienna, Austria

Address correspondence to Robert Greif, MD, Department of Anesthesia and Perioperative Care, University of California-San Francisco, 374 Parnassus Ave., 3rd Floor, San Francisco, CA 94143-0648. Address e-mail to greif{at}compuserve.com

The efficacy of pleural analgesia after nephrectomy is controversial. We therefore evaluated IV opioid requirements in patients with and without pleural bupivacaine. Patients undergoing elective nephrectomy were randomly assigned to receive postoperative IV piritramid alone (n = 18) or piritramid combined with pleural bupivacaine (n = 19). In the patients assigned to receive pleural analgesia, boluses of 20 mL of 0.25% bupivacaine were given at 6-h intervals via an pleural catheter that was inserted in the medial axillary line at the sixth intercostal space. Pain scores (10-cm visual analog scale) and opioid requirements were recorded over the first 2 postoperative days. One hour after pleural puncture, a chest radiograph was performed. The catheter was removed 48 h after insertion. Patient characteristics were similar in each group, as was the duration of surgery. Pain scores were similar in each group: 3.0 ± 2.5 in those given pleural bupivacaine and 3.1 ± 2.7 in those given piritramid alone. However, the piritramid requirement was significantly less in those given pleural bupivacaine (23 ± 3 mg) than in those given piritramid alone (45 ± 6 mg). Furthermore, the time from completion of surgery until the first opioid request was significantly longer in the patients who received bupivacaine (4.7 ± 1.0 vs 2.8 ± 1.0 h). One patient had a small pneumothorax that resolved without treatment. These data indicate that pleural analgesia is effective and provides a significant opioid-sparing effect.

Implications: We conclude that pleural analgesia significantly prolongs the time until postoperative opioid was first requested and halves the total required dose. These data indicate that pleural analgesia is effective and provides a significant opioid-sparing effect.