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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
MEDICAL ACADEMY
FACULTY OF NURSING
DEPARTMENT OF NURSING AND CARE
JOSSY ANNAMMA JOY
PAIN CONTROL AFTER THORACIC SURGERY
The graduate thesis of the Master‘s degree study programme “Advanced Nursing Practice”
(State Code 6211GX008)
Tutor of the graduate thesis
Phd ,MD, Milda Švagždienė
KAUNAS, 2019
2
TABLE OF CONTENT
ABSTRACT…………………………………………………………………………………………3
ABBREVIATIONS………………………………………….............................................................4
INTRODUCTION …………………………………………………………………..........................5
1.REWIEW OF LITERATURE……………………………………………… …………………….7
1.1 Definition of pain………………………………………………………………………………...7
1.2 Pain after thoracic surgery……………………………………………………………………….7
1.3Degree and duration of pain after thoracic surgery…………………………………………….....9
1.4Acute postthoracotomy………………………………………………………………………….10
1.5Chronic postthoracotomy pain ………………………………………………………………….11
1.5.1Mechanism of postthoracotomy pain………………………………….....................................12
1.6Pain management after thoracic surgery………………………………………………………...12
1.6.1Systemic analgesia…………………………………………….………………………………13
1.6.2Regional Anesthesia Techniques……………………………………………………………...17
2.ORGANISATION AND METHODOLOGY OF A RESEARCH……….....................................30
3 RESULTS………………………………………………………………………………………...30
4 .DISCUSSION OF THE RESULTS……………………………………………………………...32
CONCLUSIONS……………………………………………………………………………………35
PRACTICAL RECOMMENDATIONS…………………………………………………………...36
PUBLICATIONS………………………………………………………………………………… ..40
LIST OF LITERATURE SOURCES……………………………………………………………...41
ANNEXES………………………………………………………………………………………….44
DECLARATION OF THE AUTHOR’S CONTRIBUTIONS AND ACADEMIC HONESTY
3
ABSTRACT
Jossy Annamma Joy. Pain control after thoracic surgery. The graduate Master’s thesis .The tutor-
PhD MD, Milda Švagždienė. Lithuanian University of Health Science,Medical
academy,the Faculty of Nursing, Department of Nursing and Care.Kaunas,2019; 45p.
Thoracotomy is considered the most painful of surgical procedures and providing effective
analgesia is the onus for all anesthetists. Ineffective pain relief impedes deep breathing, coughing,
and remobilization culminating in atelectasis and pneumonia. Systemic opioid-based analgesic
regimen often fails in the treatment of postoperative pain after thoracotomy and the prevention of
persistent pain. AIM: * To find the optimal postoperative analgesia plan for the patients after
thoracic surgery. GOALS: *To investigate the incidence, severity and duration of acute
postthoracotomy pain. * To find the optimal analgesia method for the patient after thoracotomy. *
To investigate different methods and regiments of analgesia. METHODS For this research, the
literature search was conducted in the Pubmed, Science Direct, PLOS, SAGE, Google Scholar
databases and 35 literature sources were reviewed. Studies published in English between 2009–
2019 have been reviewed.
CONCLUSION :After surgery, pain control is central to the anesthetic management of thoracic
surgical patients. The provision of good postoperative analgesia is important in itself and is
regarded by some as the core business of anesthesia and a fundamental human right. Effective
analgesia can reduce pulmonary complications and mortality. It is unlikely that a single technique
will fulfill these goals optimally for all patients and that a balanced, multimodal approach should
therefore be used. Analgesia should be tailored to the specific patient undergoing a specific
procedure to minimize mortality, patient suffering, complications of the pulmonary system, and
other morbidity. Experience with a wide range of analgesic techniques is helpful as it allows a
suitable technique to be implemented. For open thoracotomies, a combination of regional analgesia
and opioids, sometimes supplemented with non-opioid analgesics, will best manage most patients.
Usually only consideration should be given to lumbar epidural analgesia, intrathecal opioids, or
intercostal nerve blocks if no thoracic epidural analgesia or paravertebral blocks are possible.
Currently the choice between thoracic epidural analgesia and paravertebral block is the dilemma for
thoracic anesthetists and their patients scheduled to undergo thoracotomy.
4
ABBREVIATIONS
LA : Local Anesthetic
TEA : Thoracic Epidural Analgesia
NMDA : N-methyl-d-aspartate
PTPS : Post thoracotomy pain syndrome
IV : Intra Venous
IM : Intra Muscular
PCA : Patient Controlled Analgesia
NSAIDs : Non Steroid Anti-Inflammatory Drugs
COX : Cyclooxygens
TEA : Thoracic Epidural Analgesia
ICNs : Intercostal nerves
ICNB : Intercostal Nerve Blocks
TP : Transverse Process
BR : Breathing Rate
HR : Heart Rate
ABP : Arterial Blood Gas
VAS : Visual Analogue Scale
5
INTRODUCTION
Thoracotomy is considered the most painful of surgical procedures and providing effective
analgesia is the onus for all anesthetists. Ineffective pain relief impedes deep breathing, coughing,
and remobilization culminating in atelectasis and pneumonia. This article reviews the mechanisms
of acute and chronic thoracotomy pain, the risk factors, current analgesic options, and the role
genetics may increasingly play in the management of thoracotomy pain.(1) Chest surgery may be
either thoracotomy or thoracoscopy. The incision may be either muscle-cutting or muscle-sparing
incision in thoracotomy. For most general thoracic surgical procedures, posterolateral thoracotomy
incision is used. This incision, involving division of the anterior latissimus dorsi and serratus
muscles, provides excellent thoracic cavity exposure. It is associated with significant morbidity,
however, including impaired pulmonary function, postoperative chest pain, and limited movement
of the arm and shoulder. Different muscle-sparing incisions were suggested to reduce morbidity.
Postthoracotomy pain is caused during surgery by pleural and muscle damage, costovertebral
disruption of the joint, and intercostal nerve damage. Inadequate pain relief after surgery affects the
quality of patient's recovery and exposes the patients to postoperative morbidities. There is a
tendency nowadays among thoracic surgeons and anesthesiologists toward the area of enhanced
recovery after thoracic surgery which requires careful titration of the anesthetic drugs in awake
patients undergoing thoracoscopic procedures. There is a common feeling among thoracic
anesthesiologists that postthoracoscopy procedures produce less pain intensity versus thoracotomy
which is partially true. Effective management of acute pain after either thoracotomy / thoracoscopy
is needed, however, and can prevent these complications and reduce the likelihood of chronic pain
developing. Adequate pain relief leads to early mobilization, improves breathing functions, and
decreases the response of global stress. Therefore, good management of perioperative pain
significantly reduces postoperative complications. Numerous analgesic methods are currently
available to manage acute postthoracotomy / thoracoscopy pain, including patient-controlled
analgesia, local anesthetic (LA) infiltration, intrapleural or intercostal nerve blockages, and
neuraxial blockages. In this report, we examine the newly introduced modalities for pain relief
postthoracotomy / thoracoscopy with particular reference to the new tendency
Systemic opioid-based analgesic regimen often fails in the treatment of postoperative pain after
thoracotomy and the prevention of persistent pain. Therefore, multimodal strategies involving the
use of regional and/or local anesthesia in combination with systemic analgesics are warranted and
have been shown to reduce post operative pain and the development of chronic pain .(2)
6
One of the long-term complications of thoracotomy is chronic post-thoracotomy pain. It is defined
as pain on the chest around the incision scar that persists for longer than 2months postoperatively,
or that recurs after having disappeared for a while, but that is not related to the recurrence of a
tumor or to an infection.(3)
According to various studies, the incidence of this pain is 22—67% . Pain is severe in 5—25% of
these patients. The chronic pain disturbs daily activities of almost half of the patients, sleep is
disturbed in one quarter of them . It has been suggested that the development of chronic post-
thoracotomy pain can be prevented by treating acute postoperative pain effectively and by using
good surgical techniques . According to several studies, thoracic epidural analgesia (TEA) is
superior to less invasive methods in the management of acute post-thoracotomy pain. Today it can
be considered a gold standard . Usually a combination of a local anaesthetic (bupivacaine,
ropivacaine) and an opioid (fentanyl, morphine) is used(3).
Uncontrolled acute perioperative pain and related surgical stress responses are highly associated
with poor outcomes after thoracotomy Effective analgesia reduces perioperative morbidity,
shortens hospitalization times, improves patient satisfaction, and lowers cost these principles are
long established and are now included in Joint Commission on Accreditation standards.
Uncontrolled pain in the perioperative period consistently predicts the development of chronic pain.
Strategies that emphasize pre-emptive analgesia may provide protection against chronic pain
syndromes, with some evidence suggesting as high as a 50% reduction in the incidence of chronic
pain syndromes at 1 year after thoracotomy. (et.al Brandi A. Bottiger,2014) (4)
AIM
To find the optimal postoperative analgesia plan for the patients after thoracic surgery.
GOAL
To investigate the incidence, severity and duration of acute postthoracotomy pain.
To find the optimal analgesia method for the patient after thoracotomy.
To investigate different methods and regiments of analgesia.
7
1. REWIEW OF LITERATURE
1.1Definition of pain
Pain is defined as ‘an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage’ (International Association for the
Study of Pain, Subcommittee of Taxonomy 1986b).
1.2Pain after thoracic surgery
Pain after thoracotomy arises from nociceptive and neuropathic mechanisms which may
originate from somatic and visceral affer- ents. Pain can also be referred.(1)
Nociceptive somatic afferents are conveyed by the intercostals nerves after skin incision, rib
retraction, muscle splitting, injury to the parietal pleura, and chest drain insertion to the ipsilateral
dorsal horn of the spinal cord (T4–T10). The afferents are then transmitted to the limbic system and
somatosensory cortices via the contralateral anterolateral system of the spinal cord. Nociceptive
visceral afferents are conveyed by the phrenic and vagus nerves after injury to the bronchi, visceral
pleura, and pericardium.(1)
Neuropathic pain, After intercostal nerve injury, develops via the mechanisms and results in the
paradox of reduced sensory input (from touch, temperature, and pres- sure) with hypersensitivity
(dysaesthesia, allodynia, hyperalge- sia, and hyperpathia).(1)
Referred pain
To the ipsilateral shoulder is common after thoracotomy and can often be unresponsive to the
effects of thoracic epidural analgesia (TEA). Studies have demonstrated a reduction in shoulder
pain by infiltrating local anaesthetic to block the phrenic nerve at the level of the pericardial fat
pad, or alternatively by interscalene block. This suggests that irritation of the visceral pleura and
pericardium, referred to the shoulder by the phrenic nerve, is the most likely source of this pain. As
the nerves arise from C3 to C5, TEA is ineffective in blocking this pain. The phrenic nerve may
also convey referred pain from transection of a major bronchus or irritation of the pleura from a
chest drain placed too far into the apex of the hemithorax.(1)
Factors Influencing Pain After Thoracic Surgery
Surgical factors
The posterolateral thoracotomy approach provides the best access to surgery. It involves, however,
dividing the latissimus dorsi and sometimes the anterior serratus and trapezius muscles, leading to
one of the most painful surgical incisions. Many surgeons are now using alternative muscle-sparing
approaches to replace muscle incision with dissection and reflection on the ribs. However, the
8
reduced field of view may result in excessive retraction of the rib, fracture, dislocation,
costovertebral disruption, and intercostal nerves damage. These incisions may also span multiple
dermatomes as opposed to the single dermatome of the posterolateral approach; for example, the
axillary incision extends vertically downwards. Alternatively, an increasing number of video-
assisted thoracoscopic surgery (VATS) is performed which may reduce acute pain if intercostal
nerve damage is avoided by limiting the number and size of intercostal ports used. However, the
incidence of chronic pain appears to be similar to open thoracotomy
Patient factors
The general surgical population suggests that patients who are young, female, with a history of
depression and anxiety and are poorly informed of their management plan are more likely to
experience acute post-operative pain.
