Title: Efficacy of Peri-Operative Intercostal Nerve Blockade in Standard PCNL- A Prospective Cohort Study

Authors: Dr A T Rajeevan, Dr Shanmughadas K V, Dr Piyush Gupta, Dr Felix Cardoza

 DOI:  https://dx.doi.org/10.18535/jmscr/v6i2.06

Abstract

Introduction and Aim: Percutaneous nephrolithotomy (PCNL) has become the GOLD standard for the management of renal calculi. But pain in the immediate post-op period especiallyin institutions where Standard PCNL is still being done as a routine, can be quite severe, requiring opioid administration. Intercostal Nerve Blockade (INB) is an effective way to optimize pain control and to reduce the need for opioid administration in the post-operative period in such patients. We aimed to evaluate the role of INB in Standard PCNL in terms of post-operative analgesia requirement, speed of mobilization and total duration of inpatient stay.

Methods: 60 patients undergoing elective standard PCNL were divided into Study group or Group S (0.25% bupivacaine infiltration) and Control group or Group C (without infiltration). Percutaneous INB was done in the study group at the end of the procedure prior to the patient being turned supine. The three intercostal nerves supplying the dermatomes within which the incisions were made were blocked. At each site, 5 ml of 0.25% bupivacaine in group S was infiltrated. Postoperative pain was assessed by visual analogue scale (VAS) at rest {score between 0 and 10} and dynamic visual analogue scale (DVAS) during deep breathing and coughing {score between 0 and 10} every 4 hours for first 24 hours. Intravenous tramadol was given as rescue analgesia when VAS score was >4. Time to first rescue analgesic and total amount of tramadol required in first 24 hours were noted.

Results: VAS and DVAS scores in Group S were significantly lower (p <0.05) than Group C till first 16 hours. Mean time to first rescue analgesia in Group S was significantly longer (9.07 hrs. v/s 1.50 hrs.). And total consumption of tramadol in first 24 hours was also significantly less in Group S compared to Group C (58.06mg v/s 132.76mg).

Conclusion: Intercostal nerve block is an easy, safe and inexpensive method of analgesia and provides effective postoperative analgesia after standard PCNL.

Keywords: PCNL, Intercostal Nerve Blockade, Post-operative pain scores.

References

  1. Trinchieri A, Ostini F, Nespoli R, Rovera F, Zanetti G. A prospective study of recurrence rate and risk factors for recurrence after a first renal stone. J Urol 1999;162:27—30.
  2. Sutherland JW, Parks JH, Coe FL. Recurrence after a single renal stone in a community practice. Miner Electrolyte Metab 1985;11:267—9.
  3. Miller NL, Lingeman JE. Management of kidney stones. BMJ 2007;334:468—72.
  4. LeRoy AJ, Segura JW, Williams HJ, Patterson DE. Percutaneous renal calculus removal in an extracorporeal shock wave lithotripsy practice. J Urol 1987;138(703).
  5. Madhu Sudan Agrawal, Mayank Agrawal, Tubeless percutaneous nephrolithotomy, Indian J Urol. 2010 Jan-Mar; 26(1): 16–24.
  6. Fernström I, Johannson B. Percutaneous pyelithotomy.A new extraction technique. Scand J Urol Nephrol 1976;10(257).
  7. Chan DY, Jarrett TW. Mini‑percutaneous nephrolithotomy. J Endourol 2000;14:269‑
  8. Jackman SV, Docimo SG, Cadeddu JA, Bishoff JT, Kavoussi LR, Jarrett TW. The “mini‑perc” technique: A less invasive alternative to percutaneous nephrolit-hotomy. World J Urol 1998;16:371‑
  9. Monga M, Oglevie S. Mini percutaneous neph or lithotomy.J Endourol 2000;14:419‑
  10. Trivedi NS, Robalino J, Shevde K. Interpleural block: a new technique for regional anaesthesia during percutaneous nephrostomy and nephrolithotomy. Can J Anaesth 1990;37(May (4 Pt 1)):479—81.
  11. Jonnavithula N, Pisapati MV, Durga P, Krishnamurthy V, Chilumu R, Reddy B. Efficacy of peritubal local anesthetic infiltration in alleviating postoperative pain in percutaneous nephrolithotomy. J Endourol 2009;23:857‑
  12. Noller DW, Gillenwater JY, Howards SS, Vaughan Jr ED. Intercostal nerve block with flank incision. J Urol 1977;117(June (6)):759—61.
  13. Knowles P, Hancox D, Letheren M, Eddleston J. An evaluation of intercostal nerve blockade for analgesia following renal transplantation. Eur J Anaesthesiol 1998;15(July (4)):457—61.
  14. Haleblian GE, Sur RL, Albala DM, Preminger GM. Subcutaneous bupivacaine infiltration and postoperative pain perception after percutaneous nephrolithotomy. J Urol 2007;178:925‑
  15. Viney, H. Garston, P. Patel, R. Devarajan. Perioperative intercostal nerve blockade in percutaneous nephrolithotomy A comparative cohort study. British Journal of Medical and Surgical Urology (2010) 3, 106—110
  16. Geeta P Parikh, Veena R Shah, Kalpana S Vora, Beena K Parikh, Manisha P Modi, PratibhaKumari. Peritubal infiltration in percutaneous nephrolithotomy. Indian Journal of Anaesthesia | Vol. 58 | Issue 3 | May-Jun 2014.

Corresponding Author

Dr Shanmughadas K V

Department of Urology, Government Medical College, Calicut, Kerala- 673008

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