Postthoracotomy pain management.
The following techniques appear efficacious in controlling postthoracotomy pain and reducing the amount of systemic opioids consumed: continuous intercostal blockade, paravertebral blockade, and epidural opioids and/or anesthetics. The combination of thoracic epidural opioid and local anesthetic is very effective at relieving postthoracotomy pain, however, considerable experience is required for insertion of the thoracic epidural catheter and postoperative respiratory monitoring. Intercostal and paravertebral catheters can be inserted intraoperatively under direct visualization, to reduce complications of insertion. One-time intraoperative intercostal blockade may effectively reduce postoperative pain in the first day, but is not a practical long-term method for postthoracotomy pain. The effectiveness of interpleural analgesia, even with proper technique, appears inferior to epidural and other regional techniques. We have incorporated the principles outlined in this review into our general thoracic surgery protocol, as detailed in Fig. 1. Every patient is assessed preoperatively for epidural catheter placement. Contraindications include low platelet count (< 100,000), abnormal coagulation profile, medicinal anticoagulation (aspirin and nonsteroidal anti-inflammatories are not contraindications), bony spinal abnormalities, or neurological disorders. The T5/6 interspace is our preferred level, but T10 can work well with an increased dose of bupivacaine. Upon completion of the muscle sparing, minimal-access thoracotomy, we close the wound and perform a percutaneous intercostal nerve block (two ribs above and three below the incision). We then use patient-controlled epidural analgesia, with a basal infusion of bupivacaine and hydromorphone. To supplement inadequate or nonfunctioning epidurals, intravenous patient-controlled opioids are added. When choosing an approach to postthoracotomy pain management, the thoracic surgeon and anesthesiologist must consider the following: (1) the physician's experience, familiarity and personal complication rate with specific techniques; (2) the desired extent of local and systemic pain control; (3) the presence of contraindications to specific analgesic techniques and medications; and (4) availability of appropriate facilities for patient assessment and monitoring postthoracotomy. Refinements in surgical technique including limited or muscle-sparing thoracotomy, video-assisted thoracoscopic surgery (VATS) and robotic surgery may lessen the magnitude of postthoracotomy pain. We encourage all thoracic surgeons to be knowledgeable of available techniques and maintain a protocol to generate a database for periodic assessment of safety and efficacy.
Savage
Clare
C
Division of Cardiothoracic Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555-0528, USA. claresavage@yahoo.com
McQuitty
Christopher
C
Wang
DongFang
D
Zwischenberger
Joseph B
JB
D000465:Algorithms; D015360:Analgesia, Epidural / Q000379:methods*; D000701:Analgesics, Opioid / Q000627:therapeutic use; D000779:Anesthetics, Local / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D006801:Humans; D007367:Intercostal Nerves / Q000187:drug effects; D009407:Nerve Block / Q000379:methods*; D010149:Postoperative Pain / Q000628:therapy*; D010994:Pleura / Q000187:drug effects; D016032:Randomized Controlled Trials as Topic; D013127:Spinal Nerves / Q000187:drug effects; D013908:Thoracotomy
D000701:Analgesics, Opioid; D000779:Anesthetics, Local