LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

MEDICAL ACADEMY

FACULTY OF NURSING

DEPARTMENT OF NURSING AND CARE

JOSSY ANNAMMA JOY

PAIN CONTROL AFTER THORACIC SURGERY

The graduate thesis of the Master‘s degree study programme “Advanced Nursing Practice”

(State Code 6211GX008)

Tutor of the graduate thesis

Phd ,MD, Milda Švagždienė

KAUNAS, 2019

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TABLE OF CONTENT

ABSTRACT…………………………………………………………………………………………3

ABBREVIATIONS………………………………………….............................................................4

INTRODUCTION …………………………………………………………………..........................5

1.REWIEW OF LITERATURE……………………………………………… …………………….7

1.1 Definition of pain………………………………………………………………………………...7

1.2 Pain after thoracic surgery……………………………………………………………………….7

1.3Degree and duration of pain after thoracic surgery…………………………………………….....9

1.4Acute postthoracotomy………………………………………………………………………….10

1.5Chronic postthoracotomy pain ………………………………………………………………….11

1.5.1Mechanism of postthoracotomy pain………………………………….....................................12

1.6Pain management after thoracic surgery………………………………………………………...12

1.6.1Systemic analgesia…………………………………………….………………………………13

1.6.2Regional Anesthesia Techniques……………………………………………………………...17

2.ORGANISATION AND METHODOLOGY OF A RESEARCH……….....................................30

3 RESULTS………………………………………………………………………………………...30

4 .DISCUSSION OF THE RESULTS……………………………………………………………...32

CONCLUSIONS……………………………………………………………………………………35

PRACTICAL RECOMMENDATIONS…………………………………………………………...36

PUBLICATIONS………………………………………………………………………………… ..40

LIST OF LITERATURE SOURCES……………………………………………………………...41

ANNEXES………………………………………………………………………………………….44

DECLARATION OF THE AUTHOR’S CONTRIBUTIONS AND ACADEMIC HONESTY

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ABSTRACT

Jossy Annamma Joy. Pain control after thoracic surgery. The graduate Master’s thesis .The tutor-

PhD MD, Milda Švagždienė. Lithuanian University of Health Science,Medical

academy,the Faculty of Nursing, Department of Nursing and Care.Kaunas,2019; 45p.

Thoracotomy is considered the most painful of surgical procedures and providing effective

analgesia is the onus for all anesthetists. Ineffective pain relief impedes deep breathing, coughing,

and remobilization culminating in atelectasis and pneumonia. Systemic opioid-based analgesic

regimen often fails in the treatment of postoperative pain after thoracotomy and the prevention of

persistent pain. AIM: * To find the optimal postoperative analgesia plan for the patients after

thoracic surgery. GOALS: *To investigate the incidence, severity and duration of acute

postthoracotomy pain. * To find the optimal analgesia method for the patient after thoracotomy. *

To investigate different methods and regiments of analgesia. METHODS For this research, the

literature search was conducted in the Pubmed, Science Direct, PLOS, SAGE, Google Scholar

databases and 35 literature sources were reviewed. Studies published in English between 2009–

2019 have been reviewed.

CONCLUSION :After surgery, pain control is central to the anesthetic management of thoracic

surgical patients. The provision of good postoperative analgesia is important in itself and is

regarded by some as the core business of anesthesia and a fundamental human right. Effective

analgesia can reduce pulmonary complications and mortality. It is unlikely that a single technique

will fulfill these goals optimally for all patients and that a balanced, multimodal approach should

therefore be used. Analgesia should be tailored to the specific patient undergoing a specific

procedure to minimize mortality, patient suffering, complications of the pulmonary system, and

other morbidity. Experience with a wide range of analgesic techniques is helpful as it allows a

suitable technique to be implemented. For open thoracotomies, a combination of regional analgesia

and opioids, sometimes supplemented with non-opioid analgesics, will best manage most patients.

Usually only consideration should be given to lumbar epidural analgesia, intrathecal opioids, or

intercostal nerve blocks if no thoracic epidural analgesia or paravertebral blocks are possible.

Currently the choice between thoracic epidural analgesia and paravertebral block is the dilemma for

thoracic anesthetists and their patients scheduled to undergo thoracotomy.

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ABBREVIATIONS

LA : Local Anesthetic

TEA : Thoracic Epidural Analgesia

NMDA : N-methyl-d-aspartate

PTPS : Post thoracotomy pain syndrome

IV : Intra Venous

IM : Intra Muscular

PCA : Patient Controlled Analgesia

NSAIDs : Non Steroid Anti-Inflammatory Drugs

COX : Cyclooxygens

TEA : Thoracic Epidural Analgesia

ICNs : Intercostal nerves

ICNB : Intercostal Nerve Blocks

TP : Transverse Process

BR : Breathing Rate

HR : Heart Rate

ABP : Arterial Blood Gas

VAS : Visual Analogue Scale

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INTRODUCTION

Thoracotomy is considered the most painful of surgical procedures and providing effective

analgesia is the onus for all anesthetists. Ineffective pain relief impedes deep breathing, coughing,

and remobilization culminating in atelectasis and pneumonia. This article reviews the mechanisms

of acute and chronic thoracotomy pain, the risk factors, current analgesic options, and the role

genetics may increasingly play in the management of thoracotomy pain.(1) Chest surgery may be

either thoracotomy or thoracoscopy. The incision may be either muscle-cutting or muscle-sparing

incision in thoracotomy. For most general thoracic surgical procedures, posterolateral thoracotomy

incision is used. This incision, involving division of the anterior latissimus dorsi and serratus

muscles, provides excellent thoracic cavity exposure. It is associated with significant morbidity,

however, including impaired pulmonary function, postoperative chest pain, and limited movement

of the arm and shoulder. Different muscle-sparing incisions were suggested to reduce morbidity.

Postthoracotomy pain is caused during surgery by pleural and muscle damage, costovertebral

disruption of the joint, and intercostal nerve damage. Inadequate pain relief after surgery affects the

quality of patient's recovery and exposes the patients to postoperative morbidities. There is a

tendency nowadays among thoracic surgeons and anesthesiologists toward the area of enhanced

recovery after thoracic surgery which requires careful titration of the anesthetic drugs in awake

patients undergoing thoracoscopic procedures. There is a common feeling among thoracic

anesthesiologists that postthoracoscopy procedures produce less pain intensity versus thoracotomy

which is partially true. Effective management of acute pain after either thoracotomy / thoracoscopy

is needed, however, and can prevent these complications and reduce the likelihood of chronic pain

developing. Adequate pain relief leads to early mobilization, improves breathing functions, and

decreases the response of global stress. Therefore, good management of perioperative pain

significantly reduces postoperative complications. Numerous analgesic methods are currently

available to manage acute postthoracotomy / thoracoscopy pain, including patient-controlled

analgesia, local anesthetic (LA) infiltration, intrapleural or intercostal nerve blockages, and

neuraxial blockages. In this report, we examine the newly introduced modalities for pain relief

postthoracotomy / thoracoscopy with particular reference to the new tendency

Systemic opioid-based analgesic regimen often fails in the treatment of postoperative pain after

thoracotomy and the prevention of persistent pain. Therefore, multimodal strategies involving the

use of regional and/or local anesthesia in combination with systemic analgesics are warranted and

have been shown to reduce post operative pain and the development of chronic pain .(2)

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One of the long-term complications of thoracotomy is chronic post-thoracotomy pain. It is defined

as pain on the chest around the incision scar that persists for longer than 2months postoperatively,

or that recurs after having disappeared for a while, but that is not related to the recurrence of a

tumor or to an infection.(3)

According to various studies, the incidence of this pain is 22—67% . Pain is severe in 5—25% of

these patients. The chronic pain disturbs daily activities of almost half of the patients, sleep is

disturbed in one quarter of them . It has been suggested that the development of chronic post-

thoracotomy pain can be prevented by treating acute postoperative pain effectively and by using

good surgical techniques . According to several studies, thoracic epidural analgesia (TEA) is

superior to less invasive methods in the management of acute post-thoracotomy pain. Today it can

be considered a gold standard . Usually a combination of a local anaesthetic (bupivacaine,

ropivacaine) and an opioid (fentanyl, morphine) is used(3).

Uncontrolled acute perioperative pain and related surgical stress responses are highly associated

with poor outcomes after thoracotomy Effective analgesia reduces perioperative morbidity,

shortens hospitalization times, improves patient satisfaction, and lowers cost these principles are

long established and are now included in Joint Commission on Accreditation standards.

Uncontrolled pain in the perioperative period consistently predicts the development of chronic pain.

Strategies that emphasize pre-emptive analgesia may provide protection against chronic pain

syndromes, with some evidence suggesting as high as a 50% reduction in the incidence of chronic

pain syndromes at 1 year after thoracotomy. (et.al Brandi A. Bottiger,2014) (4)

AIM

To find the optimal postoperative analgesia plan for the patients after thoracic surgery.

GOAL

To investigate the incidence, severity and duration of acute postthoracotomy pain.

To find the optimal analgesia method for the patient after thoracotomy.

To investigate different methods and regiments of analgesia.

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1. REWIEW OF LITERATURE

1.1Definition of pain

Pain is defined as ‘an unpleasant sensory and emotional experience associated with actual or

potential tissue damage, or described in terms of such damage’ (International Association for the

Study of Pain, Subcommittee of Taxonomy 1986b).

