Intrapleural Catheter Research Articles

Intrapleural Bupivacaine for Early Post-Thoracotomy Analgesia - Comparison with Bupivacaine Intercostal Block and Cryofreezing

54 patients who had posterolateral thoracotomy were prospectively studied to compare the efficacy of intrapleural bupivacaine with that of bupivacaine intercostal block and cryofreezing. Patients were randomized into three groups. The intrapleural catheter group included 16 patients who had intermittent intrapleural instillation of 20 ml of 0.25% bupivacaine for forty-eight hours postoperatively. The second group included sixteen patients who were given perioperative bupivacaine intercostal block. The third group included fifteen patients treated by cryofreezing of the intercostal nerves. Visual analogue four-hourly pain score was compared between the three groups during the first forty-eight hours postoperatively. The analgesic requirements during the first postoperative week were also assessed. There was no significant difference between the three groups in the average pain score (3.61 +/- 1.37, 3.54 +/- 1.15, and 3.33 +/- 1.47 respectively). During the first forty-eight hours postoperatively, the percentage of patients who required papaveretum in the intrapleural catheter group (56.3%) was significantly less than that in the other two groups (both 100%). The average papaveretum requirement (mg per patient) in the intrapleural catheter group (27.33 +/- 25.27) was significantly less than that in the second group (52.66 +/- 26.85) but the difference was not statistically significant from that in the third group (37.66 +/- 20.95). No complications related to the use of the intrapleural catheter or to bupivacaine toxicity were encountered. In conclusion, the technique of intermittent intrapleural bupivacaine is safe and comparable in efficacy to bupivacaine intercostal block and cryofreezing. Narcotic requirements may be reduced when this technique is used.

Intrapleural catheter misplacement during general anesthesia: The need for radiologic contrast studies

Intrapleural catheter misplacement during general anesthesia: The need for radiologic contrast studies

Bilateral intrapleural regional analgesia for postoperative pain control: A dose-finding study

Postoperative pain management for major abdominal or thoracoabdominal procedures requires bilateral multisegmental intercostal nerve blocks or epidural analgesia. This study was undertaken to examine the possible role of bilateral intrapleural regional analgesia (BIRA) and to select the proper dose for this new technique. Bilateral intrapleural catheters were inserted after surgery, using a Mancao dual-cannula system. Bupivacaine with epinephrine 1 200,000 (BE) was administered in each side as 20 mL of 0.5% in three patients. When this dose was found to be ineffective, 30 mL of 0.75% BE was administered in five patients; however, two patients complained of tinnitus and visual disturbances. Subsequently, 20 mL of 0.75% BE was used in five patients and was found to be satisfactory. Thirteen additional patients received the latter dose. Arterial blood levels of bupivacaine were determined at 15, 30, 60, and 120 minutes. The group of 18 patients (group I) who received 20 mL of 0.75% BE bilaterally were compared with a second group (group II) of 16 patients undergoing similar surgery who received only parenteral narcotics for pain management. BIRA was considered effective when patients denied pain or discomfort and when narcotics were not required in the postanesthesia recovery unit. Patients in groups I and II received narcotic medication whenever they felt pain or discomfort. The duration of BIRA was considered to be from the injection of the drug until the time a narcotic was administered to the patient. Demographic variables, changes in BP and heart rate after surgery, frequency of narcotic administration during the first four postoperative days, and postoperative hospital stay were compared in groups I and II. During the postoperative period, narcotics were administered five times more frequently in the control group than in the patients receiving BIRA. Patients receiving BIRA also had an improved sense of well-being and shorter hospital stays.

Subcutaneous tunneled intrapleural catheters in the long-term relief of right upper quadrant pain of malignant origin

A 33-yr-old, 42-kg female, with extensive hepatic metastatic disease with intractable pain unresponsive to narcotic analgesics, nonsteroidal antiinflammatory drugs, and tricyclic antidepressants, is presented. Management of this patient's intractable pain with local anesthetics administered via a tunneled intrapleural catheter is discussed. Tunneling techniques are described. The patient continued to experience excellent pain relief at 6 wk follow-up.

