Pain Management Strategies for Thoracic Surgery

Abstract

Improper management of postoperative pain following thoracic surgery can be quite debilitating and lead to a number of complications due to the multitude of comorbid conditions manifested by the population of patients undergoing these types of procedures. These can include advanced lung disease, advanced age, heart disease, renal insufficiency and obesity.¹ The source of this acute postsurgical pain is multifactorial and can include skin incisions, deep tissue injuries, thoracostomy tubes, costovertebral joint separation and rib or sternal fractures.² Benefits of effective analgesia include decreased risk of perioperative morbidity, decreased hospital stay, decreased cost and increased patient satisfaction.³ There have been numerous studies conducted to determine the best pain management regimen for control of postthoracotomy pain, however, no single technique has thus far proven to be superior. Instead, most clinicians would advocate for a multimodal approach combining regional techniques, such as thoracic epidural analgesia or paravertebral blocks, with systemic analgesic medications including a combination of cyclooxygenase (COX)-2 inhibitors, nonsteroidal anti-inflammatory drugs, opioids and other analgesic adjuncts. This chapter will examine the different analgesic options currently available and being utilized for various types of thoracic surgical procedures. This will include a review of the systemic analgesic and non-analgesic optiondis as well as regional anesthetic techniques. The chapter will conclude with a discussion of chronic post-thoracotomy pain syndrome and currently available treatments. This review contains 4 tables, and 87 references. Keywords: systemic analgesic therapy, opioid analgesic medications, regional anesthetic techniques, thoracic epidural analgesia, paravertebral analgesia, chronic post-thoracotomy pain management, Enhanced Recovery After Surgery (ERAS), intrathecal opioid analgesia, intercostal analgesia, intrapleural analgesia