British Journal of Anaesthesia, 2002, Vol. 89, No. 1 184-185
© 2002 The Board of Management and Trustees of the British Journal of Anaesthesia
Correspondence |
Methods of post-thoracotomy analgesia
Editor—I have serious misgivings about Blanloeil and colleagues’1 paper on post-thoracotomy analgesia by epidural infusion of methylprednisolone. As far as I am aware, the evidence and opinion of most anaesthetists is that local anaesthetic and opioid via a thoracic epidural is a satisfactory method of perioperative analgesia for thoracotomy, and may indeed be better than patient controlled i.v. opioid analgesia.2–5In this study,1 patients were given a thoracic local anaesthetic and opioid epidural intraoperatively. Despite having exposed the patients to the risks of having a thoracic epidural catheter inserted, the authors discontinued this perfectly adequate means of analgesia postoperatively and started PCA, a possibly less effective method of analgesia, to test, in my opinion, an unnecessary and theoretically flawed hypothesis that an epidural bolus and infusion of methylprednisolone might provide adequate analgesia. Even worse, the control for methylprednisolone was 0.9% sodium chloride, and not local anaesthetic with or without opioid.
Such a study might have been worthwhile if thoracic local anaesthetic and opioid epidural analgesia did not give adequate analgesia after thoracotomy, or even if it were likely that epidural methylprednisolone might be effective. However, we know that thoracic epidurals are effective, and there is no good evidence to suggest that epidural methylprednisolone would have any analgesic effect in this type of surgery. Abram and colleagues6 showed no analgesic effect on acute pain in rats with repeated intrathecal injection of methylprednisolone. Other papers quoted by the authors referred to surgery on the spine, where at least some inflammation was expected postoperatively, but no inflammation in the spine will be present immediately after a thoracotomy.
I was therefore not surprised that Blanloeil and colleagues found no difference between epidural methylprednisolone and sodium chloride. I also wonder, as it is not stated in the ‘Methods’ section, whether patients were told that methylprednisolone is not licensed for postoperative pain control or for epidural injection.
Patients were also exposed to large doses of steroid for no likely benefit. Each patient received a bolus of methylprednisolone 1 mg kg–1 and then had a 1.5 mg kg–1 infusion over 48 h. Thus, an average 70 kg patient would have received methylprednisolone 175 mg over 48 h. Even after 60 or 80 mg doses, there is evidence of adrenal suppression in patients for up to 4 weeks afterwards.7 8
Therefore, it is possible that the patients in Blanloeil and colleagues’ study not only received a predictably ineffective analgesic, but may also have been left with adrenal suppression and its consequences after major surgery.
E. M. Walsh
Bristol, UK
Editor—Even if we consider that epidural administration of local anaesthetic, with or without morphine, is the most appropriate means of providing analgesia after thoracotomy, this technique is not in widespread use in our department, or in France generally, for similar reasons to those observed recently in the UK.9 When epidural analgesia is not considered appropriate, one of the effective alternatives remains morphine via PCA in addition to acetaminophen and/or an NSAID.
In our thoracic department, methylprednisolone was largely used in combination with morphine, as it was in other departments in France, without any demonstration of its potential benefits. The way to investigate any possible benefit of methylprednisolone was to design a study as we did after methodological approval from our department of statistics. The experimental study of the use of methylprednisolone in animals did not convince many of our colleagues to stop using a method they considered to be satisfactory.
We are very grateful to the British Journal of Anaesthesia reviewers that they accepted a negative study of a technique that could be associated with potential adverse effects. As this paper was accepted as a short communication, we did not have the opportunity to discuss all the potential risks of such a study.
I hope that these results will have encouraged anaesthetists to stop using methylprednisolone for analgesia in this type of surgery, as is the case in our department.
Y. Blanloeil
Nantes, France
References
1 Blanloeil Y, Bizouarn P, Le Teurnier Y et al. Postoperative analgesia by epidural methylprednisolone after posterolateral thoracotomy. Br J Anaesth 2001; 87: 635–8
2 Moon MR, Luchette FA, Gibson SW et al. Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma. Ann Surg 1999; 229: 684–91[Web of Science][Medline]
3 Azad SC, Groh J, Beyer A et al. Continuous peridural analgesia vs patient-controlled intravenous analgesia for pain therapy after thoracotomy. Anaesthesist 2000; 49: 9–17[Web of Science][Medline]
4 Schultz AM, Werba, Ulbing S et al. Peri-operative thoracic epidural analgesia for thoracotomy. Eur J Anaesthesiol 1997; 14: 600–3[Medline]
5 Cook TM, Riley RH. Analgesia following thoracotomy: a survey of Australian practice. Anaesth Intens Care 1997; 25: 520–4[Web of Science][Medline]
6 Abrams SE, Marsala M, Yaksh TL. Analgesic and neurotoxic effects of intrathecal corticosteroids in rats. Anesthesiology 1994; 81: 1198–205[Web of Science][Medline]
7 Jacobs S, Pullan PT, Potter JM, Shenfield GM. Adrenal suppression following extradural steroids. Anaesthesia 1983; 38: 953–6[Web of Science][Medline]
8 Tuel SM, Meythaler JM, Cross LL. Cushing’s syndrome from epidural methylprednisolone. Pain 1990; 40: 81–4[Medline]
9 O’Higgins F, Tuckey JP. Thoracic epidural anaesthesia and analgesia: United Kingdom practice. Acta Anaesthesiol Scand 2000; 44: 1087–92[Web of Science][Medline]
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