Postoperative residual pleural space is a well-known complication contributing to prolong hospitalization in patients underwent lung resection. Many comorbidities may favour the occurrence of residual pleural space. After a thoracotomy access, patients experience postoperative pain while taking breaths at rest or at movement. Post-operative pain affects post-surgery recovery, increasing the risk of pulmonary complications. The use of bupivacaine through an epipleural catheter to block the phrenic nerve has yet successfully described to achieve pain control and to resolve residual air space persistence through hemidiaphragm temporary paralysis. We would select a number of patients with risk factors for residual air space after major thoracic surgery. They would be assigned to have phrenic nerve infiltration at diaphragm level during surgery by positioning a perineural catheter with its tip in intrapleural space, receiving infusion of 10mls of 0.25% bupivacaine. We would like to demonstrate that intra-operative phrenic nerve infiltration should be performed as a well-tolerated procedure to obtain at the same time not only an early expansion of the residual lung, facilitated by mechanical function of hemidiaphragm paralysis, but also a good pain control in the early postoperative period. This could allow the patient to mobilize more quickly after surgery and to obtain an early respiratory recovery, reducing hospitalization and complications after lung surgery. This medical intervention would produce significant health benefits at a reasonable cost respect to the existing procedures to achieve the same results.
Bupivacaine phrenic nerve infiltration was yet successfully described as to obtain pain control (back, shoulder, incision site), as to induce temporary hemidiaphragm paralysis.
Despite the well-known efficacy of phrenic nerve infiltration both for reducing thoracic pain after surgery and to achieve pulmonary expansion through hemidiaphragm paralysis, there are no studies in literature investigating the results of both functions together.
This could be the first work aimed to combine two very important effects of phrenic nerve bupivacaine infusion (pain control and pulmonary expansion) that could allow an early recovery of the patient after pulmonary surgery.
There are many advantages of the use of bupivacaine through an epipleural catheter to block the phrenic nerve: it is minimally invasive, fully controllable, well-tolerated by the patient and immediately reversible. It is considered a safe procedure, considering that the use of bupivacaine is rarely associated with seizures, with no impact on the cardiovascular system and a longer half-life instead of Ropivacaine. In a review of the literature on extra-pleural bupivacaine infusion, local complications occurred in 0.6% of patients and systemic complications in 0.8% (Detterbeck FC. ¿Efficacy of methods of intercostal nerve blockade for pain relief after thoracotomy.¿). In a previous study by Krishnamoorty et al. patients underwent phrenic nerve infiltration reported a greater reduction of other analgesic request, demonstrating a good pain control by bupivacaine infusion.
In effect, this intra-operative technique should be well-tolerated by the patient, despite other procedure, as for example pneumoperitoneum, to induce pulmonary expansion or intercostal nerve block after surgery that could be quite disagreeable and painful for patients. In that way, we would control both pain and surgical complications that could delay an early pulmonary recovery.
Existing procedures to achieve pain reduction and residual air space resolution are much slower, requiring longer time of hospitalization. Our belief is that the rapid results of the procedure applied, would improve patient¿s benefit and it would reduce the cost of long time of hospitalization. Furthermore, this significantly reduces the necessity for the use of other pain medication.
We would like to demonstrate that this new medical intervention would produce significant health benefits at a reasonable cost.