Management Of Post-thoracotomy Pain Research Articles

Pharmacological Management of Post-thoracotomy Pain

Thoracotomy is widely recognised as one of the most painful surgical procedures. The combination of extensive tissue dissection and dynamic respiratory movement postoperatively makes post-thoracotomy pain control particularly challenging. In the short term, inadequate analgesia is associated with respiratory complications, poor mobilisation, delayed discharge and respiratory infections. More importantly, poorly controlled postoperative pain is associated with developing chronic post-thoracotomy pain, also known as post-thoracotomy pain syndrome (PTPS). The reported incidence is between 25-60% and can be debilitating and difficult to treat. Increasing understanding of complex nociceptive pathways and neuropathic mechanisms has generated interest in the use of new therapeutic agents termed as adjuncts to post-operative opioid analgesia. In the area of thoracic surgery, the use of analgesic adjuncts has been subjected to a number of studies in recent years. In this article, we present a literature review of current treatment strategies for management of post-thoracotomy pain with evidence of effectiveness.

Preferences of the Thoracic-Surgery Academic Teaching Staff on Thoracotomy Opening/Closure and Post-Thoracotomy Pain Management

Background: A survey was conducted on preferences for thoracotomy opening and closure as well as post-thoracotomy pain management among academic teaching staff of thoracic surgeons in Turkey. It was aimed to assess the attitudes of the thoracic surgery training-center academicians on aforesaid topic. Methods: A 7-question questionnaire was performed by face-to-face interview or online by e-mail to the academic professionals working at resident-training centers. Eighty-eight randomly selected academicians were invited to complete the questionnaire, and 48 of them answered. Based on the complete and valid responses, the methods for opening and closure of thorax, the number of chest drains placed, the method of analgesia in per-or postoperative period and the analgesic agents used commonly were assessed. Results: Thirty-three (68.8%) of 48 were working at university hospitals and 24 (50.0%) were in age group of 40 - 49 years. Muscle-sparing (41.7%) and standard posterolateral thoracotomies (41.7%) were the most preferred incision. The most used method for closing thorax was pericostal sutures. Per-or postoperative analgesia was stated to be performed by all of the participants, while 45 (93.75%) of them reported that they preferred to administrate more than one procedure. Intercostal/paravertebral nerve block (26.4%), epidural analgesia (24.5%), systemic parenteral non-steroid drugs (24.5%) and systemic parenteral opioid (20.9%) were the most commonly used methods. Conclusion: Preventing intercostal nerve injury decreaseed post-thoracotomy pain, as well as the necessity of post-operative analgesic use. Conversely, most of the academic staff did not prefer the methods for preserving intercostal nerve. More than one analgesia procedure were said to be used by majority of the participants.

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Background: Pregabalin is effective both at controlling postoperative pain and preventing chronic neuropathic pain. Local anaesthetic infiltration is a simple and inexpensive method to provide postoperative analgesia. In this study we tested the hypothesis that pregabalin administered perioperatively combined with continuous wound infusion will aid better the post-thoracotomy pain management compared to pregabalin monotherapy.Methods: Forty five patients received either placebo (PLCB), pregabalin (PRG) or pregabalin and continuous wound infusion (PRG + CWI) of local anaesthetics. Postoperative data collection included opioid consumption, VAS scores at rest and during cough. At 1 and 3 months from surgery patients were assessed with the DN4 questionnaire for neuropathic pain.Results: VAS scores were significantly lower in the PRG+CWI group (p < 0.05) at rest while during cough the placebo group had higher scores than both treatment groups (p < 0.001 or p < 0.05). Morphine consumption measured at 48 hr PO revealed a significant difference in total morphine; PLCB: 49 ± 11mg, PRG: 33 ± 10mg and PRG+CWI: 28 ± 11mg (p < 0.001 between placebo and the other two groups). The incidence of neuropathic pain was more frequent in the placebo group (1-month: PLCB: 10 pt, PRG: 0 pt and PRG+ CWI: 0 pt (p < 0.001), 3 months: PLCB: 10 pts, PRG: 0 pt and PRG+ CWI: 0 pt (p < 0.001)). Conclusions: Perioperative administration of pregabalin significantly reduces pain scores, opioid consumption and incidence of neuropathic pain in post-thoracotomy patients. The addition of continuous wound infiltration of local anaesthetics although improved immediate postoperative analgesia at rest did not affect differently the development of neuropathic pain.

