Intercostal nerve block, interpleural analgesia, thoracic epidural block or systemic opioid application for pain relief after thoracotomy?

Post-thoracotomy analgesia

Thoracotomy is considered one of the most painful operative procedures. Due to anatomical complexity, post-thoracotomy pain requires multimodal perioperative treatment to adequately manage to ensure proper postoperative recovery. There are several different strategies to control post-thoracotomy pain including interventional techniques, such as neuraxial and regional injections, and conservative treatments including medications, massage therapy, respiratory therapy, and physical therapy. This article describes different strategies and evidence base for their use.

Assessment of Intercostal Nerve Block Analgesia for Thoracic Surgery: A Systematic Review and Meta-analysis

IMPORTANCE

The use of intercostal nerve block (ICNB) analgesia with local anesthesia is common in thoracic surgery. However, the benefits and safety of ICNB among adult patients undergoing surgery is unknown.

OBJECTIVE

To evaluate the analgesic benefits and safety of ICNB among adults undergoing thoracic surgery.

DATA SOURCES

A systematic search was performed in Ovid MEDLINE, Ovid Embase, Scopus, and the Cochrane Library databases using terms for ICNB and thoracic surgery (including thoracic surgery, thoracoscopy, thoracotomy, nerve block, intercostal nerves). The search and results were not limited by date, with the last search conducted on July 24, 2020.

STUDY SELECTION

Selected studies were experimental or observational and included adult patients undergoing cardiothoracic surgery in which ICNB was administered with local anesthesia via single injection, continuous infusion, or a combination of both techniques in at least 1 group of patients. For comparison with ICNB, studies that examined systemic analgesia and different forms of regional analgesia (such as thoracic epidural analgesia [TEA], paravertebral block [PVB], and other techniques) were included. These criteria were applied independently by 2 authors, and discrepancies were resolved by consensus. A total of 694 records were selected for screening.

DATA EXTRACTION AND SYNTHESIS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data including patient characteristics, type of surgery, intervention analgesia, comparison analgesia, and primary and secondary outcomes were extracted independently by 3 authors. Synthesis was performed using a fixed-effects model.

MAIN OUTCOMES AND MEASURES

The coprimary outcomes were postoperative pain intensity (measured as the worst static or dynamic pain using a validated 10-point scale, with 0 indicating no pain and 10 indicating severe pain) and opioid consumption (measured in morphine milligram equivalents [MMEs]) at prespecified intervals (0-6 hours, 7-24 hours, 25-48 hours, 49-72 hours, and >72 hours). Clinically relevant analgesia was defined as a 1-point or greater difference in pain intensity score at any interval. Secondary outcomes included 30-day postoperative complications and pulmonary function.

RESULTS

Of 694 records screened, 608 were excluded based on prespecified exclusion criteria. The remaining 86 full-text articles were assessed for eligibility, and 20 of those articles were excluded. All of the 66 remaining studies (5184 patients; mean [SD] age, 53.9 [10.2] years; approximately 59% men and 41% women) were included in the qualitative analysis, and 59 studies (3325 patients) that provided data for at least 1 outcome were included in the quantitative meta-analysis. Experimental studies had a high risk of bias in multiple domains, including allocation concealment, blinding of participants and personnel, and blinding of outcome assessors. Marked differences (eg, crossover studies, timing of the intervention [intraoperative vs postoperative], blinding, and type of control group) were observed in the design and implementation of studies. The use of ICNB vs systemic analgesia was associated with lower static pain (0-6 hours after surgery: mean score difference, -1.40 points [95% CI, -1.46 to -1.33 points]; 7-24 hours after surgery: mean score difference, -1.27 points [95% CI, -1.40 to -1.13 points]) and lower dynamic pain (0-6 hours after surgery: mean score difference, -1.66 points [95% CI, -1.90 to -1.41 points]; 7-24 hours after surgery: mean score difference, -1.43 points [95% CI, -1.70 to -1.17 points]). Intercostal nerve block analgesia was noninferior to TEA (mean score difference in worst dynamic panic at 7-24 hours after surgery: 0.79 points; 95% CI, 0.28-1.29 points) and marginally inferior to PVB (mean score difference in worst dynamic pain at 7-24 hours after surgery: 1.29 points; 95% CI, 1.16 to 1.41 points). The largest opioid-sparing effect of ICNB vs systemic analgesia occurred at 48 hours after surgery (mean difference, -10.97 MMEs; 95% CI, -12.92 to -9.02 MMEs). The use of ICNB was associated with higher MME values compared with TEA (eg, 48 hours after surgery: mean difference, 48.31 MMEs; 95% CI, 36.11-60.52 MMEs) and PVB (eg, 48 hours after surgery: mean difference, 3.87 MMEs; 95% CI, 2.59-5.15 MMEs).