Pre-operative Preparedness
Well-informed patients may experience less pain so that patients should be given full explanation
of the proposed analgesic technique and its probable effects, including its limitations, potential side
effects and complications.
Opioid Tolerance
Continuous exposure to opioids results in a right dose-response curve shift to opioids, resulting in
patients requiring increased opioid levels to achieve the same pharmacological effect. It is a
predictable adaptation of pharmacology. The degree of opioid tolerance is associated with the
dosage, duration, and type of opioid given. Opioid tolerance is likely due to decreased sensitivity
and density of opioid receptors, increased regulation of cyclic adenosine monophosphate and neural
adaptation. N-methyl-d-aspartate (NMDA) receptor activation plays an important role in opioid
tolerance development. Patients with opioid tolerance are relatively intolerant to pain and may be
more difficult to cope with acute pain.
Sex
In an attempt to determine the influence of the patient's sex on the pain experienced after surgery, a
considerable amount of work has been done. Female patients report more severe, frequent and
diffuse pain than male patients with similar processes of disease. The difference in male - female
pain perception decreases with age, was not found by all investigators and is usually only
moderately large. Social gender roles have a significant impact on pain tolerance levels, are
sometimes difficult to distinguish from the patient's sex, and may account for some of the
9
differences in gender pain tolerance. Coping strategies also affect pain tolerance of patients ;
disaster response is associated with increased sensitivity to experimental pain. Women are more
likely to be catastrophic, and this can help to account for the gender differences in pain tolerance.
Age
A recent systematic review found that young age was an important predictor of post-operative pain.
Ageing can affect the pharmacokinetics of analgesic medicines and older people are considered
more sensitive to systemic opioids. Likewise, there is a positive correlation between age and
thoracic epidural spread with older patients requiring approximately 40% less epidural solution.
Surgical Approach
Sternotomy
After a sternotomy, the sternum is usually fixed internally with steel wire. Therefore, bone
movement during respiration is minimal and usually only moderate post-operative pain. However,
wide or inexperienced sternal distraction can fracture the sternum, strain or even interfere with
anterior or posterior intercostal articulations with the potential to significantly increase
postoperative pain experienced.
Video-Assisted Thoracoscopic Surgery
Video-assisted thoracoscopic surgery The extent of the surgical incision is limited and early
postoperative pain can be reduced with video-assisted thoracoscopic surgery. These benefits can be
reduced by using larger-diameter instruments and/or twisting surgical instruments against the ribs
causing intercostal nerves to be injured and ribs to be bruised or even fractured. VATS is a type of
minimally invasive chest thoracic surgery performed with a thoracoscope (small videoscope) using
small incisions and special tools to minimize trauma. Other names for this procedure include
thoracoscopy, thoracoscopic surgery or pleuroscopy. Three small (about1-inch) incisions are used
during thoracoscopic surgery compared to one long 6-to8-inch chest incision used during
traditional, "open" thoracic surgery. These small incisions insert surgical instruments and the
thoracoscope.
As compared with traditional surgery, patients who undergo minimally invasive surgery
experience:
Decreased postoperative pain
Shorter hospital stay
More rapid recovery and return to work
10
Other possible benefits include reduced risk of infection and less bleeding.
Open Thoracotomy
Posterolateral Incision
Posterolateral incision is the classic thoracotomy approach as it provides good surgical access and
can be easily extended if necessary. However, it involves cutting some of the major muscles in the
chest wall and is considered to be one of the most painful surgical incisions. There is some
evidence that divided ribs are internally fixed to reduce post-operative pain.
Muscle-Sparing Incision
Many surgeons now use one or more of the many described muscle-sparing incisions. A popular
approach is the axillary muscle-sparing incision, the skin incision with obvious cosmetic
advantages extending vertically down from the axilla. Although muscle-sparing incisions initially
caused less perioperative pain, most studies did not find this reduction in peri-operative pain.
Anterior Incision
For certain cardiac and anterior mediastinal procedures, anterior incisions are used to provide
access. However, due to the heart, exposure to lung surgery is particularly limited on the left. With
this incision, rib resections are often performed to improve surgical access. Post-operative pain
depends in part on the extent of excision and the extent of surgical retraction, but after a
posterolateral thoracotomy it is similar to that. With this approach, intercostal nerve blocks are
particularly effective because the incision does not involve any part of the chest supplied by the
posterior skin nerves that originate from the dorsal rami and are not blocked by an intercostals
nerve block.(5)
1.3 Degree and duration of pain after thoracic surgery
The degree of pain following thoracic surgery is usually classified as "severe." Pain after
thoracotomy was described as one of the most severe postoperative pain modes, more than 70% of
patients needed analgesics after thoracotomy during the immediate postoperative period.
The incidence and duration of pain indicates that postoperative pain occurs more frequently and is
more severe following intrathoracic surgery (i.e. thoracotomy or sternotomy). The intensity of
steady wound pain after thoracotomy was severe in 45-65% of patients and moderate in 25-35% of
patients. Following sternotomy, steady wound pain in 60-70% of patients and moderate in 25-35%
of patients was severe. Movement that places tension on the incision, such as deep breathing,
coughing, or extensive body movements, increases pain intensity after intrathoracic operations. The
11
average duration of severe pain in this survey was 3 days after thoracotomy (range: 2-6 days) and 4
days after sternotomy (range 2-7 days).
The intercostal, vagus, and phrenic nerves convey noxious input associated with thoracic surgery to
the central nervous system. Afferent phrenic activity is believed to be the source of shoulder pain
that often accompanies thoracic procedures as phrenic but not suprascapular or epidural blockade
curtails this. Intercostal nerve dysfunction resulting from incision, retraction, trocar placement, or
suture is common and likely plays an important role in the thoracic surgery that accompanies pain.
Furthermore, the need for constant respiratory effort and an increased pulmonary toilet creates an
intense and relentless barrage of noxious input into the central nervous system. Initial reports
showed that 50% of patients describe pain 1 year after thoracotomy, with many reporting pain even
years later. Fortunately, if perioperative pain is handled aggressively, the prevalence of
postthoracotomy pain may be modifiable, with rates as low as 21% one year after surgery.
Surprisingly, video-assisted thoracic surgery (VATS) is associated with a prevalence of chronic
pain comparable to that of open procedures, with pain rates ranging from 22% to 63%, likely due
to intercostal nerve and muscle damage from insertion of trocars. Residual pain after surgery, on
the other hand, is reported to be 25% after median sternotomy, stressing the role reduced intercostal
nerve disruption and enhanced closure stability may contribute to chronic pain reduction. Several
demographic and clinical factors help identify patients who are predisposed to chronic post-
operative pain development. These include anxiety, depression, previous surgery, concurrent pain,
lesions of the chest wall, youth, female sex, and increased levels of pain and analgesic use in the
perioperative period.
1.4 Acute postthoracotomy pain
Severe acute pain after thoracotomy caused by retraction, resection, or fracture of ribs, dislocation
of costovertebral joints, injury of intercostal nerves, and further irritation of the pleura by chest
tubes is a normal response to all these insults .Acute pain after video-assisted thoracoscopic surgery
is considered less severe. Suboptimal management of pain after thoracotomy (or after video-
assisted thoracoscopic surgery in patients who have severely limited respiratory reserve) has major
respiratory consequences. Inspiration is limited by pain, which leads to reflex contraction of
expiratory muscles and consecutively to diaphragmatic dysfunction (decreased functional residual
capacity and atelectasis, shunting, and hypoxemia). Moreover, most patients are early extubated to
decrease the risk of pulmonary barotrauma (especially bronchial suture line "blowout") and to
prevent respiratory sequelae such as pulmonary infection. The incision needs to be stretched deep
breathing. Since this can be extremely painful, patients without adequate analgesia attempt to
12
prevent stretching of the skin incision by contracting their expiratory muscles, i.e. splinting, thereby
limiting the stretch during inspiration on the incision. This failure to inspire deeply before a
powerful exhalation leads to ineffective cough, which in turn promotes secretion retention, leading
to the closure of the airways and atelectasis
1.5Chronic postthoracotomy pain
Postthoracotomy pain syndrome (chronic postthoracotomy pain or post-thoracotomy
neuralgia, PTPS) is defined by the International Association for the Study of Pain as ‘‘pain that
recurs or persists along a thoracotomy incision at least two months following the surgical
procedure.’’ In general, it is burning and stabbing pain with dysesthesia and thus shares many
features of neuropathic pain . PTPS is acknowledged increasingly by anesthesiologists and
surgeons alike.(6)
Prevalence of post-thoracotomy pain
Chronic post-thoracotomy pain was commonly noted by surgeons during the Second World
War in men who had had a thoracotomy for chest trauma; it was called chronic intercostal pain.
Unfortunately, not much has changed since then, as the majority of patients do not seek help
for their pain, but mention it only when specifically asked. Furthermore, despite a commonly
held belief that post-thoracotomy pain is transient, there is no evidence that the pain experience
decreases significantly over time. For example, incidence of long-term post-thoracotomy pain
has been reported to be 80% at 3 months, 75% at 6 months, and 61% at one year after surgery;
incidence of severe pain is 3–5%, and pain that interferes with normal life is reported by about 50%
of patients .
Mechanism of postthoracotomy pain
There are several mechanisms for chronic pain after thoracotomy, and no consensus exists
regarding causality.
Intercostal nerve damage Surgery
The intercostal nerve is routinely crushed by surgery, especially as the nerve is quite exposed on the
rib's caudal side. When the chest is closed, it is also common for the nerve to be completely severed
or included in a suture. Mechanical damage during rib resection and compression with a retractor
are among the many possibilities of nerve injury. Incidental rib fractures may also immediately
damage the intercostal nerve or interfere with an in tercostal nerve during healing, resulting in
neuropathic pain symptoms. The sensation of pain in response to a normally non-painful stimulus
13
(allodynia) or an exaggerated response to a slightly painful stimulus (hyperalgesia), especially
when accompanied by numbness, is considered to be diagnostic for nerve injury. These symptoms
often occur along the intercostal nerves ' area of distribution / innervations and are the most
common feature of post-thoracotomy pain.(6)
Tumor Recurrence
Many studies showed that increased pain could also be an early tumor recurrence.