Intrapleural bupivacaine—technical considerations and intraoperative use

The authors evaluated the incidence and type of technical problems associated with blind insertion of intrapleural catheters placed in 21 anesthetized patients and then injected in a double-blind fashion with 0.5% bupivacaine (1.5 mg/kg) or isotonic saline. The patients' chests were then opened, catheter positions located, and the lungs inspected. Eleven of the catheters were located with the tips intrapleurally, three extrapleurally, and seven actually in lung tissue. Eight patients had holes in the lung surface. Three patients had a pneumothorax, two of which were under tension. Plasma bupivacaine levels reached maximal concentrations at about 20 minutes in those with intrapleurally placed catheters, but not until 60 minutes when the catheter had actually penetrated the lung. Significant variations in plasma bupivacaine levels were achieved when the catheter entered lung tissue, with potentially toxic levels in one patient. To evaluate intraoperative analgesic effects, all patients were given a standard anesthetic with isoflurane, oxygen, and a muscle relaxant. There was no significant difference in isoflurane requirement between the groups who had bupivacaine v saline injected into their intrapleural catheters before surgery. It is concluded that blind insertion of intrapleural catheters can be hazardous, especially if followed by positive-pressure ventilation. In addition, catheter placement in lung tissue, which was not uncommon, delays the time for peak plasma concentrations and may increase risk of toxicity. Intrapleural bupivacaine was not found to be a useful adjunct to general anesthesia during thoracotomies.

Intrapleural bupivacaine ν saline after thoracotomy—effects on pain and lung function—a double-blind study

The effects of intrapleural (IP) bupivacaine on pain, morphine requirement, and pulmonary function were evaluated in 15 patients for 24 hours after thoracotomy. An IP catheter was placed during surgery. Patients were randomized in a double-blind fashion to receive 1.5 mg/kg of 0.5% bupivacaine IP or saline on two occasions, eight hours apart. A standard anesthetic with thiopental, oxygen, isoflurane, and nondepolarizing muscle relaxant was given. Pain was evaluated with a visual analog pain score every hour, and forced vital capacity (FVC), forced expiratory volume one second (FEV1), peak expiratory flow (PF), and forced expiratory flow 25% to 75% (FEF) were measured 1, 2, 4, 8, and 24 hours postoperatively as well as before and 30 minutes after each IP injection. Arterial blood gases were sampled 1, 2, 8, and 24 hours postoperatively. Plasma bupivacaine concentrations were measured in 10 patients 5, 10, 20, 30, 60, 120, and 180 minutes after IP injection. With each IP bupivacaine injection, the pain score and morphine requirement decreased. There was a significant improvement in all pulmonary function tests in the patients receiving bupivacaine, but no change in the saline controls. The analgesic effect was shortlived (two to five hours), possibly because of loss of bupivacaine in the chest drains. No differences were seen between the two groups after the effect of IP bupivacaine had worn off. Plasma bupivacaine levels had a Cmax of 0.44 to 1.50 micrograms/mL, with a Tmax at 5 to 30 minutes with levels well below 2 to 4 micrograms/mL where increasing toxicity is seen.

Continuous infusion of bupivacaine via intrapleural catheter for analgesia after thoracotomy in children.

Continuous infusion of bupivacaine via intrapleural catheter for analgesia after thoracotomy in children.