CONCLUSIONS AND RELEVANCE

In this study, single-injection ICNB was associated with a reduction in pain during the first 24 hours after thoracic surgery and was clinically noninferior to TEA or PVB. Intercostal nerve block analgesia had opioid-sparing effects; however, TEA and PVB were associated with larger decreases in postoperative MMEs, suggesting that ICNB may be most beneficial for cases in which TEA and PVB are not indicated.

A Standardized Minimal Opioid Prescription Post-Thoracic Surgery Provides Adequate Pain Control

BACKGROUND

Given the national opioid crisis, post-operative analgesia at discharge must be thoughtfully prescribed. Data, specifically related to thoracic procedures, remains scarce. This study assesses adequacy of pain control with standardized and limited opioids after thoracic procedures.

METHODS

A standardized prescription comprised of 15 Hydromorphone tabs, 7 days of Acetaminophen and 3 days of Ibuprofen was provided on discharge to elective thoracic surgery patients. On the first post-operative visit, patients completed a questionnaire regarding the number of Hydromorphones used, use of additional opioids, pain-related limitation to function, and adequacy of pain control.

RESULTS

A total of 122 patients undergoing thoracic surgery procedures were surveyed. Twelve underwent open procedures and were excluded. An additional 6 who used opioids chronically preoperatively were also excluded. The remaining 104 patients were included in the study. Median age was 66 yrs. (17 to 90 yrs.), median length of stay was 2 days (1 to 15). Seventeen (16%) used all prescribed Hydromorphone and 56 (54%) used none, 18 (17%) asked for additional/other opioid, and 14 (13%) felt that their pain significantly limited their function. Nine (9%) felt that their pain was inadequately controlled.

CONCLUSIONS

Pain after thoracic procedures, especially VATS, is adequately controlled with minimal opioid doses (combined with adjuncts) with less than 1 in 5 patients requiring additional prescriptions and very few patients complaining of pain that "significantly limited their function". This study shows that a standardized limited opioid prescription is safe, adequate, and can easily be implemented for the majority of thoracic surgery patients.

A randomised evaluation of intercostal block as an adjunct to epidural analgesia for post-thoracotomy pain

Background and Aims:

Post-thoracotomy pain can be severe and disabling. The aim of this study was to examine the efficacy of intercostal nerve block when used as adjunct to thoracic epidural analgesia in patients undergoing posterolateral thoracotomy.

Methods:

This was a parallel-group randomised patient and assessor-blinded study carried out at a tertiary-referral cancer center. We included 60 adult patients undergoing elective lung resection under general anaesthesia with thoracic epidural analgesia. In addition, the intervention arm received single-shot intercostal blocks with 10 ml of 0.25% bupivacaine at the level of and two levels above and below the thoracotomy. We assessed post-operative pain scores at 2 to 4 hours and 18 to 24 hours after surgery, peri-operative fentanyl requirement, percentage of patients who needed fentanyl PCA and maximum volume achieved on bedside spirometry 18 to 24 hours after surgery. Groups were compared using the unpaired t-test for continuous data and the chi square test for categorical data at a 5% level of significance.

Results:

2 to 4 hours post-operatively, mean pain scores at rest were 3.0 in both groups (difference 0.04, 95% CI -1.1 to + 1.1) and on coughing were 4.6 (ICB group) and 4.9 (C group) (difference 0.32, 95% CI -1.0 to + 1.6). There were no differences between the groups for any of the other outcomes.

Conclusion:

Addition of intercostal block to epidural analgesia does not confer any benefit in terms of post-operative pain, fentanyl requirements or volume achieved on spirometry.

