Demmy, T.L., Nwogu, C., Solan, P., Yendamuri, S., Wilding, G., & DeLeon, O. (2009). Chest tube-delivered bupivacaine improves pain and decreases opioid use after thoracoscopy. The Annals of Thoracic Surgery, 87(4), 1040–1046; discussion 1046–1047.

To compare, in thorascopy patients, the efficacy of intrapleural bupivacaine versus that of PCA fentanyl

All patients underwent a thorascopic operation during the study. Afterward, the F group received IV fentanyl (F) by means of patient-controlled analgesia (PCA). The IB group received intermittent intrapleural bolus delivery of bupivacaine plus fentanyl. The CB group received continuous intrapleural delivery of bupivacaine plus fentanyl.

PCA fentanyl was given as 40 mcg/hour basal rate with 30 mcg every 10 min as needed to a 160 mcg/hour maximum. Patients in the IB  group received an initial bolus of 0.25% bupivacaine and the same PCA fentanyl dosage as the fentanyl-only group. If the fentanyl escalation was insufficient, the patient was prescribed additional 50 mcg boluses as needed. Patients in the CB group received 5 ml/hour continuous infusion bupivacaine via chest tube as well as PCA fentanyl. In the CB group, if fentanyl escalation was insufficient, 15–30 mg ketorolac was administered intervenously.

Nurses obtained baseline pain measures at the first postoperative complaint of pain and request for additional analgesia. Pain was also measured at 6, 12, 18, and 24 hours after the operation.

• The sample was composed of 30 patients.
• In the F group, mean patient age was 56 years. In the IB group, mean patient age was 61 years. In the CB group, mean patient age was 60.
• Of all patients, 56.6% were female and 43.3% were male. All patients underwent, during the study, thorascopic operations to achieve nonanatomic lung resections. Of all patients, 80% had cancer.

• Single setting
• Inpatient
• Roswell Park Cancer Institute, Buffalo, New York

Nonblinded prospective randomized controlled trial

• Visual analog pain score (VAPS)
• Amount of fentanyl used

• During the first six hours, authors noted a statistically significant difference (p = 0.01) among groups in total fentanyl consumed. Patients in the intrapleural infusion groups had lower consumption.
• At six hours, three patients in the fentanyl-only group were not able to bring pain to an acceptable level (p = 0.04).
• Compared to the F group, more patients in both intrapleural groups required dose escalation. The continuous bupivacaine group contained the highest proportion of patients needing escalation (p = 0.08).
• Authors noted no differences in the proportion of patients whose pain improved from baseline, and the highest pain severity scores were similar across groups.

Administering local anesthetic through a chest tube catheter can reduce fentanyl consumption and pain after a thoracoscopy.

• The study had a small sample size, with fewer than 100 patients.
• Patients' relatively brief length of stay suggests that cases involved may have been carefully selected, subjecting the sample to bias.

Intrapleural bupivacaine can be used to reduce pain after a thoroscopy; however, this approach may require ongoing adjustment and dosage escalations to achieve sufficient pain control. Intrapleural infusion may reduce total opioid consumption and attendant side effects; however, the study evidenced no differences in terms of prevalence or severity of effects. The most appropriate and effective doses of intrapleural bupivacaine remain unclear. Authors note that the continuous intrapleural infusion approach is much more costly than the other interventions. Whether study findings warrant the increased cost is unclear.