TITLE: Epidural analgesia in Lung Transplant Patients
AUTHORS: G Mund, MD, S Dogra, MD, L Lucas, MD,
WS Blau, MD, PhD, P Calhoun, RN
AFFILIATION: Department of Anesthesiology, University of North
Carolina, Chapel
Hill NC 27599-7010
We carried out a retrospective survey of 35 single lung
transplant(SLT) and
sequential double lung transplant (DLT) patients to assess the
efficacy and side
effects of epidural analgesia in the management of postoperative
pain. A
previous literature review and a MEDLINE search revealed little
information on
the management of postoperative pain in this unique subgroup of
patients.
In our institution there have been 101 single and double lung
transplants in 95
patients since the inception of the program in 1990. The initial
group of
patients had postop pain managed with intravenous bolus or
patient controlled
analgesia techniques using morphine. Postoperative epidural
analgesia was
gradually introduced from 1991 onwards. A review of the lung
transplant registry
had 35 patients who used epidurals for pain management. These
charts were
reviewed for patient demographics, time of surgery and extubation
times,
placement of epidural, efficacy of epidural analgesia and side
effects
attributable to the drugs or techniques used. Site of epidural
placement,
incision site and duration of epidural use was also noted.
The majority of patients had a preoperative diagnosis of cystic
fibrosis. The
average age was 32.10 yrs (range 4.83 to 55yrs) and average
weight was 50.10kg
(range 18.6 to 81kg). There were 10 single lung and 25 sequential
double lung
transplants. The SLTıs underwent a lateral thoracotomy incision
as compared to
the DLT patients who had a bilateral thoracotomy and transverse
sternotomy
incision (³clam-shell² incision).
In 7/35 cases epidurals were placed preoperatively (day 0) and
28/35 patients
had the epidurals placed postoperatively on day 0.81(range 0.81
to 2.9) from day
of surgery. The patients were extubated at an average 1.46(range
0.4 to 4.75)
days after surgery . Coagulation studies (prothrombin time,
activated clotting
time, and platelet count >100,000 ) were near normal in all
cases when the
epidurals were placed. Abnormal coag screens led to late
placement of epidural
catheters. The catheters were placed at the site of easiest
access with the
median being T9 (range T4 -L4). The duration of use of the
epidural catheter was
for an average of 3.76(range 0.5 to 7) days. The analgesics used
through the
epidural included fentanyl, fentanyl bupivacaine mixtures, and
morphine sulfate.
The techniques of administration included continuous infusion and
PCA mode for
fentanyl infusions, continuous infusions for fentanyl/bupivacaine
mixtures, and
continuous or bolus methods for epidural morphine. Sedative and
anxiolytic drugs
were used when indicated and included chloral hydrate, haldol and
lorazepam.
Side effects were minor and included pain, pruritus and sedation.
The dosages of
the analgesic agents were frequently adjusted with a bolus of the
epidural agent
being given when indicated for better pain control. There were
7/35 patients who
needed additional analgesia to control pain with small doses of
iv opioids.
There were 20 patients who required sedative or anxiolytic drugs.
There were
9/20 cases of mild respiratory depression and sedation in this
group of
patients.
There is a paucity of information available on using epidural
analgesia in post
lung transplant patients. This is a unique group of patients with
extensive
surgical incisions and significant postoperative pain who need
effective
analgesia to avoid pulmonary complications in the postoperative
period.
Effective analgesia also allows early extubation in these
patients with the
ability to cooperate with respiratory therapy.
Our study showed that time to extubation after epidural catheter
placement was
0.65days ( average range 0.4 to 1.85) days. At our institution,
postoperative
epidural analgesia in lung transplant patients has been found to
be a useful
method of providing effective pain relief in the critical
postoperative period
of this group of patients with a low complication rate. We
believe that epidural
analgesia is safe and effective in producing good pain control
with minimal side
effects in post lung transplant patients.
References
1. Scand J Thor Cardiovasc Surg 26:163-168, 1992.
2. J Cardiothor Vascular Anes 7:5, 1993, 529-534.
3. Pain control after thoracotomy by Katz.
TITLE: EPIDURAL ANALGESIA COMPARED WITH IVPCA IN LUNG
TRANSPLANT PATIENTS
AUTHORS: S Dogra, MD, WS Blau, MD, PhD, W Lucas, MD, P Calhoun,
RN
AFFILIATION: Department of Anesthesiology, University of North
Carolina, Chapel
Hill NC 27599-7010
Introduction. A literature review and a MEDLINE search1,2
revealed little
information on the management of postoperative pain in the unique
subgroup of
patients undergoing lung transplantation. We analyzed our
database and reviewed
records of 55 single lung transplant (SLT) and bilateral
sequential double lung
transplant (DLT) patients to assess the efficacy and side effects
of
postoperative analgesia in this unique group of individuals.
Methods. Analysis of the records revealed 35 patients who
received epidurals
and these were compared to 20 patients who had morphine infusions
via
intravenous patient controlled analgesia (IVPCA) pumps for
postoperative pain
management. These were reviewed for patient demographics, time of
surgery and
extubation times, placement of epidural, efficacy of analgesia,
and side effects
attributable to the drugs or techniques used. Site of epidural
placement,
incision site, and duration of postoperative utilization of the
analgesic
technique were also noted.
Results. The majority of patients had a preoperative diagnosis of
cystic
fibrosis and patient demographics in the two groups were similar.
The 16 SLTıs
underwent a lateral thoracotomy incision as compared to the 39
DLT patients who
had a bilateral thoracotomy and transverse sternotomy incision (³clam-shell²
incision). Coagulation studies were near normal in all cases when
the epidurals
were placed and if abnormal led to the late placement of some
epidurals. The
epidural catheters were placed preoperatively (7/35) and
postoperatively (28/35)
at the site of easiest access with the median being T8 (range T4
-L4). The
analgesics used through the epidural included fentanyl, fentanyl
bupivacaine
mixtures and morphine sulfate. The IVPCA was started soon after
surgery and
morphine was the drug most commonly used. Duration of analgesia
use was 3.76
days in the epidural group vs. 6.00 days in the IVPCA group,
until the patients
were converted to oral medications. Sedative and anxiolytic drugs
were used
when indicated and included chloral hydrate, haldol and
lorazepam. Patients in
the epidural group were extubated 1.46 days on average after
surgery as compared
to 3.49 days on average in the IVPCA group.
Side effects were minor and included pain, pruritus and sedation.
There were
20/35 patients with epidurals who needed sedative/anxiolytic
drugs compared with
14/20 in the IVPCA group. Reintubation rates differed with 10/35
(29%) in the
epidural group and 11/20 (55%) in the IVPCA group. Mortality
rates were 3/35
(9%) in the epidural patients and 4/20 (20%) in the IVPCA
patients.
Discussion. There is a surprising lack of information available
on optimal
analgesic techniques in post lung transplant patients. This is a
unique group
of patients with extensive surgical incisions and significant
postoperative pain
needs. Effective analgesia allows early extubation and may help
to avoid
reintubation. This may impact on mortality rates though our study
did not look
at the large number of other variables that will ultimately
impact on mortality.
The early use of epidural analgesia may serve as a marker of a
successful
outcome subsequently. Our study showed a trend towards shorter
time to
extubation and avoidance of reintubation in patients with
epidurals. We believe
that epidural analgesia is a safe and effective technique in
providing
satisfactory pain control with minimal side effects in post lung
transplant
patients.
References
1. Medline
2. Scand J Thor Cardiovasc Surg 26:163-168, 1992.