Management Of Post-thoracotomy Pain Research Articles

Comparison between patient-controlled tramadol infusion and additional thoracic paravertebral block in the management of post-thoracotomy pain; a retrospective study

Comparison between patient-controlled tramadol infusion and additional thoracic paravertebral block in the management of post-thoracotomy pain; a retrospective study

Advanced statistical approaches for predicting pain after pediatric thoracotomy: a cross-sectional study using zero-inflated and Poisson models

BackgroundThoracotomy is one of the surgical procedures most burdened by chronic post-operative pain. There is poor evidence regarding the possibility that even in pediatric patients, thoracotomy can be followed by post-operative pain. The primary objective of this analysis is to identify associations with home pain therapy, pain intensity, and possible protective factors acting on chronic pain in this population.MethodsA retrospective cross-sectional study was conducted at Ospedale Pediatrico Bambino Gesù IRCCS. The study included pediatric patients undergoing thoracotomy. For statistical analyses, a logistic model and a zero-inflated strategy were implemented to explore associations and predict factors related to home-based analgesic therapy and pain intensity.ResultsGender and age were identified as significant factors in the assignment of home therapy, with males having over seven times the risk compared to females (OR = 7.06, 95% CI = [2.11, 29.7]). At the last measurement, pain intensity was positively associated with age and the number of pain events during the week.ConclusionsThe study highlights significant factors influencing post-thoracotomy pain management in pediatric patients. These findings underscore the importance of tailored pain management strategies that consider gender and age to improve post-operative care and outcomes in pediatric thoracotomy patients.

Ultrasound-guided continuous erector spinae plane block vs continuous thoracic epidural analgesia for the management of acute and chronic postthoracotomy pain: a randomized, controlled,double-blind trial.

Postthoracotomy pain (PTP) is a severe pain complicating thoracic surgeries and its good management decreases the risk of PTP syndrome (PTPS). This randomized controlled study evaluated the efficacy of ultrasound-guided continuous erector spinae plane block (ESPB) with or without dexmedetomidine compared with thoracic epidural analgesia (TEA) in managing acute postoperative pain and the possible emergence of PTPS. Ninety patients with chest malignancies planned for thoracotomy were randomly allocated into 3 equal groups. Group 1: TEA (20 mL of levobupivacaine 0.25% bolus, then 0.1 mL/kg/h of levobupivacaine 0.1%), group 2: ESPB (20 mL of levobupivacaine only 0.1% bolus every 6 hours), and group 3: ESPB (20 mL of levobupivacaine 0.25% and 0.5 μg/kg of dexmedetomidine Hcl bolus every 6 hours). Resting and dynamic visual analog scales were higher in group 2 compared with groups 1 and 3 at 6, 24, and 36 hours and at 8 and 12 weeks. Postthoracotomy pain syndrome incidence was higher in group 2 compared with groups 1 and 3 at 8 and 12 weeks, whereas it was indifferent between groups 1 and 3. The grading system for neuropathic pain score was higher in group 2 compared with groups 1 and 3 at 8 and 12 weeks, whereas it was indifferent between groups 1 and 3. Itching, pruritis, and urine retention were higher in group 1 than in ESPB groups. Ultrasound-guided ESPB with dexmedetomidine is as potent as TEA in relieving acute PTP and reducing the possible emergence of chronic PTPS. However, the 2 techniques were superior to ESPB without dexmedetomidine. Erector spinae plane block has fewer side effects compared with TEA.

Comparison of post-thoracotomy pain management methods: direct intercostal local analgesia versus erector spinae plane block (ESP block)

Comparison of post-thoracotomy pain management methods: direct intercostal local analgesia versus erector spinae plane block (ESP block)

Single shot serratus anterior plane block for post-thoracotomy pain management in cardiac surgery: could it be enough?

article: Single shot serratus anterior plane block for post-thoracotomy pain management in cardiac surgery: could it be enough? - Minerva Anestesiologica 2022 September;88(9):748-9 - Minerva Medica - Journals

Comparison of continuous thoracic epidural block and continuous thoracic paravertebral block for management of post thoracotomy pain: a randomised trial

