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* From Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA.
Correspondence to: Christine Peeters-Asdourian, MD, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215
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Abstract |
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 TOP Abstract IntroductionMethods for Postthoracotomy Pain...ConclusionsReferences |
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Introduction |
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TOPAbstractIntroductionMethods for Postthoracotomy Pain...ConclusionsReferences |
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It is interesting to note that postoperative pain management is affected by choices made in the preoperative and intraoperative periods. A well-prepared patient, knowing what to expect in the postoperative period, will require less analgesic than patients receiving no information about the postoperative course.3
Intraoperatively, the anesthetic technique itself, general anesthesia with or without opioid vs the use of regional techniques, will influence the analgesic requirements in the postoperative period.4 Under regional anesthesia, the cord receives no afferent input from the surgical stimulus. Local anesthetics will block the volley of nerve impulses in the unmyelinated C fibers and prevent prolonged widespread increase in reflex excitability in the spinal cord dorsal horn. This is known as the "wind up" phenomenon or central sensitization.5 Even large doses of opioids alone will not be able to prevent this phenomenon or once established will not be able to counteract it effectively.6
In the postoperative period, there are several options for pain control. It is important, however, that pain control is initiated early in the postoperative period. This is not only to provide comfort, but also to win patient’s confidence in the medical providers, thus reducing the feeling of anxiety and helplessness, so harmful to further effective pain management. As explained above, early pain control would also avoid the "wind up" phenomenon and central sensitization.
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Methods for Postthoracotomy Pain Management |
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TOPAbstractIntroductionMethods for Postthoracotomy Pain...ConclusionsReferences |
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A large survey examining pain management after thoracotomy in 27 Australian hospitals showed that the most frequently used analgesic modalities are epidural analgesia, IV patient-controlled analgesia (PCA), and nurse-controlled IV opioid infusions. Respondents reported that cryoanalgesia, interpleural blockade, paravertebral blockade, subarachnoid infusions, ketamine, and TENS are used infrequently. Seventy-nine percent of respondents selected epidural analgesia as the best available analgesia technique, whereas 21% consider IV PCA to be the best.7
Systemic Analgesics
Opioids remain the mainstay of postoperative analgesia and have
demonstrated their efficacy in the management of severe pain. The main
concerns about the use of opioids remain their side effects: nausea,
vomiting, ileus, biliary spasms, respiratory depression, and the
potential for abuse, although in the immediate postoperative period,
this is rarely an issue. Opioids can be administered IM,
subcutaneously, or IV.
A very efficient method of delivery of opioids is via PCA devices. Numerous studies have demonstrated the safety and opioid-sparing effect of PCA.
With opioids alone, IM or IV, the analgesia may be marginal and side
effects intolerable (nausea, vomiting, sedation), thus the need for
synergy, choosing drug classes that will overlap for analgesia but not
for side effects. Drug classes that fit these requirements are as
follows: mu agonist opioids, cyclooxygenase inhibitors,
2-agonists, nitric oxide synthetase inhibitors,
N-methyl-D-aspartate receptor blockers, and local
anesthetics when delivered by thoracic epidural catheters. This
balanced analgesia or delivery of different classes of analgesics will
result in effective pain relief by synergistic or additive effect with
reduced incidence of side effects.
Nonsteroidal anti-inflammatory agents produce their effect by inhibiting the prostaglandin synthesis and release at the level of cyclooxygenase. These drugs have proven efficacy as the sole analgesic agent for management of mild-to-moderate pain in minor surgical procedures.8
Neuraxial Opioids and Local Anesthetics
This can be provided via epidural or intrathecal route. Of these,
epidural catheter infusion is the most commonly employed method and
recently, a cumulative meta-analysis of various postoperative analgesic
therapies shows that epidural opioids and epidural local anesthetics
with or without opioids decreased the incidence of pulmonary
complications as compared with systemic opioids.9 The
amount of opioids needed by neuraxial route (especially when combined
with local anesthetics) is less than that by systemic route, and thus
the systemic side effects of opioids may be less
frequent.10 In the Australian survey7 when
epidural analgesia was used, most respondents placed the catheter in
the midthoracic region (91%), used a regimen of opioids plus local
anesthetic (96%), used a constant infusion technique (100%), and
continued analgesia for up to 3 days (83%).
A single intrathecal opioid injection can also be used either alone or in combination with epidural infusion and other methods for pain control. However, the pain relief achieved with this method usually is not longer than 12 to 16 h, and the need for monitoring for possible respiratory depression is the same as for epidural opioids administration.
The relative contraindications for neuraxial interventions include coagulopathy, both intrinsic and idiopathic, infection at the local puncture area, and sepsis. The overall incidence of complications after thoracic epidural catheterization is low. In a large study of 4,185 patients, the complication rate was 3.1% (n = 128). This included dural perforation (0.7%; n = 30), unsuccessful catheter placement (1.1%; n = 45), postoperative radicular-type pain (0.2%; n = 9), responsive to catheter withdrawal in all cases, and peripheral nerve lesions (0.6%; n = 24), 0.3% (n = 14) of which were peroneal nerve palsies probably related to surgical positioning or other transient peripheral nerve lesions (0.2%; n = 10). No signs suggesting epidural hematoma were recognized, and there were no permanent sensory or motor defects attributable to epidural catheterization. A single patient experienced severe respiratory depression after receiving epidural buprenorphine but recovered without sequelae.11
It should also be noted that a combination of systemic opioid (preferably IV PCA mode) and neuraxial (preferably epidural) local anesthetic with or without opioid may provide a very effective mode of pain control.
Regional Anesthetic Techniques
Regional anesthetic techniques include different methods of
blocking intercostal nerves as well as intrapleural catheter infusion.
Intercostal nerve blocks can be performed either intraoperatively or postoperatively. They have provided good relief lasting 6 to 12 h and need to be repeated. A longer-lasting relief can be obtained by an extrapleural catheter placed next to intercostal nerves. An infusion of local anesthetics through this catheter has worked effectively for pain relief.1213 Also, good results have been obtained with cryoablation of intercostal nerves intraoperatively for a longer-lasting relief.14
An alternate route is the administration of local anesthetic through an interpleural catheter. This is done by placing a catheter between the parietal and visceral pleura and running the infusion either intermittently or continuously.15 One of the problems is the loss of the local anesthetic solution through the chest tubes or the need to clamp these tubes intermittently for this technique to be effective.
Paravertebral neuronal blockade has been performed both by multiple injections and catheters for postthoracotomy pain control with good results.16
Adjuvant Methods
The use of adjuvant methods like TENS, heat and cold application,
music therapy, and relaxation techniques have also been useful in acute
postoperative pain settings.1718
Other factors may contribute an improved outcome following thoracic surgery, and these include early mobilization, effective chest physical therapy, incentive spirometry, early feeding, all of which will be more efficient given good analgesia with minimal side effects (nausea, sedation, or orthostasis).19
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Conclusions |
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TOPAbstractIntroductionMethods for Postthoracotomy Pain...ConclusionsReferences |
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As described above, there are some other techniques available for administration of local anesthetics or opioids which have not been used widely but can be effective in pain management. We cannot overemphasize the importance of adjuvant pain control methods and also the early initiation of an effective pain management strategy.
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TOPAbstractIntroductionMethods for Postthoracotomy Pain...ConclusionsReferences |
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