Operative Intercostal Nerve Blocks With Long-Acting Bupivacaine Liposome for Pain Control After Thoracotomy

Postthoracotomy pain is quite intense. Epidural analgesia (EPI) has long been the gold standard but is often associated with hypotension and urinary retention. The recent availability of liposomal bupivacaine formulation (Exparel) stimulated us to use it for multilevel intercostal nerve blocks (IB) injected during open thoracotomy.

We reviewed the records of 85 patients who had open thoracotomies for lung, pleural, or mediastinal pathologies between March 2010 and December 2013. Clinical variables; pain score; supplemental narcotic utilization on day 1, 2, and 3; postoperative pulmonary complications; and hospital length of stay were compared in the 2 groups.

In all, 53 patients in the IB group had similar clinical data compared to 32 in the EPI group. There were statistically significant lower mean pain scores on days 1 and 3, but no significant difference in pain score on day 2. Supplemental narcotic utilization was not different between the 2 groups. There was a significant decrease in pulmonary complications in the IB group (4 of 53) compared to the EPI group (8 of 32).The total length of hospital stay was 7.4 days in the IB group versus 9.3 days in EPI group (p < 0.05).

It appears that intraoperative IB with bupivacaine liposome at 6 levels during thoracotomy provided significantly better pain control in postoperative days 1 and 3, compared to EPI in this retrospective study. This technique is simple, safe, and reproducible. It does not require epidural space invasion, infusion pumps, or another service to comanage the postoperative pain therapy.