Postthoracotomy Ipsilateral Shoulder Pain: A Literature Review on Characteristics and Treatment

Context. Postthoracotomy Ipsilateral Shoulder Pain (IPS) is a common and sometimes intractable pain syndrome. IPS is different from chest wall pain in type, origin, and treatments. Various treatments are suggested or applied for it but none of them is regarded as popular accepted effective one. Objectives. To review data and collect all present experiences about postthoracotomy IPS and its management and suggest future research directions. Methods. Search in PubMed database and additional search for specific topics and review them to retrieve relevant articles as data source in a narrative review article. Results. Even in the presence of effective epidural analgesia, ISP is a common cause of severe postthoracotomy pain. The phrenic nerve has an important role in the physiopathology of postthoracotomy ISP. Different treatments have been applied or suggested. Controlling the afferent nociceptive signals conveyed by the phrenic nerve at various levels—from peripheral branches on the diaphragm to its entrance in the cervical spine—could be of therapeutic value. Despite potential concerns about safety, intrapleural or phrenic nerve blocks are tolerated well, at least in a selected group of patient. Conclusion. Further researches could be directed on selective sensory block and motor function preservation of the phrenic nerve. However, the safety and efficacy of temporary loss of phrenic nerve function and intrapleural local anesthetics should be assessed.

Post-thoracotomy pain relief with subpleural analgesia or thoracic epidural analgesia: randomized clinical trial

CONTEXT AND OBJECTIVE

Post-thoracotomy pain is a severe and intense pain caused by trauma to ribs, muscles and peripheral nerves. The current study aimed to compare subpleural analgesia (SPA) with thoracic epidural analgesia (TEA) in patients undergoing thoracotomy.

DESIGN AND SETTING

Randomized study at Ankara Numune Education and Research Hospital, in Turkey.

METHODS

Thirty patients presenting American Society of Anesthesiologists physical status I-III were scheduled for elective diagnostic thoracotomy. The patients were randomized to receive either patient-controlled SPA or patient-controlled TEA for post-thoracotomy pain control over a 24-hour period. The two groups received a mixture of 3 µg/ml fentanyl along with 0.05% bupivacaine solution through a patient-controlled analgesia pump. Rescue analgesia was administered intravenously, consisting of 100 mg tramadol in both groups. A visual analogue scale was used to assess pain at rest and during coughing over the course of 24 hours postoperatively.

RESULTS

In the SPA group, all the patients required rescue analgesia, and five patients (33%) required rescue analgesia in the TEA group (P < 0.05). Patients who received subpleural analgesia exhibited higher visual analogue scores at rest and on coughing than patients who received thoracic epidural analgesia. None of the patients had any side-effects postoperatively, such as hypotension or respiratory depression.

CONCLUSION

Thoracic epidural analgesia is superior to subpleural analgesia for relieving post-thoracotomy pain. We suggest that studies on effective drug dosages for providing subpleural analgesia are necessary.

A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia

BACKGROUND

Thoracotomy induces severe postoperative pain and impairment of pulmonary function, and therefore regional analgesia has been intensively studied in this procedure. Thoracic epidural analgesia is commonly considered the "gold standard" in this setting; however, evaluation of the evidence is needed to assess the comparative benefits of alternative techniques, guide clinical practice and identify areas requiring further research.

METHODS

In this systematic review of randomized trials we evaluated thoracic epidural, paravertebral, intrathecal, intercostal, and interpleural analgesic techniques, compared to each other and to systemic opioid analgesia, in adult thoracotomy. Postoperative pain, analgesic use, and complications were analyzed.

RESULTS

Continuous paravertebral block was as effective as thoracic epidural analgesia with local anesthetic (LA) but was associated with a reduced incidence of hypotension. Paravertebral block reduced the incidence of pulmonary complications compared with systemic analgesia, whereas thoracic epidural analgesia did not. Thoracic epidural analgesia was superior to intrathecal and intercostal techniques, although these were superior to systemic analgesia; interpleural analgesia was inadequate.