1.2Pain after thoracic surgery

Pain after thoracotomy arises from nociceptive and neuropathic mechanisms which may

originate from somatic and visceral affer- ents. Pain can also be referred.(1)

Nociceptive somatic afferents are conveyed by the intercostals nerves after skin incision, rib

retraction, muscle splitting, injury to the parietal pleura, and chest drain insertion to the ipsilateral

dorsal horn of the spinal cord (T4–T10). The afferents are then transmitted to the limbic system and

somatosensory cortices via the contralateral anterolateral system of the spinal cord. Nociceptive

visceral afferents are conveyed by the phrenic and vagus nerves after injury to the bronchi, visceral

pleura, and pericardium.(1)

Neuropathic pain, After intercostal nerve injury, develops via the mechanisms and results in the

paradox of reduced sensory input (from touch, temperature, and pres- sure) with hypersensitivity

(dysaesthesia, allodynia, hyperalge- sia, and hyperpathia).(1)

Referred pain

To the ipsilateral shoulder is common after thoracotomy and can often be unresponsive to the

effects of thoracic epidural analgesia (TEA). Studies have demonstrated a reduction in shoulder

pain by infiltrating local anaesthetic to block the phrenic nerve at the level of the pericardial fat

pad, or alternatively by interscalene block. This suggests that irritation of the visceral pleura and

pericardium, referred to the shoulder by the phrenic nerve, is the most likely source of this pain. As

the nerves arise from C3 to C5, TEA is ineffective in blocking this pain. The phrenic nerve may

also convey referred pain from transection of a major bronchus or irritation of the pleura from a

chest drain placed too far into the apex of the hemithorax.(1)

Factors Influencing Pain After Thoracic Surgery

Surgical factors

The posterolateral thoracotomy approach provides the best access to surgery. It involves, however,

dividing the latissimus dorsi and sometimes the anterior serratus and trapezius muscles, leading to

one of the most painful surgical incisions. Many surgeons are now using alternative muscle-sparing

approaches to replace muscle incision with dissection and reflection on the ribs. However, the

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reduced field of view may result in excessive retraction of the rib, fracture, dislocation,

costovertebral disruption, and intercostal nerves damage. These incisions may also span multiple

dermatomes as opposed to the single dermatome of the posterolateral approach; for example, the

axillary incision extends vertically downwards. Alternatively, an increasing number of video-

assisted thoracoscopic surgery (VATS) is performed which may reduce acute pain if intercostal

nerve damage is avoided by limiting the number and size of intercostal ports used. However, the

incidence of chronic pain appears to be similar to open thoracotomy

Patient factors

The general surgical population suggests that patients who are young, female, with a history of

depression and anxiety and are poorly informed of their management plan are more likely to

experience acute post-operative pain.

Pre-operative Preparedness

Well-informed patients may experience less pain so that patients should be given full explanation

of the proposed analgesic technique and its probable effects, including its limitations, potential side

effects and complications.

Opioid Tolerance

Continuous exposure to opioids results in a right dose-response curve shift to opioids, resulting in

patients requiring increased opioid levels to achieve the same pharmacological effect. It is a

predictable adaptation of pharmacology. The degree of opioid tolerance is associated with the

dosage, duration, and type of opioid given. Opioid tolerance is likely due to decreased sensitivity

and density of opioid receptors, increased regulation of cyclic adenosine monophosphate and neural

adaptation. N-methyl-d-aspartate (NMDA) receptor activation plays an important role in opioid

tolerance development. Patients with opioid tolerance are relatively intolerant to pain and may be

more difficult to cope with acute pain.

Sex

In an attempt to determine the influence of the patient's sex on the pain experienced after surgery, a

considerable amount of work has been done. Female patients report more severe, frequent and

diffuse pain than male patients with similar processes of disease. The difference in male - female

pain perception decreases with age, was not found by all investigators and is usually only

moderately large. Social gender roles have a significant impact on pain tolerance levels, are

sometimes difficult to distinguish from the patient's sex, and may account for some of the

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differences in gender pain tolerance. Coping strategies also affect pain tolerance of patients ;

disaster response is associated with increased sensitivity to experimental pain. Women are more

likely to be catastrophic, and this can help to account for the gender differences in pain tolerance.

Age

A recent systematic review found that young age was an important predictor of post-operative pain.

Ageing can affect the pharmacokinetics of analgesic medicines and older people are considered

more sensitive to systemic opioids. Likewise, there is a positive correlation between age and

thoracic epidural spread with older patients requiring approximately 40% less epidural solution.

Surgical Approach

Sternotomy

After a sternotomy, the sternum is usually fixed internally with steel wire. Therefore, bone

movement during respiration is minimal and usually only moderate post-operative pain. However,

wide or inexperienced sternal distraction can fracture the sternum, strain or even interfere with

anterior or posterior intercostal articulations with the potential to significantly increase

postoperative pain experienced.

Video-Assisted Thoracoscopic Surgery

Video-assisted thoracoscopic surgery The extent of the surgical incision is limited and early

postoperative pain can be reduced with video-assisted thoracoscopic surgery. These benefits can be

reduced by using larger-diameter instruments and/or twisting surgical instruments against the ribs

causing intercostal nerves to be injured and ribs to be bruised or even fractured. VATS is a type of

minimally invasive chest thoracic surgery performed with a thoracoscope (small videoscope) using

small incisions and special tools to minimize trauma. Other names for this procedure include

thoracoscopy, thoracoscopic surgery or pleuroscopy. Three small (about1-inch) incisions are used

during thoracoscopic surgery compared to one long 6-to8-inch chest incision used during

traditional, "open" thoracic surgery. These small incisions insert surgical instruments and the

thoracoscope.

As compared with traditional surgery, patients who undergo minimally invasive surgery

experience:

Decreased postoperative pain

Shorter hospital stay

More rapid recovery and return to work

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Other possible benefits include reduced risk of infection and less bleeding.

Open Thoracotomy

Posterolateral Incision

Posterolateral incision is the classic thoracotomy approach as it provides good surgical access and

can be easily extended if necessary. However, it involves cutting some of the major muscles in the

chest wall and is considered to be one of the most painful surgical incisions. There is some

evidence that divided ribs are internally fixed to reduce post-operative pain.

Muscle-Sparing Incision

Many surgeons now use one or more of the many described muscle-sparing incisions. A popular

approach is the axillary muscle-sparing incision, the skin incision with obvious cosmetic

advantages extending vertically down from the axilla. Although muscle-sparing incisions initially

caused less perioperative pain, most studies did not find this reduction in peri-operative pain.

Anterior Incision

For certain cardiac and anterior mediastinal procedures, anterior incisions are used to provide

access. However, due to the heart, exposure to lung surgery is particularly limited on the left. With

this incision, rib resections are often performed to improve surgical access. Post-operative pain

depends in part on the extent of excision and the extent of surgical retraction, but after a

posterolateral thoracotomy it is similar to that. With this approach, intercostal nerve blocks are

particularly effective because the incision does not involve any part of the chest supplied by the

posterior skin nerves that originate from the dorsal rami and are not blocked by an intercostals

nerve block.(5)

1.3 Degree and duration of pain after thoracic surgery

The degree of pain following thoracic surgery is usually classified as "severe." Pain after

thoracotomy was described as one of the most severe postoperative pain modes, more than 70% of

patients needed analgesics after thoracotomy during the immediate postoperative period.

The incidence and duration of pain indicates that postoperative pain occurs more frequently and is

more severe following intrathoracic surgery (i.e. thoracotomy or sternotomy). The intensity of

steady wound pain after thoracotomy was severe in 45-65% of patients and moderate in 25-35% of

patients. Following sternotomy, steady wound pain in 60-70% of patients and moderate in 25-35%

of patients was severe. Movement that places tension on the incision, such as deep breathing,

coughing, or extensive body movements, increases pain intensity after intrathoracic operations. The

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average duration of severe pain in this survey was 3 days after thoracotomy (range: 2-6 days) and 4

days after sternotomy (range 2-7 days).

The intercostal, vagus, and phrenic nerves convey noxious input associated with thoracic surgery to

the central nervous system. Afferent phrenic activity is believed to be the source of shoulder pain

that often accompanies thoracic procedures as phrenic but not suprascapular or epidural blockade

curtails this. Intercostal nerve dysfunction resulting from incision, retraction, trocar placement, or

suture is common and likely plays an important role in the thoracic surgery that accompanies pain.

Furthermore, the need for constant respiratory effort and an increased pulmonary toilet creates an

intense and relentless barrage of noxious input into the central nervous system. Initial reports

showed that 50% of patients describe pain 1 year after thoracotomy, with many reporting pain even

years later. Fortunately, if perioperative pain is handled aggressively, the prevalence of

postthoracotomy pain may be modifiable, with rates as low as 21% one year after surgery.

Surprisingly, video-assisted thoracic surgery (VATS) is associated with a prevalence of chronic

pain comparable to that of open procedures, with pain rates ranging from 22% to 63%, likely due

to intercostal nerve and muscle damage from insertion of trocars. Residual pain after surgery, on

the other hand, is reported to be 25% after median sternotomy, stressing the role reduced intercostal

nerve disruption and enhanced closure stability may contribute to chronic pain reduction. Several

demographic and clinical factors help identify patients who are predisposed to chronic post-

operative pain development. These include anxiety, depression, previous surgery, concurrent pain,

lesions of the chest wall, youth, female sex, and increased levels of pain and analgesic use in the

perioperative period.

1.4 Acute postthoracotomy pain

Severe acute pain after thoracotomy caused by retraction, resection, or fracture of ribs, dislocation

of costovertebral joints, injury of intercostal nerves, and further irritation of the pleura by chest

tubes is a normal response to all these insults .Acute pain after video-assisted thoracoscopic surgery

is considered less severe. Suboptimal management of pain after thoracotomy (or after video-

assisted thoracoscopic surgery in patients who have severely limited respiratory reserve) has major

respiratory consequences. Inspiration is limited by pain, which leads to reflex contraction of

expiratory muscles and consecutively to diaphragmatic dysfunction (decreased functional residual

capacity and atelectasis, shunting, and hypoxemia). Moreover, most patients are early extubated to

decrease the risk of pulmonary barotrauma (especially bronchial suture line "blowout") and to

prevent respiratory sequelae such as pulmonary infection. The incision needs to be stretched deep

breathing. Since this can be extremely painful, patients without adequate analgesia attempt to

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prevent stretching of the skin incision by contracting their expiratory muscles, i.e. splinting, thereby

limiting the stretch during inspiration on the incision. This failure to inspire deeply before a

powerful exhalation leads to ineffective cough, which in turn promotes secretion retention, leading

to the closure of the airways and atelectasis

1.5Chronic postthoracotomy pain

Postthoracotomy pain syndrome (chronic postthoracotomy pain or post-thoracotomy

neuralgia, PTPS) is defined by the International Association for the Study of Pain as ‘‘pain that

recurs or persists along a thoracotomy incision at least two months following the surgical

procedure.’’ In general, it is burning and stabbing pain with dysesthesia and thus shares many

features of neuropathic pain . PTPS is acknowledged increasingly by anesthesiologists and

surgeons alike.(6)

Prevalence of post-thoracotomy pain

Chronic post-thoracotomy pain was commonly noted by surgeons during the Second World

War in men who had had a thoracotomy for chest trauma; it was called chronic intercostal pain.

