Pain Management in Thoracic Surgery

Abstract
Pain from thoracotomy incision is considered to be severe and intense as a
consequence of tissue damage to the ribs, muscle, and peripheral nerves. The incidence of
post-thoracotomy respiratory complications has decline in the last decade to < 10% while the
cardiac complications rate has not changed. It is now becoming evident that improvement in
post-operative care-specifically pain management- is the major cause of this decline. The
incidence of chronic post-thoracotomy pain is reported to be 44-67%, but the pain is severe in
25% of these patients. Up to 50% of patients undergoing thoracotomy will develop chronic
pain related to the surgical site.
The ideal post-thoracotomy technique will include three classes of drug: opioid,
NSAIDs, and local anesthetics. Systemic opioids alone are effective in controlling
background pain but the acute pain componenet associated with sedation and hypoventilation
in most patients. Even when administered by patient-controlled devices, pain control is
generally poor and patients have interrupted sleep patterns when serum opioid levels fall
below the therapeutic range. NSAIDs can reduce opioid consumption > 30% following
thoracotomy and particularly useful treating the ipsilateral shoulder pain that is often present
post-operatively.
With the acquisition of new scientific knowledge, epidurals have become the gold
standard for thoracotomy pain control for a number of reason. A meta-analysis of respiratory
complications following various type of surgery has shown that only epidural techniques
reduce the incidence of repiratory complication in high risk patient populations. The majority
of thoracotomies received a thoracic epidural analgesia (TEA) between T3-T8, with infusions
of bupivacaine plus either fentanyl or hydromorphone. Retrospective studies confirm
decreased morbidity and mortality with epidural analgesia. The addition of an opioid to a
thoracic epidural bupivacaine infusion gave better analgesia at rest during the first 24 hours
post-operatively, and better analgesia with movement for 72 hours. TEA could diminish post
–thoracotomy diaphragmatic dysfunction. TEA also can reduce the incidence of post-
thoracotomy arrhytmias. In one case report of a patient with primary pulmonary
hypertension, TEA produced a favorable effect on reducing the pulmonary artery pressure
and pulmonary vascular resistance more than the systemic pressure and vascular resistance.
Peripheral nerve block techniques to anesthetize the chest wall have been utilized as
alternatives to epidural analgesia. Even though nerve blocks may avoid the problems
associated with opioids, complication associated with infiltration of large quantities of local
anesthetic agent still exist. Blockade of intercostal nerves interrupts C-fiber afferent
transmission of impulse to the spinal cord. A single intercostal injection of a long acting local
anesthetic can provide pain relief and improve pulmonary function for up to 6 hours. To
achieve longer duration of analgesia, a continuous extrapleural intercostal nerve block
technique has been developed in which a catheter is placed percutaneously into an
extrapleural pocket by the thoracic surgeon. Various studies have confirmed the analgesic
efficacy of this techniques.
Paravertebral blocks (PVBs) provide a reliable multi-level intercostal block that tends
to be unilateral with a low tendency to spread to the epidural space. PVBs is superior to
intravenous analgesia in providing pain control and preserving post-operative pulmonary
function while it is equal to TEA regarding this two issues. PVBs were associated with less
urinary retension, less post-operative nausea and vomiting, less hypotension, and reduction in
pulmonary complication than epidural analgesia.
Ketamine is well known for its ability to treat acute pain, and it has been succesfully
used as an adjunct therapy in thoracic surgery. Low dose ketamine infusion (0,05 mg/kg/hr)
can reduce opioid tolerance or potentiates the analgesic effect. The psycho-mimetic effects of
ketamine was not seen with this low dose.
Gabapentin, an anticonvulsant, is indicated for and succesfully treats neuropathic
pain. Gabapentin could be a useful to treat acute pain in patient undergoing thoracic surgery
and may help to attenuate the development of neuropathic pain. Cryoanalgesia is the
application of a -6000C probe to the exposed intercostal nerves intraoperatively produced an
intercostal block that can persist for up to six months. Transcutaneous electrical nerve
stimulation may be useful in mild to moderate pain but is ineffective whwn pain is severe.

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