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Short notes
Br. J. Surg. 1987, Vol. 74, January, 63
Does intercostal blockade
improve patient comfort after
cholecystectomy?
T
T
W. B. Ross, J. H. Tweedie, Y. P. Leong,
A. Wyman and B. M. Smithers
Derbyshire Royal Infirmary, Derby City Hospital, Derby,
UK
Correspondence to: Mr W. B. Ross, Renal Transplant Unit,
Cardiff Royal Infirmary, Newport Road, Cardiff CF2 1 SZ,
UK
The aim of this trial was to investigate the effect of a single
intercostal blockade on the patient’s comfort during the early
postoperative phase.
0-12
12-24
24-36
36-48
48-60
Time after op.(hours)
intercostal block and
Figure 1 Degree of pain. Mean score k s.e m. 0,
papaveretum; 0,
papavereturn alone
Table 1 Nausea scores: linear analogue scale, 0-10
Patients and methods
A total of 107 patients were entered in the trial, but 15 patients were later
withdrawn. All patients signed an informed consent form.
The methods of pre-medication and induction and anaesthesia were
not standardized. All cholecystectomies were performed through either
a transverse upper abdominal or an oblique subcostal incision. An
operative cholangiogram was performed and patients with
choledocholithiasis were withdrawn from the trial. A plastic tube drain
was used in every case.
At the end of the operation, patients were randomly allocated to one
of two groups. Group 1 had an intercostal block combined with
papaveretum (ICB + P) for postoperative analgesia. Group 2 did not
have intercostal blockade and received papaveretum (P) only.
Intercostal blockade was performed, by the authors, using the method
described by Nunn and Slavin’. Seven nerves (T5-Tll) were blocked,
3 ml 0.5 per cent bupivacaine (contaiping 1:200000 adrenaline) were
injected in each intercostal space. A long Elastoplast dressing was
applied over the left ribs posteriorly in all patients. This kept patients
and nurses unaware of whether a blockade had or had not been
performed. Nursing staff were asked to administer papaveretum when
requested by the patients who had been instructed to request pain relief
when they required it, rather than wait to be asked.
On return to the ward, the patients were restricted to 30 ml water per
hour orally. The intravenous infusion was reduced to 500 ml per 8 hours
at midnight after surgery. The next morning, all patients were
encouraged to take oral fluids. Metoclopramide was prescribed for
nausea and vomiting as required. Patients received a standard
physiotherapy regime. Patients had been operated on during morning
and afternoon lists, but were visited twice daily, at 8 a.m. and 8 p.m.
approximately, by one of the authors in order to assess pain and nausea
(using linear analogue scales) and also to examine the chest for
atelectasis. Patients were reviewed 4 weeks after discharge. Statistical
analysis were performed using Student’s t test and ,yz tests. The
Mann-Whitney U test was applied to compare non-parametric data.
Results
Both groups were comparable in respect of age, sex, weight,
height, incidence of smoking and duration of the operation.
There was no significant difference between the two
complication rates. The definition of ‘chest infection’ was taken
to be the presence of atelectasis and pyrexia or production of
purulent sputum. Chest infections were treated with ampicillin
and physiotherapy. In Group 1 (ICB+P) 10 (24percent)
patients developed chest infections compared with 8
(16 per cent) in Group 2 (P), this was not significant. In Group 1
(ICB + P) there was a higher incidence of atelectasis (38 versus
34 per cent), but this was not significant. One patient developed
a small pneumothorax after ICB.
The mean interval between the end of the operation and
administration of the first dose of analgesic was significantly
longer in Group 1 ( I C B f P ) than in Group 2
(6.46 (s.e.m. = 1.19) versus 3.25 (s.e.m. =034) h; P<0905).
0007-1323/87/01006341$3.00
0 1987 Butterworth & Co (Publishers) Ltd
Time after operation
(h)
ICB +
papaveretum
Papaveretum
alone
&12
12-24
24-36
36-48
48-60
2.05
(0.50)
2.07
(0.46)
1.71
(0.41)
1.71
(0.44)
1.35
(0.42)
1.20
(0.36)
0.75
(0.30)
0.35
(0.15)
2.28
(0.35)
0.32
(0.08)
Values are mean +s.e.m.
This suggests that the intercostal blockade was an effective
analgesic. However, there was no difference (ICB P versus P),
between the consumption of papaveretum (0.77 (s.e.m. =0.19)
versus 0.71 (s.e.m.=0.06) mg/kg body weight) and metoclopramide (0.24 (s.e.m. =0.03) versus 0.22 (s.e.m. =0.03) mg/kg
body weight). Both groups had similar incidences of
postoperative vomiting, with an overall incidence of
31.5 per cent. Both groups experienced similar degrees of pain
(Figure I) and durations of nausea (Table I).
+
Discussion
Murphy suggested continuous intercostal nerve blockade by
insertion of a single extradural catheter into an appropriate
intercostal space and administering local anaesthetic via this ‘on
demand’’. This would appear to be an improvement on the
technique of multiple intercostal blocks reported by Moore3.
The overall incidence of vomiting (31.5 per cent) is high. This
is probably related to the observations that postoperative
vomiting is more prevalent among females and the obese4. These
factors were also prevalent in our study.
The results of this study question the effectiveness of
intercostal block in the management of pain after
cholecystectomy. There is in addition a small, but not neglible,
risk of pneumothorax. We conclude that it does not reduce the
need for narcotic analgesics and does not improve the patient’s
comfort.
References
1.
2.
3.
4.
Nunn JF, Slavin G . Posterior intercostal nerve block for pain relief
after cholecystectomy. Br J Anaesth 1980; 5 2 253-60.
Murphy DF. Continuous intercostal nerve blockade for pain relief
following cholecystectomy. Br J Anaesth 1983; 55: 5 2 1 4 .
Moore DC. Intercostal nerve block for postoperative somatic pain
following surgery of thorax and upper abdomen. Br J Anaesth
1975; 4 7 284-7.
Palazzo MGA, Strunin L. Anaesthesia and emesis. I: etiology. Can
Anaesth Soc J 1984; 31: 178-87.
Paper accepted 5 August 1986
63
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