Aim: Pain after thoracotomy is one of the most severe in clinical practice and more effective analgesia can be achieved by combining systemic and regional techniques. Though thoracic epidural analgesia (TEA) is the gold standard in the treatment, its application can be restricted due to side effects and contraindications. We investigated the hypothesis that thoracic paravertebral block (TPVB) reduced morphine consumption, pain scores, and side effects as much as TEA after thoracotomy.
 Material and Method: Fifty patients who underwent elective posterolateral thoracotomy were included in this study. Patients were randomly allocated into two groups as TEA (group I, n = 25) and TPVB (group II, n = 25). Postoperative consumption of patient-controlled morphine, visual analog scores (VAS), hemodynamic parameters, and side effects were collected in 72 hours. Additionally, pulmonary function tests (PFT) values were recorded.
 Results: Postoperative VAS values during rest were comparable between the groups (p > 0.005) and they did not have significantly difference postoperative VAS values during coughing (p > 0.005). The cumulative morphine consumption was higher in Group 2 (p < 0.05). Side effects were comparable between the groups II (p > 0.05).
 Conclusion: We conclude that TEA provided more effective analgesia than TPVB in thoracotomy patients in the early postoperative period with comparable side effects.

Serratus Anterior Plane Block as a Regional Analgesia Technique for Post Thoracotomy and Thoracoscopy Pain: Review Article

Background: Chest wall surgeries are accompanied by severe postoperative pain. Inadequate relief of this pain may lead to both pulmonary complications as lung atelectasis and infection and chronic post thoracotomy pain syndrome. Regional analgesic modalities are important portion of the multimodal therapeutic approach suggested for the management of post thoracotomy pain. Objective: To evaluate serratus anterior plane block as a regional analgesia technique for post thoracotomy and thoracoscopy pain. Recent Findings: Serratus anterior plane block (SAPB), a regional analgesic modality developed by Blanco et al. in 2013, has shown good analgesic effect after thoracotomy and thoracoscopy in many case reports and clinical trials. In such block, a local anesthetic is injected in the fascial plane deep or superficial to the serratus anterior muscle leading to block of lateral cutaneous branches of the intercostal nerves. This provides a sensory block of T2–T9 dermatomes. Conclusion:Serratus anterior plane block as a fascial plane block can be a preferred regional analgesia technique for both post-operative pain management with procedures involving anterolateral chest wall as thoracotomy, thoracoscopy and breast surgery and in cases of multiple rib fractures. This is owing to its easy technique, effective pain relief and potentially better side effects profile compared to other regional modalities and systemic opioids.

Paravertebral Block versus Thoracic Epidural Analgesia for Postthoracotomy Pain Relief: A Meta-Analysis of Randomized Trials.

Paravertebral block (PVB) and thoracic epidural analgesia (TEA) are commonly used for postthoracotomy pain management. The purpose of this research is to evaluate the effects of TEA versus PVB for postthoracotomy pain relief. A systematic literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane Library (last performed on August 2020) to identify randomized controlled trials comparing PVB and TEA for thoracotomy. The rest and dynamic visual analog scale (VAS) scores, rescue analgesic consumption, the incidences of side effects were pooled. Sixteen trials involving 1,000 patients were included in this meta-analysis. The pooled results showed that the rest and dynamic VAS at 12, 24, and rest VAS at 48 hours were similar between PVB and TEA groups. The rescue analgesic consumption (weighted mean differences: 3.81; 95% confidence interval [CI]: 0.982-6.638, p < 0.01) and the incidence of rescue analgesia (relative risk [RR]: 1.963; 95% CI: 1.336-2.884, p < 0.01) were less in TEA group. However, the incidence of hypotension (RR: 0.228; 95% CI: 0.137-0.380, p < 0.001), urinary retention (RR: 0.392; 95% CI: 0.198-0.776, p < 0.01), and vomiting (RR: 0.665; 95% CI: 0.451-0.981, p < 0.05) was less in PVB group. For thoracotomy, PVB may provide no superior analgesia compared with TEA but PVB can reduce side effects. Thus, individualized treatment is recommended. Further study is still necessary to determine which concentration of local anesthetics can be used for PVB and can provide equal analgesic efficiency to TEA.