Beneficial effects of endotracheal extubation on ventricular performance: Implications for early extubation after cardiac operations

Early endotracheal extubation has been shown to be a safe postoperative management option in patients having cardiac operations. However, few objective data exist on the response of ventricular performance to early termination of controlled ventilation. Seven patients undergoing routine elective coronary artery bypass grafting or adult repair of atrial septal defect were studied after intraoperative placement of left ventricular micromanometers, left ventricular minor axis dimension crystals, and left atrial and intrapleural pressure catheters. Physiologic data were recorded intraoperatively, during controlled mandatory ventilation in the intensive care unit, and during spontaneous respiration immediately after extubation. Extubation to spontaneous breathing was associated with a significant decline in intrapleural pressure and significant increases in left ventricular end-diastolic diameter, ejection diameter shortening, stroke work, and cardiac output. The augmented left ventricular diastolic filling seemed to result from the fall in intrapleural pressure and perhaps from normalization of right ventricular afterload. The preload recruitable stroke work relationship showed that myocardial contractility remained constant after extubation, and ventricular function improved primarily because of increased preload associated with shifting of the capacitance blood volume toward the chest. Thus endotracheal extubation enhances cardiac performance after uncomplicated cardiac surgical procedures, and by this mechanism early extubation may be clinically beneficial as a routine adjunct to postoperative care.

Use of an intrapleural catheter technique for administration of local anesthetics for pain relief in multiple rib fractures

Use of an intrapleural catheter technique for administration of local anesthetics for pain relief in multiple rib fractures

APNEA: DOES LARYNGEAL MICROASPIRATION PLAY A ROLE?

To examine physiologic mechanisms whereby gastroesophageal reflux might cause apnea, we examined the breathing pattern and airway response after intralaryngeal infusion of 0.1 and 0.5cc each of saline, cow's milk formula, and 0.1N HC1 in 9 adult cats. Anesthetized animals breathed spontaneously through a tracheostomy tube. A second tracheal cannula directed rostrally allowed direct stimulation of the larynx from below. Pulmonary function was determined from simultaneous measurements of intrathoracic pressure by intrapleural catheter, air flow by pneumotachograph, and lung volume by flow integration. Results: 1) None of the stimuli was followed by apnea defined as cessation of effective tidal volume × 15sec. 2) A cough response was elicited in 6 of 9 animals following 0.1N HCl only. 3) A short latent, rapidly adapting (20sec) decrease in respiratory rate from control (25.9±4.9 br/min) was noted following milk (19.4±3.7 br/min) and acid (13.5±1.2 br/min) infusion (p < .01) despite continued presence of stimuli in the larynx at both volumes tested. 4) 0.1N HCl alone produced a short latent, rapidly adapting (20sec) increase in total lung resistance (47.6 ±10.6 cm H2O/L/sec vs control of 23.3±1.7, p < .01). 5) Pretreatment of laryngeal mucosa with Benzocaine abolished the response to all stimuli. CONCLUSIONS: 1) Apnea is not the major response following laryngeal aspiration. 2) Aspiration of microvolumes of acid produces a more significant pulmonary response than milk aspiration. 3) Responses to both stimuli are mediated by rapidly adapting mucosal receptors. 4) Thus, in infants with apnea, combined respiratory and intraesophageal monitoring should include recording of respiratory rate and cough.

BLOOD AND INFLAMMATORY NEUTROPHIL FUNCTION FOLLOWING EXPERIMENTAL ENDOTOXEMIA

The effects of intravenous (IV) endotoxin (LPS) (E.coli 0111B4) on neutrophil (PMN) function in vitro and in vivo in an experimental pig model was examined.Six wk. old pigs were anesthetized with halothane, intubated and ventilated. Intrapleural catheters (10Fr) were inserted. LPS (1.5 ug/kg I.V.) was given and 30 mins. later 5ml zymosan activated pig serum (ZAS) or normal saline as control were placed into the pleural space. Leukocyte migration in vivo was monitored by hourly pleural lavages. In non-LPS challenged pigs,PMN migration (×106)began by lhr (40±10) and peaked at 4hr (220±50).Immature PMN (bands) were observed at 2hr(7±0.8) and peaked by 4hr (10±3). Monocytes migrated by lhr (5±1) and peaked at 6hr (35±5). Following LPS, blood PMN and bands fell by 50%, after which the number of bands increased approximately 10 fold. Migration of PMN into the pleural space was similar in LPS and non-LPS treated pigs. However, in LPS treated pigs, the number of bands migrating was significantly greater and mono - cytes significantly less. In vitro, migration and bacterial killing by blood PMN was transiently reduced after LPS. Furthermore, the bactericidal capacity of pleural PMN was significantly greater than blood PMN in both LPS and non-LPS treated pigs. Our findings illustrate the importance of assessing PMN function both in vivo and in vitro when studying the biologic effects of LPS. (MRC Canada)