Trends and New Evidence in the Management of Acute and Chronic Post-Thoracotomy Pain-An Overview of the Literature from 2005 to 2015.

IN ADDITION TO being a major stressor, thoracotomies are associated with moderate-to-severe pain, impairment of respiratory function, protracted recovery, and the potential for the development of chronic pain. Of all surgical procedures, thoracotomies may create the greatest demand for postoperative analgesia. Even after less-invasive techniques, such as videoand robotic-assisted thoracoscopic surgery, postoperative pain is of considerable concern. Uncontrolled post-thoracotomy pain has important implications for a patient’s recovery and can add significant morbidity and increase healthcare costs. Absence of adequate post-thoracotomy analgesia in patients undergoing lung surgery may be associated with delayed postoperative extubation. Cywinski et al conducted a logistic regression analysis on 2,068 patients who underwent open thoracotomy for pneumonectomy, lobectomy, or segmental lung resection and found that the absence of thoracic epidural analgesia (TEA) was a significant predictor of delayed extubation. Based on the authors’ review of the relevant literature, in the past decade no single paradigm shift in the treatment of postthoracotomy pain has been reported. Cumulatively, however, a recent body of evidence now supports an expanded armamentarium of pharmacologic and procedural interventions and an improved understanding concerning the etiology of thoracotomy pain. The aim of this review was to report on many of these numerous incremental findings by providing a concise overview and discussion of recent relevant evidence, which, in aggregate, could contribute to improved clinical outcomes.

Is pre-emptive administration of ketamine a significant adjunction to intravenous morphine analgesia for controlling postoperative pain? A randomized, double-blind, placebo-controlled clinical trial.

To evaluate if the pre-emptive administration of ketamine would potentiate the effect of intravenous morphine analgesia in the management of post-thoracotomy pain. This was a unicentre, double-blind, placebo-controlled, parallel-group, prospective study. Patients were randomly assigned to receive 1 mg/kg ketamine (ketamine group) or an equivalent dose of normal saline (placebo group) before thoracotomy in 1:1 ratio. All patients received postoperatively intravenous morphine administration as additional analgesic regimen. Primary end-point was the pain relief measured with Visual Analogue Scale at rest. The secondary end-points were the reduction of inflammatory response expressed by plasma C-reactive protein levels, the morphine consumption and the rate of side effects. The measurements were carried out 6, 12, 24, 36 and 48 hours postoperatively. A total of 75 patients were randomized of whom 38 were allocated to ketamine group and 37 to placebo group. Baseline characteristics were comparable. Ketamine compared with placebo group showed a significant reduction of pain scores (P = 0.01), C-reactive protein (P < 0.001) and morphine consumption (P < 0.001). No acute psychological side effects related to the use of ketamine were registered. The administration of ketamine before surgery may be an effective adjunct to intravenous morphine analgesia in acute post-thoracotomy pain management. In ketamine group, satisfaction of pain relief was significantly higher with a significant reduction of inflammatory response and morphine consumption compared with placebo group. Our results, if confirmed by larger studies, may be of clinical relevance in situations where epidural analgesia or other analgesic procedures different from systemic opioid analgesia are unavailable or contraindicated.

A randomized prospective study of analgesic quality after thoracotomy: paravertebral block with bolus versus continuous infusion with an elastomeric pump.

