Without adequate analgesia, most patients would experience severe pain following thoracic surgery.
Epidural analgesia is widely practiced and has been shown to provide superior pain relief compared with systemic opioids.
Multimodal analgesic strategies improve overall outcomes including patient satisfaction.
Chronic post-thoracotomy pain (CPTP) is common and remains a challenging condition to treat. Further investigation into prevention of this syndrome is needed.
The patient is a 64-year-old man who underwent a left thoracotomy and extrapleural pneumonectomy for mesothelioma. A mid-thoracic epidural catheter was placed preoperatively and used to deliver 0.6mg of hydromorphone prior to incision. Intraoperatively, no medications were administered through the epidural catheter to avoid sympathectomy and hemodynamic instability.
Upon the patient's arrival to the intensive care unit, an epidural infusion of bupivacaine 0.125% and hydromorphone 10 mcg/mL was initiated at 6 mL/h. The patient initially experienced 8/10 pain, requiring an epidural bolus of local anesthetic and an increase of the infusion rate. These adjustments resulted in reduction of his pain to 3/10. With improved analgesia, the patient was able to improve incentive spirometry performance, but he still continued to experience shoulder pain. He continued to do well with adequate pain control in the intensive care unit (pain score 3-5/10). His epidural was discontinued on postoperative day 3. He was discharged to home on postoperative day 5 with oral oxycodone as needed.
At his 2-month postoperative evaluation, the patient complained of significant chest wall pain localized to the thoracotomy incision. He described his pain as burning and aching.
The importance of postoperative pain management is well established.1 Postoperative pain following thoracic procedures causes a reversible restrictive pattern of ventilation with a decrease in vital capacity (VC) and functional residual capacity (FRC), impaired cough, rapid, shallow breathing, and often retention of secretions. These physiologic changes are particularly significant in thoracic surgery patients with preexisting pulmonary comorbidities, and may result in atelectasis, hypoxemia, and respiratory failure.2 Effective postoperative analgesia is of critical importance in these individuals. Nonetheless, effective treatment strategies for acute and chronic post-thoracotomy pain remain a significant challenge.3,4
The adverse effects of poor analgesia are not limited to the pulmonary system. Pain has been associated with increased myocardial oxygen demand, myocardial dysfunction, increased catecholamine release, poor glycemic control, deep vein thrombosis, and pulmonary embolism.5,6 These complications of inadequate pain control have been shown to lead to increased mortality and morbidity, prolonged length of hospitalization, and increased cost of patient care.7,8 In addition, several recent retrospective reviews suggest that a higher intensity of early (first week) postoperative pain is a risk factor for development of persistent pain.9,10
In this chapter, we will briefly review the mechanisms of thoracic pain. We will then discuss management strategies for acute postoperative pain and outline key concepts regarding chronic post-thoracotomy pain. The reader is referred to Chapter 6 for a more detailed discussion on ...