Unfortunately, not much has changed since then, as the majority of patients do not seek help

for their pain, but mention it only when specifically asked. Furthermore, despite a commonly

held belief that post-thoracotomy pain is transient, there is no evidence that the pain experience

decreases significantly over time. For example, incidence of long-term post-thoracotomy pain

has been reported to be 80% at 3 months, 75% at 6 months, and 61% at one year after surgery;

incidence of severe pain is 3–5%, and pain that interferes with normal life is reported by about 50%

of patients .

Mechanism of postthoracotomy pain

There are several mechanisms for chronic pain after thoracotomy, and no consensus exists

regarding causality.

Intercostal nerve damage Surgery

The intercostal nerve is routinely crushed by surgery, especially as the nerve is quite exposed on the

rib's caudal side. When the chest is closed, it is also common for the nerve to be completely severed

or included in a suture. Mechanical damage during rib resection and compression with a retractor

are among the many possibilities of nerve injury. Incidental rib fractures may also immediately

damage the intercostal nerve or interfere with an in tercostal nerve during healing, resulting in

neuropathic pain symptoms. The sensation of pain in response to a normally non-painful stimulus

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(allodynia) or an exaggerated response to a slightly painful stimulus (hyperalgesia), especially

when accompanied by numbness, is considered to be diagnostic for nerve injury. These symptoms

often occur along the intercostal nerves ' area of distribution / innervations and are the most

common feature of post-thoracotomy pain.(6)

Tumor Recurrence

Many studies showed that increased pain could also be an early tumor recurrence.

Type of incision

The amount of postoperative pain has correlated many surgical techniques. Even muscle - sparing

incisions appear to have no major advantage over posterolateral incisions Overall, subsequent pain

has not been shown to be reduced by variations in surgical techniques.( 4,5)

1.6 Pain management after thoracic surgery

1.6.1 Systemic analgesia

Systemic analgesia may be divided into systemic opioids, non steroidal anti-inflammatory drugs

(NSAIDs), paracetamol and ketamine. Opioids, NSAIDs, and ketamine can be delivered using

intravenous, intramuscular or subcutaneous routes. Patient controlled analgesia devices (PCA) can

be useful when administering intravenous opioids.

Combinations of NSAIDs and opioids or opioids and regional analgesia are also common.

Systemic opioids

Systemic opioids have been used as the cornerstone of postthoracotomy analgesia in the past;

however, pain control has often been poor. As part of a multimodal strategy including nerve blocks,

it is now appreciated that systemic opioids are best administered for open thoracotomies. Systemic

opioid titration after thoracotomy is required if the balance between beneficial effects and

detrimental effects (sedation and suppression of ventilation, coughing and sighing) is to be

achieved. IV-PCA systems provide superior analgesia and enhance patient satisfaction compared to

IM opioids. Partly because IV-PCA systems accommodate the multiple in post-operative opioid

requirement between patient variation, halving opioid requirements approximately every 24 h post-

operatively, and the small group of patients experiencing minimal post-operative pain.

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NSAIDs

Analgesia is a cornerstone of postoperative therapy to reduce postoperative complications and stay

in the hospital, not only for ethical reasons. Postoperative pain remains an unresolved problem

despite all the advances in pharmacology therapy. Perioperative pain is a complex and multi-

factorial phenomenon that often needs to be effectively controlled by combining several drugs with

different mechanisms of action to mitigate the analgesic effects with each drug's synergism and

additive effect, thereby reducing related analgesic side effects. The best choice for treating

postoperative pain is a multimodal and multidrug approach. Different techniques and drugs are

used: central and peripheral nerve blocks, opioids, NSAIDs, paracetamol, local anaesthetics,

glucocorticoids and gabapentinoids. A single analgesic class is rarely adequate. The association is

often used because some drugs have certain limitations such as ceiling effect, high-dose

contraindication, respiratory insufficiency, liver damage, risk of upper gastrointestinal

complications or kidney failure. For postoperative pain treatment, the concept of multimodal

contest-sensitive analgesia is now well accepted. Different types of analgesics have been shown to

be more effective than a single drug due to different mechanisms of action and can be used at low

doses to reduce the incidence of side effects and to improve the quality of perceived analgesia.

Many pharmacological trademarks have therefore introduced associations of analgesic drugs such

as paracetamol plus tramadol, or codeine plus paracetamol and NSAIDs at a fixed dose whose

association increases the analgesic effect for the different analgesic mechanism postulated.

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ketorolac provide pain relief by reducing

prostaglandin production through cyclooxygenase (COX) inhibition and can be administered as

adjuncts throughout the perioperative period, with their main benefit being effective pain relief

without breathing depression. In one study of patients undergoing thoracotomy, the simultaneous

use of NSAIDs reduced pain scores by about 60% and postoperative parenteral opioid consumption

by 30%. Numerous NSAIDs for the 2 COX types (I and II) are available with varying selectivity;

these can be administered perioperatively via oral or rectal routes. In particular, the convenience of

preparing for intravenous administration during the intraoperative and immediate postoperative

period resulted in ketorolac, a non-subtype selective COX inhibitor, being one of the most common

NSAIDs administered perioperatively. Due to the potential for side effects, low risk of

gastrointestinal bleeding, coagulopathy, acute kidney injury, and hypo perfusion should be

considered for patients considered for NSAID analgesia.

Paracetamol—NSAIDs

Paracetamol is classified as mild analgesic and not as NSAID because its anti-inflammatory activity

is weak. It is found that paracetamol in patients with thoracic epidural analgesia can decrease post-

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thoracotomy ipsilateral shoulder pain when given preemptively and regularly during the first 48

hours postoperatively . The pain relief from NSAIDs is due to the inhibition of cyclooxygenase, an

enzyme that is involved in the production of prostaglandins, prostacyclins and thromboxans, which

are all involved in the generation of pain . The NSAIDs usually used for postoperative pain

management are diclofenac, ketorolac, lysine acetyl salicylate, indomethacin, piroxicam, and

tenoxicam. NSAIDs affect adversely the coagulation because they cause platelet dysfunction,

making systemic bleeding more possible. This effect is independent from the route of

administration. Among the others potential adverse effects, the renal dysfunction and the

gastrointestinal bleeding are the most important . The patients with pre-existing renal disease,

hypovolemia or treatment with loop-diuretics are more vulnerable to acute renal failure.

Intramuscular diclofenac 75 mg/12 h , rectally indomethacin 200 mg/24 h or continuous

intravenous lysine acetyl salicylate (7.2 g/24 h) decrease the required quantities of morphine and

the postoperative VAS scores. Indeed, the i.v. lysine acetyl salicylate was comparable with i.v.

infusion of morphine (40 mg/24 h).

Opioid

Opioids are widely used for intraoperative and postoperative pain management and are commonly

used for severe postoperative pain management. Opioids are versatile; delivery options for

perioperative delivery include delivery of infusion to oral, intravenous, intramuscular, and

neuraxial injection or catheter. When using an intravenous strategy, advanced days include quick

initiation and titration facility. In order to minimize over sedation, a patient-controlled analgesic

system can be programmed to deliver a baseline continuous infusion of a drug with patient-

delivered or patient-delivered doses alone. Patient satisfaction with this strategy rivals neuraxial

analgesia, although opioid side effects must be cared for by the perioperative care team.

It has been shown that epidural analgesia is superior to i.v. Morphine through devices for patient-

controlled analgesia (PCA). In addition, when used as sole agents, the doses of opioids required to

produce comparable analgesia also produce significant respiratory depression; therefore, opioids

are relegated mainly to adjuncts to a regional technique. The major drawback of opioids used for

postoperative pain treatment is the narrow therapeutic window, resulting in nausea, vomiting,

somnolence, or even moderate doses of respiratory depression. In addition, patients undergoing

chronic opioid therapy may develop tolerance to these drugs, making it more difficult to relieve

pain with their use.

In that case, the use of gabapentin may provide preventive analgesia, limiting the incidence in these

patients of Chronic Post - Operative Pain Syndrome. The i.v. combination Opioids and i.v. NSAID

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With satisfactory anticoagulation and renal function safety, it has become popular. In addition there

are other regional alternatives that can be used in effective combination with the systemic use of

opioids, such as the intercostal, intrapleural, intraspinal and paravertebral blockade with the use of

local anesthetics.

Ketamine

Ketamine is a non-competitive antagonist which blocks the ion channel associated with NMDA

receptor. By this way the central hyperexcitability of dorsal horn neurons is blocked. The activation

of NMDA receptor plays an important role in post injury central sensitization and hyperalgesia,

suggesting that systemic ketamine may be used effectively in treating postoperative pain . After

thoracic surgery, i.m. administration of ketamine 1 mg/kg resulted in similar pain scores and in

weaker respiratory depression in comparison with i.m. pethidine 1 mg/kg . Ketamine is capable of

decreasing significantly immediate post-surgical pain after thoracotomy, but has no benefits in

preventing chronic pain measured in long-term follow up (post thoracotomy pain syndrome).

Intravenous administration of ketamine at induction dose 1 mg / kg, followed by infusion at

intraoperative dose 1 mg / kg /h and 1 mg / kg/24 h postoperatively improved immediate

postoperative pain, but failed to control chronic pain development at 1-2, 6 weeks and 4 months

after surgery. Similar results are generated from the addition of epidural ketamine (1.2 mg / h) to

levobupivacaine and fentanyl preventive epidural analgesia. No difference was observed between

the two groups in the incidence of chronic post-thoracotomy pain at 3 months .