Paravertebral block (PVB) with infusion of local anaesthetic (LA) through a paravertebral catheter is an effective alternative to epidural analgesia in the management of post-thoracotomy pain. PVB can be done in two ways: either through administration of a bolus dose of the LA or continuous infusion via an infusion pump; currently, there is no consensus on which route is best. Our objective was to compare the efficacy of the PVB for post-thoracotomy pain control using bolus doses versus a continuous infusion pump. We performed a prospective randomized study of 80 patients submitted to thoracotomy. Patients were divided into two independent groups (anterior thoracotomy--ANT--and posterolateral thoracotomy-POST). At the conclusion of the surgery, a catheter was inserted under direct vision in the thoracic paravertebral space at the level of the incision. In each group, patients were randomized to receive levobupivacaine 0.5% every 6 h ('Bolus' group) or levobupivacaine 0.25% in continuous infusion at 5 ml/h through an elastomeric pump ('Continuous infusion' group). Patients in both groups received the same dosage of LA: 300 mg/day. Metamizole (every 6 h) was administered as an adjunct. Subcutaneous meperidine was employed as a rescue medication. Pain scores were measured using the visual analogue scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. Thirteen (16.2%) patients required meperidine for rescue (8 in continuous infusion and 5 in the bolus group). Mean VAS scores were the following: all the cases (n = 80): 5.0 ± 1.6, ANT (n = 36): 4.4 ± 1.8, POST (n = 44): 5.4 ± 1.6, Bolus (n = 40): 4.7 ± 1.7, Continuous infusion (n = 40): 5.2 ± 1.8, ANT with bolus (n = 18): 4.1 ± 1.7, ANT with continuous infusion (n = 18): 4.7 ± 1.8, POST with bolus (n = 22): 5.2 ± 1.5, POST with continuous infusion (n = 22): 5.6 ± 1.6. Post-thoracotomy pain control using a combination of PVB and a non-steroidal anti-inflammatory drug is a safe and effective approach. Patients submitted to ANT experienced less pain than those with POST 4.4 vs 5.4 (P = 0.02). Since no statistical differences were observed, it was not possible to confirm differences between the LA administered in a bolus versus continuous infusion.

EComment. Cryoanalgesia in post-thoracotomy pain: Efficiency and pain measurement methods

We have read with great interest the article by Khanbhai et et al., concerning the effectiveness of cryoanalgesia in post-thoracotomy pain management compared to other analgesic methods used over the years [1]. Cryoanalgesia is a method that ensures prolonged intercostal blockage, and was first introduced in 1975 [2]. The results of cryoanalgesia alone or in combination with other analgesic methods (i.e. epidural analgesia) in post-thoracotomy pain management vary, as seen in the article by Khanbhai et al. The aim of this brief comment is to highlight the role of intercostal catheter analgesia with bupivacaine or similar drug, placed during surgery, and its effectiveness in post-thoracotomy pain. The key is that it is also a less invasive method, compared to epidural analgesia, and there is evidence of satisfactory results in the literature [3]. It would also be useful to evaluate and treat post-thoracotomy pain using more complete pain scales, such as the Pain Quality Assessment Scale (PQAS), and the Numeric Rating Scale (NRS-11), in order to have a more precise comparison between different types of analgesia [4,5].

Preoperatıve Ultrasound-Guıded Suprascapular Nerve Block for Postthoracotomy Shoulder Paın

BackgroundAcute postthoracotomy pain is a well-known potential problem, with pulmonary complications, ineffective respiratory rehabilitation, and delayed mobilization in the initial postoperative period, and it is followed by chronic pain. The type of thoracotomy, intercostal nerve damage, muscle retraction, costal fractures, pleural irritation, and incision scar are the most responsible mechanisms. ObjectiveOur aim was to assess whether preoperative ultrasound suprascapular nerve block with thoracic epidural analgesia was effective for postthoracotomy shoulder pain relief. MethodsThirty-six American Society of Anesthesiologist classification physical status I–III patients (2011–2012), with a diagnosis of lung cancer and scheduled for elective open-lung surgery, were prospectively included in the study. Eighteen of the patients received an ultrasound-guided suprascapular nerve block with 10-mL 0.5% levobupivacaine, using a 22-gauge spinal needle, 1 hour before operation (group S); 18 other patients had thoracic epidural analgesia only, and no nerve block was performed. Standard general anesthesia was administered. Degree of shoulder pain was assessed by a blinded observer when discharging patients from the recovery room, and thereafter at 1, 3, 6, 12, 24, 36, 48, and 72 hours on infusion at rest and 12, 24, 36, 48, and 72 hours on coughing. The same blinded observer also recorded the total amount of epidural levobupivacaine and fentanyl used by the 2 groups. ResultsIn the suprascapular block group, the total amount of levobupivacaine (P = 0.0001) and fentanyl (P = 0.005) used postoperatively was statistically lower than in the epidural group. Visual analogue scale measurements in the suprascapular group were statistically significantly lower at 0, 1, 3, 6, 12, 24, 36, and 48 hours than those in the epidural group, both at rest and coughing. ConclusionPostthoracotomy shoulder pain reduces patient function and postsurgical rehabilitation potential after thoracotomy, and various studies on explaining the etiology and management of postthoracotomy shoulder pain have been conducted. Theories of the etiology involved either musculoskeletal origin or referred pain. In this study, we concluded that preoperative ultrasound-guided suprascapular nerve block with thoracic epidural analgesia could achieve effective shoulder pain relief for 72 hours postoperatively, both at rest and coughing.

