PATIENT COMMENTS

"Return of appetite and able to enjoy activities of daily living."

"Helps to cope with any increasing pain rather then taking medication."

"Recommend this treatment to anyone who experiences pain associated with chronic pancreatitis."

The 9 patients were instructed to phone in when the pancreatitis pain returned so they could be admitted for another treatment. There was some variation in how long they would wait before requesting admission, but in general the time between treatments reflects the duration of pain relief from one interpleural catheter insertion. The average time was 10.5 months, but the time varied from 2 weeks to 52 months.

The drop in pain score was from the time of admission to discharge. Some of the patients are on opiate medication and their requirements would drop after treatment.

There was one occurrence of pneumothorax during the study. After the pneumothorax was treated, the interpleural catheter was reinserted.

Rapid changes in weight are common. One patient gained 20 Kg. in one month, then lost most of it the following month. Most patients reported relief from nausea when the catheter was in place and improvement in appetite. Two patients who appeared on the verge of starvation prior to treatment returned to a normal weight for their height and age within six months after commencement of treatment.

Patients commonly complain of shoulder tip pain the first night in hospital. No instillations of bupivicaine were made between 1800 hrs. and 0800 hrs. the next morning. Additional opiate analgesia was made available during those hours.

SUMMARY

Nine patients were treated for chronic pancreatitis pain with repeated insertion of left interpleural catheters when needed for their pain. All nine reported a decrease in pain level after a treatment, with an average decrease from 8.8 to 3.2 on the visual analogue scale. The average time between necessary treatments ranged from 2 months to 52 months with an average of 10.5 months.

Three of the nine patients had previously been treated with coeliac plexus blocks. All felt that the pain relief from the interpleural catheter was superior.

Since the beginning of 2002 four patients with cancer(3 ca. pancreas, 1 stomach) have received this treatment in our clinic. All reported pain relief while the catheter was in place, and two have reported prolonged pain relief. One, who had been in intense pain for 17 months has been pain free for 8 weeks.

The use of interpleural catheters for pancreatitis pain has been reported as early as 1988 but has not come into wide use.(4)

The purpose of this paper is to raise awareness of this technique which we have found to be so beneficial for our patients.

Insertion of Interpleural Catheter

Step One: Prepare the patient.

 The patient lies with the right side down with a small pillow under the lumbar area.

The catheter is placed in the mid-axillary line just below the edge of the lung.  Chest is auscultated and the interspace where the breath sounds start to disappear is marked.  This is usually the T10-11 interspace. 

Insertion of Interpleural Catheter

Step Two: Prepare necessary materials.

In preparation of the inter pleural catheter an epidural mini-pack is opened and the tip of the catheter is cut to remove the side holes on the catheter.  If the side holes are left in place they can cause an inadvertent interstitial injection of local anaesthetic into the chest wall rather than into the inter pleural space.

Insertion of Interpleural Catheter

Step Three: Insert Tuohy needle and find loss of resistance.

After infiltrating the skin with local anaesthetic, the skin over the insertion site is retracted  caudad.  An ordinary 18 gauge needle is used to make a hole in the skin and the Tuohy needle is inserted to contact the rib immediately below the insertion point.  Then a glass syringe filled with 5ml of .5% Marcaine E is attached to the needle and the skin is allowed to return to the cephalad position and the Tuohy needle is slid over the top of the rib, the needle is advanced through the parietal pleura until a loss of resistance is found and the fluid in the syringe can be easily injected.    

Insertion of Interpleural Catheter

Step Four: Pass the interpleural catheter and remove the Tuohy needle.

 The catheter is threaded through the Tuohy needle into the interpleural space . Once 3 or 4 centimetres of catheter have been  passed through the tip of the needle the Tuohy  needle is slid off the catheter.

Insertion of Interpleural Catheter

Step Five: Place the injection hub on the catheter and test it.

The hub is then placed on the end of the catheter with an anti bacterial filter and the remainder of the Marcaine E in the glass syringe is injected through the bacterial filter to test the catheter.  Prior to attaching the bacterial filter to the hub it should be filled with the local anaesthetic solution to avoid injecting air into the interpleural space.  

Insertion of Interpleural Catheter

Step Seven: Inject the catheter.

The remainder of the 20ml of Marcaine E .5% is injected using a regular ten millilitre syringe through the catheter.  While injecting place your index finger over the injection site to prevent the jet effect from pushing the catheter out through the insertion site.  After the catheter has been placed and tested the patient is placed in a Semi-Fowlers position for about 5 minutes to allow the local anaesthetic to set in the proper position.  The vital signs are checked every half hour for the first two hours and an intravenous of ringers lactate is run at a 100ml/ hour for that period of time.  A chest x-ray is taken to rule out pneumothorax and the patient is returned to the ward.  Over the next two days the patient is given 20ml of .5% Marcaine E through the catheter 3 times a day.  It is not unusual for the patient to experience some shoulder pain and moderate discomfort during the first night and narcotic sedation should be made available.  Generally speaking they are more comfortable on the second night.  On the evening of the third day after the third infusion of local anaesthetic through the catheter, the catheter is removed, the skin area is washed and a band-aid is placed on the injection site.  The patient can be discharged within the hour from the hospital.   

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