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Pain

Analgesic techniques following thoracic surgery: a survey of United Kingdom practice

Kotemane, Naren C; Gopinath, Niraj; Vaja, Rakesh

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European Journal of Anaesthesiology: October 2010 - Volume 27 - Issue 10 - p 897-899
doi: 10.1097/EJA.0b013e32833d1259
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Abstract

Introduction

Pain after thoracotomy is considered one of the most severe forms of pain after surgery.1 The high incidence of associated co-morbidities and abnormal pulmonary function due to pre-existing lung disease puts the thoracic surgical patient at great risk of postoperative respiratory complications. It is particularly important to optimize postoperative analgesia in these patients, as poor analgesia contributes to further deterioration.2 A variety of systemic and regional methods of analgesia have been described for post-thoracotomy pain.3,4 The aim of this national survey was to determine the current practice of postoperative analgesia after major thoracic procedures in the United Kingdom.

Methods

A list of hospitals performing thoracic surgery was obtained from the Society for Cardiothoracic Surgery in Great Britain and Ireland. We identified 36 centres performing thoracic surgery in the United Kingdom. The anaesthetic department of each centre was contacted to find the number of anaesthetists performing regular thoracic surgery lists. The thoracic anaesthetists in each centre were sent a survey questionnaire by post. The questionnaire included a list of five commonly performed thoracic operations [pneumonectomy, lobectomy, radical decortication of pleura, other pleural surgery and lung volume reduction surgery (LVRS)] via either thoracotomy or video-assisted thoracoscopic surgery (VATS). We asked the responder what was their first choice analgesic technique for each surgery from a choice of (1) epidural, (2) thoracic paravertebral block, (3) intravenous patient-controlled analgesia (PCA), (4) any combination of (1)–(3). Options for choosing additional analgesic regimes such as nonsteroidal anti-inflammatory drug (NSAID) and other systemic analgesics were made available. Replies were collated and analysis was performed using descriptive statistics. The centres predominantly performing paravertebral blocks for open thoracotomy were resurveyed to ascertain the incidence of paravertebral catheter use for providing postoperative analgesia. The audit was approved by our institutions' Clinical Audit, Standards and Effectiveness department.

Results

Thirty-six thoracic centres in the United Kingdom were surveyed. A total of 240 questionnaires were sent by post. Replies were received from 187 thoracic anaesthetists (78%). The results are summarized in Fig. 1.

F1-8
Fig. 1

In patients undergoing video assisted thoracoscopic (VATS) lobectomy, the commonest technique for postoperative analgesia was paravertebral block combined with PCA with morphine (50%). Only 10% of the respondents used epidural analgesia for this procedure. This was mirrored in the patients undergoing VATS decortication or pleurectomy. In the VATS procedures, PCA morphine alone was used by one third of the respondents.

In patients undergoing open thoracotomy for lobectomy or decortication of pleura, epidural analgesia was the main technique for pain relief after surgery in nearly 50% of the respondents. The other major analgesic technique in this patient group was the combination of paravertebral block with PCA morphine (41%). There were 18 centres utilizing paravertebral block for providing postoperative analgesia after open thoracotomy. Six centres used a single-shot technique in combination with PCA morphine. In 12 centres, paravertebral catheter infusion technique was used. The paravertebral catheters were inserted in over 90% cases by surgeons intra-operatively under direct vision.

The majority of the patients undergoing video-assisted LVRS had a regional anaesthetic technique for postoperative analgesia: epidural (46%) or paravertebral block with PCA morphine (41%). Only 13% had PCA with morphine.

Paracetamol and NSAID were used as adjuncts to the above analgesic techniques. Ninety-three percent of the respondents used paracetamol as an adjunct. NSAID use as an adjunct was avoided by 30% of the respondents in patients undergoing VATS and by 41% of respondents in patients undergoing open thoracotomy. Nearly half of the respondents (48%) preferred to avoid NSAIDs with epidural analgesia.

Other less commonly used techniques were intrathecal morphine for open thoracotomy and tramadol or fentanyl PCA for video-assisted procedures.