Comparison of Intravenous Morphine, Epidural Morphine With/Without Bupivacaine or Ropivacaine in Postthoracotomy Pain Management With Patient Controlled Analgesia Technique

Background and objectivesThe aim of this randomized, double-blinded, prospective study was to determine the effectiveness and side effects of intravenous or epidural use of morphine, bupivacaine or ropivacaine on post-thoracotomy pain management. MethodsSixty patients undergoing elective thoracotomy procedure were randomly allocated into 4 groups by the sealed envelope technique. Group IVM, EM, EMB and EMR received patient controlled intravenous morphine, and epidural morphine, morphine-bupivacaine and morphineropivacaine, respectively. Perioperative heart rate, blood pressure and oxygen saturation and postoperative pain at rest and during cough, side effects and rescue analgesic requirements were recorded at the 30th and 60th minutes and the 2nd, 4th, 6th, 12th, 24th, 36th, 48th, and 72nd hour. ResultsDiclofenac sodium requirement during the study was lower in Group EM. Area under VAS-time curve was lower in Group EM compared to Group IVM, but similar to Group EMB and EMR. Pain scores at rest were higher at the 12, 24, 36, and 48th hour in Group IVM compared to Group EM. Pain scores at rest were higher at the 30th and 60th minutes in Group EM and Group IVM compared to Group EMB. Pain scores during cough at the 30th minute were higher in Group EM compared to Group EMB. There was no difference between Group IVM and Group EMR. ConclusionsMorphine used at the epidural route was found more effective than the intravenous route. While Group EM was more effective in the late period of postoperative, Group EMB was more effective in the early period. We concluded that epidural morphine was the most effective and preferred one.

Comparison of Intravenous Morphine, Epidural Morphine With/ Without Bupivacaine or Ropivacaine in Postthoracotomy Pain Management With Patient Controlled Analgesia Technique

Background and objectivesThe aim of this randomized, double-blinded, prospective study was to determine the effectiveness and side effects of intravenous or epidural use of morphine, bupivacaine or ropivacaine on post-thoracotomy pain management. MethodsSixty patients undergoing elective thoracotomy procedure were randomly allocated into 4 groups by the sealed envelope technique. Group IVM, EM, EMB and EMR received patient controlled intravenous morphine, and epidural morphine, morphine-bupivacaine and morphineropivacaine, respectively. Perioperative heart rate, blood pressure and oxygen saturation and postoperative pain at rest and during cough, side effects and rescue analgesic requirements were recorded at the 30th and 60th minutes and the 2nd, 4th, 6th, 12th, 24th, 36th, 48th, and 72nd hour. ResultsDiclofenac sodium requirement during the study was lower inGroup EM. Area under VAS-time curve was lower in Group EM compared to Group IVM, but similar to Group EMB and EMR. Pain scores at rest were higher at the 12, 24, 36, and 48th hour in Group IVM compared to Group EM. Pain scores at rest were higher at the 30th and 60th minutes in Group EM and Group IVM compared to Group EMB. Pain scores during cough at the 30th minute were higher in Group EM compared to Group EMB. There was no difference between Group IVM and Group EMR. ConclusionsMorphine used at the epidural route was found more effective than the intravenous route. While Group EM was more effective in the late period of postoperative, Group EMB was more effective in the early period. We concluded that epidural morphine was the most effective and preferred one.

114 The role of acupuncture in the management of post-thoracotomy pain: description and evaluation of an acupuncture service in lung cancer survivorship

114 The role of acupuncture in the management of post-thoracotomy pain: description and evaluation of an acupuncture service in lung cancer survivorship

Postoperative Analgesia in Thoracic Surgery: A Comparison between Continuous Paravertebral Nerve Block and Continuous Incisional Infusion with OnQ Pain Relief System

