Evaluation of intrapleural analgesia in the management of blunt traumatic chest wall pain: a clinical trial.

Intrapleural analgesia (IPA) has been successfully used for the relief of chest wall pain. Previous studies investigating its use have yielded conflicting results and have often suffered from design defects. The theoretical lower incidence of respiratory and circulatory depression with IPA suggests significant advantages over epidural analgesia. Patients who had documented blunt chest wall trauma were entered into a prospective, randomized, double-blinded, crossover, placebo-controlled study within 16 hours of their injury. Patients who were intubated or had significant trauma outside of the chest wall were not entered. Intrapleural catheters were placed using a standardized technique. Each patient received either a placebo solution of normal saline or a combination of bupivacaine/lidocaine in a blinded, crossover fashion for two 24-hour periods. Data were obtained on the use of supplementary narcotics, transcutaneous pCO(2') pulse oximetry, pulmonary function tests, and both patient and nursing evaluations of pain based on a numeric analogue scale. A series of 16 patients from a Level I trauma center were identified over a 2-year period. The ratio of male to female was approximately 2:1, with an age range of 35-80 years. There were no complications related to catheter placement or anesthetic toxicity. Mean values for patient and nursing pain ratings revealed opposite trends. We found no significant difference in the mean values for supplemental narcotic use, pCO(2') p0(2') forced vital capacity, or forced expiratory volume between the placebo and the test solution. Although previous studies have suggested that IPA may be beneficial in the management of chest wall pain, this was not confirmed in our study for blunt chest injuries. The addition of IPA to the more traditional use of opioid analgesics was not more effective for management of blunt chest wall pain. Despite our small patient population (n = 16), the crossover design should have allowed clinically significant differences to become evident (alpha value = 0.95). A review of the literature and a historical basis for the evolution in the management of this type of pain is included.