Type of incision
The amount of postoperative pain has correlated many surgical techniques. Even muscle - sparing
incisions appear to have no major advantage over posterolateral incisions Overall, subsequent pain
has not been shown to be reduced by variations in surgical techniques.( 4,5)
1.6 Pain management after thoracic surgery
1.6.1 Systemic analgesia
Systemic analgesia may be divided into systemic opioids, non steroidal anti-inflammatory drugs
(NSAIDs), paracetamol and ketamine. Opioids, NSAIDs, and ketamine can be delivered using
intravenous, intramuscular or subcutaneous routes. Patient controlled analgesia devices (PCA) can
be useful when administering intravenous opioids.
Combinations of NSAIDs and opioids or opioids and regional analgesia are also common.
Systemic opioids
Systemic opioids have been used as the cornerstone of postthoracotomy analgesia in the past;
however, pain control has often been poor. As part of a multimodal strategy including nerve blocks,
it is now appreciated that systemic opioids are best administered for open thoracotomies. Systemic
opioid titration after thoracotomy is required if the balance between beneficial effects and
detrimental effects (sedation and suppression of ventilation, coughing and sighing) is to be
achieved. IV-PCA systems provide superior analgesia and enhance patient satisfaction compared to
IM opioids. Partly because IV-PCA systems accommodate the multiple in post-operative opioid
requirement between patient variation, halving opioid requirements approximately every 24 h post-
operatively, and the small group of patients experiencing minimal post-operative pain.
14
NSAIDs
Analgesia is a cornerstone of postoperative therapy to reduce postoperative complications and stay
in the hospital, not only for ethical reasons. Postoperative pain remains an unresolved problem
despite all the advances in pharmacology therapy. Perioperative pain is a complex and multi-
factorial phenomenon that often needs to be effectively controlled by combining several drugs with
different mechanisms of action to mitigate the analgesic effects with each drug's synergism and
additive effect, thereby reducing related analgesic side effects. The best choice for treating
postoperative pain is a multimodal and multidrug approach. Different techniques and drugs are
used: central and peripheral nerve blocks, opioids, NSAIDs, paracetamol, local anaesthetics,
glucocorticoids and gabapentinoids. A single analgesic class is rarely adequate. The association is
often used because some drugs have certain limitations such as ceiling effect, high-dose
contraindication, respiratory insufficiency, liver damage, risk of upper gastrointestinal
complications or kidney failure. For postoperative pain treatment, the concept of multimodal
contest-sensitive analgesia is now well accepted. Different types of analgesics have been shown to
be more effective than a single drug due to different mechanisms of action and can be used at low
doses to reduce the incidence of side effects and to improve the quality of perceived analgesia.
Many pharmacological trademarks have therefore introduced associations of analgesic drugs such
as paracetamol plus tramadol, or codeine plus paracetamol and NSAIDs at a fixed dose whose
association increases the analgesic effect for the different analgesic mechanism postulated.
Non-steroidal anti-inflammatory drugs (NSAIDs) such as ketorolac provide pain relief by reducing
prostaglandin production through cyclooxygenase (COX) inhibition and can be administered as
adjuncts throughout the perioperative period, with their main benefit being effective pain relief
without breathing depression. In one study of patients undergoing thoracotomy, the simultaneous
use of NSAIDs reduced pain scores by about 60% and postoperative parenteral opioid consumption
by 30%. Numerous NSAIDs for the 2 COX types (I and II) are available with varying selectivity;
these can be administered perioperatively via oral or rectal routes. In particular, the convenience of
preparing for intravenous administration during the intraoperative and immediate postoperative
period resulted in ketorolac, a non-subtype selective COX inhibitor, being one of the most common
NSAIDs administered perioperatively. Due to the potential for side effects, low risk of
gastrointestinal bleeding, coagulopathy, acute kidney injury, and hypo perfusion should be
considered for patients considered for NSAID analgesia.
Paracetamol—NSAIDs
Paracetamol is classified as mild analgesic and not as NSAID because its anti-inflammatory activity
is weak. It is found that paracetamol in patients with thoracic epidural analgesia can decrease post-
15
thoracotomy ipsilateral shoulder pain when given preemptively and regularly during the first 48
hours postoperatively . The pain relief from NSAIDs is due to the inhibition of cyclooxygenase, an
enzyme that is involved in the production of prostaglandins, prostacyclins and thromboxans, which
are all involved in the generation of pain . The NSAIDs usually used for postoperative pain
management are diclofenac, ketorolac, lysine acetyl salicylate, indomethacin, piroxicam, and
tenoxicam. NSAIDs affect adversely the coagulation because they cause platelet dysfunction,
making systemic bleeding more possible. This effect is independent from the route of
administration. Among the others potential adverse effects, the renal dysfunction and the
gastrointestinal bleeding are the most important . The patients with pre-existing renal disease,
hypovolemia or treatment with loop-diuretics are more vulnerable to acute renal failure.
Intramuscular diclofenac 75 mg/12 h , rectally indomethacin 200 mg/24 h or continuous
intravenous lysine acetyl salicylate (7.2 g/24 h) decrease the required quantities of morphine and
the postoperative VAS scores. Indeed, the i.v. lysine acetyl salicylate was comparable with i.v.
infusion of morphine (40 mg/24 h).
Opioid
Opioids are widely used for intraoperative and postoperative pain management and are commonly
used for severe postoperative pain management. Opioids are versatile; delivery options for
perioperative delivery include delivery of infusion to oral, intravenous, intramuscular, and
neuraxial injection or catheter. When using an intravenous strategy, advanced days include quick
initiation and titration facility. In order to minimize over sedation, a patient-controlled analgesic
system can be programmed to deliver a baseline continuous infusion of a drug with patient-
delivered or patient-delivered doses alone. Patient satisfaction with this strategy rivals neuraxial
analgesia, although opioid side effects must be cared for by the perioperative care team.
It has been shown that epidural analgesia is superior to i.v. Morphine through devices for patient-
controlled analgesia (PCA). In addition, when used as sole agents, the doses of opioids required to
produce comparable analgesia also produce significant respiratory depression; therefore, opioids
are relegated mainly to adjuncts to a regional technique. The major drawback of opioids used for
postoperative pain treatment is the narrow therapeutic window, resulting in nausea, vomiting,
somnolence, or even moderate doses of respiratory depression. In addition, patients undergoing
chronic opioid therapy may develop tolerance to these drugs, making it more difficult to relieve
pain with their use.
In that case, the use of gabapentin may provide preventive analgesia, limiting the incidence in these
patients of Chronic Post - Operative Pain Syndrome. The i.v. combination Opioids and i.v. NSAID
16
With satisfactory anticoagulation and renal function safety, it has become popular. In addition there
are other regional alternatives that can be used in effective combination with the systemic use of
opioids, such as the intercostal, intrapleural, intraspinal and paravertebral blockade with the use of
local anesthetics.
Ketamine
Ketamine is a non-competitive antagonist which blocks the ion channel associated with NMDA
receptor. By this way the central hyperexcitability of dorsal horn neurons is blocked. The activation
of NMDA receptor plays an important role in post injury central sensitization and hyperalgesia,
suggesting that systemic ketamine may be used effectively in treating postoperative pain . After
thoracic surgery, i.m. administration of ketamine 1 mg/kg resulted in similar pain scores and in
weaker respiratory depression in comparison with i.m. pethidine 1 mg/kg . Ketamine is capable of
decreasing significantly immediate post-surgical pain after thoracotomy, but has no benefits in
preventing chronic pain measured in long-term follow up (post thoracotomy pain syndrome).
Intravenous administration of ketamine at induction dose 1 mg / kg, followed by infusion at
intraoperative dose 1 mg / kg /h and 1 mg / kg/24 h postoperatively improved immediate
postoperative pain, but failed to control chronic pain development at 1-2, 6 weeks and 4 months
after surgery. Similar results are generated from the addition of epidural ketamine (1.2 mg / h) to
levobupivacaine and fentanyl preventive epidural analgesia. No difference was observed between
the two groups in the incidence of chronic post-thoracotomy pain at 3 months .
Noxious inputs of pain cause prolonged firing of nociceptors of C-fibre resulting in glutamate
release. Glutamate is a major exciting transmitter in the central nervous system that activates
postsynaptic NMDA receptors that contribute to pain treatment and pain phenomena such as wind
up and neural plasticity of the spinal cord. Enhanced activation of the NMDA receptor plays a role
in inflammatory and neuropathic pain and results in secondary hyperalgesia activation and
exacerbation. Since ketamine blocks the NMDA receptors, its administration before the noxious
stimulus (thoracotomy) may prevent the central sensitization of pain (pre-emptive effect).
The clinical effect was better pain control as shown in the first 48 postoperative hours by lower
VAS scores in ketamine compared to placebo group. While VAS score was only measured at rest
and not at movement, ketamine also provided pain relief during chest wall mobilization in theory.
Ketamine compared with placebo group presented a lower trend of chest drainage duration and of
atelectasis that required bronchoscopic aspiration. In theory, the better control of pain during the
mobilization of chest wall allowed efficacious cough with a rapid re-expansion of the lung and an
early surgical recovery. Pre-operative administration of ketamine may be an effective adjunct to i.v.
17
Opioid analgesia in pain management with acute post-thoracotomy. Patients with ketamine
experienced a significant reduction in pain scores, inflammatory response and morphine intake
compared to placebo. Thus, the preventive administration of ketamine followed by i.v, in line with
a philosophy of multianalgesic treatments of post-thoracotomy pain. In situations where epidural
analgesia or other analgesic procedures differ from i.v., morphine analgesia may be clinically
relevant. Analgesia with opioids is not available or contraindicated.
1.6.2 Regional Anesthesia Techniques
In thoracic surgeries, regional anesthesia plays an important role. After thoracic surgery, severe
pain is common. Regional anesthesia results in better pain control, better stress response control,
and lower respiratory complications compared to systemic opioid analgesia. This will improve
overall patient outcomes.
Furthermore, chronic pain following thoracic surgery is common and may persist for several years,
this complication may be reduced by using regional analgesic techniques. Non-intubated surgery
with regional anesthesia has recently been reported for high-risk patients. There are several
techniques for thoracic surgery for regional anesthesia.
Regional anesthesia techniques for patients undergoing thoracic surgery can provide excellent pain
management. Because of their superior track record of pain control and improved results, both
thoracic epidural analgesia and paravertebral analgesia are often considered optimal modalities for
postthoracotomy analgesia. Other regional technologies, including but not limited to intrathecal
opioid analgesia, intercostal nerve block (ICNB), intercostal cryoanalgesia and intrapleural
analgesia, can help improve pain scores and reduce opioid use.(2)
Anatomy Crucial To Thoracic Surgery
Thoracic surgery involves several nerves. The intercostal nerve at the incision site and ribs is the
most important component in the skin and muscles. Damage to the intercostal nerve can lead to
chronic pain, and regional anesthesia should block nociceptive transmission through the intercostal
nerve. The vagus and phrenic nerves are associated with mediastinal and diaphragmatic pleura pain
stimuli, and after surgery the brachial plexus is associated with shoulder pain. Therefore,
multimodal analgesia with opioids and non-steroidal anti-inflammatory drugs (NSAIDs) should be
considered together with the use of regional analgesia techniques. The intercostal nerve runs
between the muscle and pleura of the internal intercostal. The intercostal nerve block (INB)
involves a distal approach to the intercostal nerve, whereas a more proximal approach is involved
in the thoracic paravertebral block (TPVB). TPVB provides multi-segmental intercostal nerve
18
blockade as well as sympathetic block; therefore, it is a good alternative for epidural analgesia for
thoracic surgeries.