Oesophageal pressure measurements in ventilated preterm babies.

Oesophageal pressure measured with an air-filled, thin latex balloon on a 6 French gauge catheter can accurately measure intraoesophageal pressures in ventilated preterm babies. Intraoesophageal pressures and intrapleural pressures are equivalent. Less than 10% of the applied positive ventilator pressure is transmitted to the oesophageal balloon and the intrapleural catheter (intercostal drain). The oesophageal traces show that ventilated babies breath independently of the ventilator. The largest deflections recorded from the oesophageal trace are from spontaneous inspiratory activity. During paralysis with pancuronium spontaneous respiration is inhibited, peristaltic waves are still recorded, and there is little transmitted pressure from the ventilator to the oesophagus or intercostal drain.

Vagotomy reverses apnea induced by high-frequency oscillatory ventilation.

Apnea has been observed in both animals and patients during high-frequency oscillatory ventilation. The effects of vagotomy were studied during periods of oscillator-induced apnea in 11 pentobarbital-anesthetized dogs. The animals were intubated and breathing spontaneously. An arterial cannula was inserted for monitoring blood pressure and blood gases. Intratracheal airway pressure was measured, and respiratory activity was assessed using either an intrapleural catheter or esophageal balloon. The dogs then underwent high-frequency ventilation at 15 Hz. Apnea was induced by appropriate selection of volume displacement of the piston pump and the distal airway pressure in eucapnic animals. Segments of right and left vagus nerves were exposed in the neck, bathed in local anesthetic, and transected. Spontaneous ventilation resumed immediately in nine animals and could not be suppressed at the same CO2 partial pressure despite continuation of oscillation. We conclude that the apnea observed during high-frequency ventilation is mediated by active vagal inhibition of central respiratory activity and is usually reversed by vagotomy.

Management of spontaneous pneumothorax using a Heimlich flutter valve.

Intrapleural evacuation of air was achieved with a Heimlich flutter (non-return) valve in 16 patients with a total of 18 pneumothoraces, 17 of which were spontaneous. Complete lung expansion occurred in 17 (94·4%) of these episodes by five days, and 12 (66%) showed full expansion within one hour. Valve blockage occurred in one patient whose pneumothorax was associated with exudation through the intrapleural catheter and standard under water drainage is recommended in this situation or where there is effusion. The flutter valve precludes the need for the cumbersome apparatus of under water seal drainage and therefore avoids the well-known possible dangers of connecting an intrapleural catheter to a water trap. Another advantage is the immediate mobility of the patient.

Roentgenographic evaluation of bronchial size following pulmonary embolization.

