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Abstract
Inadequate treatment of postoperative pain causes needless suffering and may develop many complications as cardiovascular, pulmonary, central nervous system, gastrointestinal, genitourinary, metabolic and psychological complications.
Upper abdominal surgeries are usually performed through one of three possible incisions: flank, subcostal, or thoracoabdominal which cause severe pain that adversely affects a patient ability to cough and breath deeply, leading to sputum retention and respiratory insufficiency, predisposing the patient to chest infection and pneumonia and may lead to mechanical ventilation. Regional analgesia is the most logical approach to control postoperative pain as opioids have many detrimental effects, especially on respiration and oxygenation .
Since its first description, pleural analgesia has proven a safe and effective treatment for pain resulting from laparoscopic cholecystectomy, open cholecystectomy, multiple fractured ribs, blunt thoracic trauma, herpes zoster, and pancreatic tumors.
Despite the large positive experience with pleural analgesia after cholecystectomy, only a few studies have evaluated the method for treatment of nephrectomy pain .
The present study was designed to investigate the role of interpleural block in postoperative analgesia in patients undergoing major renal surgery.
Thirty two patients who fulfilled the criteria of the study was randomly assigned to one of the two equal study groups using a table of random numbers. Group I received loading I.V. morphine (3mg), then connected to PCA device. While group II received interpleural 20 ml bupivacaine 0.5%, through interpleural catheter, followed by 20 ml bupivacaine 0.25% every 6 hours.
Patients were evaluated by history, physical examinations and laboratory investigations were requested preoperatively. Patients were visited the day before surgery. Visual analogue scale was explained.
There is an overall decrease in the heart rate and mean arterial blood pressure in the interpleural group compared to the PCA group which reveals less stress response.
Regarding the analgesic effect, 68.75% of the patients in the interpleural group did not request additional analgesia, while the remaining 31.25% needed additional analgesia and used the PCA morphine.
Regarding the time to first request for analgesia, in the current study it was greatly longer in the interpleural group (5.4 ±0.6 h.) than that in the PCA group (2.8 ±0.8 h.), which was statistically significant (p<0.01).
In the current study, the average morphine consumption in the first 24 hours after surgery was (15 ±3 mg) in the interpleural group while it is (36 ±6 mg) in the PCA group and this difference was statistically significant (p<0.01).
Postoperative pain assessment using the visual analogue scale (VAS) in the first 24 hours showed that the mean value in the PCA group was gradually increasing in the first 12.5 hours, then gradually decreasing then after, while the VAS in the interpleural group showed a significant reduction in the pain score half an hour after each interpleural bupivacaine injection with an overall lower pain scores than that of the PCA group both at rest and on coughing.
A rough estimation for the postoperative stress response by measuring the RBS in the study groups patients revealed that the mean RBS was similar in both groups in the first 2 hours, but its value was significantly lower in the interpleural group after that.
There was no recorded complications among the patients in the two studied groups.
It could be concluded that interpleural block is a safe and effective method providing adequate analgesia and a decrease in the postoperative morphine requirement following major renal surgery.