Ultrasound guided paravertebral block versus intravenous lidocaine infusion for management of post-thoracotomy pain

ABSTRACT Background To compare the analgesic effects of thoracic paravertebral block versus lidocaine infusion for management of post-thoracotomy pain. Methods 60 patients who were scheduled for thoracotomy were randomly divided into two equal groups: IV group received 1.5 mg/kg of 1% lidocaine over 10 min then infusion of 1.5 mg/kg/h, and thoracic paravertebral group (PVB) received 10 ml lidocaine 1% over 30 s then infusion of 1.5 mg/kg/h through catheter was inserted under ultrasound guidance. Hemodynamic and respiratory variables, frequency and duration of postoperative mechanical ventilation, duration of ICU stay, time till start of respiratory exercise and till chest tube removal, analgesia was assessed using 100-point visual analogue scale and defined as VAS <30 mm at rest, and in case of inadequate analgesia, IV morphine 2 mg bolus was given. Frequencies of complications and postoperative hospital stay were also recorded. Results 17 patients of both groups were maintained on MV for mean duration of 1.5 ± 0.5 days. PVB group was successfully weaned from MV and extubated after significantly shorter duration. Mean duration of ICU stay, time till start of respiratory exercise, and till removal of chest tube were significantly shorter in PVB group. All patients requested analgesia, but the frequency of consumption and mean number of requests were significantly higher in IV group. VAS scores determined at 1, 2, 12, 36 and cumulative 48 hours were significantly lower in PVB group compared to IV group. Conclusion Ultrasound guidance allowed safe paravertebral space catheterization. PVB using continuous lidocaine infusion provided adequate analgesia for post-thoracotomy pain with significant reduction of rescue analgesia, shorter time till respiratory exercises start, minimal complications and shorter hospital stay.

Pre-emptive epidural analgesia for acute and chronic post-thoracotomy pain in adults: a systematic review and meta-analysis

Background and objectivesEpidural analgesia is the gold standard for post-thoracotomy pain management and can be started before or after surgical incision. This systematic review and meta-analysis investigated whether pre-emptive epidural...

Ultrasound-Guided Erector Spinae Plane Block Versus Intercostal Nerve Block for Post-Minithoracotomy Acute Pain Management: A Randomized Controlled Trial

Several nerve block procedures are available for post-thoracotomy pain management. In this randomized trial, the authors aimed to determine whether the analgesic effect of preoperative ultrasound-guided erector spinae plane block (ESPB) might be superior to that of intraoperative intercostal nerve block (ICNB) in pain control in patients undergoing minithoracotomy. University hospital. Sixty consecutive adult patients scheduled to undergo minithoracotomy for lung resection were enrolled. Patients were allocated randomly in a 1:1 ratio to receive either single-shot ESPB or ICNB. The primary outcome was the intensity of postoperative pain at rest, assessed with the numeric rating scale (NRS). The secondary outcomes were (1) dynamic NRS values (during cough); (2) perioperative analgesic requirements; (3) patient satisfaction, on the basis of a verbal scale (Likert scale); and (4) respiratory muscle strength, considering the maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) variation from baseline. The ESPB group showed lower postoperative static and dynamic NRS values than the ICNB group (p < 0.05). Total remifentanil consumption and requirements for additional analgesics were lower in the ESPB group (p < 0.05). Patient satisfaction was higher in the ESPB group (p < 0.001). A significant overall time effect was found in MIP and MEP variation (p < 0.001); ESPB values were higher at all points, reaching a statistically significant level at the first and sixth hours for MIP, and at the first, 12th, 24th, and 48th hours for MEP (p < 0.05). ESPB was demonstrated to provide superior analgesia, lower perioperative analgesic requirements, better patient satisfaction, and less respiratory muscle strength impairment than ICNB in patients undergoing minithoracotomy.

Pain Management Strategies for Thoracic Surgery

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

Role of Perioperative Pregabalin in the Management of Acute and Chronic Post-Thoracotomy Pain.