The first choice of regional thoracic surgery anesthesia is epidural analgesia. Recently ultrasound-
guided TPVB is a good alternative when patients receiving anti-coagulant therapy or those with
bleeding tendencies are contraindicated with epidural analgesia. Although TPVB is safer for these
patients than epidural analgesia, care should be taken to select it. The intercostal nerve block or
interpleural block may be considered when these two blocks are contraindicated.
Thoracic Epidural Analgesia
A thoracic epidural injection is a shot that temporarily contributes to thoracic region pain relief.
That's the back's upper to middle. Medicine is injected into a spinal cord area. This area is referred
to as the epidural space. The spinal cord is a delicate bundle of nerves running from the lower back
to the brain. The spinal cord nerves enable the brain to communicate with the rest of the body. The
spinal cord is surrounded by the epidural space. The column of many small bones (vertebrae) is the
hard structure of the spine or backbone. The spinal column bones help protect the spinal cord
against injury. There are intervertebral disks between these bones. These disks are cushioning the
vertebrae. They also provide flexibility for the backbone. Nerves that leave the spinal cord may get
pinched or inflamed at times. For example, this could happen when part of an intervertebral disk
presses into the spinal cord and nerves space.
Indications
Thoracic epidural analgesia continues to be a key component of acute pain services based on
anesthesia and is used after thoracic surgery, abdominal surgery, and rib fractures to treat acute
pain. TEA is warranted when a thoracic or upper abdominal incision is expected to be moderate to
large. In fast-track surgery, TEA can also be a useful adjunct by optimizing pain relief, attenuating
the response of surgical stress, and allowing early mobility. TEA with local anesthetic is an
important component of colorectal fast-track procedures as it reduces postoperative ileus duration.
Provides a comprehensive list of open surgical procedures in which postoperative pain can be
treated with TEA. There is no unique TEA contraindication that is not applicable to all neuraxial
procedures. TEA is widely used thoracotomy analgesic technique. Inserting a thoracic epidural
before general anesthesia facilitates patient feedback on improper placement and allows evaluation
of its effectiveness. The insertion point is usually at the level of T5–T6 midway along the
dermatomic distribution of the incision thoracotomy. Due to the steep caudal angulation of the
spinous processes at this level, difficulties in locating the epidural space are often encountered;
19
therefore, some anaesthetists prefer a paramedic approach that avoids spinous processes. Because
of its proven record of excellent dynamic pain relief and prevention of postoperative pulmonary
complications, TEA has long been considered the gold standard regimen for patients undergoing
thoracic operations. Epidurals can be placed eitherpre-operatively or post-operatively, depending
on the size of the surgical incisions (VATS vs thoracotomy) and the patient's tolerance (opioid-
dependent vs naive). Although the timing of initiation of TEA remains controversial, it has been
shown that its continuous use for at least 48 hours postthoracotomy provides the benefits of optimal
pain control and improved results. Our typical practice is to keep epidurals in place until drains
from the chest tube are removed.
The shoulder pain reported by patients with thoracotomy is mostly referred to as pain, and epidural
analgesia does not cover it. Most surgeons would agree that shoulder pain is a major problem of
postoperative pain that deserves particular attention.
Shoulrer Pain
More than 75% of patients with thoracotomy report constant severe ache in the post-surgery
ipsilateral shoulder. This pain is relatively resistant to opioids intravenous and is only partially
relieved through NSAIDs. Postulated mechanisms include transection of a major bronchus,
ligamentous strain caused by malposition or surgical mobilization of the scapula, pleural irritation
caused by the thoracostomy tube, or referred pain caused by pericardial irritation or mediastinal and
diaphragmatic pleural surfaces. Several methods with varying results have been investigated. There
was no effective pain relief intrapleural bupivacaine. Superficial cervical plexus or brachial plexus
blocks in some patients effectively reduced localized shoulder pain, whereas suprascapular nerve
block was not helpful. Through intraoperative infiltration of the periphrenic fat pad with lidocaine,
the incidence of shoulder pain decreased from 85% to 33% and the overall pain scores decreased.
Ropivacaine reduced incidence by 0.2 percent and postoperatively delayed the onset of shoulder
pain for the first 24 hours without adverse effects on respiratory function. It appears that pain can
be referred to as the main source of shoulder pain via the phrenic nerve (blocked by periphrenic
infiltration and interscalene brachial plexus block) with a contribution from positioning and surgery
(coracoid impingement syndrome and coraco-clavicular ligament strain), partially relieved by the
use of NSAIDS) and acetoaminophen. However, pain was still reported by some patients who
received phrenic nerve infiltration. This may be due to anatomical variations in the emergence of
phrenic nerve sensory fibers, reaching the pleura's fibrous pericardium and parietal layers The most
effective management strategy would be multimodal, consisting of acetoaminophen (preventive and
20
regular), if not contraindicated NSAIDS, and long-acting local anesthetic infiltration of the phrenic
nerve.
Intercostal Nerve Blocks
Intercostal nerve blocks are simple to perform and useful for pain management either as the
primary intervention or as adjuncts. They are useful for pain in the chest wall and upper abdomen.
The intercostal nerves (ICNs) intimate the major parts of the skin and musculature of the chest and
abdominal wall. In the 1940s, clinicians noticed that intercostal nerve blocks (ICNBs) may reduce
pulmonary complications and opioid requirements after upper abdominal surgery. Continuous
ICNB was introduced in 1981 to overcome the issues associated with repeated multiple injections.
Today, ICNB is used in a variety of acute and chronic pain conditions that affect the thorax and
upper abdomen, including breast and chest wall surgery. In addition, it facilitates its practice by
introducing ultrasonic guidance to regional anesthesia practice.
Indications
Incisional pain from thoracic surgery
Analgesia for thoracostomy
Herpes zoster or post-herpetic neuralgia
Rib fractures
Breast surgery
Upper abdominal surgery
Differentiating between visceral and somatic pain
Contraindications
Patient refusal for the procedure and active infection over the injection site are the only absolute
contraindications. Other relative contraindications include local anesthetic allergy, prior nerve
injury or damage, patient's inability to consent to the procedure, anticoagulation or coagulopathy.
The expected results of the intercostal nerve block and relevant potential complications should be
advised to patients. If patients have prior nerve injury or neuromuscular disease involving the area
to be blocked, special consideration should also be given.
Equipment
Equipment includes:
Skin antiseptic
Sterile towels
Sterile gauze
21
50 cm 22 g needle for local anesthetic injection
25 g needle for skin wheal
Local anesthetic
Sterile gloves
Ultrasound machine
Marking pen
ECG monitor
Blood pressure monitor
Pulse oximetry
Generally, to maximize pain control, a long-acting local anesthetic such as 0.2% ropivacaine or
0.25% bupivacaine is chosen. It may be considered that continuous blocks with a nerve catheter are
rarely used for this particular nerve block. Because of the high degree of local anesthetic intake
from the intercostal space, local anesthetics can be considered and the maximum dosage allowed
should be calculated, especially if multiple levels are to be blocked.
Technique
Successful intercostal nerve block results in local anesthetic being deposited outside the parietal
pleura in the intercostal sulcus. Correct positioning will result in ipsilateral numbness of the
blocked individual intercostal levels. Unless a large amount of local anesthetic is injected or the
needle placed too close to the midline resulting in spread to the paravertebral space, it is rare for the
blockade to extend to higher or lower levels. The block level is usually determined by the number
of blocks performed and is restricted to the dermatome of the targeted intercostal nerves.
The spinal cord's nerves split into a dorsal ramus. The upper 11 ventral thoracic rami is the
intercostal nerve running between the ribs in the intercostal spaces. Each intercostal nerve provides
a lateral cutaneous branch that pierces proximal intercostal muscles to the rear axillary line to
provide the chest wall's lateral aspect. Therefore, to ensure that the lateral cutaneous branches are
blocked and thus the lateral aspect of the chest wall, it is important to block the intercostal nerves
posterior to the posterior axillary line. The thoracic dorsal rami passes backwards near the vertebrae
to provide the cutaneous innervation to the back. The dorsal rami is not blocked by an intercostal
nerve block. This limits the effectiveness with intercostal nerve blocks of posterolateral
thoracotomies. The intercostal nerves can be easily blocked under direct vision, while the chest is
open, but due to the relatively short half-life of most local anesthetics, repeated percutaneous
blocks are usually required. Although the position of intercostal nerves within the intercostal space
varies considerably, intercostal nerves consistently lie in a plane deep within the intercostal muscle.
22
A small (5 ml) bolus of local anesthetic deposited in the proper plane blocks the appropriate
intercostal nerve. Larger doses can also block adjacent intercostal nerves by spreading medially or
directly to adjacent spaces. The systemic take-up of local anesthetics from the highly vascular
intercostal space is rapid and the dose of local anesthetics administered by this route needs to be
adequately restricted. Intercostal nerve blocks significantly reduce the need for postoperative pain
and analgesic post-thoracotomy.
Complication
To avoid infection, care should be taken to perform this block using sterile technique. In order to
reduce the risk of bleeding, the history of coagulopathy or anticoagulation should be discussed.
Performing this block wake may alert the provider to pneumothorax or intraneural injection
symptoms that may go unnoticed in a patient with sedation or anesthesia. Pneumothorax is rare and
usually requires only monitoring, although providers should be prepared to decompress needles or
insert a chest tube if necessary. Fortunately, local anesthetic systemic toxicity is also a rare
occurrence. However, this region's local anesthetic take-up is high, and providers should be able to
recognize last and provide adequate treatment. Using diluted local anesthetic concentrations and
keeping the total dose below the maximum permitted dose will reduce the risk of systemic toxicity.
Several inadvertent spinal case reports were described after intercostal nerve block. This is thought
to be secondary to local anesthetic spreading through the dura medially, or to the rare occurrence of
injection into a dural sac described as protruding from the vertebral foramen laterally. In order to
try to exclude these complications, aspiration to exclude intravascular, intrapleural or intrathecal
injection should be performed before injection, but negative aspiration is not a guarantee. Patients
should be monitored for 20 to 30 minutes after the block has been removed.(7)(8)
Paravertebral blockade
Paravertebral blocks can be performed as so-called "single-shot" blocks, with the introduction of a
single dose of long-acting local anesthetic, or they can take the form of a continuous block, by
placing a catheter that allows local anesthetic infusion. Continuous thoracic paravertebral blocks
can provide excellent post-thoracotomy analgesia, and several studies have shown that analgesia is
comparable to that provided by thoracic epidurals but with fewer complications such as urinary
retention, hypotension, nausea, vomiting, and pruritis and less perioperative hemodynamic
instability.
The thoracic paravertebral space begins at T1 and extends caudally to T12.