Objectives: Thoracotomy is one of the most painful surgical stimuli and inadequate management of postthoracotomy pain is often associated with pulmonary and cardiac complications. The aim of this prospective, randomized, double-blinded study was to compare continuous paravertebral block versus continuous incisional infusion with OnQ Pain Relief System. Methods: Forty eight patients, undergoing thoracotomy for elective lobectomy, were randomized to receive a continuous paravertebral infusion of bupivacaine 0.25% through an elastomeric pump which delivers 0.1 mL/Kg/h (group A) or a continuous incisional infusion of bupivacaine 0.25% at an infusion rate of 4 mL/h with OnQ Pain Relief System (group B). Both infusions were started before wound closure, and continued for 48 postoperative hours. General anaesthesia was standardized. In the recovery room, patients were provided with intravenous morphine patient-controlled analgesia (PCA). Visual analogue scale at rest (VASr) and when coughing (VASi), rescue patientcontrolled analgesia morphine consumption, hemodynamic, time to ambulation and side-effects were evaluated within 48 h. Results: The two groups were comparable regarding to patients’ number and characteristics, type of surgery, time to ambulation and side-effects; postoperative hemodynamic profile was stable in all the patients. Absolute pain scores were low in both groups; patients in group A reported significant lower VASr and VASi values during the postoperative 48 hours compared with group B (p<0.001). Total morphine consumption and PCA requests number were significantly lower in group A than in group B (p= 0.05 and p< 0.01). Conclusions: Continuous incisional infusion of local anesthetic is not as effective as paravertebral analgesia after thoracotomy.

ANAESTHESIOLOGY AND INTENSIVE CARE The efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Sagiroglu G, Baysal A, Copuroglu E, et al. ANAESTHESIOLOGY AND INTENSIVE CAREThe efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2013;10(2):139-148. doi:10.5114/kitp.2013.36135. APA Sagiroglu, G., Baysal, A., Copuroglu, E., Karamustafaoglu, Y., Sagiroglu, T., & Yuksel, V. et al. (2013). ANAESTHESIOLOGY AND INTENSIVE CAREThe efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 10(2), 139-148. https://doi.org/10.5114/kitp.2013.36135 Chicago Sagiroglu, Gonul, Ayse Baysal, Elif Copuroglu, Yekta Altemur Karamustafaoglu, Tamer Sagiroglu, Volkan Yuksel, and Serhat Huseyin. 2013. "ANAESTHESIOLOGY AND INTENSIVE CAREThe efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management". Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery 10 (2): 139-148. doi:10.5114/kitp.2013.36135. Harvard Sagiroglu, G., Baysal, A., Copuroglu, E., Karamustafaoglu, Y., Sagiroglu, T., Yuksel, V., and Huseyin, S. (2013). ANAESTHESIOLOGY AND INTENSIVE CAREThe efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 10(2), pp.139-148. https://doi.org/10.5114/kitp.2013.36135 MLA Sagiroglu, Gonul et al. "ANAESTHESIOLOGY AND INTENSIVE CAREThe efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management." Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, vol. 10, no. 2, 2013, pp. 139-148. doi:10.5114/kitp.2013.36135. Vancouver Sagiroglu G, Baysal A, Copuroglu E, Karamustafaoglu Y, Sagiroglu T, Yuksel V et al. ANAESTHESIOLOGY AND INTENSIVE CAREThe efficacy of thoracic epidural and paravertebral blocks for post-thoracotomy pain management. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2013;10(2):139-148. doi:10.5114/kitp.2013.36135.

Ultrasound-Guided Thoracic Paravertebral Catheter Placement in a Patient Undergoing Thoracotomy Who Had the Relative Contraindication of Thrombocytopenia to Epidural Placement

