Pain after surgery Inflammatory pain Nociceptive pain Neuropathic pain Inflammatory pain Nociceptive pain Neuropathic pain
Type of thoracotomy Pain: Thoracotomy produces nociceptive (tissue damage and ribs) and neuropathic pain (peripheral nerves) that is aggravated by respiration and coughing. Pain may be further exacerbated by the presence of chest tubes and drains.
Severity/Duration: Thoracotomy pain is generally severe and intense that may last for weeks. Patients may develop post-thoracotomy pain syndromes lasting months to years.
reports : 50% may have pain up to 1 year post thoracotomy. Dajczman et al ; chest 1991 Prevalence of post thoracotomy pain may be modified with rates as low as 21% with aggressive perioperative pain management. ochroch et al ; anesthesiology 2002
The insufficient treatment of post thoracotomy pain results in : 1- reduced pulmonary compliance 2- inability to breath deeply or cough forcefully and retention of secretions atelectasis and pneumonia 3- prolonged immobility related to pain may lead to DVT and P.E
CHOICES FOR PAIN CONTROL Administration of opioids via IV, IM, or IV PCA routes Thoracic epidural analgesia Paravertebral blocks Intercostal nerve blocks Intrapleural catheter Cryoanalgesia has been used
Analgesia following thoracotomy: a survey of Australian practice. Anaesth Intensive Care. 1997 Oct;25(5):520-4. Cook TM, Riley RH Cook TMRiley RH The most frequently used analgesic modalities are epidural analgesia, intravenous patient- controlled analgesia (IVPCA), and nurse- controlled intravenous opioid infusions
Systemic Analgesics Systemic analgesics are the main alternative to more invasive techniques. Intravenous patient-controlled opioids is the main component of systemic analgesics. Systemic systemic opioids can be associated with significant side effects, which has prompted the search for alternative systemic medications.
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, a2-agonists, nitric oxide synthetase inhibitors,N-methyl-d-aspartate receptor blockers
PCA Patient Controlled Analgesia Advantages : Safe, effective, good analgesia, reduces delay, saves nursing time, high patient satisfaction, few complications Disadvantages : Respiratory depression, nausea and vomiting, programming errors, costs
nonsteroidal anti-inflammatory drugs continue to be an important adjunct to opioid analgesia Rhodes et al : Nonsteroidal antiinflammatory drugs for postthoracotomy pain J Thorac Cardiovasc Surg 1992; 103:17–20
Nimesulide 90 mg Orally Twice Daily Does Not Influence Postoperative Morphine Requirement After MajorChest Surgery. Harney et al (Anesth Analg 2008;106:294 –300)
Adding ketamine to morphine for patient-controlled analgesia after thoracic surgery: influence on morphine consumption, respiratory function, and nocturnal desaturation Michelet et al British Journal of Anaesthesia 2007;99:396-403
Copyright restrictions may apply. Michelet, P. et al. Br. J. Anaesth. 2007 99:396-403; doi:10.1093/bja/aem168 Cumulative morphine consumption by 12 h period between the morphine group and morphine/ketamine group
intrathecal morphine to patient- controlled administration (PCA) morphine improves post-thoracotomy pain relief and respiratory function Askar FZ et al Journal of International Medical Research 2007;35: 314-322
Tramadol administered by continuous intravenous infusion may be as effective as thoracic epidural morphine Bloch et al. Anesth Analg 2002; 94:523–8
Mainstay of postoperative pain There is good evidence that aggressive pain control in the form of epidural analgesia with local anesthesia following thoracic surgery improves pulmonary function, reduces morbidity, and reduces the length of stay in intensive care.
Epidural Analgesia - Side Effects From the technique dural puncture epidural haematoma epidural abscess nerve root trauma From LA hypotension paraesthesia motor weakness From opioid delay resp depress urinary retention pruritus
Effective postoperative pain control may be achieved by delivering an opioid or a combination of an opioid and local anesthetic into the thoracic epidural space (Mahon et al., 1999; Miguel & Hubbell, 1993; Brichon et al., 1994).Mahon et al., 1999Miguel & Hubbell, 1993Brichon et al., 1994
Postoperative patients can consume 50 to 100 mg of I.V morphine during the first 24 hours postoperatively when given by a PCA device In comparison, epidural doses of 5 mg of morphine can provide post operative analgesia for 12 to 24 hours Ferrante FM. Principles and practice of anesthesiology, 2nd ed. St. Louis, MO:Mosby, 1998:2331–51.
Commonly used opioid–local anesthetic mixtures reported : include fentanyl-bupivacaine, morphine- bupivacaine, and fentanyl-ropivacaine. Levo-bupivacaine, an isomer of bupivacaine with decreased cardiotoxicity, alone and in conjunction with opiates. Ropivacaine has a similar onset and duration of action to bupivacaine, but it has an enhanced safety profile due to decreased cardiotoxicity and a less profound motor blockade than either bupivacaine or levo-bupivacaine.
Shorrab et al has concluded : Ropivacaine– fentanyl thoracic epidural analgesia after thoracotomy is comparable to bupivacaine – fentanyl analgesia in terms of pain control and side effects The Internet Journal of Anesthesiology. 2007;(13) 1.