CONCLUSIONS

Either thoracic epidural analgesia with LA plus opioid or continuous paravertebral block with LA can be recommended. Where these techniques are not possible, or are contraindicated, intrathecal opioid or intercostal nerve block are recommended despite insufficient duration of analgesia, which requires the use of supplementary systemic analgesia. Quantitative meta-analyses were limited by heterogeneity in study design, and subject numbers were small. Further well designed studies are required to investigate the optimum components of the epidural solution and to rigorously evaluate the risks/benefits of continuous infusion paravertebral and intercostal techniques compared with thoracic epidural analgesia.

The benefits of adding epidural analgesia to general anesthesia: a metaanalysis

The purpose of this metaanalysis was to determine the benefits of postoperative epidural analgesia in patients operated on under general anesthesia. By searching the American National Library of Medicine's Pubmed database from 1966 to July 10, 2004, 70 studies were identified. These included 5402 patients, of which 2660 had had epidural analgesia. Epidural analgesia reduces the incidence of arrhythmia, odds ratio (OR) = 0.59 (95%CI = 0.42, 0.81, P = 0.001); time to tracheal extubation, OR = -3.90 h (95%CI = -6.37, -1.42, P = 0.002); intensive care unit stay, OR = -2.94 h (95%CI = -5.66, -0.22, P = 0.03); visual analogical pain (VAS) scores at rest, OR = -0.78 (95%CI = -0.99, -0.57, P < 0.00001) and during movement, OR = -1.28 (95%CI = -1.81, -0.75, P < 0.00001); maximal blood epinephrine, OR = -165.70 pg.ml(-1) (95%CI = -252.18, -79.23, P = 0.0002); norepinephrine, OR = -134.24 pg.ml(-1) (95%CI = -247.92, -20.57, P = 0.02); cortisol, OR = -55.81 nmol.l(-1) (95%CI = -79.28, -32.34, P < 0.00001); and glucose concentrations achieved, OR = -0.87 nmol.l(-1) (95%CI = -1.37, -0.37, P = 0.0006). It also reduces the first 24-h morphine consumption, OR = -13.62 mg (95%CI = -22.70, -4.54, P = 0.003), and improves the forced vital capacity (FVC), OR = 0.23 l (95%CI = 0.09, 0.37, P = 0.001) at 24 h. A thoracic epidural containing a local anesthetic reduces the incidence of renal failure: OR = 0.34 (95%CI = 0.14, 0.81, P = 0.01). Epidural analgesia may thus offer many advantages over other modes of postoperative analgesia.

Efficacy of Methods of Intercostal Nerve Blockade for Pain Relief After Thoracotomy

Intercostal nerve blockade for postthoracotomy pain relief can be accomplished by continuous infusion of local anesthetics through a catheter in the subpleural space or through an interpleural catheter, by cryoanalgesia, and by a direct intercostal nerve block. A systematic review of randomized studies indicates that an extrapleural infusion is at least as effective as an epidural and significantly better than narcotics alone. The other techniques of intercostal blockade do not offer an advantage over narcotics alone.

Continuous epidural or intercostal analgesia following thoracotomy: a prospective randomized double-blind clinical trial

BACKGROUND

Pain following thoracotomy is frequently associated with clinically important abnormalities of pulmonary function. The aim of the current study was to compare the efficacy of continuous thoracic epidural analgesia (EDA) to continuous intercostal (IC) block for postoperative pain and pulmonary function in a prospective, randomized, double-blinded clinical trial.

METHODS

Fifty patients undergoing lung lobectomy for malignancies were randomized into two groups (25/group). Respiratory function (forced vital capacity, forced expiratory volume per 1 s/forced vital capacity, maximum midexpiratory flow rate, peak expiratory flow rate) were evaluated preoperatively, within 4 h after the operation and on the first postoperative day. Visual analog scale (VAS: 0-10) scores were evaluated four-hourly for 20 h.

RESULTS

The VAS scores were significantly lower in the EDA versus IC group at the 4th, 8th, and 12th h of observation (mean +/- SD) 5.5 +/- 2.9 vs. 7.3 +/- 2.2 P = 0.04; 4.1 +/- 2.1 vs. 5.1 +/- 2.9 P = 0.02; 3.6 +/- 1.9 vs. 5.2 +/- 2.4 P = 0.01, respectively. Respiratory function parameters deteriorated significantly in both groups (P < 0.001) with no significant difference between the groups. Only one major adverse effect was detected: one patient suffered from rib osteomyelitis after intercostal cannulation and healed following surgical repair.

