Anaesth. Intens. Care (1976), 4, 259
INTERCOSTAL BLOCK FOR POST OPERATIVE PAIN RELIEF K.
D. CRONIN* AND
.\1.
J.
DAVIESt
St. Vincent's Hospital, Melbourne SUMMARY
Intercostal nerve blocks with 0·5 per cent bupivicaine were used for post operative pain relief in 100 patients having upper abdominal operations. The blocks were very effective in 86 patients and had an average duration of 11 hours. Two asymptomatic pneumothoraces occurred. INTRODUCTION
Intercostal nerve block has been largely neglected as a form of post operative pain relief mainly because of short duration of action and the possible complication of pneumothorax. Using bupivicaine the blocks need only be repeated twice daily, which is more practical in most situations. The problem of pneumothorax has also been exaggerated; on reviewing the literature the incidence is generally less than two per cent. Our series was aimed at determining the effectiveness and duration of these blocks using bupivicaine.
European origin and had difficulty in speaking English; however, it was generally very obvious if they had effective pain relief. Most of the patients had cholecystectomies (63) or gastric operations (19), however, the type of intercostal block required was determined by the site of the incision. The type of incisions are shown in Table 1. Those patients having subcostal incisions had unilateral intercostal blocks, but occasionally their incisions crossed the midline so that some bilateral blocks were carried out. Patients who had a paramedian incision generally required bilateral blocks for complete pain relief.
1 Incisions
TABLE
Subcostal .. Midline Paramedian Transverse Thoraco-abdominal Others Total..
62 19 7 6 3 3 100
MATERIALS AND METHODS
One hundred patients having upper abdominal surgery were selected at random for intercostal blockade. There were 56 females and H males and their ages ranged from 20 to 82 years. !lIany of the patients (53) were of Southern
* "LB., B.S., F.F ..\.R.A.C.S., Assistant to the Director of Anaesthesia. -r M.B., B.S., F.F ..\.R.A.C.S., Senior Anaesthetic Registrar. Address for reprints: Dr. K D. Cronin, Department of Anaesthesia, St. Vincent's Hospital, Fitzroy, Vic. 3065, Australia. Anaesthesia and Illtl'l1sive Care, J'ol. IV, .\'0 . .3, A Ugllst, 1976
FIGURE I.-Equipment for intercostal blocks.
K. D.
CROX'X .\XI)
The technique used wa~ a modification of that described by :\loore in his book on Regional Block p100re 1973). The equipment used was simple and readily available in both theatre and ward. It consisted of bupivicaine, a :W ml syringe, a drawing up cannula, a 23G. disposable needle, a rubber marker and some swabs to prepare the skin (Figure 1). The blocks were generally performed with the patient in the lateral position (Figure 2); repositioning to the other side for bilateral blocks. It is important to hang the upper arm over the side of the bed in order to rotate the scapula away from the ribs. Occasionally the sitting position was used for bilateral blocks. ';Ye found the use of a rubber marker (the rubber diaphragm from a Gord needle) very helpful to ensure that the needle point was not inserted deeper than 3 to ;i mm from the depth of the outer surface of the rib. The hands were placed against the back of the patient (Figure :{), so that if the patient moved during insertion of the block, the needle and syringe 1l1Oved with the patient and made inadvertent puncture of the lung less likely.
:\1.
.J.
D,\\"'E~
The blocks were generally performed pril"~ to emergence from anaesthesia and repeHed approximately 12 hourly for :)fi to 48 hour:;. post operatively. The patients were assessed after they had the blocks performed and asked if they had any pain. If the patients had no pain then the blocks were considered effective and this was often confirmed by the extent of analgesia to pin prick or wound pressure. If the patients complained of pain then they were questioned more closely to determine the CUhe of the pain.
I:)C!"HE
of
t1H'
:{.-I'o:iitiun of hands of operator and :.'l' lllarker to define the depth of
in~l'rti(l:'
(If
thl' needle. RESl'I,T~
F!GL"I{E
.)
-Lateral position \\"ith scapula rotated ,I\\ay from the che:it wall.