BACKGROUND:Post-thoracotomy pain syndrome (PTPS) can be challenging to treat.AIM:This study aimed to evaluate the efficacy of perioperative pregabalin in the prevention of acute and chronic post-thoracotomy pain.METHODS:Sixty patients scheduled for thoracotomy for oncologic surgeries were randomly allocated to one of two groups; Pregabalin and Control. In the Pregabalin group, pregabalin 150 mg was administered one hour before thoracotomy and 12 hours later, then every 12 hours for five days. Pain intensity was assessed using the Visual Analogue Scale (VAS) at rest (VAS-R) and dynamic (VAS-D) in the ICU and during the next four days. Morphine consumption and the frequency of side effects were recorded. Assessment of PTPS was done using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale at 1, 2, and 3 months.RESULTS:The VAS-R and VAS-D scores and the total morphine consumption were significantly lower in Pregabalin group during days 0 through 4. Neuropathic pain, allodynia, and hyperalgesia were significantly lower in Pregabalin group after 1, 2, and 3 months.CONCLUSION:Pregabalin is effective in the reduction of chronic neuropathic pain at 1, 2, and 3 months after thoracotomy and it also reduces pain and opioid consumption during the acute postoperative period with few adverse effects.

Patient-controlled paravertebral analgesia for video-assisted thoracoscopic surgery lobectomy.

BackgroundParavertebral block has been proven to be an efficient method to provide post-thoracotomy pain management. This study aimed to compare patient-controlled paravertebral analgesia (PCPA) and intravenous patient-controlled analgesia (IVPCA) in terms of analgesic efficiency, respiratory function, and adverse effects after video-assisted thoracoscopic surgery (VATS) lobectomy.Patients and methodsThe prospective randomized trial study was carried out on 60 patients who underwent VATS lobectomy (randomly allocated 30 patients in each group). In the PCPA group, an initial dose of 0.3 mL/kg of 0.125% bupivacaine with fentanyl 2 µg/mL was administered, followed by a 3 mL/h continuous infusion with patient-controlled analgesia (2 mL bolus, 10-minute lockout interval, 25 mL/4 h limit). In the IVPCA group with morphine 1 mg/mL solution, an infusion device was programmed to deliver a 1.0 mL demand bolus with no basal infusion rate, with a 10-minute lockout interval and a maximum of 20 mL/4 h period. Postoperative pain was assessed by visual analog scale at rest and on coughing. Arterial blood gas and spirometry were monitored and recorded for the first 3 postoperative days. Side effects to include were also recorded.ResultsThe PCPA group had statistically significant lower pain scores (P<0.0001) at rest at all times. Lower pain scores on coughing were statistically significant in PCPA group in the first 4 hours. Postoperative spirometry showed that both the groups had comparable recovery trajectories for their pulmonary function. Arterial blood gas analysis showed pH and PaCO2 were in a normal range in both the groups. The incidence of headache was higher in the IVPCA group (13.3% vs 0%; P=0.038).ConclusionPCPA effectively managed pain after VATS lobectomy, with lower pain scores, similar respiratory function, and fewer side effects than standard IVPCA treatment.

Comparison of the Efficacy of Ultrasound-Guided Serratus Anterior Plane Block, Pectoral Nerves II Block, and Intercostal Nerve Block for the Management of Postoperative Thoracotomy Pain After Pediatric Cardiac Surgery

The aim of this study was to compare the relative efficacy of ultrasound-guided serratus anterior plane block (SAPB), pectoral nerves (Pecs) II block, and intercostal nerve block (ICNB) for the management of post-thoracotomy pain in pediatric cardiac surgery. A prospective, randomized, single-blind, comparative study. Single-institution tertiary referral cardiac center. The study comprised 108 children with congenital heart disease requiring surgery through a thoracotomy. Children were allocated randomly to 1 of the 3 groups: SAPB, Pecs II, or ICNB. All participants received 3 mg/kg of 0.2% ropivacaine for ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal and fentanyl was used for rescue analgesia. A modified objective pain score (MOPS) was evaluated at 1, 2, 4, 6, 8, 10, and 12 hours post-extubation. The early mean MOPS at 1, 2, and 4 hours was similar in the 3 groups. The late mean MOPS was significantly lower in the SAPB group compared with that of the ICNB group (p < 0.001). The Pecs II group also had a lower MOPS compared with the ICNB group at 6, 8, and 10 hours (p < 0.001), but the MOPS was comparable at hour 12 (p = 0.301). The requirement for rescue fentanyl was significantly higher in ICNB group in contrast to the SAPB and Pecs II groups. SAPB and Pecs II fascial plane blocks are equally efficacious in post-thoracotomy pain management compared with ICNB, but they have the additional benefit of being longer lasting and are as easily performed as the traditional ICNB.

