Download POST THORACOTOMY PAIN MANAGMENT

Post Thoracotomy Analgesia
Recent Trends
Dr.Ahmed Turkistani MD,FCCM
Associate Professor & Chairman
King khalid university hospital
Pain
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What is pain?
“An unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms
of such damage.”
Physiological Mechanism of
Acute Pain
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Nociceptors
Peripheral chemical mediators
Pain transmission pathway
Pain modulation by excitation thru Nmethyl D aspartate ( NMDA ) OR by
inhibition thru opiates receptor
Cerebral cortex - clinical pain
Pain after surgery
Inflammatory pain
Neuropathic pain
Inflammatory pain
Nociceptive pain
Nociceptive pain
Neuropathic pain
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Type of thoracotomy Pain:
Thoracotomy produces nociceptive
(tissue damage and ribs) and
neuropathic pain (peripheral nerves)
that is aggravated by respiration and
coughing. Pain may be further
exacerbated by the presence of chest
tubes and drains.
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Severity/Duration:
Thoracotomy pain is generally severe
and intense that may last for weeks.
Patients may develop post-thoracotomy
pain syndromes lasting months to
years.
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reports : 50% may have pain up to 1
year post thoracotomy .
Dajczman et al ; chest 1991
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Prevalence of post thoracotomy pain
may be modified with rates as low as
21% with aggressive perioperative pain
management .
ochroch et al ; anesthesiology 2002
The insufficient treatment of post thoracotomy
pain results in :
1- reduced pulmonary compliance
2- inability to breath deeply or cough forcefully
and retention of secretions
atelectasis and pneumonia
3- prolonged immobility related to pain may
lead to DVT and P.E
plan should be
developed
preoperatively
CHOICES FOR PAIN CONTROL
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Administration of opioids via IV, IM, or
IV PCA routes
Thoracic epidural analgesia
Paravertebral blocks
Intercostal nerve blocks
Intrapleural catheter
Cryoanalgesia has been used
Analgesia following thoracotomy: a survey of Australian
practice. Anaesth Intensive Care. 1997 Oct;25(5):520-4.
Cook TM, Riley RH
The most frequently used analgesic modalities
are epidural analgesia, intravenous patientcontrolled analgesia (IVPCA), and nursecontrolled intravenous opioid infusions
Systemic Analgesics
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Systemic analgesics are the main alternative
to more invasive techniques .
Intravenous patient-controlled opioids is the
main component of systemic analgesics .
Systemic systemic opioids can be associated
with significant side effects, which has
prompted the search for alternative systemic
medications.
Patient controlled analgesia
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With opioids alone, IM or IV, the analgesia may be
marginal and side effects intolerable (nausea,
vomiting,sedation), thus the need for synergy,
choosing drug classes that will overlap for analgesia
but not for side effects.
Drug classes that fit these requirements
are as follows: mu agonist opioids, cyclooxygenase
inhibitors, a2-agonists, nitric oxide synthetase
inhibitors,N-methyl-d-aspartate receptor blockers
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nonsteroidal anti-inflammatory drugs
continue to be an important adjunct to
opioid analgesia
Rhodes et al : Nonsteroidal antiinflammatory drugs for postthoracotomy pain
J Thorac Cardiovasc Surg 1992; 103:17–20
Nimesulide 90 mg Orally Twice Daily Does Not
Influence Postoperative Morphine Requirement
After MajorChest Surgery .
Harney et al (Anesth Analg 2008;106:294 –300)
Adding ketamine to morphine for
patient-controlled analgesia after
thoracic surgery: influence on
morphine consumption, respiratory
function, and nocturnal desaturation
Michelet et al
British Journal of Anaesthesia 2007;99:396-403
Cumulative morphine consumption by 12 h period between the morphine group and
morphine/ketamine group
Michelet, P. et al. Br. J. Anaesth. 2007 99:396-403; doi:10.1093/bja/aem168
Copyright restrictions may apply.
intrathecal morphine to patientcontrolled administration (PCA)
morphine improves post-thoracotomy
pain relief and respiratory function
Askar FZ et al
Journal of International Medical Research
2007;35: 314-322
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Tramadol administered by continuous
intravenous infusion may be as effective
as thoracic epidural morphine
Bloch et al . Anesth Analg 2002; 94:523–8
Epidural analgesia
Mainstay of postoperative pain
 There is good evidence that aggressive
pain control in the form of epidural
analgesia with local anesthesia
following thoracic surgery improves
pulmonary function, reduces morbidity,
and reduces the length of stay in
intensive care.
Epidural Analgesia - Side Effects
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From the technique
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dural puncture
epidural haematoma
epidural abscess
nerve root trauma
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From LA
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hypotension
paraesthesia
motor weakness
From opioid
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delay resp depress
urinary retention
pruritus
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Effective postoperative pain control may
be achieved by delivering an opioid or a
combination of an opioid and local
anesthetic into the thoracic epidural
space (Mahon et al., 1999; Miguel &
Hubbell, 1993; Brichon et al., 1994).
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Postoperative patients can consume 50
to 100 mg of I.V morphine during the
first 24 hours postoperatively when
given by a PCA device
In comparison, epidural doses of 5 mg
of morphine can provide post operative
analgesia for 12 to 24 hours
Ferrante FM. Principles and practice of anesthesiology, 2nd ed. St. Louis,
MO:Mosby, 1998:2331–51.
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Commonly used opioid–local anesthetic mixtures
reported : include fentanyl-bupivacaine, morphinebupivacaine, and fentanyl-ropivacaine.
