Thoracotomy induces severe postoperative pain and impairment of pulmonary function. Severe postoperative pain is one of many predictors of long-term pain after thoracotomy. An estimated 5 -65% of patients will develop persistent pain after surgery, it will be moderate to severe in 10% of patients. ANZCA chapter 1, Table 1.2, p 11. Early and aggressive treatment of pain may help to reduce the currently high frequency of chronic pain encountered in these patients. ANZCA chapter 9.1.3., p 236, German section 4.2.1.1, p 19.

Evidence-based treatment recommendations specific to the condition

For overall recommendations see PROSPECT/ Thoracotomy/Overall Prospect recommendations/Recommendations

For interventionsNOTrecommended see PROSPECT/Thoracotomy/Overall Prospect recommendations / NOT recommended

Preoperative

See: PROSPECT/ Thoracotomy/SUMMARY recommendations/pre-operative

• First choice: Thoracic epidural LA and opioid combination as a bolus before surgery and continued as an infusion during surgery and after.
  • Epinephrine is recommended in the epidural solution if a low dose of epidural LA and/or opioid is used.
  • Should be started before skin incision. German section 4.2.1.1, p 19.
• Alternatively: Paravertebral block (PVB) with LA (bolus pre-operatively or at the end of surgery, followed by continuous infusion in the postoperative period) French section 10.2, p 408. German section 4.2.1.1, p 19.
• When epidural or PVB are not possible: a single bolus of spinal morphine as part of a multi-analgesic regimen.
• Intercostal nerve block (single shot, several injections or continuous infusion) if thoracic epidural or PVB are not possible. German section 4.2.1.1, p 20-21.
• Lumbar epidural strong opioid is not recommended as the first choice of epidural technique. However, lumbar epidural with a hydrophilic strong opioid provides better compared with systemic analgesia.

Intraoperative

See: PROSPECT/ Thoracotomy/SUMMARY recommendations/intra-operative

Continue blocks as above.

Postoperative

See: PROSPECT/ Thoracotomy/SUMMARY recommendations/intra-operative

Local, regional and neuraxial analgesia-based techniques

• Thoracic epidural LA + strong opioid, continuous infusion for 2–3 days
  • Epinephrine in the epidural solution is recommended if a low dose of epidural LA and/or opioid is used
  • Epidural analgesia offers better analgesia compared to all forms of paraenteral opioids (including PCA) with the exception of epidural using hydrophilic opioids. ANZCA chapter 7.2.3, p 189.
  • Epidural analgesia with LA improves oxygenation and reduction in pulmonary complications, including infections, compared to parenteral opioids. ANZCA chapter 7, ‘Key messages’ p 189.
• Paravertebral block with LA, continuous infusion for 2–3 days, as an alternative to thoracic epidural analgesia
• Intercostal nerve block with LA, continuous infusion for 2–3 days, if thoracic epidural analgesia and paravertebral block are not possible
• When epidural therapy ends, systemic analgesics should be given, titrated to the patient’s level of pain German section 4.2.2.2. p 23.

Systemic-based options

• Whenever possible, patients should be given multimodal pain management.
  • COX-2 selective NSAIDs, nonselective NSAIDs, and calcium channel α-2-δ antagonists (gabapentin and pregabalin) should be considered as part of a postoperative multimodal pain management regimen.
  • Unless contraindicated, patients should receive an around-the-clock regimen of NSAIDs, COXIBs, or acetaminophen. ASA section V Multimodal techniques for Pain Management, p 253-254.
• Intravenous PCA strong opioid, if regional analgesic techniques fail or are not possible.
• Weak opioids for moderate- (VAS>30<50 mm) or low- (VAS£30 mm) intensity pain in the late postoperative period, only if conventional NSAIDs/COX-2-selective inhibitors plus paracetamol are insufficient or contraindicated.

Non-pharmacologic

High intensity (>15 mA, strong but comfortable), Transcutaneous Electrical Nerve Stimulation (TENS) provided relief. The evidence is not consistent. German, section 3.3.1.4., p 5.

Analgesia for chest tube removal PROSPECT/Thoracotomy/Summary recommendations

• Ice pack
• Interpleural local anaesthestic
• Topical local anaesthetic

Advice / Guidance to patients

Advise patients that pain after surgery may be severe and for extended period of time; that the absence or tolerable levels of pain are crucial for rehabilitation after surgery as this will facilitate coughing, taking deep breaths and early mobilization. German 4.2.1, p 18.

Issues related to nursing / monitoring of patients

Physiotherapy should begin when diagnosis is made, on an Outpatient basis, or on admission and continue after surgery. German 4.2.1, p 18-19

Summary

Thoracotomy is associated with severe pain after surgery. Thoracic epidural (with a solution of LA and opioid and epinephrine) orparavertebral block with LA are the preferred techniques for providing analgesia, starting before surgery and continuing for 2-3 days after surgery. If neither methods are possible, alternatives aresingle bolus spinal opioid and intercostal LA given as a continuous infusion during surgery and for 2-3 days after surgery. Multimodal pain management, including gabapentin to prevent chronic pain, should also be employed.

Supplementary reading

1. Hughes R and Gao, F Pain control for thoracotomy,Contin Educ Anaesth Crit Care Pain (2005)5(2):56-60.
2. Rawal N. Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med. 2012 May;37(3):310-7.
3. Roy G. et al Acute Pain Management for Patients Undergoing Thoracotomy. Ann Thorac Surg 2003;75:1349 –57
4. Wenk M, Schug S. Perioperative pain management after thoracotomy Current Opinion in Anaesthesiology: 2011. 24(1) 8–12.