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Three Part Question

[After insertion of a chest drain] does [the use of local anaesthetic down the drain] reduce [patient's pain]?

Clinical Scenario

A 25 year old chap with a history of spontaneous pneumothorax presents to the ED with a further large pneumothorax. Unfortunately, attempted aspiration fails due to a permanent leak, and he requires an intercostal drain. He has had a chest drain inserted in the past and admits that it was very painful whilst the drain was in situ. You wonder whether administration of local anaesthetic down the tube would provide good analgesia, and decrease the need for oral/iv meds.

Search Strategy

MEDLINE OVID INTERFACE 1966 - Aug 2006
exp anesthetics, local/ OR local anaesth$.mp. OR exp lignocaine/ OR bupivicaine.mp. OR marcain.mp. OR lignocaine.mp. OR lidocaine.mp. OR exp lidocaine/ OR (local adj5 anaesthetic).mp. AND chest drain.mp. OR intercostal drain.mp. OR chest tube.mp. OR exp chest tubes/ OR exp drainage/ OR exp thoracostomy/ limit to english and humans

Search Outcome

190 articles found, 2 relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Engdahl et al Feb 1993 Sweden	22 patients with indwelling chest drains - 8 hourly boluses of 20ml interpleural bupivicaine with 0.5% adrenaline, compared with placebo - visual analogue scale scores compared	Randomised double blind trial	VAS scores after 1st injection (exclude pt 2)	lower in bupivicaine group at 5,15, 30 and 60 mins p<0.01	small study 8 hours between boluses though bupivivaine is relatively short acting timing of 1st intrapleural injection not standardised - "at 4hrs or earlier if in severe pain"
			VAS score 4 hrs post 1st injection	no difference between groups
			VAS scores after injections 2-10	only significant difeerence in favour of bupivicaine at 5 mins post 2nd injuection, and post 7th injection, otherwise pain VAS comparable
			Use of IV morphine	not significant, though tended to be asked for earlor in control group
			Use of oral analgesia	no difference in consumption

Comment(s)

Patients with indwelling chest drains may have severe pain and require oral or intravenous analgesia including opiates. There has been much research on the use of intrapleural analgesia after chest trauma and thoracostomy, but only one study which looks at the use of intrapleural analgesia solely for the relief of pain from the indwelling drain. Although the number of patients is small, it seems to suggest that there may be a role for intrapleural analgesia in this subset of patients. No side effects of treament were noted. The biggest benefit of intrapleural bupivicaine seems to be gained with its early introduction, and also if it is given regularly, at least every 4 h, due to its short half life. Oral analgesia should still be given to these patients. Better pain relief in this group of patients would also be beneficial, as it would improve the patients's ablility to cough and deep breathe, and thus reduce the number of secondary chest infections.

Clinical Bottom Line

Intrapleural bupivicaine should be considered in patients who have chest drains inserted, in addition to regular oral/parenteral analgesia.

References

1. Engdahl et al Interpleural bupivicaine for analgesia during chest drainage treatment for pneumothorax. A randomised double blind study. Acta Anaesthesiologica Scandinavica 37(2):149-53, 1993 Feb