23
PVBs can be performed in the cervical and lumbar regions but there is no direct communication
between adjacent levels in these areas. Most PVBs are therefore performed at the thoracic level.
The thoracic paravertebral space is wedge shaped in all three dimensions.
Medially: The bodies of the vertebrae, intervertebral discs, and intervertebral foraminae.
Anterolaterally: the parietal pleura and the innermost intercostal membrane.
Posteriorly: the transverse processes (TPs) of the thoracic vertebrae, heads of the ribs, and the
superior costotransverse ligament.
The paravertebral space contains spinal nerves, white and grey rami communicantes, the
sympathetic chain, intercostal vessels, and fat.
Indications
Paravertebral nerve blocks are indicated for surgical procedures requiring unilateral analgesia or
anesthesia. Common cases benefitting from unilateral paravertebral blocks are breast surgery,
thoracotomy, herniorrhaphy, open cholecystectomy, and open nephrectomy. Bilateral paravertebral
blocks can be a viable option for midline abdominal surgery. The clinician may consider thoracic
paravertebral blockade over thoracic epidural analgesia in patients for whom bilateral
sympathectomy and subsequent hypotension would be especially detrimental. For example, the use
of thoracic paravertebral blockade in a patient with severe aortic stenosis has been reported. In
another study, thoracic paravertebral blockade resulted in more stable hemodynamics and
equivalent analgesia when compared to thoracic epidural analgesia in thorocotomy patients.
However, because bilateral spread can occur , which may cause hemodynamic compromise similar
to epidural blockade. Another unique feature of thoracic paravertebral blockade compared with
thoracic epidural analgesia is the relative safety when performing these blocks on patients with a
marginal coagulation cascade. This does not mean, however, that thoracic paravertebral blockade
can be performed on patients with coagulopathy without caution. According to the American
Society of Regional Anesthesia and Pain Medicine’s evidence-based guidelines, in the patient
receiving antithrombotic or thrombolytic therapy, the exact same precautions should be taken when
placing thoracic paravertebral blockade as when placing an epidural. However, if bleeding occurs
in the thoracic paravertebral space, significant blood loss will be the likely complication rather than
epidural hematoma and neurologic deficit.
Methods Of Performing Paravertebral Blocks
Several approaches to access the paravertebral space are described, and they can be widely divided
into those performed preoperatively using landmark or ultrasound-guided techniques and those
24
performed intraoperatively under direct vision. The patient can be positioned either sitting or in the
lateral decubitus position when blocks are performed in the awake patient. The anesthetized patient
is usually positioned in the lateral decubitus position after anesthesia induction, with the side to be
blocked at the top. Blocks should generally be performed at the level of the intended incision(s)
described, due to the more caudal position of the ports, for thoracoscopic surgery, performing
blocks and inserting catheters at T5/6 for upper / middle lobe surgery and T6/7 for lower lobe
operation.
Ultrasound-Guided Methods
Percutaneous paravertebral thoracic blocks are technically easy to perform but have a failure rate of
up to 10 %. Using the guidance for ultrasound may result in lower failure rates. Ultrasound-guided
paravertebral thoracic blockade can be divided into in-plane techniques where the needle's long
axis is fully visualized as it traverses the ultrasound plane to the target and out - of-plane techniques
where the needle enters the skin away from the probe and across the scanning plane, allowing it to
be visualized only in its short axis. The approach can be either in the plane of transversal or sagittal.
The most frequently performed blocks described are using a linear ultrasound transducer and this is
reflected in the accompanying images. Some groups advocate using micro-convex array
transducers to enable deeper structures to be better imaged. For all techniques, correct identification
of landmarks is essential, although their appearance will vary depending on the transducer's
orientation. Published a detailed description of the para-vertebral space's ultrasonographic anatomy
and its adjacent tissues.(9),(16)
Open Methods
It has been shown that placing a paravertebral catheter through a percutaneous approach is
challenging and the catheter tip's eventual position is unpredictable. The position of paravertebral
catheters in cadavers was assessed with ultrasound guidance Only 60 percent of catheters were
positioned as intended. Twenty percent had passed into the pre tebral space before the vertebral
bodies, 15 percent had passed into the soft tissue after the vertebral bodies, and 5 percent had
passed into the epidural space. Thus, while catheters can be percutaneously placed in the
paravertebral space, it may be more appropriate for the surgeon to insert the catheter under direct
vision in the paravertebral space while the chest is open. Direct placement facilitates the catheter's
clear progression along the paravertebral space to create a narrow longitudinal pocket that can
block enough dermatomas to provide adequate analgesia.(10)
25
Advantages Of Thoracic Paravertebral Block
Technical
Simple and easy to learn
Safer and easier than thoracic epidural
Palpation of rib not necessary and scapula does not interfere with block
Safe to perform in sedated and ventilated patients
Catheter placement under direct vision during thoracic surgery is safe and accurate
Chest drain loss of local anesthetic is four times lower than that of interpleural block
Clinical
Single injection produces multi dermatomal ipsilateral somatic and sympathetic nerve block
Reliably blocks the posterior primary ramus
Abolishes cortical responses to thoracic dermatomal stimulation
Inhibits stress and pressor response to surgical stimuli
Maintains hemodynamic stability
Reduces opioid requirements
Low incidence of complication
Preserves bladder sensation
Preserves lower limb motor power
Promotes early mobilization
No additional nursing vigilance required
Complications
Complications of paravertebral nerve blocks may include the following:
Failed block
Hypotension
Vascular puncture
Pleural puncture
Pneumothorax
Intradural opioid analgesia
Intrathecal opioid administration can provide an excellent method of controlling acute
postoperative pain and is an attractive analgesic technique as the drug is directly injected into the
26
CSF, near the central nervous system structures where the opioid acts. The procedure is simple, fast
and the risk of technical complications or failure is relatively low. In the intradural route, a
lipophilic opioid such as fentanyl (20-40 μg) and/or a hydrophilic opioid such as morphine (100-
300 μg) are increasingly associated with opioids of different characteristics. In the form of a pre-
operative bolus with LA to ensure coverage during both the immediate (2-4 h) and the late (12-24
h) post-operative period. The association of a lipophilic opioid with bupivacaine or lidocaine leads
to a shortening of the block's onset and an improvement in intraoperative analgesia, as well as
during the first hours of the postoperative period without prolonging the engine block or extending
the discharge time, making it a good choice for outpatient surgery.
The use of intrathecal medicines in the treatment of acute pain, a maximum effective dose of
morphine has been recommended, the negative effects of which seem to exceed the beneficial
effects ; after doses > 300 μg, nausea and itching usually appear, as well as severe urinary retention,
and in studies of healthy volunteers, all of them with respiratory depression when doses exceeded
600 μg.
Pain Relief after Thoracic Surgery
Continuous thoracic paravertebral infusion of local anesthetics through a catheter placed under
direct thoracotomy vision is a safe, simple and effective method for post-thoracotomy analgesia.
Usually used in adults in conjunction with adjunct medicines (opioid or non-steroidal anti-
inflammatory medicines) to provide optimal pain relief after thoracotomy. Although additional
analgesics are required, there is a significant reduction in opioid requirements. A continuous
thoracic paravertebral infusion of local anesthetic together with adjunct medicines provides very
effective pain relief with few side effects. Pain relief is superior to placebo and patient-controlled
morphine intravenous and comparable to interpleural analgesia, lumbar epidural morphine, and
bupivacaine or bupivacaine fentanyl mixture thoracic epidural administration. Paravertebral
analgesia thoracic preserves better respiratory function and produces fewer side effects than
analgesia interpleural. There is also less frequency of hypotension and urinary retention than
thoracic epidural analgesia. Local anesthetic continuous thoracic paravertebral infusion provides
better control of pain after thoracotomy than an intermittent regimen of bolus. It reduces
postoperative decline in respiratory function, increases breathing mechanics recovery, and reduces
chronic postthoracotomy neuralgia generation. A balanced analgesic regimen, which includes
preoperative pain prophylaxis (opioid and non-steroidal anti-inflammatory drug premedication with
pre-incisional TPVB) in conjunction with postoperative paravertebral thoracic infusion of
bupivacaine, regular nonsteroidal anti-inflammatory drug and opioid on-demand, is very effective
27
in patients with thoracotomy. It prevents postoperative plasma cortisol increase preserves
preoperative respiratory function, and is superior to a balanced analgesic regimen with thoracic
epidural bupivacaine. (11),(19)
Infiltration Of Surgical Wound With Local Anesthestics
Now an integral part of modern anesthetic practice is effective postoperative pain management.
Management of postoperative pain not only minimizes patient suffering, but can also reduce
cardiorespiratory morbidity and facilitate rapid recovery. Early hospital discharge has a beneficial
effect on the costs of hospitals. While regional anesthetic techniques such as epidural analgesia or
perineural catheters have been shown to provide excellent analgesia, many of these analgesic
methods are time-consuming, expensive, and not without side effects. Since a significant proportion
of surgical pain is caused by the surgical wound, it would appear logical to use local anaesthetics at
the surgery site to manage perioperative pain. Local anesthetic has been used for many years for
simple incisional infiltration. Promising advances that may help improve this technique are the use
of longer-acting local anesthetic agents or placing a catheter directly in the wound at the end of the
procedure to infuse local anesthetic.(10)(21)(25)
Methods of local anaesthetic infiltration
Incisional infiltration perioperatively
In recent years, an important component of multimodal analgesia has been the infiltration of local
anesthetic around the surgical wound. It offers simplicity and low cost advantages. However, it has
one major drawback: analgesia duration is limited to local anesthetic action duration. For
bupivacaine and ropivacaine, this tends to be 4–8 h. The procedures in which incisional infiltration
appears to be particularly helpful1 are those in which there is a smaller component of visceral pain,
such as inguinal herniotomies in which pain scores were reduced for up to 24 hours and pain
consumption decreased overall. Following minor day surgery, local anesthetic infiltration has been
shown to reduce postoperative nausea and vomiting by reducing opioid requirements.(26)
Continuous Local Anaesthetic Wound Infiltration
The short-term problem of analgesia associated with incisional infiltration can be overcome by
providing a continuous infusion of a local anesthetic. The surgeon places a catheter directly in the
wound at the end of the surgical procedure. This is then attached to a pump that allows the infusion
of a predetermined amount of local anesthetic into the wound per hour.
28
Table1 Comparison of The Different Methods of Local Anaesthetic Infiltration
Local anaesthetic
infiltration method
Advantages Disadvantages
Single dose Simple
low cost; very useful for
small procedures
Limited efficacy; short duration of action;
potential for adverse local toxic effects
Continuous infusion
catheter
Prolonged provision of
analgesia; less PONV as
opioid sparing; no motor
block; decreases hospital stay
Needs skills and resources; catheter
dislodges easily; wound site leakage and
potential for infection; technical failure of
pumps; potential for adverse local toxic
effects
Tumescent Simple; low cost; improved
analgesia and prolong
duration; allows larger dose.
