|Year : 2017 | Volume
| Issue : 3 | Page : 166-169
A comparative study to evaluate the efficacy of butorphanol as an adjuvant to epidural analgesia for rib fractures
Department of Anaesthesiology, Jawaharlal Nehru Medical College, DMIMS (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
|Date of Web Publication||2-Feb-2018|
Dr. Virendrakumar Belekar
No. 10, M.1, Meghdoot Apartment, Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Pain management through epidural catheters has emerged as optimal method of pain control in patients with rib fractures. This study was done to evaluate the efficacy of butorphanol in this subset of patients. Materials and Methods: Sixty patients were randomly allocated in two Groups R and B. Group R patients received 0.2% ropivacaine epidurally (10 mL) while Group B patients who received 0.2% ropivacaine and 1 mg butorphanol epidurally (10 mL). Baseline respiratory rate, oxygen saturation, partial pressure of oxygen, visual analog score (VAS), and peak inspiratory flow rate were noted in both the groups. Results: There was a significant increase in duration of analgesia and nonsignificant reduction in VAS score in Group B and nonsignificant decrease in invasive ventilation cases and significant reduction in length of Intensive Care Unit (ICU) stay in Group B. There were no significant adverse effects in both the groups except for nausea in Group B. Conclusion: Butorphanol as an adjuvant to epidural analgesia leads to better oxygenation, decreased length of ICU stay, and duration of mechanical ventilation without increase in significant side effects.
Keywords: Butorphanol, epidural analgesia, rib fracture, ropivacaine
|How to cite this article:|
Belekar V. A comparative study to evaluate the efficacy of butorphanol as an adjuvant to epidural analgesia for rib fractures. J Datta Meghe Inst Med Sci Univ 2017;12:166-9
|How to cite this URL:|
Belekar V. A comparative study to evaluate the efficacy of butorphanol as an adjuvant to epidural analgesia for rib fractures. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2018 Apr 26];12:166-9. Available from: http://www.journaldmims.com/text.asp?2017/12/3/166/224703
| Introduction|| |
Rib fracture (RF) associated with thoracic trauma is a significant cause of morbidity and mortality in our society. Despite continued progress in therapeutic interventions, RFs continue to be associated with significant adverse sequelae, including diminished ventilatory effort, atelectasis, pneumonia, longer hospital and Intensive Care Unit (ICU) lengths of stay, and higher mortality.,,,, Increases in RF-related morbidity and mortality parallel the increasing number of RFs. Many of the untoward clinical effects of RFs are likely related to associated acute pain.,,
The treatment for injuries of the bony thorax has varied over the years ranging from of mechanical stabilization through obligatory ventilator support. Pain management in thoracic injuries with chest physiotherapy and early mobilization is established mode of treatment. Mechanical ventilation in these patients carries high morbidity and mortality. Pain management through epidural catheters has emerged as optimal method of pain control.
Within recent years, a lot of newer drugs with better safety profile have been added to anesthesiologist's armamentarium for pain control through epidural route. This study was done to evaluate the efficacy of butorphanol in this subset of patients.
| Materials and Methods|| |
After prior permission from Institutional Ethical Committee, this prospective, comparative, observational study was carried out at Acharya Vinoba Bhave Rural Hospital, Wardha. Inclusion criteria included patients aged 20–60 years of either sex with blunt trauma chest with three or more consecutive RFs. Patients with sternal fractures and flail chest and patients who were intubated with any contraindication to epidural catheterization and comorbid conditions such as hypertension, heart disease, and obstructive pulmonary disease were excluded from the study. This study comprised of sixty patients with RFs admitted to surgical ICU (SICU) from July, 2011, to December, 2014. They were randomly allocated to two groups using computer-generated codes.