Estimates of the changes in bronchial dimensions following pulmonary embolization have largely been derived from measurements of total lung resistance, anatomic dead space, lung compliance, and other parameters that are assumed to change with bronchoconstriction. Surprisingly, only one group, Jesser and de Takats (6), has attempted to visualize the bronchial response directly by instilling radiopaque material into the bronchial tree prior to embolization. With the use of bronchography, these investigators believed that they could demonstrate bronchoconstriction with pulmonary embolization by the appearance of radiopaque material “squeezed into the terminal radicals.” They did not measure any changes in bronchial dimensions, however, nor can any be definitely recognized in the published roentgenograms. Also, their report that these changes could be prevented by vagotomy, a procedure more recently shown to have no effect in preventing embolism-induced bronchoconstriction (1, 4, 8), suggests that their method was open to question. The development of newer pharmacologically inert contrast media and more refined roentgen technics led us to this investigation in an attempt to visualize directly the bronchial response to pulmonary embolization. To aid in determining the location and extent of bronchoconstriction, histamine and serotonin, two agents thought to mediate bronchoconstriction with pulmonary embolization, were employed, together with balloon occlusion of the left pulmonary artery and with pulmonary embolism itself. Materials and Methods Healthy mongrel dogs weighing 17 to 23 kg were selected for the study. The animals were lightly anesthetized by the intravenous administration of 20 to 25 mg/kg sodium pentobarbital and then intubated with a cuffed tracheal tube 1.2 cm in diameter. Total lung resistance was measured in 20 of 25 animals by technics described by Mead and Whittenberger (7). Briefly, these consisted of introducing a No. 10 Malecot catheter through one of the lower intercostal spaces into the intrapleural cavity, evacuating any pneumothorax, and then suturing the catheter in place. Transpulmonary pressure was measured with a Statham differential transducer, with one side connected to the intrapleural catheter and the other side to a connection in the tracheal cannula. Air flow was measured by a pneumotacho-pretation and should be identified. The contrast medium may itself produce alterations in bronchial width either by its pharmacological effects or by blocking air flow at critical points. This interference with air flow could prevent bronchial distention proximal to the blockage. Probably more important, it could interfere with distal gas exchange and lead to alterations in blood gas composition and pH, as well as prevent the more distal bronchi from contributing to the measurement of total lung resistance. For these reasons special effort was made only to coat the bronchial lumens, rather than to fill them completely.

A Flutter Valve to Replace Underwater Drainage Bottles

To the Editor:— An intrapleural catheter is customarily inserted following thoracotomy or persistent pneumothorax and is attached to an underwater drainage bottle. This apparatus drains the chest and allows the lung to expand, at the same time preventing air from reentering the pleural space. The underwater drainage bottle system has several disadvantages. When the patient is transferred from the operating table to the recovery room, the chest drainage tube must be clamped so that the fluid in the bottle will not flow back. During this clamping, air and blood can accumulate in the chest, collapsing the lung and resulting in the formation of clots that may clog the tubing. A cumbersome alternative is to carry the bottle system at floor level. The tubing that connects the chest catheter to the underwater drainage bottle confines the patient to his bed or chair, preventing ambulation for several days. Few nurses fully understand

Spontaneous Pneumothorax

Two hundred consecutive cases of benign, nontraumatic, nontuberculous spontaneous pneumothorax, unassociated with other pulmonary disease as pneumonia, tumor, etc., are presented. Nearly all were men, and 80 per cent were under 40 years of age. Right and left sides were affected equally. The median time for re-expansion of the collapsed lung was four weeks in the nonsurgical group, three weeks in the repeated needle aspiration group, and two weeks in a small group treated with intrapleural catheter. Most of the patients under 40 years of age were thin. Those older usually had pulmonary emphysema. Only 1.5 per cent had asthmatic attacks just prior to the pneumothorax, and only 3 per cent were engaged in significant physical exertion shortly before. Chest pain was present in 98.5 per cent, and 82 per cent had dyspnea. Gross intrapleural bleeding occurred in 4.5 per cent. Erythrocyte sedimentation rate, white blood count and body temperature were usually normal. One patient with severe emphysema and spontaneous hemopneumothorax and one with severe emphysema and congestive heart failure died shortly after admission. Recurrence occurred usually on the same side in 27 per cent of these patients. More than one recurrence was observed in 9.5 per cent. Almost all were treated conservatively with modified bed rest until the collapsed lung had re-expanded to about 80 per cent of its volume. Full ambulation was then permitted. With complete re-expansion, the patients returned to normal activities.