Levo-bupivacaine, an isomer of bupivacaine with
decreased cardiotoxicity, alone and in conjunction with
opiates .
Ropivacaine has a similar onset and duration of action
to bupivacaine, but it has an enhanced safety profile due
to decreased cardiotoxicity and a less profound motor
blockade than either bupivacaine or levo-bupivacaine.
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Shorrab et al has concluded : Ropivacaine–
fentanyl thoracic epidural analgesia after
thoracotomy is comparable to bupivacaine –
fentanyl analgesia in terms of pain control and
side effects
The Internet Journal of Anesthesiology. 2007;(13) 1.
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Thoracic vs. lumbar epidurals ?
L.A vs.L.A combined with opiates ?
Opiates alone ?
What type of opiates ?
Comparison of thoracic and lumbar epidural infusions
of bupivacaine and fentanyl for post-thoracotomy
analgesia
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no significant differences in analgesia and pulmonary
function were seen; however, less opioid was required
in patients receiving thoracic epidural analgesia
Hurford et al.. J Cardiothorac Vasc Anesth 1993
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Patients who received epidural bupivacaine had a
reduced incidence of SVT when compared with patients
who only received epidural opiates.
The reduction was due to the reduced sympathetic tone
this reduction could have a significant impact on the
postoperative cardiac morbidity of thoracotomy
patients.
Oka et al. Thoracic epidural bupivacaine attenuates supraventricular
tachyarrhythmias after pulmonary resection. Anesth Analg 2001;93:253–9
Paravertebral block
Paravertebral block
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single shot or continuous techniques are also useful
in providing postoperative analgesia following
thoracic surgical procedures (Carabine et al., 1995).
Continuous paravertebral blocks provide superior
postoperative analgesia when compared to single
shot techniques (Catala et al., 1996).
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G. Davies, P. S. Myles, and J. M. Graham
comparison of the analgesic efficacy and sideeffects of paravertebral vs epidural blockade
for thoracotomy—a systematic review and
meta-analysis of randomized trials
Br. J. Anaesth. 2006 96: 418-426
A meta-analysis of trials comparing PVB with epidural analgesia on postoperative pulmonary
complications
Davies, R. G. et al. Br. J. Anaesth. 2006 96:418-426; doi:10.1093/bja/ael020
Copyright restrictions may apply.
A meta-analysis of trials comparing PVB with epidural analgesia on morphine consumption after
surgery
Davies, R. G. et al. Br. J. Anaesth. 2006 96:418-426; doi:10.1093/bja/ael020
Copyright restrictions may apply.
conclusion :
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PVB and epidural analgesia provide
comparable pain relief after thoracic
surgery, but PVB has a better sideeffect profile and is associated with a
reduction in pulmonary complications.
PVB can be recommended for major
thoracic surgery
Randomized Controlled Phase III Trial of Paravertebral
Catheter vs. Epidural Catheter for Post Thoracotomy
Pain Control ( IN PRESS )
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M. J. Liptay1 et al. 1Evanston Northwestern
Healthcare, Evanston, IL, 2Indiana
University, Indianapolis, IN,
CONCLUSIONS:
Intraoperative paravertebral catheter insertion
provides comparable pain relief to the thoracic
epidural catheter. Ease of insertion makes it an
alternative to routine epidural insertion.
Inetrcostal block
Intercostal nerve blocks
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Sustained benefit can be obtained by
the use of local anesthetic infusion into
intercostal catheters placed under direct
vision above and below the incision
prior to wound closure ( extraplueral
inetrcostal block )
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it has been demonstrated radiologically,
that the site of action of local anesthetic
via an extrapleural intercostal catheter
is primarily via the paravertebral space
Eng J, Sabanathan S. Site of action of continuous extrapleural
intercostal nerve block. Ann Thorac Surg 1991; 51: 387–9
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Kaiser et al 1998 had concluded that extrapleural
intercostal analgesia might be a valuable alternative
to thoracic epidural analgesia for pain control after
thoracotomy and should particularly be considered in
patients who do not qualify for thoracic epidural
analgesia.
Thoracic Epidural Versus Intercostal
Nerve Catheter Plus Patient-Controlled
Analgesia: A Randomized Study
Luketich et al Ann Thorac Surg 2005;79
Conclusion :
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Satisfactory pain control was achieved after
thoracotomy using either EPI or ICN-PCA.
The ICN-PCA achieved equivalent pain control
compared with EPI.
ICN was placed by the surgeon with no delays
in surgery .
decreased requirement for Foley catheter
duration.
Extrapleural Intercostal Catheter Vs.
Thoracic Epidural for Thoracotomy
Pain
This study is currently recruiting
participants.
Information provided by Virginia
Commonwealth University
Completion Date March 2008
Cryoanalgesia
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Cryoanalgesia of intercostal nerves performed
prior to wound closure produces intercostal
blockade lasting several months. Despite the
theoretical attractions, in one of the few
controlled trials of the technique it did not
produce improved pain scores or respiratory
function. In addition, cryoanalgesia may lead
to the development of intercostal neuralgia
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cryoanalgesia be considered as a
simple, inexpensive, long-term
form of post-thoracotomy pain
relief, which does not cause any
long-term histological damage to
intercostal nerves
Moorjani et al Eur J Cardiothorac Surg 2001;20:502-507
Conclusion :
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Analgesic plan should start preoperatively .
Multimodal approach by modulating different
pain pathways.
Mid Thoracic epidurals are the standard of
analgesia.
Extradural intercostal and paravertbral
catheters are gaining popularity and are
excellent alternative .