Pain relief after thoracoscopy (video-assisted thoracic surgery): patient-controlled analgesia (PCA) with IV opioids vs. intercostal blocks or interpleural analgesia

Systemic opioids and thoracic epidural analgesia are common techniques used to provide post-operative analgesia following thoracoscopy (video-assisted thoracic surgery). The aim of the present prospective randomised study was to evaluate the efficacy of two less invasive analgesic techniques, interc ostal blocks (ICB) and interpleural analgesia (IPA). After approval from th e ethics committee and informed consent from the patients, 36 patients sche duled for thoracoscopic surgery were randomly assigned to a group for posto perative pain management: group ICE: intercostal blocks of the segments inv olved with 5 mi 0.5 % bupivacaine at the end of surgery and 6 h later; grou p IPA: interpleural analgesia with 20 mi 0.25 % bupivacaine applied every 4 h using a catheter placed during surgery near the apex of the interpleural space; control group: IV-opiod-PCA with piritamide. Patients in the ICE an d TPA groups had access to pain relief by PCA with piritramide as well. Add itional medication for all groups if the analgesia was insufficient consist ed of metamizol. There were no significant differences in piritramide consu mption between the two regional analgesia groups and the control group up t o the 3rd and 7th postoperative day. Up to the 7th day piritramide consumpt ion in group ICE was 78 mg, in group IPA 75 mg and 80 mg in the control gro up. Patients in group ICE showed significantly less pain at rest measured b y the visual analogue scale (VAS) on the Ist postoperative day (U-test, P < 0.05), but otherwise there were no statistical differences regarding pain scores. Respiratory parameters such as forced vital capacity, forced expira tory volume, peak flow and the Tiffeneau test (FVC,FEV1, PF, FEV1/FVC) were reduced significantly after thoracoscopy and showed a slow recovery in all three groups without significant intergroup differences. Thoracoscopic sur gery causes less and shorter lasting pain in comparison to thoracotomy. Nev ertheless, effective pain management is necessary. We could not demonstrate a significant reduction in piritramide consumption for the techniques of r egional analgesia tested here (ICB, IPA). We conclude that the use of these techniques is not complementary after thoracoscopy, since an opioid (PCA w ith piritramide) combined with a non-opioid (metamizol) resulted in satisfa ctory analgesia.