VOLUME 29, Issue 1

THE CHANGING LANDSCAPE OF INVASIVE THORACOTOMY PAIN TECHNIQUES

Samuel J. Hankins, MD

Acute pain after thoracotomy is often severe and requires specific planning in the pre- and intraoperative periods for optimization. As physicians, we know that uncontrolled pain after thoracotomy leads to splinting, diaphragmatic dysfunction, atelectasis and a host of other physiologic disturbances. In today’s medical environment where the goal is early postoperative extubation in order to shorten ICU and overall hospital length of stay, optimal control of acute postoperative pain becomes even more important.1

Most of us remember the transition in thoracotomy pain management from systemic medications to more focused regional techniques. Currently, thoracic epidural anesthesia (TEA) is a popular option for these procedures. However, this approach is being challenged because of the known pitfalls of TEA coupled with the availability of a new pharmacologic agent: liposomal bupivacaine.

Daniel Tolpin, MD

Liposomal bupivacaine (LipoB [Experal; Pacira Pharmaceuticals, Parsippany, NJ]) is a formulation of bupivacaine that allows continuous release of the anesthetic from liposomal vesicles over a 96-hour period and, thus, can provide prolonged tissue concentrations of local anesthetic after a single application without the need for indwelling catheters.2 A significant drawback of LipoB is cost: since it is still currently under patent, the charge even for single-shot use can be high (e.g. the patient’s charge at the author’s hospital is currently $947/20mL vial versus $51/30mL vial of 0.25% bupivacaine).

The re-emergence of paravertebral blockade (PVB) and intercostal blockade (ICB) has been invigorated by the availability of LipoB for ultra-long-acting single-shot blocks. Some early studies have indicated that single-shot ICB with LipoB can decrease hospital length of stay without increasing perioperative complications versus TEA.3 However, it should be noted that the use of LipoB for regional blockade is still off-label. Advantages of PVB and ICB over TEA include easier placement, focused unilateral analgesia, less sympathetic blockade, and less stringent requirements for cessation of anticoagulation or anti-platelet agents. In general, they also provide a relative cost benefit, since TEA placement requires closer patient monitoring, maintenance of epidural pumps, and personnel to round on and troubleshoot patients receiving continuous epidural infusions.

ICB is usually accomplished by injecting 2-4 mL of local anesthetic per level inferior to the rib at a point 6-8cm lateral to the spinous process (midline). While many of the advantages of ICB mirror those of PVB, some centers prefer ICB as an intraoperative option due to the fact that local anesthetic placement can be directly visualized by the performing surgeon.3 However, ICB does not achieve as dependable and as complete a block as PVB techniques. Using the anatomical approach, PVB blockade is performed by injecting 4-5 mL of local anesthetic per level at a point 2.5cm lateral to midline by either walking off the respective transverse process or by testing loss-of-resistance. In addition, many have adopted ultrasound guided techniques for placement of PVB’s. Traditional local anesthetics (i.e. bupivacaine) coupled with additives can achieve a duration of about 18 hours, and a continuously-infusing catheter can be placed if analgesia is desired for periods longer than this. Some centers are using liposomal bupivacaine as a single-shot medication in the paravertebral space to achieve even longer analgesic durations (greater than 47 hours from single shots have been reported).4

As the pressure to speed recovery, reduce cost, and improve patient outcomes after surgery increases, changing strategies for optimizing the perioperative experience will be encountered. In thoracic surgery, the release of LipoB coupled with renewed interest in PVB and ICB shows promise as a means to satisfy these goals. Studies to-date have shown an acceptable safety profile, but additional investigation is needed to prove definitive advantage over traditional methods.

References:

  1. Wenk M, Schug SA. Perioperative pain management after thoracotomy. Curr Opin Anaesthesiol. 2011
    Feb;24(1):8-12.
  2. Hu D, Onel E, Singla N, Kramer WG, Hadzic A. Pharmacokinetic profile of liposome bupivacaine
    injection following a single administration at the surgical site. Clin Drug Investig. 2013 Feb;33(2):109-15.
  3. Rice DC, Cata JP, Mena GE, Rodriguez-Restrepo A, Correa AM, Mehran RJ. Posterior Intercostal Nerve
    Block With Liposomal Bupivacaine: An Alternative to Thoracic Epidural Analgesia. Ann Thorac Surg.
    2015 Jun;99(6):1953-60.
  4. Hutchins, J. Single Shot Paravertebral Block with Multivesicular Liposomal Bupivicaine (Exparel) in
    Breast Surgery. Poster session presented at: Annual Regional Anesthesiology and Acute Pain Medicine
    Meeting (ASRA); 2014 Apr 3-6; Chicago, IL.

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