Noxious inputs of pain cause prolonged firing of nociceptors of C-fibre resulting in glutamate

release. Glutamate is a major exciting transmitter in the central nervous system that activates

postsynaptic NMDA receptors that contribute to pain treatment and pain phenomena such as wind

up and neural plasticity of the spinal cord. Enhanced activation of the NMDA receptor plays a role

in inflammatory and neuropathic pain and results in secondary hyperalgesia activation and

exacerbation. Since ketamine blocks the NMDA receptors, its administration before the noxious

stimulus (thoracotomy) may prevent the central sensitization of pain (pre-emptive effect).

The clinical effect was better pain control as shown in the first 48 postoperative hours by lower

VAS scores in ketamine compared to placebo group. While VAS score was only measured at rest

and not at movement, ketamine also provided pain relief during chest wall mobilization in theory.

Ketamine compared with placebo group presented a lower trend of chest drainage duration and of

atelectasis that required bronchoscopic aspiration. In theory, the better control of pain during the

mobilization of chest wall allowed efficacious cough with a rapid re-expansion of the lung and an

early surgical recovery. Pre-operative administration of ketamine may be an effective adjunct to i.v.

17

Opioid analgesia in pain management with acute post-thoracotomy. Patients with ketamine

experienced a significant reduction in pain scores, inflammatory response and morphine intake

compared to placebo. Thus, the preventive administration of ketamine followed by i.v, in line with

a philosophy of multianalgesic treatments of post-thoracotomy pain. In situations where epidural

analgesia or other analgesic procedures differ from i.v., morphine analgesia may be clinically

relevant. Analgesia with opioids is not available or contraindicated.

1.6.2 Regional Anesthesia Techniques

In thoracic surgeries, regional anesthesia plays an important role. After thoracic surgery, severe

pain is common. Regional anesthesia results in better pain control, better stress response control,

and lower respiratory complications compared to systemic opioid analgesia. This will improve

overall patient outcomes.

Furthermore, chronic pain following thoracic surgery is common and may persist for several years,

this complication may be reduced by using regional analgesic techniques. Non-intubated surgery

with regional anesthesia has recently been reported for high-risk patients. There are several

techniques for thoracic surgery for regional anesthesia.

Regional anesthesia techniques for patients undergoing thoracic surgery can provide excellent pain

management. Because of their superior track record of pain control and improved results, both

thoracic epidural analgesia and paravertebral analgesia are often considered optimal modalities for

postthoracotomy analgesia. Other regional technologies, including but not limited to intrathecal

opioid analgesia, intercostal nerve block (ICNB), intercostal cryoanalgesia and intrapleural

analgesia, can help improve pain scores and reduce opioid use.(2)

Anatomy Crucial To Thoracic Surgery

Thoracic surgery involves several nerves. The intercostal nerve at the incision site and ribs is the

most important component in the skin and muscles. Damage to the intercostal nerve can lead to

chronic pain, and regional anesthesia should block nociceptive transmission through the intercostal

nerve. The vagus and phrenic nerves are associated with mediastinal and diaphragmatic pleura pain

stimuli, and after surgery the brachial plexus is associated with shoulder pain. Therefore,

multimodal analgesia with opioids and non-steroidal anti-inflammatory drugs (NSAIDs) should be

considered together with the use of regional analgesia techniques. The intercostal nerve runs

between the muscle and pleura of the internal intercostal. The intercostal nerve block (INB)

involves a distal approach to the intercostal nerve, whereas a more proximal approach is involved

in the thoracic paravertebral block (TPVB). TPVB provides multi-segmental intercostal nerve

18

blockade as well as sympathetic block; therefore, it is a good alternative for epidural analgesia for

thoracic surgeries.

The first choice of regional thoracic surgery anesthesia is epidural analgesia. Recently ultrasound-

guided TPVB is a good alternative when patients receiving anti-coagulant therapy or those with

bleeding tendencies are contraindicated with epidural analgesia. Although TPVB is safer for these

patients than epidural analgesia, care should be taken to select it. The intercostal nerve block or

interpleural block may be considered when these two blocks are contraindicated.

Thoracic Epidural Analgesia

A thoracic epidural injection is a shot that temporarily contributes to thoracic region pain relief.

That's the back's upper to middle. Medicine is injected into a spinal cord area. This area is referred

to as the epidural space. The spinal cord is a delicate bundle of nerves running from the lower back

to the brain. The spinal cord nerves enable the brain to communicate with the rest of the body. The

spinal cord is surrounded by the epidural space. The column of many small bones (vertebrae) is the

hard structure of the spine or backbone. The spinal column bones help protect the spinal cord

against injury. There are intervertebral disks between these bones. These disks are cushioning the

vertebrae. They also provide flexibility for the backbone. Nerves that leave the spinal cord may get

pinched or inflamed at times. For example, this could happen when part of an intervertebral disk

presses into the spinal cord and nerves space.

Indications

Thoracic epidural analgesia continues to be a key component of acute pain services based on

anesthesia and is used after thoracic surgery, abdominal surgery, and rib fractures to treat acute

pain. TEA is warranted when a thoracic or upper abdominal incision is expected to be moderate to

large. In fast-track surgery, TEA can also be a useful adjunct by optimizing pain relief, attenuating

the response of surgical stress, and allowing early mobility. TEA with local anesthetic is an

important component of colorectal fast-track procedures as it reduces postoperative ileus duration.

Provides a comprehensive list of open surgical procedures in which postoperative pain can be

treated with TEA. There is no unique TEA contraindication that is not applicable to all neuraxial

procedures. TEA is widely used thoracotomy analgesic technique. Inserting a thoracic epidural

before general anesthesia facilitates patient feedback on improper placement and allows evaluation

of its effectiveness. The insertion point is usually at the level of T5–T6 midway along the

dermatomic distribution of the incision thoracotomy. Due to the steep caudal angulation of the

spinous processes at this level, difficulties in locating the epidural space are often encountered;

19

therefore, some anaesthetists prefer a paramedic approach that avoids spinous processes. Because

of its proven record of excellent dynamic pain relief and prevention of postoperative pulmonary

complications, TEA has long been considered the gold standard regimen for patients undergoing

thoracic operations. Epidurals can be placed eitherpre-operatively or post-operatively, depending

on the size of the surgical incisions (VATS vs thoracotomy) and the patient's tolerance (opioid-

dependent vs naive). Although the timing of initiation of TEA remains controversial, it has been

shown that its continuous use for at least 48 hours postthoracotomy provides the benefits of optimal

pain control and improved results. Our typical practice is to keep epidurals in place until drains

from the chest tube are removed.

The shoulder pain reported by patients with thoracotomy is mostly referred to as pain, and epidural

analgesia does not cover it. Most surgeons would agree that shoulder pain is a major problem of

postoperative pain that deserves particular attention.

Shoulrer Pain

More than 75% of patients with thoracotomy report constant severe ache in the post-surgery

ipsilateral shoulder. This pain is relatively resistant to opioids intravenous and is only partially

relieved through NSAIDs. Postulated mechanisms include transection of a major bronchus,

ligamentous strain caused by malposition or surgical mobilization of the scapula, pleural irritation

caused by the thoracostomy tube, or referred pain caused by pericardial irritation or mediastinal and

diaphragmatic pleural surfaces. Several methods with varying results have been investigated. There

was no effective pain relief intrapleural bupivacaine. Superficial cervical plexus or brachial plexus

blocks in some patients effectively reduced localized shoulder pain, whereas suprascapular nerve

block was not helpful. Through intraoperative infiltration of the periphrenic fat pad with lidocaine,

the incidence of shoulder pain decreased from 85% to 33% and the overall pain scores decreased.

Ropivacaine reduced incidence by 0.2 percent and postoperatively delayed the onset of shoulder

pain for the first 24 hours without adverse effects on respiratory function. It appears that pain can

be referred to as the main source of shoulder pain via the phrenic nerve (blocked by periphrenic

infiltration and interscalene brachial plexus block) with a contribution from positioning and surgery

(coracoid impingement syndrome and coraco-clavicular ligament strain), partially relieved by the

use of NSAIDS) and acetoaminophen. However, pain was still reported by some patients who

received phrenic nerve infiltration. This may be due to anatomical variations in the emergence of

phrenic nerve sensory fibers, reaching the pleura's fibrous pericardium and parietal layers The most

effective management strategy would be multimodal, consisting of acetoaminophen (preventive and

20

regular), if not contraindicated NSAIDS, and long-acting local anesthetic infiltration of the phrenic

nerve.

Intercostal Nerve Blocks

Intercostal nerve blocks are simple to perform and useful for pain management either as the

primary intervention or as adjuncts. They are useful for pain in the chest wall and upper abdomen.

The intercostal nerves (ICNs) intimate the major parts of the skin and musculature of the chest and

abdominal wall. In the 1940s, clinicians noticed that intercostal nerve blocks (ICNBs) may reduce

pulmonary complications and opioid requirements after upper abdominal surgery. Continuous

ICNB was introduced in 1981 to overcome the issues associated with repeated multiple injections.

Today, ICNB is used in a variety of acute and chronic pain conditions that affect the thorax and

upper abdomen, including breast and chest wall surgery. In addition, it facilitates its practice by

introducing ultrasonic guidance to regional anesthesia practice.

Indications

Incisional pain from thoracic surgery

Analgesia for thoracostomy

Herpes zoster or post-herpetic neuralgia

Rib fractures

Breast surgery

Upper abdominal surgery

Differentiating between visceral and somatic pain

Contraindications

Patient refusal for the procedure and active infection over the injection site are the only absolute

contraindications. Other relative contraindications include local anesthetic allergy, prior nerve

injury or damage, patient's inability to consent to the procedure, anticoagulation or coagulopathy.

The expected results of the intercostal nerve block and relevant potential complications should be

advised to patients. If patients have prior nerve injury or neuromuscular disease involving the area

to be blocked, special consideration should also be given.

Equipment

Equipment includes:

Skin antiseptic

Sterile towels

Sterile gauze

21

50 cm 22 g needle for local anesthetic injection

25 g needle for skin wheal

Local anesthetic

Sterile gloves

Ultrasound machine

Marking pen

ECG monitor

Blood pressure monitor

Pulse oximetry

Generally, to maximize pain control, a long-acting local anesthetic such as 0.2% ropivacaine or

0.25% bupivacaine is chosen. It may be considered that continuous blocks with a nerve catheter are

rarely used for this particular nerve block. Because of the high degree of local anesthetic intake

from the intercostal space, local anesthetics can be considered and the maximum dosage allowed

should be calculated, especially if multiple levels are to be blocked.