Out of total 140 patients admitted to SICU with RFs, 70 patients were having associated major organ injury and traumatic brain injury, 6 patients were managed with oral medications, and had <3 RF. Of the total 60 patients, 30 patients having 3 or more RF were included in the study with or without any other major organ injury including traumatic brain injury. Patients with blunt trauma chest admitted to SICU were assigned to either of two groups. Group R included 30 patients and received 0.2% ropivacaine epidurally (10 mL) while Group B included 30 patients who received 0.2% ropivacaine and 1 mg butorphanol epidurally (10 mL). Baseline respiratory rate (RR), oxygen saturation, partial pressure of oxygen (PaO2), visual analog score (VAS), and peak inspiratory flow rate (PIFR) were noted in both the groups. After positioning the patients and taking all aseptic precautions, epidural needle was introduced and space identified using loss of resistance to saline technique at the level of fractured ribs. Epidural catheter was inserted by an experienced anesthesiologist, with minimum 3 years of training in anesthesia.
The study drug was given by on-duty nurse staff, and all parameters were noted. PIFR was noted every hourly till VAS score was <4. The drug doses were repeated when VAS score was >4. Pain-free duration of analgesia was noted (patient in VAS score <4). Arterial blood gas was done after study drug administration, and PaO2 was noted.
Complications such as nausea, vomiting, bradycardia, hypoventilation, hypotension, and any other were noted in both the groups. Mean RR, duration of analgesia, mean VAS score, Ramsay sedation score, mean PIFR, length of ICU stay, incidence of mechanical ventilation, and mortality were all noted and compared statistically.
| Results|| |
Out of one-forty patients admitted to SICU with RFs, eighty patients were excluded from the study. Sixty patients were enrolled in the study and divided into two groups (Group R and Group B) of thirty each. As observed in [Table 1], the two groups did not differ in terms of age, gender, and weight (P > 0.05). Both the groups were identical in terms of number of RFs (P > 0.05).
[Table 2] shows clinical parameters in the two groups.
- The mean baseline variables (RR, PaO2, VAS, P/F ratio, and PIFR) in both the groups were comparable and not statistically significant (P > 0.05)
- The posttest decrease in mean RR was significantly lower in both the groups as compared to their respective pretest values (P < 0.05). However, the decrease in Group B was significantly more than in Group R (P < 0.05)
- The posttest increase in mean PaO2 was significant in both the groups as compared to their respective pretest values (P < 0.05) and was comparable to each other (P > 0.05)
- The posttest decrease in mean VAS was significant in both the groups as compared to their respective pretest values (P < 0.05) and was comparable to each other (P > 0.05)
- The posttest increase in mean P/F ratio was significant in both the groups as compared to their respective pretest values (P < 0.05) and was comparable to each other (P > 0.05)
- The posttest increase in mean PIFR was significant in both the groups as compared to their respective pretest values (P < 0.05) and was comparable to each other (P > 0.05).
[Table 3] shows characteristics of patient analgesia and sedation.
The mean duration of analgesia was significantly higher in Group B as compared to Group R (P < 0.05).
The mean Ramsay sedation score was significantly more in Group B as compared to Group R (P < 0.05).
Group B required significantly less number of rescue analgesics per day as compared to Group R (P < 0.05).
Other parameters [Table 4] such as incidence of mechanical ventilation and mortality were comparable in both the groups and were statistically nonsignificant (P > 0.05).
Although less number of patients required invasive ventilation in Group B, the difference was not significant (P > 0.05).
Length of ICU stay was significantly less in Group B as compared to Group R (P < 0.05).
The incidence of adverse effects [Table 5] was same in both the groups and was statistically nonsignificant (P > 0.05) except for nausea which was significantly higher in Group B (P < 0.05).
| Discussion|| |
Blunt trauma chest remains a significant cause of morbidity and mortality in the present world associated with high-speed vehicular accidents, with as many as 25% deaths attributable to thoracic injuries., RFs are associated with increased morbidity and mortality due to resultant associated pain. Severe pain leads to splinting of respiratory muscles resulting in respiratory dysfunction. Respiratory dysfunction causes atelectasis, impaired clearance of respiratory secretions, impaired cough leading to hypoxemia, increased shunt, pulmonary infections, and requirement of mechanical ventilatory support., Keeping in mind, this association of pain due to RFs and pulmonary complications, a lot of research have been done to determine the safety and the efficacy of different analgesic techniques and pharmacotherapy.
