The effect of peroperative intercostal nerve block on postoperative epidural morphine consumption, analgesia quality and pulmoner function in postthoracotomy pain

Postthoracotomy pain, is known as the most severe form of postoperative pain and effective treatment is essential. In this prospective clinical study, the effect of peroperative multiple segment intercostal nerve block with bupivacaine on postoperative epidural morphine consumption, analgesia quality and pulmoner function in patients undergoing thoracotomy was investigated. Following local ethics committee approval, sixty patients (ASA I-III, aged between 18-65 yr) scheduled for elective thoracotomy were included. They were randomly assigned into two groups equally ; (i) epidural analgesia (EA) group and (ii) epidural + intercostal analgesia (EIA) group. At the end of the surgery, before closure of the thoracotomy, 3 mg of morphine was administered to all patients via epidural catheter which was inserted preoperatively. Ten mL of 0.9 % NaCl was administered to the surgical incision site, to the two upper and two lower segments of incision site in patients of EA group. Ten mL of 0.5 % bupivacaine was administered to the same sites as mentioned above in patients of EIA group in order to achieve intercostal nevre block. Postoperative analgesia was provided with epidural morphine (0.1 mg/mL) by using patient controlled analgesia (PCA) device (bolus dose: 0.5 mg, lock out time: 30 min, 4 hour limit: 3 mg). At the end of the surgery, the trachea was extubated in all patients. Static and dynamic pain scores of patients, morphine consumption, analgesic demand numbers and adverse effects of morphine were determined hourly during the first four hours and then at the 4th, 12th., 24th, 48th and 72nd hours postoperatively. Pulmonary function tests were performed preoperatively and at the postoperative 24th and 72nd hours. Except gender distribution (number of female patients of EIA group > EA Group, p<0.05), no significant differences in the demographics and in the clinical characteristics were found between groups (p>0.05). Static VAS scores (0., 1., 2., 3., 4., 12., 48. and 72. hr, p<0.05), dynamic VAS scores (0., 1., 2., 3., 4., 24., 48. and 72.hr, p<0.05) and morphine consumption (24. hr [EA Group:145.6±52.8 ?g/kg, EIA Group: 117.9±53.0 ?g/kg], 48. hr [EA Group:218.1±81.0 ?g/kg, EIA Group: 164.3±91.0 ?g/kg] and 72. hr [EA Group: 267.8±104.5 ?g/kg, EIA Group: 188.1±101.0 ?g/kg], p<0.05) were significantly lower in patients of EIA group compared to those of EA Group. Analgesic demand numbers from PCA device were significantly higher in EA Group at the 4th, 24th, 48th and 72nd hours (p<0.05). Although obtained basal values of FVC, FEV1 were statistically lower in EIA group, postoperative values of FVC, FEV1, FEF25-75 and PaO2 were similar between the two groups (p>0.05). In our study, lomber epidural morphine administration in combination with the intercostal nerve block was more effective than a single lomber epidural morphine administration in order to control postthoracotomy pain. The results of our study suggest that multimodal analgesic approach should be preferred for postthoracotomy pain.