Technique

Successful intercostal nerve block results in local anesthetic being deposited outside the parietal

pleura in the intercostal sulcus. Correct positioning will result in ipsilateral numbness of the

blocked individual intercostal levels. Unless a large amount of local anesthetic is injected or the

needle placed too close to the midline resulting in spread to the paravertebral space, it is rare for the

blockade to extend to higher or lower levels. The block level is usually determined by the number

of blocks performed and is restricted to the dermatome of the targeted intercostal nerves.

The spinal cord's nerves split into a dorsal ramus. The upper 11 ventral thoracic rami is the

intercostal nerve running between the ribs in the intercostal spaces. Each intercostal nerve provides

a lateral cutaneous branch that pierces proximal intercostal muscles to the rear axillary line to

provide the chest wall's lateral aspect. Therefore, to ensure that the lateral cutaneous branches are

blocked and thus the lateral aspect of the chest wall, it is important to block the intercostal nerves

posterior to the posterior axillary line. The thoracic dorsal rami passes backwards near the vertebrae

to provide the cutaneous innervation to the back. The dorsal rami is not blocked by an intercostal

nerve block. This limits the effectiveness with intercostal nerve blocks of posterolateral

thoracotomies. The intercostal nerves can be easily blocked under direct vision, while the chest is

open, but due to the relatively short half-life of most local anesthetics, repeated percutaneous

blocks are usually required. Although the position of intercostal nerves within the intercostal space

varies considerably, intercostal nerves consistently lie in a plane deep within the intercostal muscle.

22

A small (5 ml) bolus of local anesthetic deposited in the proper plane blocks the appropriate

intercostal nerve. Larger doses can also block adjacent intercostal nerves by spreading medially or

directly to adjacent spaces. The systemic take-up of local anesthetics from the highly vascular

intercostal space is rapid and the dose of local anesthetics administered by this route needs to be

adequately restricted. Intercostal nerve blocks significantly reduce the need for postoperative pain

and analgesic post-thoracotomy.

Complication

To avoid infection, care should be taken to perform this block using sterile technique. In order to

reduce the risk of bleeding, the history of coagulopathy or anticoagulation should be discussed.

Performing this block wake may alert the provider to pneumothorax or intraneural injection

symptoms that may go unnoticed in a patient with sedation or anesthesia. Pneumothorax is rare and

usually requires only monitoring, although providers should be prepared to decompress needles or

insert a chest tube if necessary. Fortunately, local anesthetic systemic toxicity is also a rare

occurrence. However, this region's local anesthetic take-up is high, and providers should be able to

recognize last and provide adequate treatment. Using diluted local anesthetic concentrations and

keeping the total dose below the maximum permitted dose will reduce the risk of systemic toxicity.

Several inadvertent spinal case reports were described after intercostal nerve block. This is thought

to be secondary to local anesthetic spreading through the dura medially, or to the rare occurrence of

injection into a dural sac described as protruding from the vertebral foramen laterally. In order to

try to exclude these complications, aspiration to exclude intravascular, intrapleural or intrathecal

injection should be performed before injection, but negative aspiration is not a guarantee. Patients

should be monitored for 20 to 30 minutes after the block has been removed.(7)(8)

Paravertebral blockade

Paravertebral blocks can be performed as so-called "single-shot" blocks, with the introduction of a

single dose of long-acting local anesthetic, or they can take the form of a continuous block, by

placing a catheter that allows local anesthetic infusion. Continuous thoracic paravertebral blocks

can provide excellent post-thoracotomy analgesia, and several studies have shown that analgesia is

comparable to that provided by thoracic epidurals but with fewer complications such as urinary

retention, hypotension, nausea, vomiting, and pruritis and less perioperative hemodynamic

instability.

The thoracic paravertebral space begins at T1 and extends caudally to T12.

23

PVBs can be performed in the cervical and lumbar regions but there is no direct communication

between adjacent levels in these areas. Most PVBs are therefore performed at the thoracic level.

The thoracic paravertebral space is wedge shaped in all three dimensions.

Medially: The bodies of the vertebrae, intervertebral discs, and intervertebral foraminae.

Anterolaterally: the parietal pleura and the innermost intercostal membrane.

Posteriorly: the transverse processes (TPs) of the thoracic vertebrae, heads of the ribs, and the

superior costotransverse ligament.

The paravertebral space contains spinal nerves, white and grey rami communicantes, the

sympathetic chain, intercostal vessels, and fat.

Indications

Paravertebral nerve blocks are indicated for surgical procedures requiring unilateral analgesia or

anesthesia. Common cases benefitting from unilateral paravertebral blocks are breast surgery,

thoracotomy, herniorrhaphy, open cholecystectomy, and open nephrectomy. Bilateral paravertebral

blocks can be a viable option for midline abdominal surgery. The clinician may consider thoracic

paravertebral blockade over thoracic epidural analgesia in patients for whom bilateral

sympathectomy and subsequent hypotension would be especially detrimental. For example, the use

of thoracic paravertebral blockade in a patient with severe aortic stenosis has been reported. In

another study, thoracic paravertebral blockade resulted in more stable hemodynamics and

equivalent analgesia when compared to thoracic epidural analgesia in thorocotomy patients.

However, because bilateral spread can occur , which may cause hemodynamic compromise similar

to epidural blockade. Another unique feature of thoracic paravertebral blockade compared with

thoracic epidural analgesia is the relative safety when performing these blocks on patients with a

marginal coagulation cascade. This does not mean, however, that thoracic paravertebral blockade

can be performed on patients with coagulopathy without caution. According to the American

Society of Regional Anesthesia and Pain Medicine’s evidence-based guidelines, in the patient

receiving antithrombotic or thrombolytic therapy, the exact same precautions should be taken when

placing thoracic paravertebral blockade as when placing an epidural. However, if bleeding occurs

in the thoracic paravertebral space, significant blood loss will be the likely complication rather than

epidural hematoma and neurologic deficit.

Methods Of Performing Paravertebral Blocks

Several approaches to access the paravertebral space are described, and they can be widely divided

into those performed preoperatively using landmark or ultrasound-guided techniques and those

24

performed intraoperatively under direct vision. The patient can be positioned either sitting or in the

lateral decubitus position when blocks are performed in the awake patient. The anesthetized patient

is usually positioned in the lateral decubitus position after anesthesia induction, with the side to be

blocked at the top. Blocks should generally be performed at the level of the intended incision(s)

described, due to the more caudal position of the ports, for thoracoscopic surgery, performing

blocks and inserting catheters at T5/6 for upper / middle lobe surgery and T6/7 for lower lobe

operation.

Ultrasound-Guided Methods

Percutaneous paravertebral thoracic blocks are technically easy to perform but have a failure rate of

up to 10 %. Using the guidance for ultrasound may result in lower failure rates. Ultrasound-guided

paravertebral thoracic blockade can be divided into in-plane techniques where the needle's long

axis is fully visualized as it traverses the ultrasound plane to the target and out - of-plane techniques

where the needle enters the skin away from the probe and across the scanning plane, allowing it to

be visualized only in its short axis. The approach can be either in the plane of transversal or sagittal.

The most frequently performed blocks described are using a linear ultrasound transducer and this is

reflected in the accompanying images. Some groups advocate using micro-convex array

transducers to enable deeper structures to be better imaged. For all techniques, correct identification

of landmarks is essential, although their appearance will vary depending on the transducer's

orientation. Published a detailed description of the para-vertebral space's ultrasonographic anatomy

and its adjacent tissues.(9),(16)

Open Methods

It has been shown that placing a paravertebral catheter through a percutaneous approach is

challenging and the catheter tip's eventual position is unpredictable. The position of paravertebral

catheters in cadavers was assessed with ultrasound guidance Only 60 percent of catheters were

positioned as intended. Twenty percent had passed into the pre tebral space before the vertebral

bodies, 15 percent had passed into the soft tissue after the vertebral bodies, and 5 percent had

passed into the epidural space. Thus, while catheters can be percutaneously placed in the

paravertebral space, it may be more appropriate for the surgeon to insert the catheter under direct

vision in the paravertebral space while the chest is open. Direct placement facilitates the catheter's

clear progression along the paravertebral space to create a narrow longitudinal pocket that can

block enough dermatomas to provide adequate analgesia.(10)

25

Advantages Of Thoracic Paravertebral Block

Technical

Simple and easy to learn

Safer and easier than thoracic epidural

Palpation of rib not necessary and scapula does not interfere with block

Safe to perform in sedated and ventilated patients

Catheter placement under direct vision during thoracic surgery is safe and accurate

Chest drain loss of local anesthetic is four times lower than that of interpleural block

Clinical

Single injection produces multi dermatomal ipsilateral somatic and sympathetic nerve block

Reliably blocks the posterior primary ramus

Abolishes cortical responses to thoracic dermatomal stimulation

Inhibits stress and pressor response to surgical stimuli

Maintains hemodynamic stability

Reduces opioid requirements

Low incidence of complication

Preserves bladder sensation

Preserves lower limb motor power

Promotes early mobilization

No additional nursing vigilance required

Complications

Complications of paravertebral nerve blocks may include the following:

Failed block

Hypotension

Vascular puncture

Pleural puncture

Pneumothorax

Intradural opioid analgesia

Intrathecal opioid administration can provide an excellent method of controlling acute

postoperative pain and is an attractive analgesic technique as the drug is directly injected into the

26

CSF, near the central nervous system structures where the opioid acts. The procedure is simple, fast

and the risk of technical complications or failure is relatively low. In the intradural route, a

lipophilic opioid such as fentanyl (20-40 μg) and/or a hydrophilic opioid such as morphine (100-

300 μg) are increasingly associated with opioids of different characteristics. In the form of a pre-

operative bolus with LA to ensure coverage during both the immediate (2-4 h) and the late (12-24

h) post-operative period. The association of a lipophilic opioid with bupivacaine or lidocaine leads

to a shortening of the block's onset and an improvement in intraoperative analgesia, as well as

during the first hours of the postoperative period without prolonging the engine block or extending

the discharge time, making it a good choice for outpatient surgery.