PAIN AFTER THORACOTOMY is severe, often leading to significant respiratory complications and postoperative morbidity. 1 Gerner P. Postthoracotomy pain management problems. Anesthesiol Clin. 2008; 26: 355-367 Abstract Full Text Full Text PDF PubMed Scopus (158) Google Scholar The quality of postoperative analgesia is a major determinant of post-thoracotomy pulmonary function. 2 Richardson J. Sabanathan S. Shah R. Post-thoracotomy spirometric lung function: The effect of analgesia A review. J Cardiovasc Surg. 1999; 40: 445-456 PubMed Google Scholar Currently, thoracic epidural analgesia is used widely in the management of post-thoracotomy pain 3 Soto R.G. Fu E.S. Acute pain management for patients undergoing thoracotomy. Ann Thorac Surg. 2003; 75: 1349-1357 Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar and is the standard against which other modes of analgesia are compared. Epidural analgesia, however, can be limited because of the resulting sympathectomy and side effects of neuraxial opioids. There is an emerging body of evidence suggesting that thoracic paravertebral catheters are comparable in efficacy to epidural catheters with fewer side effects. 4 Davies R.G. Myles P.S. Graham J.M. A comparison of analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy A systematic review and meta-analysis of randomised trials. Br J Anaesth. 2006; 96: 418-426 Crossref PubMed Scopus (522) Google Scholar , 5 Joshi G.P. Bonnet F. Shah R. et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg. 2008; 107: 1026-1040 Crossref PubMed Scopus (458) Google Scholar , 6 Gulbahar G. Kocer B. Muratli S.N. et al. A comparison of epidural and paravertebral catheterization techniques in post-thoracotomy pain management. Eur J Cardiothorac Surg. 2010; 37: 467-472 PubMed Google Scholar Paravertebral catheters additionally offer the potential benefit of being placed in patients who are denied thoracic epidural analgesia because of the risk of epidural hematoma. However, prospective data to support this claim do not exist. The authors report a case of a patient undergoing thoracotomy whose thrombocytopenia (platelet count of 72 × 103/μL) represented a relative contraindication to epidural analgesia. Using real-time ultrasound guidance, a thoracic paravertebral catheter was placed successfully and used for postoperative analgesia.

Wandering Epidural Catheter

Massachusetts General Hospitaljc.brookman.md@gmail.comA MALE patient, 73 yr old, had a Flexitip Plus® (Arrow International, Reading, PA) 19-gauge end-hole, wire-reinforced thoracic epidural catheter inserted for postthoracotomy pain management. He underwent high-resolution spiral computed tomography scan with the catheter in situ before its use to evaluate previous bronchoscopic findings. A composite set of sagittal computed tomography images (figs. A and B) show two- and three-dimensional thoracic spine reconstructions that highlight the track of the epidural catheter in this patient. FigureA shows a three-dimensional reconstruction of the spine sliced down midline, looking toward the right with the catheter looped away from the viewer, and resting adjacent to the pedicle (bold arrow). FigureB is a two-dimensional cross-sectional computed tomography image demonstrating the course of the epidural catheter from outside the skin to within the epidural space, with anterolateral placement of the catheter tip terminating adjacent to the pedicle (circles). The catheter first loops into the anterior and then back into the lateral epidural space terminating adjacent to the pedicle. This is a commonly underappreciated track of an epidural catheter. It is generally assumed that epidural catheters travel cephalad in the posterior epidural space. However, this image shows definitive evidence of the circuitous route often taken by an epidural catheter. Conventional teaching is to insert an epidural catheter 5 cm into the epidural space. Several studies contradict this and show that a low number of catheters are successfully advanced into the epidural space without coiling or deviating from their intended track.1Loose areolar tissue, fat, and blood vessels in the epidural space can contribute to deviations in final placement of the catheter tip. Lim et al. showed that approximately 65% of epidural catheter tips deviate laterally in the epidural space immediately after leaving the Tuohy needle tip. The catheter tip followed a straight direction in the posterior epidural space for more than 2 cm in only 35% of placements. Further, only 13% of catheter tips could be advanced ≥4 cm without coiling.1Choi et al. observed 17.6% of epidural catheters curling in the epidural space. They also reported that 63.5% of cephalad-directed thoracic epidural catheters (Touhy bevel up) were actually advanced as such, and 78% of caudally directed epidural catheters (Touhy bevel down) were advanced that direction.2A negative consequence of lateral epidural catheter tip deviation is misplacement into the paravertebral area via an intervertebral foramen. Misplacement into the anterior epidural space is one of the most common causes of unilateral epidural block.3The authors thank Jeanine P. Weiner-Kronish, M.D., Ph.D., Anesthetist-in-Chief and Professor of Anesthesia, and Paul Alfille, M.D., Ph.D., Assistant Professor of Anesthesia (both Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts), for their guidance and initial review of this manuscript.