\\'c used :{ Illl of () .,-, per cent bupivicaine with adrenaline pry intercostal nerve. For bilateral blocks 10 to 1-1- nerves were blocked and in general \\'e aimed not to use more than 10 ml or 200 mg of the drug. :\loore (H)j5) ha~ reported the use of 300 mg of bupivicaine without toxic effecb. \\'e emphasize the use of adrenaline containing solutions because of the risk of having toxic reactions to high doses of the plain solutions (Yoshikawa IH61'). : 200,000
In our series we had R6 patients who had g )od pain relief while the blocks were effectl\'e. Partial success occurred in 12 patients mJ.ml~· because they had other causes of pain ,lOt covered by the blocks. Post operative p1in may also result from bowel distention, refereed pain, painful buttocks, sore throat and painiuc to the nasogastric tube or thrombophlebItis. Our patients were very awake and aware and would often not tolerate these other sources of pain which would normally be covered by parenteral analgesics. The two failures were due to our inability to assess the patients adequately because one :lacl Delirium Tremens and the other spokL- nu English and there was no interpreter avaihl)k. Table 2 shows the frequency of analg"sic supplements while the patients were ha\:ng intercostal blocks. :\Iost of the patienb had none or one dose of opiate, usua 11:; this was
261
I",TERCOSTAL BLOCK
gin'I1 in the early mornmg when the previous day's blocks had worn off. \Ve generally repeated the blocks at about 8 a.m. The duration of action of the blocks was assessed from the time the blocks were inserted until the patient complained of pain. Not all the blocks could be timed, as sometimes they were repeated before the previous blocks had worn off, and occasionally the patients couldn't TABLE
2
Analgesic S u pplcmenls Doses
I
~
I
2~
3
I
remember the time when the pain returned. The average duration was 11 hours, the range being from 6 to 18 hours. These were taken from 128 timed blocks. Complications were uncommon and acceptable, though we did detect two pneumothoraces. These were asymptomatic and clinically not detected until after chest X-rays were performed. Twenty other chest X-rays performed in our series showed no pneumothoraces. TABLE 3 Incidence of Pneumothorax Following Intercostal Block
Chivers Bartlett Safar Bennett :\loore :\Ioore Engberg :\loore
(1946) (1952) (1954) (1956) (1962) (1962) (1975) (1975)
CONCLUSION
Intercostal blocks with bupivicaine is a good method for post operative pain relief in patients having upper abdominal operations. The technique is safe, simple and easily learnt. It does require more work by the anaesthetist, though this work is rewarding.
Patients
---0---1-:384
not perform these blocks. In the literature the incidence of pneumothorax following intercostal block is quite low, and except for one series, quite acceptable (Table 3).
Hl% 2'6% 0'0% 0·3% 0·1% 0·5% 0·9% 0'1%
(19 in 100) (1 in 38) (0 in 40) (2 in 600) (4 in 4333) (1 in 200) f (1 in 112) (8 in 10,941)
DISCUSSION
The duration of action of the blocks was impressive, and supports the claim by Engberg (1975) that even the performing of one block is worthwhile. The complication of pneumothorax is probably the most common reason why anaesthetists will
ACKXOWLEDGEMENTS
We wish to acknowledge the encouragement and help of Dr. Ralph Clark, Director of Anaesthesia at St. Vincent's Hospital, the Consultant Anaesthetists and the Anaesthetic Registrars who performed some of the blocks and allowed us to follow up the patients. We also wish to thank Dr. R. Cowie who introduced us to the technique, the photography department for the figures and l\Iiss Jennifer :\lason for typing the manuscript. REFERENCES
Bartlett, R. W., Eastwood, D. W. (1952): "Long Acting Bilateral Intercostal Xen'e Block for l'pper Abdominal Surgery", Surgery, 32, \l56. Chivers, E. 11. (1946): "Pulmonary Complications Following Regional Analgesia for Abdominal Operations ", Brit. J. Anaesth., 20, 55. Engberg, G. (1975): "Single Dose Intercostal Xerve Blocks with Etidocaine for Pain Relief after Upper Abdominal Surgery", Acta anaesth. scand., Suppl., 60, 48. :\Ioore, D. C., Bridenbaugh, L. D. (1!l62) : " Intercostal Nerve Block in 4,333 Patients ", Anesth. Analg., 41, 1. :\Ioore, D. c., Bridenbaugh, L. D. (Ui62) : " Pneumothorax ", J. Amer. Med, Ass., 182, 1005. Moore, D. C. (1973) : Intercostal Nerve Block Re{:ional Block. Fourth Edition, Charles C. Thomas. Springfield, 163. :\Ioore, D. C. (1975): "Intercostal Nerve Block for Post Operative Somatic Pain Following Surgery of Thorax and Upper Abdomen ", Brit. ]. Anaesth., 47,284. Safar, P. (1\l54): "Intercostal Nerve Block and Minimal General Anaesthesia for Major Abdominal Surgery", Anesth. Analg., 33, 98. Yoshikawa, K., Mima, T., and Egawa. J. (1968): "Blood Level of Marcain in Axillary Plexus Blocks, Intercostal Nerve Blocks and Epidural Anaesthesia ", Acta A naesth. scand., 12, 1.