Limited to selected types of surgery;
potential for systemic local anaesthetic
toxicity if poor technique or very large
doses
Sustained release LA Simple to administer;
prolonged provision of
analgesia
Not commercially available (currently
phase 1–3 drug trials); delayed onset of
analgesia; unsteady levels in
experimental formulations;
unnecessarily long duration in some
formulations
Infiltration of local anesthetic at the site of surgical incision offers a rational approach to
perioperative analgesia. Unfortunately, due to the unfavorable pharmacokinetics of local
anesthetics, this technique is limited by a short duration of action. However, the idea of incisional
infiltration has been further developed and newer techniques such as continuous local anesthetic
wound infiltration systems, tumescent techniques, and sustained release local anesthetics have been
developed.There remain more details to be learnt with regard to these techniques, particularly in
relation to optimal dosing regimens, optimal placement, use of analgesic adjuvant, and whether
local toxic effects are more than a theoretical concern. However, given the relative simplicity and
potential efficacy of these techniques, they are certainly worthy of consideration and continued
investigation to define their role as a technique for perioperative analgesia.(10)(33)
29
Patient controlled analgesia (PCA)
PCA can approach the near optimal state of analgesia, maintained with minimum sedation and side
effects. The patient adjusts the repetition of dose to the analgesic needs, outreaching the minimum
effective analgesic concentration. Toxic drug concentrations cannot be reached because the
subsequent sedation acts prophylactically by stopping the dose repetition from the patient.
PCA can be used for drug delivery via intravenous (most frequently) or epidural route. PCA is not a
good analgesic alternative if the patient is confused and not capable of using the PCA pump
handset. Before the initiation of PCA use, a sufficient analgesic state should be established.
In the case of epidural PCA, a solution of L-bupivacaine 0.125 with fentanyl 4 mcg/mL gives
satisfactory analgesia. The bolus dose should be 3-5 mL, the lockout period 10-15 min with no
background continuous infusion. If the latter is the case, then the bolus dose should be decreased
and the lockout period increased!
If PCA is used for intravenous drug administration, it is commonly combined with paravertebral or
intercostal nerve blocks. Otherwise, the systemic opioids side effects may limit the dosage,
resulting in suboptimal analgesia with subsequent respiratory complications in thoracotomy
patients. The bolus doses could be morphine 1-2 mg, fentanyl 10-20 mg, pethidine 10 mg or
tramadol 10 mg. The lockout time should not be less than 5-8 min according to the above doses.
The background infusion may increase the incidence of respiratory depression and is useful only in
opioid tolerant patients.(26)(34)(35)
The major concern with the function of PCA is the respiratory depression. The risk is increased if
there is a background infusion, in elderly patients, if concomitant sedatives are administered, in
respiratory disease, in obstructive sleep apnea, and if there are operator or equipment errors. The
administration of bolus naloxone 400 mg i.v. or more reverses the respiratory depression, and
perhaps continuous naloxone infusion may be required, due to its shorter half life.
One of the most commonly used means of delivering opioid analgesics after major abdominal
surgery is patient-controlled analgesia (PCA). Using this reliable, programmable delivery system, a
variety of narcotic drugs including morphine, hydromorphone, meperidine, and fentanyl can be
self-administered. For several variables, including demand (bolus) dose, lockout interval, and
background infusion a PCA device can be programmed.(30)
Preemptive analgesia and thoracotomy
Some of the allodynia and hyperalgesia development mechanisms are well known. The concept of
sensitization has resulted in increased efforts to control acute pain through a more or less total
afferent blockade, with the aim of reducing post-thoracotomy pain development. Preventive
30
analgesia is intended to prevent incisional and inflammatory injuries from establishing central
sensitization. Basic research has shown that analgesic drugs are more effective if they are given a
noxious stimulus before, rather than after. Some clinical studies using local anesthetics, opioids,
and non-steroidal anti-inflammatory drugs have supported the benefit of preventive analgesia.
However, the clinical utility of preventive analgesia remained controversial, probably due in part to
the wide variation in conditions of study such as surgery, drugs, doses, routes of administration and
duration of treatment. It has also been shown that the degree of acute pain following thoracic
surgery predicts long-term post-thoracotomy pain, and therefore aggressive early post-operative
pain management may reduce the likelihood of long-term post-thoracotomy pain. A good analgesic
regime in the immediate perioperative period not only reduces pulmonary complications, but also
helps in early mobilization. A thoracic epidural is the most common technique for pain relief, with
the catheter in the mid-thoracic region having a continuous infusion of local anesthetics and
narcotics.(27)
2.ORGANISATION AND METHODOLOGY OF A RESEARCH
For this research, the literature search was conducted in the Pubmed, Science Direct, PLOS,
SAGE, Google Scholar databases and 35 literature sources were reviewed. Studies published in
English between 2009–2019 have been reviewed.
3.RESULTS
3.1Case study
49 years old white male was admitted to the Clinic of Cardiothoracic and Vascular surgery due to
rib fracture and haemothorax after trauma (trauma was 2 days ago). He was transferred from
emergency room after drainage of pleurae. He has history of allergy to pollen (hay fever), and had
appendectomy 5 years ago, otherwise healthy.
On admission to Department of Thoracic Surgery the patient complains for severe pain on the right
side of the chest due to trauma and drainage. Examinations shows the patient is conscious and
adequate to his status. Breathing is compromised by pain – BR – 25 x/min., inhalations are shallow.
The right side of the chest is painful to palpation, crepitation at the site of the ribs VIII-XI is felt.
HR – 90 x/min. ABP – 130/60 mmHg. According to VAS the pain intensity is 5–6 score at rest and
7–8 at movement.
The drainage is effective. The control chest x-ray shows better aeration of the right lung, no fluid in
right pleura. For pain management analgesic medications are prescribed as follows:
1. Paracetamol 1 g 4 x/ day
2. Tramadol 100 mg 2x/day
31
On the second to fourth day the patient feels better, the pain intensity according to VAS decrease to
from 3–4 score to no pain at rest and from 4–5 to 2–3 score at movement. The secretion from chest
drainage is decreasing. On the 8th
day the drainage is removed and patient is discharged from the
hospital in good physical status on the day 10th.
Three days after discharge patient returned back to the hospital due to the fever (38, 5 C) and
chills, shortness of breath. Laboratory exams show leucocytosis and increased CRP (leuk 10,62x
109/ l, CRP 138, 68 mg/l). The punction of pleura was performed and 700 ml of serohaemoragic
fluid was received. But the chest x- ray shows fluid still remaining in right pleura. It is decided to
perform chest CT in suspicion of organised and infected haemothorax. CT scan approves the
suspicion and the patient is scheduled for the right thoracotomy and evacuation of haemothorax.
On the morning of the surgery after written approval of the patient anaesthesiologist insert thoracic
epidural catheter into the epidural space at the level of Th5-6. After the test (Sol. Lidocaine 2 % – 8
ml) to verify the localisation of the catheter the standard general anaesthesia is induced. For
induction patient receive fentanyl, propofol and rocuronium. After induction patient is intubated
with left endobronchial double lumen tube N. 39. The localisation of the tube is verified with
fiberoptic bronchoscope. During the surgery anaesthesia is maintained with sevoflurane for
hypnotic sleep and analgesia is ensured by epidural anaesthesia (Sol. Bupivacaine 0,5 % 20 ml +
0,2 mg fentanyl + Sol. Na Cl 0,9 % up to 40 ml, continuous infusion at the rate of 6 ml/hour). At
the end of the surgery wound infiltration with lidocaine and bupivacaine mixture (2 % lidocaine 4
ml + 0,5 % bupivacaine 4 ml) was performed. After the surgery the patient is extubated in the OR
and conscious though under light sedation, breathing spontaneously oxygen via face mask is
transferred to ICU.
After admission to ICU pain according to VAS the pain at rest was 0–1, at movement – 2–3 score.
Analgesia is maintained by TEA continuous infusion 0,25 % bupivacaine 6 ml/hour. But on the
third to fourth hours after the surgery the patient complained for the pain in his right shoulder (VAS
– 4–5 score). For analgesia ketorolac 100 mg i/v was prescribed. The pain decreased to VAS 1–2.
Anyway after two more hours the pain in the thoracotomy region increased. TEA infusion rate was
increased to 7 ml/hour and fentanyl 0,1 mg was added to analgesic solution, but analgesia was
ineffective. It was decided that the epidural catheter was dislocated and it was removed. Systemic
analgesia i/v was prescribed. As the pain at rest was VAS 6–8 score and at movement 8 score,
continuous i/v infusion of morphine was administered (sol. Morphine 20 mg/ 20 ml, the rate on
infusion 2 ml/hour) as well as NSAIDs were prescribed as follows:
1. Ketonali 100 mg 3x/day
2. Diclophenaci 75 mg 2x/ day
32
3. Paracetamoli 1 g 4x/day.
Systemic analgesia was effective, on the next hour and later on the pain score was ≤ 1–2 score at
rest and ≤ 2–3 score at movement.
4. DISCUSSION OF THE RESULTS
Thoracic surgical procedures can be either thoracotomy or thoracoscopy. In thoracotomy, the
incision could be either muscle-cutting or muscle-sparing incision. The posterolateral thoracotomy
incision is used for most general thoracic surgical procedures. This incision, which involves
division of the latissimus dorsi and serratus anterior muscles, affords excellent exposure of the
thoracic cavity. However, it is associated with significant morbidity, including impaired pulmonary
function, postoperative chest pain, and restricted arm and shoulder movement. Various muscle-
sparing incisions have been proposed to decrease the morbidity. Postthoracotomy pain originates
from pleural and muscular damage, costovertebral joint disruption, and intercostal nerve damage
during surgery. Inadequate pain relief after surgery affects the quality of patient's recovery and
exposes the patients to postoperative morbidities. There is a tendency nowadays among thoracic
surgeons and anesthesiologists toward the area of enhanced recovery after thoracic surgery which
requires careful titration of the anesthetic drugs in awake patients undergoing thoracoscopic
procedures. There is a common feeling among thoracic anesthesiologists that postthoracoscopy
procedures produce less pain intensity versus thoracotomy which is partially true. However,
effective management of acute pain following either thoracotomy/thoracoscopy is needed and may
prevent these complications and reduce the likelihood of developing chronic pain. Adequate pain
relief leads to early mobilization, improves respiratory functions, and decreases global stress
response. Thus, good perioperative pain management significantly reduces postoperative
complications. Currently, numerous analgesic methods are available for the management of acute
postthoracotomy/thoracoscopy pain including patient controlled analgesia, infiltration with local
anesthetic (LA), intrapleural or intercostal nerve blockades, and neuraxial blocks. In this report, we
review the newly introduced postthoracotomy/thoracoscopy pain relief modalities with special
reference to the new tendency of awake thoracic surgical procedures and its impact on enhanced
recovery after surgery. (28)
In thoracic surgery, postoperative analgesia is important to prevent respiratory problems and
chronic pain. Sensory afferent nerves involved at the sites of pain following thoracotomy are
carried by intercostal nerves (T4-T6) at the incision site, intercostal nerves (T7-T8) at the sites of
thoracic drains, the vagus nerve in the mediastinal pleura, the phrenic nerve (C3-C5) at the central
diaphragmatic pleura, and the brachial plexus at the ipsilateral shoulder.