A comparison of epidural and paravertebral catheterisation techniques in post-thoracotomy pain management☆

Thoracotomy is a surgical procedure associated with severe pain. Operative morbidity rates reduce by effective postoperative pain control. The aim of this study is to compare the effectiveness of the thoracic epidural blockade (TEB) and the paravertebral blockade (PVB) methods in relieving the pain caused by a thoracotomy incision. We studied 44 consecutive patients who underwent elective posterolateral thoracotomy. The patients were classed into two groups: TEB (n=19) and PVB (n=25). Patients in both the groups could self-control the infusion of bupivacaine infusion and diclofenac sodium. The groups were compared according to the parameters such as analgesic efficacy (VAS), respiratory function tests (forced expiratory volume in 1s (FEV(1)), peak expiratory flow rate (PEFR) and arterial blood gases), stress response (serum cortisol and glucose levels), adverse effects, necessity for additional analgesia, duration of catheter application procedure, mean hospital stay and postoperative follow-up. Results are analysed statistically by Mann-Whitney U, Wilcoxon, chi-square and Fisher's exact tests, and a p-value of <0.05 was accepted to be statistically significant. There was no significant difference between the two groups with regard to age, gender, VAS, FEV(1), PEFR, serum cortisol and glucose levels, necessity for additional analgesia and hospital staying days. In contrast, adverse effects and duration of catheterisation were statistically significantly lower in group PVB (p=0.001 and p<0.001, respectively). PVB catheterisation can be easily performed and placed in a short span perioperatively. Therefore, it might be the preferred method over TEB which has a high incidence of adverse effects and complication rates.

A prospective study of analgesic quality after a thoracotomy: paravertebral block with ropivacaine before and after rib spreading☆

Paravertebral block (PVB) is an effective alternative to epidural analgesia in the management of post-thoracotomy pain. Rib spreading (RS) is an important noxious stimulus considered a major cause of post-thoracotomy pain. Our hypothesis was that a bolus of ropivacaine 0.2% through a paravertebral catheter (PVC) inserted before RS could decrease pain during the first 72 postoperative hours. The methodology employed was to perform a prospective randomised study of 60 consecutive patients submitted to thoracotomy. Patients were divided in two independent groups (anterior thoracotomy (AT) and posterolateral thoracotomy (PT)). A catheter was inserted under direct vision in the thoracic paravertebral space at the level of incision. In each group, patients were randomised to receive a bolus of 20 ml of ropivacaine 0.2% before rib spreading (pre-RS) or after (post-RS), just before closing the thoracotomy. They postoperatively received 15 ml of ropivacaine 0.2% every 6 h combined with methamizol (every 6h). Subcutaneous meperidine was employed as a rescue drug. The level of pain was measured with the visual analogue scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. The need of meperidine as a rescue drug and secondary effects were also recorded. We did not register secondary effects in relation to the PVC (paravertebral or cutaneous bleeding or haematoma, respiratory depression, cardiotoxicity, confusion, sedation, urinary retention, nausea, vomiting or pruritus). Seven patients (11.6%) needed meperidine as rescue drug (four pre-RS and three post-RS). The mean VAS values were the following: all cases (n=60): 4.7+/-2.0; AT (n=32): 4.0+/-2.1; PT (n=28): 5.6+/-1.8; pre-RS (n=30): 4.8+/-1.9; post-RS (n=30): 4.6+/-2.0; AT-pre-RS (n=16): 4.1+/-2.0; AT-post-RS (n=16): 3.9+/-2.1; PT-pre-RS (n=14): 5.6+/-1.6; PT-post-RS (n=14): 5.4+/-1.7. Post-thoracotomy analgesia combining PVC and a non-steroidal anti-inflammatory drug is a safe and effective practice. VAS values are acceptable (only 11.6% of patients required meperidine). It prevents the risk of side effects related to epidural analgesia. Patients submitted to AT experienced less pain than those with PT (4.0 vs 5.6; p<0.01). PVB with ropivacaine before RS got similar VAS values than the block after RS (4.8 vs 4.6; p>0.05). The moment of the insertion of the PVC does not seem to affect postoperative pain levels.

Thoracic paravertebral block after thoracotomy: comparison of three different approaches☆

Thoracic paravertebral block (TPVB) is a regional block technique increasingly used for the early management of post-thoracotomy pain. We compare three different postoperative analgesic approaches based on TPVB: anesthetist, anesthetist plus surgeon, and surgeon. We randomized 54 patients undergoing elective thoracotomy to three different postoperative analgesia groups: paravertebral percutaneous catheter (PVA group), paravertebral percutaneous catheter plus incisional (subcutaneous) catheter (PVA+Inc), and paravertebral catheter under direct vision (PVS group). During early postoperative 48h, we measured pain intensity, intravenous morphine afforded by the patient-controlled analgesia pump, and the spirometric test. There were no statistically significant differences among the collected preoperative data. No significant differences were observed on postoperative spirometric values. Analgesic quality was better in PVA+Inc group at 12 and 24 postoperative hours. In this group, intravenous morphine use to improve analgesia was significantly lower from 8h until 48h postoperative. Association of thoracic paravertebral block to continuous infusion of a local anesthetic in the surgical incision area affords a better pain relief than paravertebral block alone (introduced by the surgeon or the anesthetist).