Effect of Adding Magnesium Sulphate to Epidural Bupivacaine and Morphine on Post-Thoracotomy Pain Management: A Randomized, Double-Blind, Clinical Trial.

Post-thoracotomy pain is very severe and may cause pulmonary complications. Thoracic epidural analgesia can greatly decrease the pain experience and its consequences. However, finding new methods to decrease the amount of administered opioids is an important issue of research. We aimed to evaluate the effect of adding epidural magnesium sulphate to bupivacaine and morphine on pain control and the amount of opioid consumption after thoracotomy. Eighty patients undergoing thoracotomy at a tertiary cardiothoracic referral centre were enrolled in a randomized, double-blind trial. Patients were randomly allocated to two groups. Bupivacaine (12.5 mg) and morphine (2 mg) were administered epidurally to all patients at the end of operation. Patients in the magnesium (Mg) group received epidural magnesium sulphate (50 mg), and patients in the control (C) group received normal saline as an adjuvant. Visual analogue scale (VAS) score and the amount of morphine consumption were measured during 24 hr post-operation. Thirty-nine patients in the Mg group and 41 patients in the C group completed the study. Patients in the Mg group had significantly less VAS score at recovery time (p < 0.05), 2 hr (p < 0.01) and 4 hr (p < 0.05) after surgery. The patient-controlled analgesia pump was started earlier in the C group than in the Mg group (p < 0.05). The amount of morphine needed in the Mg group was significantly lower than in the C group (5.64 ± 1.69 mg/24 hr versus 8.44 ± 3.98 mg/24 hr; p < 0.001). Pruritus was seen in the C group (9.7%) and absent in the Mg group (p < 0.05). Co-administration of magnesium sulphate with bupivacaine and morphine for thoracic epidural analgesia after thoracotomy leads to a reduction in post-operative pain score and the need for opioid administration.

The efficacy of serratus anterior plane block in analgesia for thoracotomy: a retrospective study.

A multimodal analgesic approach is necessary for post-thoracotomy pain, which can be severe. Intravenous access, central and peripheral nerve blocks are frequently used. The aim of this study was to evaluate the efficacy of serratus anterior plane block (SAPB) in the management of post-thoracotomy pain. A total of 40 patients who underwent thoracotomy between January 2014 and January 2016 were retrospectively analyzed. The patients were divided into two groups: Group M (intravenous patient-controlled analgesia morphine; n=20) and Group S (intravenous patient-controlled analgesia morphine+SAPB; n=20). The Visual Analogue Scale (VAS) was used for pain evaluation at the 1st, 2nd, 4th, 6th, 8th, 12th and 24th postoperative hours and morphine consumption was evaluated at the 6th, 12th and 24th postoperative hours. Secondary outcomes were additional analgesic requirement, side effects, the Ramsay Sedation Scale (RSS) scores, block onset time and block level. The VAS scores and the amount of morphine consumed at the 6th, 12th and 24th hours were found to be significantly lower in Group S than in Group M (P<0.001). No statistically significant difference was found in the rate of side effects, including nausea, vomiting, pruritus, respiratory depression, bradycardia and hypotension, and RSS outcomes between the groups. Our study suggests that SAPB is an effective adjuvant treatment option for thoracotomy analgesia.