Thoracic vs. lumbar epidurals ? L.A vs.L.A combined with opiates ? Opiates alone ? What type of opiates ?
Comparison of thoracic and lumbar epidural infusions of bupivacaine and fentanyl for post-thoracotomy analgesia no significant differences in analgesia and pulmonary function were seen; however, less opioid was required in patients receiving thoracic epidural analgesia Hurford et al.. J Cardiothorac Vasc Anesth 1993
Patients who received epidural bupivacaine had a reduced incidence of SVT when compared with patients who only received epidural opiates. The reduction was due to the reduced sympathetic tone this reduction could have a significant impact on the postoperative cardiac morbidity of thoracotomy patients. Oka et al. Thoracic epidural bupivacaine attenuates supraventricular tachyarrhythmias after pulmonary resection. Anesth Analg 2001;93:253–9
single shot or continuous techniques are also useful in providing postoperative analgesia following thoracic surgical procedures (Carabine et al., 1995).Carabine et al., 1995 Continuous paravertebral blocks provide superior postoperative analgesia when compared to single shot techniques (Catala et al., 1996).Catala et al., 1996
G. Davies, P. S. Myles, and J. M. Graham comparison of the analgesic efficacy and side- effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials Br. J. Anaesth. 2006 96: 418-426
Copyright restrictions may apply. Davies, R. G. et al. Br. J. Anaesth. 2006 96:418-426; doi:10.1093/bja/ael020 A meta-analysis of trials comparing PVB with epidural analgesia on postoperative pulmonary complications
Copyright restrictions may apply. Davies, R. G. et al. Br. J. Anaesth. 2006 96:418-426; doi:10.1093/bja/ael020 A meta-analysis of trials comparing PVB with epidural analgesia on morphine consumption after surgery
conclusion : PVB and epidural analgesia provide comparable pain relief after thoracic surgery, but PVB has a better side- effect profile and is associated with a reduction in pulmonary complications. PVB can be recommended for major thoracic surgery
Randomized Controlled Phase III Trial of Paravertebral Catheter vs. Epidural Catheter for Post Thoracotomy Pain Control ( IN PRESS ) M. J. Liptay 1 et al. 1 Evanston Northwestern Healthcare, Evanston, IL, 2 Indiana University, Indianapolis, IN, CONCLUSIONS: Intraoperative paravertebral catheter insertion provides comparable pain relief to the thoracic epidural catheter. Ease of insertion makes it an alternative to routine epidural insertion.
Intercostal nerve blocks Sustained benefit can be obtained by the use of local anesthetic infusion into intercostal catheters placed under direct vision above and below the incision prior to wound closure ( extraplueral inetrcostal block )
it has been demonstrated radiologically, that the site of action of local anesthetic via an extrapleural intercostal catheter is primarily via the paravertebral space Eng J, Sabanathan S. Site of action of continuous extrapleural intercostal nerve block. Ann Thorac Surg 1991; 51: 387–9
Kaiser et al 1998 had concluded that extrapleural intercostal analgesia might be a valuable alternative to thoracic epidural analgesia for pain control after thoracotomy and should particularly be considered in patients who do not qualify for thoracic epidural analgesia.
Thoracic Epidural Versus Intercostal Nerve Catheter Plus Patient-Controlled Analgesia: A Randomized Study Luketich et al Ann Thorac Surg 2005;79
Conclusion : Satisfactory pain control was achieved after thoracotomy using either EPI or ICN-PCA. The ICN-PCA achieved equivalent pain control compared with EPI. ICN was placed by the surgeon with no delays in surgery. decreased requirement for Foley catheter duration.
Extrapleural Intercostal Catheter Vs. Thoracic Epidural for Thoracotomy Pain This study is currently recruiting participants. Information provided by Virginia Commonwealth University Completion Date March 2008
Cryoanalgesia Cryoanalgesia of intercostal nerves performed prior to wound closure produces intercostal blockade lasting several months. Despite the theoretical attractions, in one of the few controlled trials of the technique it did not produce improved pain scores or respiratory function. In addition, cryoanalgesia may lead to the development of intercostal neuralgia
cryoanalgesia be considered as a simple, inexpensive, long-term form of post-thoracotomy pain relief, which does not cause any long-term histological damage to intercostal nerves Moorjani et al Eur J Cardiothorac Surg 2001;20:502-507
Intrathecal opioids Intrathecal administration of opioids has been used successfully to provide postoperative analgesia following thoracic surgical procedures. Intrathecal opiates may be used to provide postoperative analgesia following thoracotomy. This technique is associated with good analgesia at rest and a reduction in the need for opiates delivered via other routes during the first 24 hours. It may also be associated with a higher incidence of side effects when compared with epidural opioids or epidural local anesthetic and opioid combinations.
Conclusion : Analgesic plan should start preoperatively. Multimodal approach by modulating different pain pathways. Mid Thoracic epidurals are the standard of analgesia. Extradural intercostal and paravertbral catheters are gaining popularity and are excellent alternative.