33
Epidural analgesia is accepted as the gold standard for thoracotomy pain. The paravertebral block is
another option to be used for analgesia. This provides a level of analgesia similar to the epidural
block and have a lower rate of side effects . Analgesia could be provided using a multi-level ICNB
through the administration of local analgesics through intra/extrapleural catheters. ICNB and IV
routes could also be used in the management of thoracotomy pain . For thoracotomy pain, a wide
space should be blocked and long-term analgesia should be required. In ICNB, a limited space is
blocked by a single injection. Therefore, the use of ICNB is limited due to the necessity of multiple
injections and the requirement of frequent repeats of these blocks. On the other hand, drugs that are
administered solely intravenously are effective in pain control, but higher doses of opioids are
needed to relieve the pain that is aggravated with coughing and respiration . The side effects of
thoracic epidural injections such as neuraxial hematomas, hypotension, vomiting, and urinary
retention are higher in frequency compared to the paravertebral block . Nevertheless, the
paravertebral block also has complications (such as total spinal block, pneumothorax, and neural
damage) which are reported in between 2.6% and 5.7% of cases .
In many surgical procedures, pain is often treated inadequately. Acute postoperative pain can have
detrimental effects on multiple organ systems, such as cardiovascular stress, autonomic
hyperactivity, tissue breakdown (catabolism with anabolic hormone suppression), increased
metabolic rate, pulmonary dysfunction (most significant after upper abdominal and thoracic
surgery), increased blood clotting (hypercoagulability), fluid retention, immune system
dysfunction, delayed bowel function (ileus) and chronic pain syndrome development following
certain surgeries (phantom limb pain following amputation, post-thoracotomy syndrome)
Preventive analgesia may have a potential role in reducing postoperative pain, as shown in animal
post-injury pain reduction, but human studies have produced controversial results. It has been
shown that epidural, intravenous and intramuscular opioids reduce the severity of postoperative
pain when given prior to surgical stimulation.
There are several studies in which the preventive effect of TEA was used to reduce post-
thoracotomy pain, but in only one, preventive thoracic analgesia was suggested to decrease pain
intensity for 2 or 3 days ; Before surgery, an epidural block of mepivacaine reduced long-term post-
thoracotomy pain. This study compared the effects of TEA pre- and postoperative initiation and
found a significant clinical effectiveness of preventive analgesia for the first 72 h.
In contrast, in post-thoracotomy pain, some studies found no preventive effect of epidural
anesthesia. Preventive effect in thoracotomy of thoracic epidural bupivacaine. They gave
bupivacaine of 8 mL of 0.5% containing 5 μg mL−1 of adrenaline through an extradural thoracic
catheter 30 min before incision and maintained anesthesia with propofol, alfentanil, and atracurium
infusions. In comparison with the placebo group after thoracotomy, thoracic epidural block with
34
bupivacaine did not have a significant preventive effect. Preoperative administration of bupivacaine
plus fentanyl has a marked preventive effect and reduces post-thoracotomy pain significantly for
postoperative 12 hours.
PCEA can provide several advantages over conventional continuous epidural infusion or bolus
techniques. After thoracotomy, use of PCEA with bupivacaine and fentanyl provided good
analgesia. Previous studies also showed effective postoperative analgesia with continuous infusions
of bupivacaine and morphine, bupivacaine and fentanyl, bupivacaine and sufentanil and epidural
boluses.
Post-Thoracotomy Pain Assessment
It has been suggested that'' making the pain visible'' is the key issue of postoperative pain
management strategies. This can be done through accurate documentation of pain assessment, as
well as monitoring the effectiveness of pain treatment, and the documentation should also include
the satisfaction of the patient. The American Pain Society emphasizes that pain should be
considered by health care professionals as the fifth vital sign. The pain of the patient should
therefore be evaluated at least as frequently as vital signs are taken. Many suggested evaluation
tools were found in the literature and many scales were developed to help the nurse determine the
severity of pain. The Numeric Rating Scale (NRS) and the Visual Analog Scale (VAS) are among
the most com-monly suggested standardized tools.
When using the NRS, the patient is asked to rate their pain intensity to 10 (the worst possible pain)
on a scale of 0 (no pain). The VAS is a 100 mm long horizontal line anchored at each end by word
descriptors. The patient marks the point of his current state on the line. The VAS score is
determined from the left hand end to the marks of the patient by measuring in millime-tres.
When assessing postoperative pain, the nurse must pay attention to the following:
Assess pain both at rest and on movement
Take patient self-reporting pain into account and implement the appropriate pain scale,
document intensity, quality, location, timing & duration, aggravating and alleviating factors,
and prior pain treatments and their efficacy.
Evaluation of pain before and after each treatment procedure.
On the surgical ward, regularly evaluate, treat and re-evaluatepain and patient response (e.g.
every 4-8 hours).
Defines the maximum score of pain above which pain relief is available.
Report the results to the pain management team.
Despite the focus on meeting postoperative pain management standards, there is an
overwhelming lack of patient reassessment by nurses after analgesic administration.
35
CONCLUSIONS
After surgery, pain control is central to the anesthetic management of thoracic surgical patients.
The provision of good postoperative analgesia is important in itself and is regarded by some as the
core business of anesthesia and a fundamental human right. Effective analgesia can reduce
pulmonary complications and mortality. It is unlikely that a single technique will fulfill these goals
optimally for all patients and that a balanced, multimodal approach should therefore be used.
Analgesia should be tailored to the specific patient undergoing a specific procedure to minimize
mortality, patient suffering, complications of the pulmonary system, and other morbidity.
Experience with a wide range of analgesic techniques is helpful as it allows a suitable technique to
be implemented. For open thoracotomies, a combination of regional analgesia and opioids,
sometimes supplemented with non-opioid analgesics, will best manage most patients. Usually only
consideration should be given to lumbar epidural analgesia, intrathecal opioids, or intercostal nerve
blocks if no thoracic epidural analgesia or paravertebral blocks are possible. Currently the choice
between thoracic epidural analgesia and paravertebral block is the dilemma for thoracic anesthetists
and their patients scheduled to undergo thoracotomy. Thoracic epidurals have been well established
to produce excellent post-thoracotomy analgesia. However, thoracic epidurals are associated with a
risk of permanent injury and epidural hematomas are the most common disabling complications. It
has been shown that paravertebral blocks and infusions produce equivalent analgesia but with a
preferred profile of side effects. An increasing number of patients presenting for thoracic surgery
are receiving, not all of which are prescribed, drugs that affect coagulation. Current medication for
anticoagulants and antiplatelets increases the risk of an unquantified amount of epidural. Impaired
coagulation is less of a contraindication to paravertebral thoracics, especially when inserted under
direct vision. Serious complications with paravertebrals are rare, and thus paravertebral blocks are
increasing in popularity as "single shots" and catheters allow continuous infusion. In the future, the
development of clinically useable ultra-long-acting local anesthetics could allow significant further
advances in post-thoracotomy analgesia provision.(5)
Acute postoperative pain management for patients with thoracotomy remains a challenging task for
the anesthesiologist and the pain service involved, but the picture has become somewhat clearer
over the past 5 years and several strategies have emerged to provide beneficial effects to patients.
Multimodal treatment of pain using paravertebral nerve blocks or thoracic epidural catheters
,appears to be the most promising approach to adequate post-operative pain control and possibly to
reduce the risk of persistent post-thoracotomy pain development. Thoracic epidural catheters,
which have long been considered the gold standard, do not seem to provide superior pain relief. It
should, however, not be forgotten that these patients do benefit from a multimodal analgesic
36
approach involving nonopioid analgesics, to support the regional technique and to cover the
extraordinary high incidence of unpleasant post-thoracotomy shoulder pain.
The coexisting medical diseases that the patient has the poor baseline pulmonary function that
exists for which the surgery is needed, the invasiveness of the surgical procedure and the anesthetic
technique may contribute to the type and severity of post-operative pulmonary problems.
Acute pain from postthoracotomy is usually severe, may require high doses of opioids, and
may last for several days. When the patient moves or coughs, postthoracotomy pain is
particularly severe.
I.v. diclofenac and ketorolac improved analgesia and significantly reduced morphine
consumption after thoracotomy. They were safe with regard to both haemostasis and renal
function. However, NSAIDs should be used cautiously in patients who are at high risk of
developing renal problems during surgery. Special attention should be paid to fluid balance
and urine output. None of the three local anaesthetic techniques, i.e. intercostal, epidural or
paravertebral, provided good pain relief after thoracotomy. The required PCA-doses of
morphine were high and respiratory depression occurred in one-third of the patients.
A major problem is chronic post-thoracotomy pain. After surgery, it is equally common for
benign and malignant diseases with an incidence of 50 %. Chronic thoracotomy pain is
associated with higher intake of NSAIDs during the first five postoperative days, i.e.
patients who experience more pain during the first week following surgery are at higher risk
of developing a post-thoracotomy pain syndrome than other patients. More studies on
epidemiology and chronic post-thoracotomy pain treatment are needed.
PRACTICAL RECOMMENDATIONS
Most clinical studies reporting acute pain after surgery focus on the in hospital acute phase, and at
home there are limited data on the sub-acute phase. This phase is important because central
sensitization continues to stop persistent pain predisposing the patient. This study presents
information on the intensity of acute postoperative pain, the occurrence of chronic post-
thoracotomy pain as well as the pain experienced during the first week after being discharged from
hospital. Top revent persistent post-thoracotomy pain, extended protocol for high-quality pain
managers t in hospital covering also the sub-acute phase at home, is important.
The health care professional should always believe in evaluating the patient's own pain. Pain is best
treated before a severe level is reached. Routine frequent pain assessments can detect this, and not
rely on vital signs to determine its severity. Use of intravenous drugs to treat acute POP and avoid
intramuscular drugs.
37
Acute POP should be treated as the initial choice of analgesic with opioids and should be
administered on a scheduled basis rather than as required. It is different from addiction to physical
dependence. Addiction is a psychological problem in the first place and is extremely rare. Less than
1% of patients are addicted. Anxiety and drug-seeking behavior can occur in patients with
continued pain.
Once the pain is relieved, these behaviors disappear. Patients who have regularly used opioids for
about 7 days or more are considered tolerant of opioids and will require higher doses for acute POP
control. For opioid analgesia, there is no maximum or ceiling dose. Naloxone administration should
be used only in emergency situations and for patients who are unresponsive. To change from one
opioid to another or from one route of administration to another, it is advisable to use
equianalgesics. In a patient with severe pain, side effects of opioids should be managed rather than
discontinued using analgesics. Commitment to the ethical issues of POP patient care.
These include: ensuring the personal privacy of patients, respecting their belief system, addressing
their needs, believing them when reporting pain, providing timely and appropriate pain relief
interventions.(11)
To reduce the experience of pain, nurses administer analgesics to patients. The knowledge of
pharmacology, including the dose of the drug, the duration of its analgesic effect, and its
pharmacokinetics, is of great importance to nurses. Then the appropriate drug delivery route (per
oral, IV, IM, etc.) is chosen according to the needs of the patient. The pain relief effectiveness is
monitored after 15 to 30 minutes and at intervals of 1 to 2 hours.