Epidural analgesia using local anesthetic agents has been proven to be better than systemic opioid analgesics in providing thoracotomy pain management.,, Based on the same principles, improved pain management using epidural analgesia in patients with RFs is associated with improved vital capacity and improved inspiratory and expiratory flow rates and better outcome., Epidural analgesia increases the patient's compliance and cooperation for pulmonary toileting, thereby improving pulmonary functions and decreasing pulmonary complication.
We studied effect of epidural analgesia with local anesthetic agent, ropivacaine with and without opioid, and butorphanol in patients with chest wall injuries. Ropivacaine has a greater degree of motor sensory differentiation, which is desirable in patients with RFs where analgesia is of prime importance, and motor blockade is undesirable. Moreover, it is also associated with decreased potential for central nervous system toxicity and cardiotoxicity.
Butorphanol, a lipid-soluble narcotic, has strong analgesic and sedative properties without respiratory depression. Butorphanol has been frequently used for postoperative analgesia and labor analgesia. When compared with more potent narcotics such as fentanyl, epidural butorphanol provides significantly prolonged analgesia with minimum cardiorespiratory side effects.
Till date, various investigators have compared epidural analgesia with systemic opioids and epidural local anesthetic agents (bupivacaine) with or without adjuvants., However, no study has been done to study the efficacy of epidural butorphanol and ropivacaine in these participants as mentioned above.
Demographic profile and patient characteristics with respect to the number of RFs, unilateral/bilateral, were comparable in both the groups and were found statistically nonsignificant (P > 0.05).
In our study, we found that there was significant increase in duration of analgesia and nonsignificant reduction in VAS score in Group B, which was associated with better compliance for deep breathing exercises, better vital capacity, and nonsignificant decrease in invasive ventilation cases (4 in Group B vs. 5 in Group R) and significant reduction in length of ICU stay in Group B.
Epidural analgesia has been shown to increase functional residual volume, lung capacity compliance, and vital capacity, decrease airway resistance, and increase PaO2. Patients remain awake and cooperate with pulmonary toileting  and chest physiotherapy. These were apparent in patients of this study as well.
Dittman in his series of articles on pain management in blunt trauma chest showed that intubation and positive pressure ventilation can be avoided in patients using epidural analgesia and can be managed on spontaneous breathing. Similar results were shown by various investigators using local anesthetics with or without morphine through epidural catheters.,,
Although the Ramsay sedation scores were significantly more in Group B, no patients required airway intervention and were responsive to the verbal commands.
There was a significant increase in PaO2, P/F ratios, and PIFR in both the groups, but the degree of increase in two groups was comparable and nonsignificant. Several small studies have been conducted wherein it was observed that epidural analgesia with opioid adjuvant improves vital capacity, oxygenation, and PIFRs and reduces pulmonary complications.
Epidural analgesia is associated with various complications; on comparing the adverse effects in both groups, we found hypotension, bradycardia, nausea, vomiting, and urinary retention in both the groups. Number of patients having hypotension (8 in Group B vs. 6 in Group R), vomiting (6 in Group B vs. 4 in Group R), and urinary retention (4 in Group B vs. 3 in Group R). These incidents were more in Group B than in Group R, but the difference was nonsignificant (P > 0.05). Hypotension was corrected by intravenous (IV) fluids, and no patient in any group required vasopressors. Vomiting was treated with ondansetron 0.1 mg/kg. Urinary retention was treated with urinary catheterization which was removed after draining the urine. A significant number of patients had nausea in Group B than Group R. All the adverse effects were attributable to epidural analgesia, which was augmented by addition of butorphanol in Group B. No patient in any group had serious complications associated with epidural analgesia such as dural puncture neurological injury, epidural hematoma, infection, accidental subarachnoid injection with its serious consequences, and local anesthetic toxicity associated with accidental IV injection. Mortality in both the groups was comparable and was nonsignificant.