The use of intrathecal medicines in the treatment of acute pain, a maximum effective dose of

morphine has been recommended, the negative effects of which seem to exceed the beneficial

effects ; after doses > 300 μg, nausea and itching usually appear, as well as severe urinary retention,

and in studies of healthy volunteers, all of them with respiratory depression when doses exceeded

600 μg.

Pain Relief after Thoracic Surgery

Continuous thoracic paravertebral infusion of local anesthetics through a catheter placed under

direct thoracotomy vision is a safe, simple and effective method for post-thoracotomy analgesia.

Usually used in adults in conjunction with adjunct medicines (opioid or non-steroidal anti-

inflammatory medicines) to provide optimal pain relief after thoracotomy. Although additional

analgesics are required, there is a significant reduction in opioid requirements. A continuous

thoracic paravertebral infusion of local anesthetic together with adjunct medicines provides very

effective pain relief with few side effects. Pain relief is superior to placebo and patient-controlled

morphine intravenous and comparable to interpleural analgesia, lumbar epidural morphine, and

bupivacaine or bupivacaine fentanyl mixture thoracic epidural administration. Paravertebral

analgesia thoracic preserves better respiratory function and produces fewer side effects than

analgesia interpleural. There is also less frequency of hypotension and urinary retention than

thoracic epidural analgesia. Local anesthetic continuous thoracic paravertebral infusion provides

better control of pain after thoracotomy than an intermittent regimen of bolus. It reduces

postoperative decline in respiratory function, increases breathing mechanics recovery, and reduces

chronic postthoracotomy neuralgia generation. A balanced analgesic regimen, which includes

preoperative pain prophylaxis (opioid and non-steroidal anti-inflammatory drug premedication with

pre-incisional TPVB) in conjunction with postoperative paravertebral thoracic infusion of

bupivacaine, regular nonsteroidal anti-inflammatory drug and opioid on-demand, is very effective

27

in patients with thoracotomy. It prevents postoperative plasma cortisol increase preserves

preoperative respiratory function, and is superior to a balanced analgesic regimen with thoracic

epidural bupivacaine. (11),(19)

Infiltration Of Surgical Wound With Local Anesthestics

Now an integral part of modern anesthetic practice is effective postoperative pain management.

Management of postoperative pain not only minimizes patient suffering, but can also reduce

cardiorespiratory morbidity and facilitate rapid recovery. Early hospital discharge has a beneficial

effect on the costs of hospitals. While regional anesthetic techniques such as epidural analgesia or

perineural catheters have been shown to provide excellent analgesia, many of these analgesic

methods are time-consuming, expensive, and not without side effects. Since a significant proportion

of surgical pain is caused by the surgical wound, it would appear logical to use local anaesthetics at

the surgery site to manage perioperative pain. Local anesthetic has been used for many years for

simple incisional infiltration. Promising advances that may help improve this technique are the use

of longer-acting local anesthetic agents or placing a catheter directly in the wound at the end of the

procedure to infuse local anesthetic.(10)(21)(25)

Methods of local anaesthetic infiltration

Incisional infiltration perioperatively

In recent years, an important component of multimodal analgesia has been the infiltration of local

anesthetic around the surgical wound. It offers simplicity and low cost advantages. However, it has

one major drawback: analgesia duration is limited to local anesthetic action duration. For

bupivacaine and ropivacaine, this tends to be 4–8 h. The procedures in which incisional infiltration

appears to be particularly helpful1 are those in which there is a smaller component of visceral pain,

such as inguinal herniotomies in which pain scores were reduced for up to 24 hours and pain

consumption decreased overall. Following minor day surgery, local anesthetic infiltration has been

shown to reduce postoperative nausea and vomiting by reducing opioid requirements.(26)

Continuous Local Anaesthetic Wound Infiltration

The short-term problem of analgesia associated with incisional infiltration can be overcome by

providing a continuous infusion of a local anesthetic. The surgeon places a catheter directly in the

wound at the end of the surgical procedure. This is then attached to a pump that allows the infusion

of a predetermined amount of local anesthetic into the wound per hour.

28

Table1 Comparison of The Different Methods of Local Anaesthetic Infiltration

Local anaesthetic

infiltration method

Advantages Disadvantages

Single dose Simple

low cost; very useful for

small procedures

Limited efficacy; short duration of action;

potential for adverse local toxic effects

Continuous infusion

catheter

Prolonged provision of

analgesia; less PONV as

opioid sparing; no motor

block; decreases hospital stay

Needs skills and resources; catheter

dislodges easily; wound site leakage and

potential for infection; technical failure of

pumps; potential for adverse local toxic

effects

Tumescent Simple; low cost; improved

analgesia and prolong

duration; allows larger dose.

Limited to selected types of surgery;

potential for systemic local anaesthetic

toxicity if poor technique or very large

doses

Sustained release LA Simple to administer;

prolonged provision of

analgesia

Not commercially available (currently

phase 1–3 drug trials); delayed onset of

analgesia; unsteady levels in

experimental formulations;

unnecessarily long duration in some

formulations

Infiltration of local anesthetic at the site of surgical incision offers a rational approach to

perioperative analgesia. Unfortunately, due to the unfavorable pharmacokinetics of local

anesthetics, this technique is limited by a short duration of action. However, the idea of incisional

infiltration has been further developed and newer techniques such as continuous local anesthetic

wound infiltration systems, tumescent techniques, and sustained release local anesthetics have been

developed.There remain more details to be learnt with regard to these techniques, particularly in

relation to optimal dosing regimens, optimal placement, use of analgesic adjuvant, and whether

local toxic effects are more than a theoretical concern. However, given the relative simplicity and

potential efficacy of these techniques, they are certainly worthy of consideration and continued

investigation to define their role as a technique for perioperative analgesia.(10)(33)

29

Patient controlled analgesia (PCA)

PCA can approach the near optimal state of analgesia, maintained with minimum sedation and side

effects. The patient adjusts the repetition of dose to the analgesic needs, outreaching the minimum

effective analgesic concentration. Toxic drug concentrations cannot be reached because the

subsequent sedation acts prophylactically by stopping the dose repetition from the patient.

PCA can be used for drug delivery via intravenous (most frequently) or epidural route. PCA is not a

good analgesic alternative if the patient is confused and not capable of using the PCA pump

handset. Before the initiation of PCA use, a sufficient analgesic state should be established.

In the case of epidural PCA, a solution of L-bupivacaine 0.125 with fentanyl 4 mcg/mL gives

satisfactory analgesia. The bolus dose should be 3-5 mL, the lockout period 10-15 min with no

background continuous infusion. If the latter is the case, then the bolus dose should be decreased

and the lockout period increased!

If PCA is used for intravenous drug administration, it is commonly combined with paravertebral or

intercostal nerve blocks. Otherwise, the systemic opioids side effects may limit the dosage,

resulting in suboptimal analgesia with subsequent respiratory complications in thoracotomy

patients. The bolus doses could be morphine 1-2 mg, fentanyl 10-20 mg, pethidine 10 mg or

tramadol 10 mg. The lockout time should not be less than 5-8 min according to the above doses.

The background infusion may increase the incidence of respiratory depression and is useful only in

opioid tolerant patients.(26)(34)(35)

The major concern with the function of PCA is the respiratory depression. The risk is increased if

there is a background infusion, in elderly patients, if concomitant sedatives are administered, in

respiratory disease, in obstructive sleep apnea, and if there are operator or equipment errors. The

administration of bolus naloxone 400 mg i.v. or more reverses the respiratory depression, and

perhaps continuous naloxone infusion may be required, due to its shorter half life.

One of the most commonly used means of delivering opioid analgesics after major abdominal

surgery is patient-controlled analgesia (PCA). Using this reliable, programmable delivery system, a

variety of narcotic drugs including morphine, hydromorphone, meperidine, and fentanyl can be

self-administered. For several variables, including demand (bolus) dose, lockout interval, and

background infusion a PCA device can be programmed.(30)

Preemptive analgesia and thoracotomy

Some of the allodynia and hyperalgesia development mechanisms are well known. The concept of

sensitization has resulted in increased efforts to control acute pain through a more or less total

afferent blockade, with the aim of reducing post-thoracotomy pain development. Preventive

30

analgesia is intended to prevent incisional and inflammatory injuries from establishing central

sensitization. Basic research has shown that analgesic drugs are more effective if they are given a

noxious stimulus before, rather than after. Some clinical studies using local anesthetics, opioids,

and non-steroidal anti-inflammatory drugs have supported the benefit of preventive analgesia.

However, the clinical utility of preventive analgesia remained controversial, probably due in part to

the wide variation in conditions of study such as surgery, drugs, doses, routes of administration and

duration of treatment. It has also been shown that the degree of acute pain following thoracic

surgery predicts long-term post-thoracotomy pain, and therefore aggressive early post-operative

pain management may reduce the likelihood of long-term post-thoracotomy pain. A good analgesic

regime in the immediate perioperative period not only reduces pulmonary complications, but also

helps in early mobilization. A thoracic epidural is the most common technique for pain relief, with

the catheter in the mid-thoracic region having a continuous infusion of local anesthetics and

narcotics.(27)

2.ORGANISATION AND METHODOLOGY OF A RESEARCH

For this research, the literature search was conducted in the Pubmed, Science Direct, PLOS,

SAGE, Google Scholar databases and 35 literature sources were reviewed. Studies published in

English between 2009–2019 have been reviewed.

3.RESULTS

3.1Case study

49 years old white male was admitted to the Clinic of Cardiothoracic and Vascular surgery due to

rib fracture and haemothorax after trauma (trauma was 2 days ago). He was transferred from

emergency room after drainage of pleurae. He has history of allergy to pollen (hay fever), and had

appendectomy 5 years ago, otherwise healthy.

On admission to Department of Thoracic Surgery the patient complains for severe pain on the right

side of the chest due to trauma and drainage. Examinations shows the patient is conscious and

adequate to his status. Breathing is compromised by pain – BR – 25 x/min., inhalations are shallow.

The right side of the chest is painful to palpation, crepitation at the site of the ribs VIII-XI is felt.