The degree and duration of pain relief should be documented and all necessary information should
be recorded in the patient file. A new analgesic is administered in the event that analgesic
medication does not relieve the pain of patients.
Nurses must continue to monitor the side effects of the patient and be prepared to tackle these
problems. Psychological support for patients is important pre-operatively as it could potentially
threaten the expected result.
When the patient it transferred from the operating room to the Intensive Care Unit, and if no major
complication occurs (bleeding or respiratory failure), recovery begins .
Patient age and gender are also important.
Special attention should be given to the dose of analgesia to older patients as pre-existing
complications such as renal failure can lead to additional problems. Research suggests that women
need higher doses of analgesics compared to men.
38
Clinical pain evaluation
In evaluating post-operative pain, health professionals (medical and nursing staff) should evaluate
the condition of the patient at regular intervals, according to the recommendations of the” American
Society of Pain-2006”. The assessment should be conducted during rest and movement periods
using specific pain assessment tools.
If patient pain complaints after a therapeutic intervention, the pain level should be reassessed and a
detailed record should be obtained. Through continuous patient care, nurses play an important role
in ensuring a thorough evaluation using the available evaluation tools to achieve post-operative
pain relief.
Post-operative pain assessment aims at creating a personalized patient care plan and then taking
specific steps to address and ultimately relieve the present symptom. Medical and nursing staff use
care planning collectively. Clinical pain assessment begins with an understanding of the condition
as an unpleasant experience of the patient.
Furthermore, it is necessary to determine the characteristics of pain if it is acute, chronic or
intermittent and its intensity, i.e. mild, moderate, severe or very serious. If the patient experiences
pain in different parts of the body, they must be ranked by the nurse in order to be treated with
priority. Psychological condition of the patient and/or other medicines and substances is an
important factor. Despite advances in nursing science, effective new medicines and the use of
innovative postoperative analgesic methods, pain remains a challenge for nurses. Recent research
has shown that over 50% of patients report severe pain and inadequate postoperative pain
management.
To reduce and manage postoperative pain, many preoperative, intraoperative and
postoperative interventions and management strategies are currently available.
Optimal management begins with the preoperative evaluation of patients and the
development of a care plan specific to each patient and procedure.
In multimodal treatment, due to the different adverse effect profile for each analgesic
medication or technique used, appropriate monitoring is required to identify and manage
adverse events.
Patient, setting, and surgical procedure should be tailored to specific components of
effective multimodal care (strong recommendation; low-quality evidence).
Multimodal treatment should include use of around-the-clock acetaminophen and/or
NSAIDs for adults and children without contraindications (strong recommendation; high-
quality evidence).
39
In patients who can tolerate oral administration, oral opioids are preferred to IV opioids
because the effectiveness of IV is not superior to oral. Since postoperative pain is often
initially continuous, it often requires the first 24 hours of dosing around the clock.
In the immediate postoperative period, long-acting oral opioids are generally not
recommended. Analgesics should not be administered intramuscularly due to the fact that
intramuscular administration can cause significant pain, absorption is unreliable, and there
are no clear benefits to other routes of administration.
40
PUBLICATIONS
Annamma Joy Jossy , Švagždienė Milda.Pain control after thoracic surgery .In 2019 the
abstract was accepted for the oral presentation.
41
LIST OF LITERATURE SOURCES
1. Mesbah A, Yeung J, Gao F. Pain after thoracotomy. BJA Educ [Internet]. 2016;16(1):1–7.
Available from: http://dx.doi.org/10.1093/bjaceaccp/mkv005
2. Elmore B, Nguyen V, Blank R, Yount K, Lau C. Pain Management Following Thoracic
Surgery. Thorac Surg Clin [Internet]. 2015;25(4):393–409. Available from:
http://dx.doi.org/10.1016/j.thorsurg.2015.07.005
3. Tiippana E, Nilsson E, Kalso E. Post-thoracotomy pain after thoracic epidural analgesia: A
prospective follow-up study. Acta Anaesthesiol Scand. 2003;47(4):433–8.
4. Bottiger BA, Esper SA, Stafford-Smith M. Pain management strategies for thoracotomy and
thoracic pain syndromes. Semin Cardiothorac Vasc Anesth. 2014;18(1):45–56.
5. Pennefather SH, Quarterman CP, Klinger RY, Kanellakos GW. Principles and Practice of
Anesthesia for Thoracic Surgery [Internet]. 2011. Available from:
http://link.springer.com/10.1007/978-1-4419-0184-2
6. Gerner P. Postthoracotomy Pain Management Problems. Anesthesiol Clin. 2008;26(2):355–
67.
7. Hutchins J, Sanchez J, Andrade R, Podgaetz E, Wang Q, Sikka R. Ultrasound-Guided
Paravertebral Catheter Versus Intercostal Blocks for Postoperative Pain Control in Video-
Assisted Thoracoscopic Surgery: A Prospective Randomized Trial. J Cardiothorac Vasc
Anesth [Internet]. 2017 Apr;31(2):458–63. Available from:
http://dx.doi.org/10.1053/j.jvca.2016.08.010
8. Sparks A, Stewart JR. Review of Pain Management in Thoracic Surgery Patients, 2018. J
Anesth Clin Res. 2018;09(04):9–11.
9. Pennefather SH, Quarterman CP, Klinger RY, Kanellakos GW, Guillaumin J, Adin CA.
Principles and Practice of Anesthesia for Thoracic Surgery [Internet]. Second Edi. Small
Animal Critical Care Medicine, Second Edition. Elsevier Inc.; 2014. 703-707 p. Available
from: http://dx.doi.org/10.1016/B978-1-4557-0306-7.00134-3
10. Whiteman A, Bajaj S, Hasan M. Novel techniques of local anaesthetic infiltration. Contin
Educ Anaesthesia, Crit Care Pain. 2011;11(5):167–71.
11. Siopi V, Valasiou I, Papageorgiou E, Veliki N, Tzinevi M, Rallis Th, Gogakos A.S,
Paliouras D, Asteriou Ch, Anisoglou S BN. Nursing care plan in post-thoracotomy pain
management. Greek E-Journal Perioper Med. 2015;13(b):71–81.
12. Wenk M, Schug SA. Perioperative pain management after thoracotomy. Curr Opin
Anaesthesiol. 2011;24(1):8–12.
13. Fiorelli A, Morgillo F, Milione R, Pace MC, Passavanti MB, Laperuta P, et al. Control of
42
post-thoracotomy pain by transcutaneous electrical nerve stimulation: Effect on serum
cytokine levels, visual analogue scale,pulmonary function and medication. Eur J Cardio-
thoracic Surg. 2012;41(4):861–8.
14. Shelley B, MacFie A, Kinsella J. Anesthesia for thoracic surgery: A survey of UK practice. J
Cardiothorac Vasc Anesth [Internet]. 2011;25(6):1014–7. Available from:
http://dx.doi.org/10.1053/j.jvca.2011.06.018
15. Manuscript A, Problems PPM. NIH Public Access. 2009;26(2):1–12.
16. Goto T. What is the best pain control after thoracic surgery? J Thorac Dis. 2018;10(3):1335–
8.
17. Omara AFA and AF. Small dose of naloxone as an adjuvant to bupivacaine in intrapleural
infiltration after thoracotomy surgery: a prospective, controlled study. Korean J Pain
[Internet]. 2019 Apr;32(2):105–12. Available from:
http://www.epain.org/journalDOIx.php?id=10.3344/kjp.2019.32.2.105
18. N. T, H. H, C. T, K. M, Y. Y. Comparison of Postoperative Pain after Different Thoracic
Surgery Approaches as Measured by Electrical Stimulation. Thorac Cardiovasc Surg.
2015;63(6):519–25.
19. Hegarty D. Post Thoracotomy Pain Syndrome : what pain management options do we have ?
Post Thoracotomy Pain Syndrome : What Pain Management Options do we have ?
2017;(October).
20. Brennan TJ, Ph D. Surgery. 2017;(5):938–51.
21. Wheatley GH, Rosenbaum DH, Paul MC, Dine AP, Wait MA, Meyer DM, et al. Improved
pain management outcomes with continuous infusion of a local anesthetic after thoracotomy.
J Thorac Cardiovasc Surg. 2005;130(2):464–8.
22. Newcastle T, Nhs H, Trust F. RVI Paravertebral Continuous Infusion Guideline. 2019;1–6.
23. Ende D, Zeballos JL. Thoracic paravertebral block. Pain Med An Essent Rev. 2017;(3):313–
7.
24. Scarfe AJ, Schuhmann-Hingel S, Duncan JK, Ma N, Atukorale YN, Cameron AL.
Continuous paravertebral block for post-cardiothoracic surgery analgesia: A systematic
review and meta-analysis. Eur J Cardio-thoracic Surg. 2016;50(6):1010–8.
25. Komatsu T, Sowa T, Takahashi K, Fujinaga T. Paravertebral block as a promising analgesic
modality for managing post-thoracotomy pain. Ann Thorac Cardiovasc Surg.
2014;20(2):113–6.
26. Rice DC, Cata JP, Mena GE, Rodriguez-Restrepo A, Correa AM, Mehran RJ. Posterior
intercostal nerve block with liposomal bupivacaine: An alternative to thoracic epidural
analgesia. Ann Thorac Surg [Internet]. 2015;99(6):1953–60. Available from:
43
http://dx.doi.org/10.1016/j.athoracsur.2015.02.074
27. Ghee CD, Fortes DL, Liu C, Khandhar SJ. A Randomized Controlled Trial of Continuous
Subpleural Bupivacaine After Thoracoscopic Surgery. Semin Thorac Cardiovasc Surg
[Internet]. 2018;30(2):240–9. Available from: https://doi.org/10.1053/j.semtcvs.2017.09.012
28. Bakalis N, Vescio G, Chounti M, Michalopoulou E, Kiekkas P, Rizzuto A, et al. Nursing
assessment of post-operative pain in patients undergoing general ( thoracic ) surgery.
2018;2(4):1–7.
29. Marco CA, Marco AP. Assessment of pain. Emerg Dep Analg An Evidence-Based Guid.
2008;101(1):10–8.
30. Steegers MAH, Snik DM, Verhagen AF, van der Drift MA, Wilder-Smith OHG. Only Half
of the Chronic Pain After Thoracic Surgery Shows a Neuropathic Component. J Pain.
2008;9(10):955–61.
31. Maxwell C, Nicoara A. New developments in the treatment of acute pain after thoracic
surgery. Curr Opin Anaesthesiol. 2014;27(1):6–11.
32. Bayman EO, Parekh KR, Keech J, Selte A, Brennan TJ. A Prospective Study of Chronic Pain
after Thoracic Surgery. Anesthesiology. 2017;126(5):938–51.
33. Baxter CS, Fitzgerald BM. Intercostal Nerve Block. [Updated 2019 Mar 9]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK482273/?report=classic
34. https://emedicine.medscape.com/article/2000541-overview#showal
35. Richardson J, Lönnqvist PA, Naja Z. Bilateral thoracic paravertebral block: potential and
practice. Br J Anaesth. 2011 Feb. 106(2):164-71. [Medline].