Discussion

Acute pain after thoracotomy continues to represent a challenge for the anaesthetic and surgical community.5 Although thoracic epidural when effective provides excellent analgesia, the incidence of failed thoracic epidural is still high even in experienced hands. Alternative regional anaesthesia techniques such as paravertebral block are gaining popularity, and a recent review has confirmed paravertebral block to be equally effective with an improved side-effect profile when compared to thoracic epidural analgesia.6

The advent of VATS has seen a reduction in open thoracotomy procedures. However, open surgery remains the only suitable technique for major lung resections and radical pleural surgery. Excellent analgesia after thoracotomy is imperative not only to alleviate suffering but to minimize deterioration in lung function after surgery and anaesthesia. The multimodal perioperative analgesic regimen chosen must be effective, with minimal side effects and with an aim to decrease the potentially harmful consequences of thoracic surgery on the immediate and long-term patient well being. It must provide good analgesia during deep breathing and movement to allow coughing and physiotherapy.2

Epidural analgesia has long been considered as the ‘gold standard’ among regional anaesthetic techniques for providing pain relief after thoracotomy. A survey of analgesic techniques, after thoracotomy, in Australian hospitals showed that 79% of respondents regarded epidural blockade as the best available technique.2 A similar survey in the United Kingdom by Cook and Eaton7 showed that epidural analgesia was the most frequently used form of regional analgesia technique used after thoracotomy. Although epidural analgesia was the favoured technique used by nearly half of the respondents, paravertebral blocks combined with PCA morphine is fast gaining acceptance as a viable alternative to epidural analgesia in open thoracotomy procedures (Fig. 1). There are risks associated with epidural analgesia such as dural puncture, hypotension, neurological injury and paraplegia and management of epidural analgesia may necessitate the use of high dependency beds in some institutions. Epidural technique can occasionally fail as a result of difficult anatomy or poor technique and is contraindicated in sepsis, coagulation disorders, pre-existing neurological disorders and difficult thoracic vertebral anatomy. In these situations, paravertebral block can offer an attractive alternative that has few contraindications. Placement of the paravertebral catheter intraoperatively by the surgeon avoids some of the concerns regarding epidural placement in the presence of difficult anatomy, local sepsis or impaired coagulation. It has been shown that epidural analgesia can be associated with significantly higher adverse effects such as block failure, hypotension, urinary retention, pulmonary complications and nausea when compared to paravertebral analgesia.6 A recent national audit on major complications after central neuraxial blocks found the incidence of permanent injury after adult perioperative epidural anaesthesia or analgesia to be 17.4 per 100 000 (one in 5800).8

The most common analgesic technique after both VATS lobectomy and VATS pleural surgery is the paravertebral block combined with PCA morphine. One third of the respondents used PCA with morphine alone as the major analgesic technique. It is interesting to note that epidural analgesia was used by only one tenth of the respondents in this group of patients. This is in contrast with video-assisted LVRS where nearly half of the respondents (46%) preferred epidural analgesia. Paravertebral block combined with PCA morphine was the other common technique (41%). The other less commonly used analgesic techniques were intrathecal morphine and tramadol or fentanyl PCA.

Pain after open thoracotomy can arise from multiple sites and includes somatic, visceral and neurogenic components. Effective analgesia and blockade of perioperative stress response may improve outcome and facilitate recovery after thoracic surgery. The multifactorial origin of post-thoracotomy pain favours a multimodal analgesic approach. This includes a combination of regional anaesthetic techniques with opioids, paracetamol and NSAIDs. Nearly all the respondents in this survey used a balanced analgesic regimen for providing pain relief after both thoracoscopic and open procedures.

This survey shows that paravertebral block is the most popular regional anaesthetic technique providing analgesia after thoracoscopic procedures and its use after open thoracotomy is increasing. Paravertebral catheter technique was popular in two thirds of the centres utilizing paravertebral blocks for open thoracotomy and in nearly all the centres, the catheters were inserted by surgeons under direct vision. Epidural analgesia continues to remain popular after open thoracic surgery.

References

1 Loan WB, Morrison JD. The incidence and severity of postoperative pain. Br J Anaesth 1967; 39:695–698.
2 Cook TM, Riley RH. Analgesia following thoracotomy: a survey of Australian practice. Anaesth Intensive Care 1997; 25:520–524.
3 Kavanagh BP, Katz J, Sandler AN. Pain control after thoracic surgery. A review of current techniques. Anaesthesiology 1994; 81:737–759.
4 Conacher ID. Pain relief after thoracotomy. Br J Anaesth 1990; 65:806–812.
5 Burlacu CL. PCEA vs. PCA for postthoracotomy pain: is this any longer the question? J Postgrad Med 2008; 54:80–81.
6 Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs. epidural blockade for thoracotomy: a systematic review and meta-analysis of randomized controlled trials. Br J Anaesth 2006; 96:418–426.
7 Cook TM, Eaton JM. Epidural analgesia after thoracotomy: United Kingdom practice. Euro J Anaesthesiol 1997; 14:108–111.
8 Cook TM, Counsell D, Wildsmith JA. Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009; 102:179–190.
Keywords:

analgesia; paravertebral blocks; thoracic surgery

© 2010 European Society of Anaesthesiology