Anaesthesia and Intensive Care, Vol. IV, No. 3, Au{:ust, 1976
INTERCOSTAL BLOCK FOR POST OPERATIVE PAIN RELIEF K.
D. CRONIN* AND
.\1.
J.
DAVIESt
St. Vincent's Hospital, Melbourne SUMMARY
Intercostal nerve blocks with 0·5 per cent bupivicaine were used for post operative pain relief in 100 patients having upper abdominal operations. The blocks were very effective in 86 patients and had an average duration of 11 hours. Two asymptomatic pneumothoraces occurred. INTRODUCTION
Intercostal nerve block has been largely neglected as a form of post operative pain relief mainly because of short duration of action and the possible complication of pneumothorax. Using bupivicaine the blocks need only be repeated twice daily, which is more practical in most situations. The problem of pneumothorax has also been exaggerated; on reviewing the literature the incidence is generally less than two per cent. Our series was aimed at determining the effectiveness and duration of these blocks using bupivicaine.
European origin and had difficulty in speaking English; however, it was generally very obvious if they had effective pain relief. Most of the patients had cholecystectomies (63) or gastric operations (19), however, the type of intercostal block required was determined by the site of the incision. The type of incisions are shown in Table 1. Those patients having subcostal incisions had unilateral intercostal blocks, but occasionally their incisions crossed the midline so that some bilateral blocks were carried out. Patients who had a paramedian incision generally required bilateral blocks for complete pain relief.
1 Incisions
TABLE
Subcostal .. Midline Paramedian Transverse Thoraco-abdominal Others Total..
62 19 7 6 3 3 100
MATERIALS AND METHODS
One hundred patients having upper abdominal surgery were selected at random for intercostal blockade. There were 56 females and H males and their ages ranged from 20 to 82 years. !lIany of the patients (53) were of Southern
* "LB., B.S., F.F ..\.R.A.C.S., Assistant to the Director of Anaesthesia. -r M.B., B.S., F.F ..\.R.A.C.S., Senior Anaesthetic Registrar. Address for reprints: Dr. K D. Cronin, Department of Anaesthesia, St. Vincent's Hospital, Fitzroy, Vic. 3065, Australia. Anaesthesia and Illtl'l1sive Care, J'ol. IV, .\'0 . .3, A Ugllst, 1976
FIGURE I.-Equipment for intercostal blocks.
K. D.
CROX'X .\XI)
The technique used wa~ a modification of that described by :\loore in his book on Regional Block p100re 1973). The equipment used was simple and readily available in both theatre and ward. It consisted of bupivicaine, a :W ml syringe, a drawing up cannula, a 23G. disposable needle, a rubber marker and some swabs to prepare the skin (Figure 1). The blocks were generally performed with the patient in the lateral position (Figure 2); repositioning to the other side for bilateral blocks. It is important to hang the upper arm over the side of the bed in order to rotate the scapula away from the ribs. Occasionally the sitting position was used for bilateral blocks. ';Ye found the use of a rubber marker (the rubber diaphragm from a Gord needle) very helpful to ensure that the needle point was not inserted deeper than 3 to ;i mm from the depth of the outer surface of the rib. The hands were placed against the back of the patient (Figure :{), so that if the patient moved during insertion of the block, the needle and syringe 1l1Oved with the patient and made inadvertent puncture of the lung less likely.
:\1.
.J.
D,\\"'E~
The blocks were generally performed pril"~ to emergence from anaesthesia and repeHed approximately 12 hourly for :)fi to 48 hour:;. post operatively. The patients were assessed after they had the blocks performed and asked if they had any pain. If the patients had no pain then the blocks were considered effective and this was often confirmed by the extent of analgesia to pin prick or wound pressure. If the patients complained of pain then they were questioned more closely to determine the CUhe of the pain.
I:)C!"HE
of
t1H'
:{.-I'o:iitiun of hands of operator and :.'l' lllarker to define the depth of
in~l'rti(l:'
(If
thl' needle. RESl'I,T~
F!GL"I{E
.)
-Lateral position \\"ith scapula rotated ,I\\ay from the che:it wall.
