Continuous Intercostal Blockade With Lidocaine After Thoracic Surgery

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Abstract
The efficacy and the side effects of a continuous infusion of lidocaine in the fifth intercostal space for the management of postoperative pain after lateral thoracotomy were evaluated in 20 adults. An indwelling catheter was inserted in the appropriate intercostal space before thoracotomy closure. After recovery from general anesthesia, a loading dose of 3 mg/kg of 1.5% lidocaine with epinephrine 1:160,000 was injected through the catheter, followed by a continuous infusion of 1% lidocaine without epinephrine at a rate of 1 mg .cntdot. kg-1 .cntdot. h-1 for 54 h. In seven patients pharmacokinetic data were obtained. Pain, assessed by visual continuous analog scale, decreased from a median score of 8 (range, 7-10) to a score of 5 (range, 2-7) 20 min after the loading dose of lidocaine and continued to decrease until the end of the study (P = 0.0001). Complete cutaneous analgesia, assessed by pinprick test, was seen in a median of three thoracic spinal segments (range, 0-6) with partial cutaneous analgesia in seven segments (range, 6-9) 40 min after the loading dose, and levels that remained unchanged for 54 h (P = 0.0001). Peak lidocaine serum concentrations, 1.9 .+-. 0.7 .mu.g/mL, were present 9 .+-. 3 min after injection of the loading dose. Serum concentrations of lidocaine under steady state conditions averaged 4.8 .+-. 0.9 .mu.g/mL (range, 3.5-5.8 .mu.g/mL). This level under steady state conditions, though below the toxic level, suggests that additional bolus injection of lidocaine during the course of infusion might result in potentially toxic serum levels of lidocaine. Our data show that the intercostal infusion of lidocaine in a single intercostal segment after thoracotomy provides prompt, prolonged, and effective analgesia, without side effects and with a pharmacokinetic profile indicating that serum levels remain below toxic threshold values.