CONCLUSIONS

The results of the present study show that following thoracotomy in the early postoperative period continuous EDA is a better pain relieving method than continuous IC block, as indicated by the VAS scores.

Post-thoracotomy analgesia

Pain relief has come a long way in 20 years. Many aspects of the relief of pain of thoracic surgery must be rationalized and modernized to meet the demands placed on services and subject to new dynamics. To place the present state of practice and knowledge in the context of an anticipation that such attitudes will impact on and, ultimately, drive services for relief of pain, the key issues of safety, defining and measuring quality, and giving value for money must be addressed. Rationing is the impetus; the exercise to be conducted by those interested in the field of thoracic pain relief is to recognize that not all patients can have or require five-star services and gold standard techniques but are entitled to an equally high quality and measure of pain relief. Newer drugs, such as clonidine, ropivacaine, and modified local anesthetics, are on the horizon; old drugs, such as ketamine, are being revisited. Their place in the field will become apparent only if the ways that outcome measures are presented are more uniform and standard. Disaggregation analysis, pain profiling, a revisitiation of respiratory restoration factor, and optimization modeling are suggested ways forward to meet the clinical and organizationally holistic population forces being generated on the cusp of the third millennium. Increasingly, we live in a world defined by guidelines and protocols. The challenge is ensuring that these measure up to the watchwords--effective, safe, affordable.

Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma

OBJECTIVE

To evaluate systemic versus epidural opioid administration for analgesia in patients sustaining thoracic trauma.

SUMMARY BACKGROUND DATA

The authors have previously shown that epidural analgesia significantly reduces the pain associated with significant chest wall injury. Recent studies report that epidural analgesia is associated with a lower catecholamine and cytokine response in patients undergoing elective thoracotomy compared with patient-controlled analgesia (PCA). This study compares the effect of epidural analgesia and PCA on pain relief, pulmonary function, cathechol release, and immune response in patients sustaining significant thoracic trauma.

METHODS

Patients (ages 18 to 60 years) sustaining thoracic injury were prospectively randomized to receive epidural analgesia or PCA during an 18-month period. Levels of serum interleukin (IL)-1beta, IL-2, IL-6, IL-8, and tumor necrosis factor-alpha (TNF-alpha) were measured every 12 hours for 3 days by enzyme-linked immunosorbent assay. Urinary catecholamine levels were measured every 24 hours. Independent observers assessed pulmonary function using standard techniques and analgesia using a verbal rating score.

RESULTS

Twenty-four patients of the 34 enrolled completed the study. Age, injury severity score, thoracic abbreviated injury score, and length of hospital stay did not differ between the two groups. There was no significant difference in plasma levels of IL-1beta, IL-2, IL-6, or TNF-alpha or urinary catecholamines between the two groups at any time point. Epidural analgesia was associated with significantly reduced plasma levels of IL-8 at days 2 and 3, verbal rating score of pain on days 1 and 3, and maximal inspiratory force and tidal volume on day 3 versus PCA.

CONCLUSIONS

Epidural analgesia significantly reduced pain with chest wall excursion compared with PCA. The route of analgesia did not affect the catecholamine response. However, serum levels of IL-8, a proinflammatory chemoattractant that has been implicated in acute lung injury, were significantly reduced in patients receiving epidural analgesia on days 2 and 3. This may have important clinical implications because lower levels of IL-8 may reduce infectious or inflammatory complications in the trauma patient. Also, tidal volume and maximal inspiratory force were improved with epidural analgesia by day 3. These results demonstrate that epidural analgesia is superior to PCA in providing analgesia, improving pulmonary function, and modifying the immune response in patients with severe chest injury.

Continuous extrapleural intercostal nerve block with continuous infusion of lidocaine after thoracotomy. A descriptive pilot study

Continuous extrapleural intercostal block (EPIB) with bupivacaine has been reported to be an effective analgesic technique in patients after thoracotomy. We report a retrospective study of EPIB using a continuous infusion of 1% lidocaine hydrochloride at a dose of 1 mg/kg/h. A posterior parietal pleural pocket was created and cannulated with a 16-g polyethylene catheter. