Describe the regional analgesic techniques available for postoperative pain relief. Which are applicable to this patient?
Regional analgesic techniques with local anesthetics are invaluable, underutilized techniques for the treatment of postoperative pain. The simple infiltration of a wound with a long-acting local anesthetic can greatly decrease pain in the postoperative period. Blockage of peripheral nerves to the hands and arms (brachial plexus analgesia), legs (femoral or popliteal blocks), and chest and upper abdomen (intercostal blocks) can reliably provide up to 12 hours of analgesia postoperatively, as can blockade of the ilioinguinal and iliohypogastric nerves after inguinal her-nia surgery. The recent resurgence of the use of indwelling catheters for peripheral nerve anesthesia and analgesia has greatly expanded the utility of these procedures. Analgesia obtained by these methods is free from the sympathectomy and its attendant hypotension seen with local anesthetic blockade of the neuraxis.
Interpleural catheters were utilized in the 1990s for uni-lateral thoracic or upper abdominal surgery. Local anes-thetics may be administered into the interpleural space by placing a catheter between the parietal and visceral pleura of the lung. In this location, local anesthetics bathe the intercostal nerves and, to a lesser extent, the thoracic sym-pathetic nerves. Analgesia is obtained in the distribution of these nerves. Their use fell into disfavor for many reasons including difficulty of placement, risk of pneumothorax, high local anesthetic blood levels, and the inability to use them effectively with a chest tube in place.
Neuraxial opioids, by the spinal or epidural route, can provide profound analgesia, with a lower incidence of side-effects compared with the use of parenteral opioids, including those administered via PCA. Adding a dilute concentration of a local anesthetic (i.e., bupivacaine 0.1%) can enhance the analgesia, allow the use of lower doses of opioids (with a lower incidence of side-effects), and still avoid the motor blockade and hypotension seen with higher concentrations of epidural local anesthetics.
Appropriate choices for this patient include wound infiltration and the use of neuraxial opioids. Although intercostal blocks could be performed, the need to perform bilateral blocks at multiple levels makes this an impractical option.