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J Thorac Cardiovasc Surg 2004;128:155
© 2004 The American Association for Thoracic Surgery
Letter to the editor |
Professor of Surgery, University of Louisville, Louisville, KY 40202, USA
We are responding to the letter of Racigno and Carnelos. As they described, we performed a double-blind randomized controlled trial in which patients undergoing elective bypass surgery received either bilateral intercostal nerve block with ropivacaine or a saline placebo. At wound closure, two catheters with multiple side openings were inserted percutaneously and placed directly over the sternum. The same agent (ropivacaine or saline solution) was then administered as a continuous regional infusion for 48 hours through an elastomeric pump. The main findings of our study were that patients in the ropivacaine group had improved postoperative pain control and required less narcotic analgesia. Additionally, patients in the ropivacaine group had significantly lower pain scores than did patients who received placebo, and length of stay was also decreased in the ropivacaine group.
Racigno and Carnelos report doing a similar randomized trial in which they were unable to demonstrate any effectiveness of this treatment. In their letter, however, it is not clear how similar the therapeutic approaches truly were. We believe that a key component in our study was the development and clinical use of catheters with multiple side openings, which allow even distributions of the anesthetic agent throughout the operative field. Racigno and Carnelos reported using a small-diameter catheter, but it is not clear whether this catheter was effective in providing a true regional anesthetic. They further suggested that the difference in outcome may have been related to the use in our study of bilateral intercostal nerve block before performing wound closure.
We believe this is unlikely to explain the major differences seen between our two groups for a number of reasons. First, it is widely documented that intercostal nerve blocks, even with long-acting anesthetic agents, do not provide pain control beyond 6 to 8 hours. Second, we assessed pain scores on the second postoperative day to eliminate the effect of this and other confounding variables, such as residual analgesia given at the time of operative therapy. We were able to demonstrate marked decrease in narcotic use on the second postoperative day, when clearly the patient would not be receiving any benefit from the intercostal nerve block.
In addition, since the submission of our article a similar study has been performed that has demonstrated the advantages of a continuous local infusion for pain management after median sternotomy.1 White and colleagues1 performed a prospective, randomized, placebo-controlled trial with the same catheter system that was used in our study. These investigators also showed a significant reduction in pain scores, morphine use, patient dissatisfaction, time to ambulation, and duration of hospital stay.
In our opinion, the results of our study and that of White and colleagues1 strongly suggest that this approach will result in improved patient comfort and satisfaction, as well as decreased narcotic use after median sternotomy. As noted in both studies, the use of the catheter does not require any physician or nursing intervention after its placement, and there has been no morbidity associated with this approach. We consider this approach an excellent first step to improving the overall approach to pain management for our patients.
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