HR – 90 x/min. ABP – 130/60 mmHg. According to VAS the pain intensity is 5–6 score at rest and

7–8 at movement.

The drainage is effective. The control chest x-ray shows better aeration of the right lung, no fluid in

right pleura. For pain management analgesic medications are prescribed as follows:

1. Paracetamol 1 g 4 x/ day

2. Tramadol 100 mg 2x/day

31

On the second to fourth day the patient feels better, the pain intensity according to VAS decrease to

from 3–4 score to no pain at rest and from 4–5 to 2–3 score at movement. The secretion from chest

drainage is decreasing. On the 8th

day the drainage is removed and patient is discharged from the

hospital in good physical status on the day 10th.

Three days after discharge patient returned back to the hospital due to the fever (38, 5 C) and

chills, shortness of breath. Laboratory exams show leucocytosis and increased CRP (leuk 10,62x

109/ l, CRP 138, 68 mg/l). The punction of pleura was performed and 700 ml of serohaemoragic

fluid was received. But the chest x- ray shows fluid still remaining in right pleura. It is decided to

perform chest CT in suspicion of organised and infected haemothorax. CT scan approves the

suspicion and the patient is scheduled for the right thoracotomy and evacuation of haemothorax.

On the morning of the surgery after written approval of the patient anaesthesiologist insert thoracic

epidural catheter into the epidural space at the level of Th5-6. After the test (Sol. Lidocaine 2 % – 8

ml) to verify the localisation of the catheter the standard general anaesthesia is induced. For

induction patient receive fentanyl, propofol and rocuronium. After induction patient is intubated

with left endobronchial double lumen tube N. 39. The localisation of the tube is verified with

fiberoptic bronchoscope. During the surgery anaesthesia is maintained with sevoflurane for

hypnotic sleep and analgesia is ensured by epidural anaesthesia (Sol. Bupivacaine 0,5 % 20 ml +

0,2 mg fentanyl + Sol. Na Cl 0,9 % up to 40 ml, continuous infusion at the rate of 6 ml/hour). At

the end of the surgery wound infiltration with lidocaine and bupivacaine mixture (2 % lidocaine 4

ml + 0,5 % bupivacaine 4 ml) was performed. After the surgery the patient is extubated in the OR

and conscious though under light sedation, breathing spontaneously oxygen via face mask is

transferred to ICU.

After admission to ICU pain according to VAS the pain at rest was 0–1, at movement – 2–3 score.

Analgesia is maintained by TEA continuous infusion 0,25 % bupivacaine 6 ml/hour. But on the

third to fourth hours after the surgery the patient complained for the pain in his right shoulder (VAS

– 4–5 score). For analgesia ketorolac 100 mg i/v was prescribed. The pain decreased to VAS 1–2.

Anyway after two more hours the pain in the thoracotomy region increased. TEA infusion rate was

increased to 7 ml/hour and fentanyl 0,1 mg was added to analgesic solution, but analgesia was

ineffective. It was decided that the epidural catheter was dislocated and it was removed. Systemic

analgesia i/v was prescribed. As the pain at rest was VAS 6–8 score and at movement 8 score,

continuous i/v infusion of morphine was administered (sol. Morphine 20 mg/ 20 ml, the rate on

infusion 2 ml/hour) as well as NSAIDs were prescribed as follows:

1. Ketonali 100 mg 3x/day

2. Diclophenaci 75 mg 2x/ day

32

3. Paracetamoli 1 g 4x/day.

Systemic analgesia was effective, on the next hour and later on the pain score was ≤ 1–2 score at

rest and ≤ 2–3 score at movement.

4. DISCUSSION OF THE RESULTS

Thoracic surgical procedures can be either thoracotomy or thoracoscopy. In thoracotomy, the

incision could be either muscle-cutting or muscle-sparing incision. The posterolateral thoracotomy

incision is used for most general thoracic surgical procedures. This incision, which involves

division of the latissimus dorsi and serratus anterior muscles, affords excellent exposure of the

thoracic cavity. However, it is associated with significant morbidity, including impaired pulmonary

function, postoperative chest pain, and restricted arm and shoulder movement. Various muscle-

sparing incisions have been proposed to decrease the morbidity. Postthoracotomy pain originates

from pleural and muscular damage, costovertebral joint disruption, and intercostal nerve damage

during surgery. Inadequate pain relief after surgery affects the quality of patient's recovery and

exposes the patients to postoperative morbidities. There is a tendency nowadays among thoracic

surgeons and anesthesiologists toward the area of enhanced recovery after thoracic surgery which

requires careful titration of the anesthetic drugs in awake patients undergoing thoracoscopic

procedures. There is a common feeling among thoracic anesthesiologists that postthoracoscopy

procedures produce less pain intensity versus thoracotomy which is partially true. However,

effective management of acute pain following either thoracotomy/thoracoscopy is needed and may

prevent these complications and reduce the likelihood of developing chronic pain. Adequate pain

relief leads to early mobilization, improves respiratory functions, and decreases global stress

response. Thus, good perioperative pain management significantly reduces postoperative

complications. Currently, numerous analgesic methods are available for the management of acute

postthoracotomy/thoracoscopy pain including patient controlled analgesia, infiltration with local

anesthetic (LA), intrapleural or intercostal nerve blockades, and neuraxial blocks. In this report, we

review the newly introduced postthoracotomy/thoracoscopy pain relief modalities with special

reference to the new tendency of awake thoracic surgical procedures and its impact on enhanced

recovery after surgery. (28)

In thoracic surgery, postoperative analgesia is important to prevent respiratory problems and

chronic pain. Sensory afferent nerves involved at the sites of pain following thoracotomy are

carried by intercostal nerves (T4-T6) at the incision site, intercostal nerves (T7-T8) at the sites of

thoracic drains, the vagus nerve in the mediastinal pleura, the phrenic nerve (C3-C5) at the central

diaphragmatic pleura, and the brachial plexus at the ipsilateral shoulder.

33

Epidural analgesia is accepted as the gold standard for thoracotomy pain. The paravertebral block is

another option to be used for analgesia. This provides a level of analgesia similar to the epidural

block and have a lower rate of side effects . Analgesia could be provided using a multi-level ICNB

through the administration of local analgesics through intra/extrapleural catheters. ICNB and IV

routes could also be used in the management of thoracotomy pain . For thoracotomy pain, a wide

space should be blocked and long-term analgesia should be required. In ICNB, a limited space is

blocked by a single injection. Therefore, the use of ICNB is limited due to the necessity of multiple

injections and the requirement of frequent repeats of these blocks. On the other hand, drugs that are

administered solely intravenously are effective in pain control, but higher doses of opioids are

needed to relieve the pain that is aggravated with coughing and respiration . The side effects of

thoracic epidural injections such as neuraxial hematomas, hypotension, vomiting, and urinary

retention are higher in frequency compared to the paravertebral block . Nevertheless, the

paravertebral block also has complications (such as total spinal block, pneumothorax, and neural

damage) which are reported in between 2.6% and 5.7% of cases .

In many surgical procedures, pain is often treated inadequately. Acute postoperative pain can have

detrimental effects on multiple organ systems, such as cardiovascular stress, autonomic

hyperactivity, tissue breakdown (catabolism with anabolic hormone suppression), increased

metabolic rate, pulmonary dysfunction (most significant after upper abdominal and thoracic

surgery), increased blood clotting (hypercoagulability), fluid retention, immune system

dysfunction, delayed bowel function (ileus) and chronic pain syndrome development following

certain surgeries (phantom limb pain following amputation, post-thoracotomy syndrome)

Preventive analgesia may have a potential role in reducing postoperative pain, as shown in animal

post-injury pain reduction, but human studies have produced controversial results. It has been

shown that epidural, intravenous and intramuscular opioids reduce the severity of postoperative

pain when given prior to surgical stimulation.

There are several studies in which the preventive effect of TEA was used to reduce post-

thoracotomy pain, but in only one, preventive thoracic analgesia was suggested to decrease pain

intensity for 2 or 3 days ; Before surgery, an epidural block of mepivacaine reduced long-term post-

thoracotomy pain. This study compared the effects of TEA pre- and postoperative initiation and

found a significant clinical effectiveness of preventive analgesia for the first 72 h.

In contrast, in post-thoracotomy pain, some studies found no preventive effect of epidural

anesthesia. Preventive effect in thoracotomy of thoracic epidural bupivacaine. They gave

bupivacaine of 8 mL of 0.5% containing 5 μg mL−1 of adrenaline through an extradural thoracic

catheter 30 min before incision and maintained anesthesia with propofol, alfentanil, and atracurium

infusions. In comparison with the placebo group after thoracotomy, thoracic epidural block with

34

bupivacaine did not have a significant preventive effect. Preoperative administration of bupivacaine

plus fentanyl has a marked preventive effect and reduces post-thoracotomy pain significantly for

postoperative 12 hours.

PCEA can provide several advantages over conventional continuous epidural infusion or bolus

techniques. After thoracotomy, use of PCEA with bupivacaine and fentanyl provided good

analgesia. Previous studies also showed effective postoperative analgesia with continuous infusions

of bupivacaine and morphine, bupivacaine and fentanyl, bupivacaine and sufentanil and epidural

boluses.

Post-Thoracotomy Pain Assessment

It has been suggested that'' making the pain visible'' is the key issue of postoperative pain

management strategies. This can be done through accurate documentation of pain assessment, as

well as monitoring the effectiveness of pain treatment, and the documentation should also include

the satisfaction of the patient. The American Pain Society emphasizes that pain should be

considered by health care professionals as the fifth vital sign. The pain of the patient should

therefore be evaluated at least as frequently as vital signs are taken. Many suggested evaluation

tools were found in the literature and many scales were developed to help the nurse determine the

severity of pain. The Numeric Rating Scale (NRS) and the Visual Analog Scale (VAS) are among

the most com-monly suggested standardized tools.

When using the NRS, the patient is asked to rate their pain intensity to 10 (the worst possible pain)

on a scale of 0 (no pain). The VAS is a 100 mm long horizontal line anchored at each end by word

descriptors. The patient marks the point of his current state on the line. The VAS score is

determined from the left hand end to the marks of the patient by measuring in millime-tres.

