REGIONAL VERSUS CONVENTIONAL METHODS FOR PAIN MANAGEMENT IN SURGICAL INTENSIVE CARE UNITS

Abstract

The goal of adequate pain management in thoracic trauma is to improve ventilatory mechanics, allowing the patient to breathe deeply and to cough effectively to mobilize and clear secretions. Adequate pain control in the thoracic region not only prevents atelectasis and respiratory infections but more importantly can prevent episodes of hypoxia that may otherwise lead to the increased requirements for mechanical ventilation. The standard of care has evolved from intubation and medical ventilation for all patients to optimization of pain control combined with chest physiotherapy. The purpose of this study was to investigate the effect of route of analgesia delivery in traumatic chest injury on pain relief, pulmonary functions, and plasma levels of the hyperalgesic cytokines interleukin (IL)-1 J3 and tumour necrosis factor (TNF)-a by comparing parenteral morphine versus regional bupivacaine analgesia techniques. The study was conducted on 60 adult patients admitted to the surgical intensive care unit (SICt.J) with thoracic injuries and thoracotomies. The Acute Physiology and Chronic Health Evaluation II (APACHE II) and the Glasgow Coma Scale scores were determined at the time of admission to the SICU. Patients were allocated randomly into one of 2 groups. Group I Regional analgesia group (n = 40) using one of the following techniques: thoracic epidural analgesia, unilateral or bilateral paravertebral analgesia, interpleural analgesia and extrapleural intercostal nerve blocks. All through continuous infusion of bupivacaine 0.25%. Group II Narcotic nalgesia group (n = 20) Standard intermittent I. V. bolus doses of morphine (0.15 mglkg) were used as soon as the patients complained of pain and the doses were titrated to acceptable pain• relief The level of pain relief was assessed by Visual Analogue Scale (VAS). Verbal Rating Score (VRS) and Retrospective Verbal Pain Score. Hemodynamics, respiratory parameters, complications and side effects were recorded and analysed. The serum levels of the hyperalgesic cytokines interleukin -I p and Tumor necrosis factor-a were mesaured at day I and 5. Results.-The regional analgesia group had lower pain scores (VAS,VRS) at rest and on movement 30 min after analgesia and at day !compared to narcotic analgesia group (p <0.05)Serum TNF-a showed a significant increase on day 5 in both groups (p <0.01 in group 1, p <0.05 in group 11). However, the route of analgesia did not have a significant effect on either IL-l J3 or TNF-a levels. The incidence of chest infection was more in the narcotic analgesia group (40 %) compared to the regional analgesia group (18%) (P <0.05). Also the incidence of nausea and vomiting was higher in the narcotic analgesia group (45%) compared to regional analgesia group (5%) (p <0.05). There was a significant decrease in the percentage of ventilated patient in the regional analgesia group compared to narcotic analgesia group at day I (P<O 01) and day 2 (P<O.OS). The Sedation score was significantly lower in the narcotic analgesia group all through the study period compared to the regional analgesia group. No significant differences in len!,>th of S1C'U stay, total hospital stay and time of ambulation between both groups Conclusions. --In patients with traumatic chest injuries and thoracotomies, regional analgesia provided better pain relief than the standard narcotic analgesia as evidenced by the significantly lower VAS and VRS scores 30 min after analgesia and on day one both at rest and on movement Also there was a significant decrease in the percentage of ventilated patients in the regional analgesia group with improved tidal volumes. Patients in both groups had equivalent lengths of stay in the S1CU, total hospital stay and time of ambulation. However patients in the narcotic analgesia group were more sedated and had a higher incidence of chest infection and nausea and vomiting Serum TNF-a showed a significant increase on day 5 in both groups. However, the route analgesia did not have a significant effect on either IL-l J3 or TNF-a.