The use of epidural analgesia requires epidural catheters which adds up to overall cost of hospital stay which is detrimental in developing countries, primarily in rural setups. Improved survival, decreased length of ICU stay, and decreased requirement of mechanical ventilation will effectively bring down the cost of hospital care.
| Conclusion|| |
The advantages of the epidural analgesia with local analgesics have been well established in the patients with RFs as reflected by improvements in VAS scores, inspiratory flow rates, oxygenation, and pulmonary compliance and reduced pulmonary complications. Addition of butorphanol to this results in augmentation of these advantages with decrease length of ICU stay and duration of mechanical ventilation without increase in significant side effects. Further studies are required to evaluate the role of butorphanol as adjuvant to local anesthetics for epidural analgesia for RFs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bulger EM, Edwards T, Klotz P, Jurkovich GJ. Epidural analgesia improves outcome after multiple rib fractures. Surgery 2004;136:426-30.
Kieninger AN, Bair HA, Bendick PJ, Howells GA. Epidural versus intravenous pain control in elderly patients with rib fractures. Am J Surg 2005;189:327-30.
Stawicki SP, Grossman MD, Hoey BA, Miller DL, Reed JF 3rd
. Rib fractures in the elderly: A marker of injury severity. J Am Geriatr Soc 2004;52:805-8.
Wisner DH. A stepwise logistic regression analysis of factors affecting morbidity and mortality after thoracic trauma: Effect of epidural analgesia. J Trauma 1990;30:799-804.
Wu CL, Jani ND, Perkins FM, Barquist E. Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash. J Trauma 1999;47:564-7.
Rao PM, Puri GD, Bharadwaj N, Chari P, Acup D. ICU management of blunt chest trauma: Our experience. Ann Card Anaesth 1998;1:31-5.
Trunkey DD. Trauma. Accidental and intentional injuries account for more years of life lost in the U.S. Than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research. Sci Am 1983;249:28-35.
Ullman DA, Fortune JB, Greenhouse BB, Wimpy RE, Kennedy TM. The treatment of patients with multiple rib fractures using continuous thoracic epidural narcotic infusion. Reg Anesth 1989;14:43-7.
Cicala RS, Voeller GR, Fox T, Fabian TC, Kudsk K, Mangiante EC, et al.
Epidural analgesia in thoracic trauma: Effects of lumbar morphine and thoracic bupivacaine on pulmonary function. Crit Care Med 1990;18:229-31.
Shulman M, Sandler AN, Bradley JW, Young PS, Brebner J. Postthoracotomy pain and pulmonary function following epidural and systemic morphine. Anesthesiology 1984;61:569-75.
Asantila R, Rosenberg PH, Scheinin B. Comparison of different methods of postoperative analgesia after thoracotomy. Acta Anaesthesiol Scand 1986;30:421-5.
Zwarts SJ, Hasenbos MA, Gielen MJ, Kho HG. The effect of continuous epidural analgesia with sufentanil and bupivacaine during and after thoracic surgery on the plasma cortisol concentration and pain relief. Reg Anesth 1989;14:183-8.
Simon BJ, Cushman J, Barraco R, Lane V, Luchette FA, Miglietta M, et al.
Pain management guidelines for blunt thoracic trauma. J Trauma 2005;59:1256-67.
Kuthiala G, Chaudhary G. Ropivacaine: A review of its pharmacology and clinical use. Indian J Anaesth 2011;55:104-10.
] [Full text]
Kaur J, Bajwa SJ. Comparison of epidural butorphanol and fentanyl as adjuvants in the lower abdominal surgery: A randomized clinical study. Saudi J Anaesth 2014;8:167-71.
] [Full text]
Jarvis AM, Cook CH, Lindsey DE, Reilley TE, Steinberg SM, Beery PR 2nd
, et al
. Comparison of epidural versus parenteral analgesia for traumatic rib fractures: A meta-analysis. OPUS 12 Sci 2009;3:50-7.
Parris R. Towards evidence based emergency medicine: Best BETs from the manchester royal infirmary. Epidural analgesia/anaesthesia versus systemic intravenous opioid analgesia in the management of blunt thoracic trauma. Emerg Med J 2007;24:848-9.
Dittmann M, Ferstl A, Wolff G. Epidural analgesia for the treatment of multiple rib fractures. Eur J Intensive Care Med 1975;1:71-5.
Dittmann M, Keller R, Wolff G. A rationale for epidural analgesia in the treatment of multiple rib fractures. Intensive Care Med 1978;4:193-7.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]