Ultrasound-Guided Interscalene Brachial Plexus Nerve Block With an Ultralow Volume of Local Anesthetic for Post-Thoracotomy Shoulder Girdle Pain

To evaluate the efficacy of ultrasound-guided interscalene nerve block using an ultralow volume of local anesthetic (5 mL of ropivacaine, 0.75%) for the management of post-thoracotomy shoulder girdle pain. Open-cohort, prospective, single-center study. University hospital. Patients with post-thoracotomy shoulder girdle pain (visual analog scale [VAS] ≥5) received an ultrasound-guided interscalene nerve block. Thirty minutes after block implementation, the VAS was used to quantify pain across the shoulder girdle. The index (I) was calculated to indicate improvement of pain as follows: [Formula: see text] Nerve bocks resulting in I ≥75% were considered excellent. Total tramadol consumption 36 hours after nerve blocks, patients' satisfaction, and complications related to the procedure also were assessed. Patients were segregated in the following 2 groups: group A, which comprised patients with pain in the shoulder area (glenohumeral and acromioclavicular joints) (n = 30), and group B, which comprised patients with pain in the scapula (n = 17). I was significantly greater in group A (88.3% ± 14%) than in group B (43.2% ± 22%). In groups A and B, 90% and 11% of patients, respectively, demonstrated excellent pain control. Total tramadol consumption in group A, 25 (0-100) mg, was significantly less that of group B, 250 (150-500) mg. Patients' satisfaction also was significantly higher in group A compared with group B. No complications were recorded. Ultrasound-guided interscalene nerve block can substantially alleviate post-thoracotomy pain in the shoulder but not in the scapular area.

Perioperative Ketamine Administration for Thoracotomy Pain

Background: Of all the postsurgical pain conditions, thoracotomy pain poses a particular therapeutic challenge in terms of its prevalence, severity, and ensuing postoperative morbidity. Multiple pain generators contribute to the severity of post-thoracotomy pain, and therefore a multimodal analgesic therapy is considered to be a necessary strategy. Along with opioids, thoracic epidural analgesia, and paravertebral blocks, N-Methyl-D-Aspartate (NMDA) receptor antagonists such as ketamine have been used as adjuvants to improve analgesia. Objective: We reviewed the evidence for the efficacy of intravenous and epidural administration of ketamine in acute post-thoracotomy pain management, and its effectiveness in reducing chronic postthoracotomy pain. Study Design: Systematic literature review and an analytic study of a data subset were performed. Methods: We searched PubMed, Embase, and Cochrane reviews using the key terms “ketamine,” “neuropathic pain,” “postoperative,” and “post-thoracotomy pain syndrome.” The search was limited to human trials and included all studies published before January 2015. Data from animal studies, abstracts, and letters were excluded. All studies not available in the English language were excluded. The manuscript bibliographies were reviewed for additional related articles. We included randomized controlled trials and retrospective studies, while excluding individual case reports. Results: This systematic literature search yielded 15 randomized control trials evaluating the efficacy of ketamine in the treatment of acute post-thoracotomy pain; fewer studies assessed its effect on attenuating chronic post-thoracotomy pain. The majority of reviewed studies demonstrated that ketamine has efficacy in reduction of acute pain, but the evidence is limited on the long-term benefits of ketamine to prevent post-thoracotomy pain syndrome, regardless of the route of administration. A nested analytical study found there is a statistically significant reduction in acute post-thoracotomy pain with IV or epidural ketamine. However currently, the evidence for a role of ketamine as a preventative agent for chronic postthoracotomy pain is insufficient due to the heterogeneity of the studies reviewed with regard to the route of administration, dosage, and outcome measures. Limitations: The evidence for a role of ketamine as a preventative agent for chronic post-thoracotomy pain is insufficient due to the heterogeneity of the studies reviewed. Conclusion: The majority of randomized controlled trials reviewed show no role for ketamine in attenuating or preventing post-thoracotomy pain syndrome at variable follow-up lengths. Therefore, additional research is warranted with consideration of risk factors and long-term follow-up for chronic post-thoracotomy pain though the evidence for benefit appears clear for acute post-thoracotomy pain. Key words: Ketamine, postoperative, thoracotomy pain, post thoracotomy pain syndrome, neuropathic pain

Ultra Sound Guided Paravertebral Block versus Intravenous Lidocaine Infusion for Management of Post-Thoracotomy Pain

Ultra Sound Guided Paravertebral Block versus Intravenous Lidocaine Infusion for Management of Post-Thoracotomy Pain