Review
Acute pain management for patients undergoing thoracotomy

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Abstract

Management of thoracotomy pain can be difficult, but the benefits of effective pain control are significant. A variety of modalities for treating postoperative pain after thoracotomy are available, including systemic opiates, regional analgesics, and new oral and parenteral agents. This work provides a review of the literature and recommendations for the clinician.

Section snippets

Methods

Literature review for this work was performed using the National Library of Medicine’s PubMed search engine and the MDConsult journal search engine. Key words used for searching included thoracotomy, preemptive analgesia, VATS, video-assisted thoracic surgery, postthoracotomy pain, postoperative pain, and epidural.

Overview of postoperative pain management

Almost 200,000 patients a year are diagnosed with bronchogenic carcinoma, and nearly one-quarter of these patients will undergo surgical resection [1]. In addition to loss of lung tissue and pulmonary reserve, postoperative thoracotomy patients experience painful wound incisions that alter chest wall mechanics [2]. Ineffective chest expansion may predispose to atelectasis, ventilation/perfusion mismatching, hypoxemia, and infection 3, 4. Thus, the goal of the clinician is to develop an

Concepts in postoperative pain

Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, as described in terms of such damage. Local tissue damage results in inflammation and propagation of stimuli to the central nervous system. These stimuli are modulated by excitatory (N-methyl-D-aspartate [NMDA]) and inhibitory (opiate) pathways. Clinical and laboratory observations suggest that pain can result in hyperexcitability in the spinal cord, resulting in increasing

Chronic postthoracotomy pain

Up to 50% of patients undergoing thoracotomy will develop chronic pain related to the surgical site. Chronic postthoracotomy pain has been defined as a continuous dysesthetic burning and aching in the general area of the incision that persists at least 2 months after thoracotomy [21]. Although no one surgical technique has been proven to decrease the incidence of chronic pain, intercostal nerve damage due to rib retraction seems to be involved in the development of the neuralgia [22]. A recent

Epidural analgesia as the mainstay of postoperative pain management

Epidural analgesia has emerged as the analgesic technique of choice for postoperative thoracotomy pain management. Not only does the technique provide excellent pain control, but it also avoids much of the sedation associated with systemic opiates. Furthermore, the epidural catheter allows for continued dosing postoperatively, and avoids much of the motor blockade associated with intrathecal drug administration.

Compared with systemic administration, much lower doses of drug administered in the

Peripheral neural blockade

Peripheral nerve block techniques to anesthetize the chest wall have been utilized as alternatives to epidural analgesia. Many patients are not candidates for epidural analgesia because of anatomic consideration or patient refusal [46]. Adverse effects seen with systemic and epidural opioids can also be avoided by employing peripheral nerve block techniques in which only local anesthetic agents are administered. Even though nerve blocks may avoid the problems associated with opioids,

Systemic treatment options

As discussed previously, opioids have been the mainstay of postoperative pain management for decades. Unfortunately, systemic opioids can be associated with significant side effects, which has prompted the search for alternative systemic medications.

Paravertebral nerve block

Recent interest has reemerged in the management of thoracotomy pain by paravertebral nerve blockade. Blockade is achieved with a catheter placed surgically into a localized extrapleural paravertebral pocket. Several recent studies have suggested that paravertebral analgesia can be an effective alternative to epidural analgesia in thoracotomy patients [80]. Richardson and associates [81] found that when compared with patients receiving analgesia through a thoracic epidural catheter, patients in

Conclusions and recommendations

Pain control is a significant concern in hospitalized patients, with many clinicians now considering pain to be the fifth vital sign [99]. Although a myriad of pain treatment options is available, it can be difficult to formulate a rational treatment plan based on the frequently conflicting literature. Based on the literature reviewed above, we make the following conclusions and recommendations.

Preemptive analgesia, although an attractive concept, has not been proven to provide the same benefit

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