238 Journal ofPain and Symptom Management lrot. 8 No. 4 May 1993

Case Reptn-ts in Anesthesia and Analgesia

Interpleural Analgesia: Its Use, and a

Complication, in a Quadriplegic Patient with Chronic Benign Pain Patricia Harrison, MD, Edward A. Kent, MD, and Mark J. lema, MD

Departments of Anesthesiology and Physiology, Roswell Park Cancer Institute and

the State University of New York, Buffalo, New York

Interpleural analgesia has been successfully used in the management of postoperative pain and chronic pain. l-4 We describe the applica- tion of this approach to the treatment of pain in a ventilator-dependent quadriplegic patient and discuss a complication that occurred during therapy.

Case Rejmrt A 49-yr-old woman sustained a cervical spine

fracture at the age of 21 yr as the result of a swimming accident. In 1986, she developed syringomyelia and underwent a C2-3 laminec- tomy, drainage of the syrinx, and placement of a syringo-subarachnoid shunt. At this time, she became ventilator dependent.

Pain had been experienced in the right shoulder, neck, and lateral aspect of the forearm for 3 yr. A series of trigger point injections provided short-term relief, as did a series of stellate ganglion b:ocks. Several injec- tions of steroid into the bursa of the shoulder joint also yielded no sustained relief, and further injections were refused. She was main- tained on baclofen 100 mg daily, acetamino- phen 350 mg four times daily, hydromorphone 3 mg every 3 hr, and amitriptyline 50 mg twice daily, but this regimen failed to provide ade- quate analgesia.

When she came to the Pain Clinic, examina-

tion revealed a ventilated patient with a trache- ostomy. There was limited range of motion of her neck, especially on rotation to the right. Neck movement was not painful. The neck was obese, and there was a posterior scar as a result of her previous laminectomy. Neurologic ex- amination revealed flaccid quadriplegia, ab- sent sensation ‘below C,, decreased reflexes in both upper and lower extremities, negative Babinski signs bilaterally, and finger contrac- tures of both hands. Cervical spine radiographs showed demineralization of the lower cervical vertebrae, with no focal abnormality.

The remainder of the examination was unremarkable. The right scapular pain was thought to be secondary to cervical osteoarthri- tis, and the shoulder pain was ascribed to bursitis.

Cervical cpidural steroid injections were considered, but were then rejected due to the technical difficulties posed by a patient with an obese short neck, limited range of movement, prior neck surgery, and a tracheostomy band around the neck. A trial of interpleural analge- sics was planned.

With the patient in the left lateral position, a 17-gauge Tuohy needle was advanced at the T7-8 interspace. The interpleural space was identified using a “passive loss of resistance” technique. This method allows l-2 mI, of air from a syringe to be drawn into the interpleural

@ U.S. Cancer Pain Relief Committee, 1993 Published by Elsevier, New York, New York 088539!?4/93/$6.00

Vol. 8 No. 4 May 1993 COlU?lW 239

Fig. 1. Chest radiograph showing the catheter tip and a pooling of contrast in the right midlung. The dye has entered the right tracheobronchial tree and reflexed imo the left side.

space by its negative pressure. The catheter was inserted G-10 cm into the chest and secured. A total of 15 ml of 0.375% bupivacaine + 5 mg preservative-free morphine sulfate was in-

jected. This decreased the pain from 10 to 2 on a IO-point scale. A further 5 mL of 0.5% bupivacaine given 30 min later reduced her pain to l/ 10. A chest radiograph showed no evidence of pneumothorax, and the patient was discharged with instructions to the home- care nurse to give 5 mL bolus injections of 0.375% bupivacaine every 5 min to a maximum of 20 mL when the pain returned. She experi- enced good pain control and required only one treatment (10-20 mL of 0.375% bupiva- Caine) every 8-10 days.

One month later, the patient returned for the placement of a permanent interpleural catheter. The interpleural space l\rds identified as previously described and a Racz catheter was inserted to a distance of 12-15 cm. The distal end of the catheter was tunneled 10 cm anteriorly in the subcutaneous plane and then

joined at a separate incision site to a silastic catheter,. The silastic catheter was attached to a resemoir, which was implanted subcutaneously, inferior to the costal margin at the right anterior axillary line. A chest radiograph veri- fied the catheter placement and showed no et-idence of a pneumothorax. The patient was discharged to home and, as before, had excellent pain control with boius doses of bupikacaine every 8-10 days.

Four months after the permanent interpleu- ral catheter was implanted, the duration of pain relief gradually decreased, and the patient began to report a cold sensation in her neck during injection. Fluid was also obsewed leak- ing from the injection site overlying the resemoir. Contrast material \ras injected under fluoroscopic guidance, and a small pool was seen in the right midlung, which entered the right tracheobronchial tree and then refluxed into the left tracheobronchial tree (Figure 1). The patient experienced the same cold sensa- tion in her neck.