\\'c used :{ Illl of () .,-, per cent bupivicaine with adrenaline pry intercostal nerve. For bilateral blocks 10 to 1-1- nerves were blocked and in general \\'e aimed not to use more than 10 ml or 200 mg of the drug. :\loore (H)j5) ha~ reported the use of 300 mg of bupivicaine without toxic effecb. \\'e emphasize the use of adrenaline containing solutions because of the risk of having toxic reactions to high doses of the plain solutions (Yoshikawa IH61'). : 200,000
In our series we had R6 patients who had g )od pain relief while the blocks were effectl\'e. Partial success occurred in 12 patients mJ.ml~· because they had other causes of pain ,lOt covered by the blocks. Post operative p1in may also result from bowel distention, refereed pain, painful buttocks, sore throat and painiuc to the nasogastric tube or thrombophlebItis. Our patients were very awake and aware and would often not tolerate these other sources of pain which would normally be covered by parenteral analgesics. The two failures were due to our inability to assess the patients adequately because one :lacl Delirium Tremens and the other spokL- nu English and there was no interpreter avaihl)k. Table 2 shows the frequency of analg"sic supplements while the patients were ha\:ng intercostal blocks. :\Iost of the patienb had none or one dose of opiate, usua 11:; this was
261
I",TERCOSTAL BLOCK
gin'I1 in the early mornmg when the previous day's blocks had worn off. \Ve generally repeated the blocks at about 8 a.m. The duration of action of the blocks was assessed from the time the blocks were inserted until the patient complained of pain. Not all the blocks could be timed, as sometimes they were repeated before the previous blocks had worn off, and occasionally the patients couldn't TABLE
2
Analgesic S u pplcmenls Doses
I
~
I
2~
3
I
remember the time when the pain returned. The average duration was 11 hours, the range being from 6 to 18 hours. These were taken from 128 timed blocks. Complications were uncommon and acceptable, though we did detect two pneumothoraces. These were asymptomatic and clinically not detected until after chest X-rays were performed. Twenty other chest X-rays performed in our series showed no pneumothoraces. TABLE 3 Incidence of Pneumothorax Following Intercostal Block
Chivers Bartlett Safar Bennett :\loore :\Ioore Engberg :\loore
(1946) (1952) (1954) (1956) (1962) (1962) (1975) (1975)
CONCLUSION
Intercostal blocks with bupivicaine is a good method for post operative pain relief in patients having upper abdominal operations. The technique is safe, simple and easily learnt. It does require more work by the anaesthetist, though this work is rewarding.
Patients
---0---1-:384
not perform these blocks. In the literature the incidence of pneumothorax following intercostal block is quite low, and except for one series, quite acceptable (Table 3).
Hl% 2'6% 0'0% 0·3% 0·1% 0·5% 0·9% 0'1%
(19 in 100) (1 in 38) (0 in 40) (2 in 600) (4 in 4333) (1 in 200) f (1 in 112) (8 in 10,941)
DISCUSSION
The duration of action of the blocks was impressive, and supports the claim by Engberg (1975) that even the performing of one block is worthwhile. The complication of pneumothorax is probably the most common reason why anaesthetists will
ACKXOWLEDGEMENTS
We wish to acknowledge the encouragement and help of Dr. Ralph Clark, Director of Anaesthesia at St. Vincent's Hospital, the Consultant Anaesthetists and the Anaesthetic Registrars who performed some of the blocks and allowed us to follow up the patients. We also wish to thank Dr. R. Cowie who introduced us to the technique, the photography department for the figures and l\Iiss Jennifer :\lason for typing the manuscript. REFERENCES
Bartlett, R. W., Eastwood, D. W. (1952): "Long Acting Bilateral Intercostal Xen'e Block for l'pper Abdominal Surgery", Surgery, 32, \l56. Chivers, E. 11. (1946): "Pulmonary Complications Following Regional Analgesia for Abdominal Operations ", Brit. J. Anaesth., 20, 55. Engberg, G. (1975): "Single Dose Intercostal Xerve Blocks with Etidocaine for Pain Relief after Upper Abdominal Surgery", Acta anaesth. scand., Suppl., 60, 48. :\Ioore, D. C., Bridenbaugh, L. D. (1!l62) : " Intercostal Nerve Block in 4,333 Patients ", Anesth. Analg., 41, 1. :\Ioore, D. c., Bridenbaugh, L. D. (Ui62) : " Pneumothorax ", J. Amer. Med, Ass., 182, 1005. Moore, D. C. (1973) : Intercostal Nerve Block Re{:ional Block. Fourth Edition, Charles C. Thomas. Springfield, 163. :\Ioore, D. C. (1975): "Intercostal Nerve Block for Post Operative Somatic Pain Following Surgery of Thorax and Upper Abdomen ", Brit. ]. Anaesth., 47,284. Safar, P. (1\l54): "Intercostal Nerve Block and Minimal General Anaesthesia for Major Abdominal Surgery", Anesth. Analg., 33, 98. Yoshikawa, K., Mima, T., and Egawa. J. (1968): "Blood Level of Marcain in Axillary Plexus Blocks, Intercostal Nerve Blocks and Epidural Anaesthesia ", Acta A naesth. scand., 12, 1.
Anaesthesia and Intensive Care, Vol. IV, No. 3, Au{:ust, 1976