Interpleural Morphine vs Bupivacaine for Postthoracotomy Pain Relief

This prospective randomized double-blind trial was designed to compare the analgesic effects of interpleural bupivacaine and interpleural morphine for postthoracotomy pain management. Thirty-six American Society of Anesthesiologists class I and II patients undergoing an elective posterolateral thoracotomy were randomly divided into 2 groups of 18 each. Before chest closure, an interpleural catheter was inserted under direct vision. At the end of the operation and every 4 hours thereafter, they received either 0.25% bupivacaine with epinephrine or 0.2 mg x kg(-1) morphine sulfate interpleurally for 24 hours. The chest tubes were clamped during injection and for 15 min afterwards. Supplementary doses of intravenous morphine were given on request. The pain severity was evaluated at rest and on coughing before and 30 min after each interpleural injection, using an 11-point visual analog scale. Supplemental analgesic consumption and side effects were recorded. Both interpleural morphine and bupivacaine significantly reduced pain scores 30 min after each injection. However, pain scores and supplementary analgesic requirements were significantly lower in the interpleural morphine group. No serious side effects were detected in either group. Interpleural morphine provides better pain control than interpleural bupivacaine after a posterolateral thoracotomy.

Comparative analysis of analgesic quality in the postoperative of thoracotomy: paravertebral block with bupivacaine 0.5% vs ropivacaine 0.2%☆

Paravertebral block is an effective alternative to epidural analgesia in the management of post-thoracotomy pain, however, there are no established guidelines regarding what is the most suitable strategy when varying drugs and dosages between different groups. Our objective was to evaluate the effectiveness of paravertebral block comparing the most frequently employed drugs in this procedure (bupivacaine vs ropivacaine). Prospective randomized study of 70 patients submitted to thoracotomy. Patients were divided in two independent groups (anterior thoracotomy (AT) and posterolateral thoracotomy (PT)). At the end of surgery a catheter was inserted under direct vision in the thoracic paravertebral space at the level of incision. In each group (AT or PT) patients were randomized to receive a bolus of 15 ml of bupivacaine 0.5% or 20 ml of ropivacaine 0.2% before closing the thoracotomy. They postoperatively received 10 ml of bupivacaine or 15 ml of ropivacaine every 6h combined with methamizol (every 6h). Subcutaneous meperidine was employed as rescue drug. The level of pain was measured with the visual analogic scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. The need of meperidine as rescue drug and secondary effects was also recorded. We did not register secondary effects in relation to the paravertebral catheter (paravertebral or cutaneous bleeding or hematoma, respiratory depression (respiratory rate <8 breaths per minute), cardiotoxicity, confusion, sedation, urinary retention, nausea, vomiting and pruritus). Eleven patients (16%) needed meperidine as rescue drug (six with ropivacaine and five with bupivacaine). Mean VAS values were the following: all the cases (n=70): 5.2+/-2.1, AT (n=38): 4.5+/-2.1, PT (n=32): 5.9+/-1.7, bupivacaine (n=35): 4.9+/-2.1, ropivacaine (n=35): 5.4+/-1.9, AT with bupivacaine (n=19): 4.2+/-2.2, AT with ropivacaine (n=19): 4.9+/-2.0, PT with bupivacaine (n=16): 5.7+/-1.6, PT with ropivacaine (n=16): 6.0+/-1.7. Post-thoracotomy analgesia combining paravertebral catheter and a nonsteroidal anti-inflammatory drug is a safe and effective practice, VAS values are acceptable (only 16% of patients required meperidine as rescue). It prevents the risk of side effects related to epidural analgesia. Patients submitted to AT experienced less pain than those with PT (4.5 vs 5.9, p<0.01). Bupivacaine got slightly better VAS values than ropivacaine (4.9 vs 5.4 p<0.05). Higher doses and volumes of local anesthetic could be used to obtain better VAS values.