240 Column Vol. 8 No. 4 May 1993

A bronchoscopy was performed prior to removal of the interpleural catheter, but the catheter tip was not visualized. With the patient in the lateral position, the components of the catheter were removed via two incisions. Close monitoring revealed no evidence of pneumo- thorax despite positive pressure ventilation, and the decision was made to insert another tunneled interpleural catheter with a subcuta- neous reservoir. A total of 10 mL 0.375% bupivacaine provided good pain relief. Chest radiography and monitoring over several hours in the recovery room revealed no evidence of a pneumothorax and the patient was discharged home. Since that time, bolus injections of 8-10 mL 0.375% bupivacaine every S-10 days have provided excellent pain control. Her hydro- morphone usage has been reduced to 3 mg twice daily as needed.

The first report of interpleural analgesia was made by Kvalheim and Reiestad in 1984.’ They described the use of an epidural catheter in the interpleural space for postoperative pain con- trol. Since that time, interpleural analgesia has been used in the management of postoperative pain and chronic pain associated with pan- creatitis,zs postherpetic neuralgia,” and can- cer.’ We report a case of successful interpleural analgesia in a quadriplegic patient with chronic shoulder and arm pain.

The management of this patient illustrates the potential efficacy and complications of iaterpleural analgesia. In 1990, Stromskag and colleagues published a review of the literature on interpleural analgesia and its complications.” In 703 cases, the most fre- quent complications were pneumothorax, sys- temic local anesthetic toxicity, and pleural effusions (3.7%). There was a 2% overall incidence of complications related to the catheter, but the authors observed that their series included patients reported as case descriptions of the technique and its compli- cations, and therefore, the true incidence of catheter displacements is probably less. In another series of 18 patients, 12 of the catheters were displaced:” three catheter tips became lodged in the thoracic wall, two in necrotic tumors, and seven migrated into the lung itself. Reiestad and Stromskag’ also reported one case of catheter displacement in

a patient with a history of pleuritis and pleural adhesions.

The frequency of catheter problems in- creases with the use of the “active loss of resistance” technique (pressing on the plunger of the syringe while advancing the needle), which was not used in our patient. The length of the implanted catheter (15 cm was retrieved at the time of removal) may have contributed to the catheter displacement, and the new catheter was inserted only 6 cm inside the interpleural cavity. The replacement cathe- ter also had a flexible blue tip to reduce lung penetration (Arrow International).

A second potential problem was also identi- fied in this case. Examination of the reservoir (PMT Products) revealed a leak in the dome, where multiple injections with a 22-gauge needle had been given during the previous 4 mo. A change to 25-gauge needles was recom- mended to delay the onset of this problem.

Following recognition that the catheter tip was lodged in a bronchus, several management problems became apparent. If the tract re- mained patent after the catheter was removed, there was the potential for a tension pneumo- thorax to develop, especially wi’!l the coexistent positive pressure ventilation. Hence, bronchos- copy was performed prior to catheter removal in case laser coagulation was indicated to close the hole. Preparations for chest tube insertion and ICU admission were made if a pneumothorax occurred. When these complications failed to develop, the catheter was replaced, and the efficacy of the approach was regained.

&f erences

1. Kvalheim L, Reiestad F. Interpleural catheter in the management of postoperative pain [absl]. Anes thesiology 1984;61:A231.

2. Durrani Z, Winnie A, Ikuta P. InterpIeural catheter analgesia for pancreatic pain. AnesIh Analg 1988;67:479-481.

3. Sihota MK, Ikuta PT, Molmblad BR, Rciestad F, Zsigmond EK. Successful pain management of chronic pancreatitis and post-herpetic neuralgia with intrapleural technique. Reg Anaesth 1988; 13:s40.

4. Waldman SD. Subcutaneous tunneled intrapleu- ral catheters in the long term relief of upper quadrant pain of malignant origin: description of a new technique and preliminary results. Reg Anaesth 1989;14:S54.

z Stromskag KE, Minor B, Steen PA. Side effects c

Vbl. 8 No. 4 May I993 Column 241

and complications related to interpleural analge- sia: an update. _Acta Anaesthesiol Stand 1990; 34:473-477.

live analgesia: a dangerous technique? Anesth Analg 1988;67:Sl-S266.

6. Gomcz MN, Symreng T, Johnson B, Rossie Xl’, Chiang CK Intrapleural bupivacaine for intraopera-

7 Rcirstad F, Stroxnskag KE. Interpleural catheter in the management of postoperative pain: a prelimi- nary report. Reg Anaesth 1986;11:89-91.