When assessing postoperative pain, the nurse must pay attention to the following:

Assess pain both at rest and on movement

Take patient self-reporting pain into account and implement the appropriate pain scale,

document intensity, quality, location, timing & duration, aggravating and alleviating factors,

and prior pain treatments and their efficacy.

Evaluation of pain before and after each treatment procedure.

On the surgical ward, regularly evaluate, treat and re-evaluatepain and patient response (e.g.

every 4-8 hours).

Defines the maximum score of pain above which pain relief is available.

Report the results to the pain management team.

Despite the focus on meeting postoperative pain management standards, there is an

overwhelming lack of patient reassessment by nurses after analgesic administration.

35

CONCLUSIONS

After surgery, pain control is central to the anesthetic management of thoracic surgical patients.

The provision of good postoperative analgesia is important in itself and is regarded by some as the

core business of anesthesia and a fundamental human right. Effective analgesia can reduce

pulmonary complications and mortality. It is unlikely that a single technique will fulfill these goals

optimally for all patients and that a balanced, multimodal approach should therefore be used.

Analgesia should be tailored to the specific patient undergoing a specific procedure to minimize

mortality, patient suffering, complications of the pulmonary system, and other morbidity.

Experience with a wide range of analgesic techniques is helpful as it allows a suitable technique to

be implemented. For open thoracotomies, a combination of regional analgesia and opioids,

sometimes supplemented with non-opioid analgesics, will best manage most patients. Usually only

consideration should be given to lumbar epidural analgesia, intrathecal opioids, or intercostal nerve

blocks if no thoracic epidural analgesia or paravertebral blocks are possible. Currently the choice

between thoracic epidural analgesia and paravertebral block is the dilemma for thoracic anesthetists

and their patients scheduled to undergo thoracotomy. Thoracic epidurals have been well established

to produce excellent post-thoracotomy analgesia. However, thoracic epidurals are associated with a

risk of permanent injury and epidural hematomas are the most common disabling complications. It

has been shown that paravertebral blocks and infusions produce equivalent analgesia but with a

preferred profile of side effects. An increasing number of patients presenting for thoracic surgery

are receiving, not all of which are prescribed, drugs that affect coagulation. Current medication for

anticoagulants and antiplatelets increases the risk of an unquantified amount of epidural. Impaired

coagulation is less of a contraindication to paravertebral thoracics, especially when inserted under

direct vision. Serious complications with paravertebrals are rare, and thus paravertebral blocks are

increasing in popularity as "single shots" and catheters allow continuous infusion. In the future, the

development of clinically useable ultra-long-acting local anesthetics could allow significant further

advances in post-thoracotomy analgesia provision.(5)

Acute postoperative pain management for patients with thoracotomy remains a challenging task for

the anesthesiologist and the pain service involved, but the picture has become somewhat clearer

over the past 5 years and several strategies have emerged to provide beneficial effects to patients.

Multimodal treatment of pain using paravertebral nerve blocks or thoracic epidural catheters

,appears to be the most promising approach to adequate post-operative pain control and possibly to

reduce the risk of persistent post-thoracotomy pain development. Thoracic epidural catheters,

which have long been considered the gold standard, do not seem to provide superior pain relief. It

should, however, not be forgotten that these patients do benefit from a multimodal analgesic

36

approach involving nonopioid analgesics, to support the regional technique and to cover the

extraordinary high incidence of unpleasant post-thoracotomy shoulder pain.

The coexisting medical diseases that the patient has the poor baseline pulmonary function that

exists for which the surgery is needed, the invasiveness of the surgical procedure and the anesthetic

technique may contribute to the type and severity of post-operative pulmonary problems.

Acute pain from postthoracotomy is usually severe, may require high doses of opioids, and

may last for several days. When the patient moves or coughs, postthoracotomy pain is

particularly severe.

I.v. diclofenac and ketorolac improved analgesia and significantly reduced morphine

consumption after thoracotomy. They were safe with regard to both haemostasis and renal

function. However, NSAIDs should be used cautiously in patients who are at high risk of

developing renal problems during surgery. Special attention should be paid to fluid balance

and urine output. None of the three local anaesthetic techniques, i.e. intercostal, epidural or

paravertebral, provided good pain relief after thoracotomy. The required PCA-doses of

morphine were high and respiratory depression occurred in one-third of the patients.

A major problem is chronic post-thoracotomy pain. After surgery, it is equally common for

benign and malignant diseases with an incidence of 50 %. Chronic thoracotomy pain is

associated with higher intake of NSAIDs during the first five postoperative days, i.e.

patients who experience more pain during the first week following surgery are at higher risk

of developing a post-thoracotomy pain syndrome than other patients. More studies on

epidemiology and chronic post-thoracotomy pain treatment are needed.

PRACTICAL RECOMMENDATIONS

Most clinical studies reporting acute pain after surgery focus on the in hospital acute phase, and at

home there are limited data on the sub-acute phase. This phase is important because central

sensitization continues to stop persistent pain predisposing the patient. This study presents

information on the intensity of acute postoperative pain, the occurrence of chronic post-

thoracotomy pain as well as the pain experienced during the first week after being discharged from

hospital. Top revent persistent post-thoracotomy pain, extended protocol for high-quality pain

managers t in hospital covering also the sub-acute phase at home, is important.

The health care professional should always believe in evaluating the patient's own pain. Pain is best

treated before a severe level is reached. Routine frequent pain assessments can detect this, and not

rely on vital signs to determine its severity. Use of intravenous drugs to treat acute POP and avoid

intramuscular drugs.

37

Acute POP should be treated as the initial choice of analgesic with opioids and should be

administered on a scheduled basis rather than as required. It is different from addiction to physical

dependence. Addiction is a psychological problem in the first place and is extremely rare. Less than

1% of patients are addicted. Anxiety and drug-seeking behavior can occur in patients with

continued pain.

Once the pain is relieved, these behaviors disappear. Patients who have regularly used opioids for

about 7 days or more are considered tolerant of opioids and will require higher doses for acute POP

control. For opioid analgesia, there is no maximum or ceiling dose. Naloxone administration should

be used only in emergency situations and for patients who are unresponsive. To change from one

opioid to another or from one route of administration to another, it is advisable to use

equianalgesics. In a patient with severe pain, side effects of opioids should be managed rather than

discontinued using analgesics. Commitment to the ethical issues of POP patient care.

These include: ensuring the personal privacy of patients, respecting their belief system, addressing

their needs, believing them when reporting pain, providing timely and appropriate pain relief

interventions.(11)

To reduce the experience of pain, nurses administer analgesics to patients. The knowledge of

pharmacology, including the dose of the drug, the duration of its analgesic effect, and its

pharmacokinetics, is of great importance to nurses. Then the appropriate drug delivery route (per

oral, IV, IM, etc.) is chosen according to the needs of the patient. The pain relief effectiveness is

monitored after 15 to 30 minutes and at intervals of 1 to 2 hours.

The degree and duration of pain relief should be documented and all necessary information should

be recorded in the patient file. A new analgesic is administered in the event that analgesic

medication does not relieve the pain of patients.

Nurses must continue to monitor the side effects of the patient and be prepared to tackle these

problems. Psychological support for patients is important pre-operatively as it could potentially

threaten the expected result.

When the patient it transferred from the operating room to the Intensive Care Unit, and if no major

complication occurs (bleeding or respiratory failure), recovery begins .

Patient age and gender are also important.

Special attention should be given to the dose of analgesia to older patients as pre-existing

complications such as renal failure can lead to additional problems. Research suggests that women

need higher doses of analgesics compared to men.

38

Clinical pain evaluation

In evaluating post-operative pain, health professionals (medical and nursing staff) should evaluate

the condition of the patient at regular intervals, according to the recommendations of the” American

Society of Pain-2006”. The assessment should be conducted during rest and movement periods

using specific pain assessment tools.

If patient pain complaints after a therapeutic intervention, the pain level should be reassessed and a

detailed record should be obtained. Through continuous patient care, nurses play an important role

in ensuring a thorough evaluation using the available evaluation tools to achieve post-operative

pain relief.

Post-operative pain assessment aims at creating a personalized patient care plan and then taking

specific steps to address and ultimately relieve the present symptom. Medical and nursing staff use

care planning collectively. Clinical pain assessment begins with an understanding of the condition

as an unpleasant experience of the patient.

Furthermore, it is necessary to determine the characteristics of pain if it is acute, chronic or

intermittent and its intensity, i.e. mild, moderate, severe or very serious. If the patient experiences

pain in different parts of the body, they must be ranked by the nurse in order to be treated with

priority. Psychological condition of the patient and/or other medicines and substances is an

important factor. Despite advances in nursing science, effective new medicines and the use of

innovative postoperative analgesic methods, pain remains a challenge for nurses. Recent research

has shown that over 50% of patients report severe pain and inadequate postoperative pain

management.

To reduce and manage postoperative pain, many preoperative, intraoperative and

postoperative interventions and management strategies are currently available.

Optimal management begins with the preoperative evaluation of patients and the

development of a care plan specific to each patient and procedure.

In multimodal treatment, due to the different adverse effect profile for each analgesic

medication or technique used, appropriate monitoring is required to identify and manage

adverse events.

Patient, setting, and surgical procedure should be tailored to specific components of

effective multimodal care (strong recommendation; low-quality evidence).

Multimodal treatment should include use of around-the-clock acetaminophen and/or

NSAIDs for adults and children without contraindications (strong recommendation; high-

quality evidence).

39

In patients who can tolerate oral administration, oral opioids are preferred to IV opioids

because the effectiveness of IV is not superior to oral. Since postoperative pain is often

initially continuous, it often requires the first 24 hours of dosing around the clock.

In the immediate postoperative period, long-acting oral opioids are generally not

recommended. Analgesics should not be administered intramuscularly due to the fact that

intramuscular administration can cause significant pain, absorption is unreliable, and there

are no clear benefits to other routes of administration.

40

PUBLICATIONS

Annamma Joy Jossy , Švagždienė Milda.Pain control after thoracic surgery .In 2019 the

abstract was accepted for the oral presentation.

41

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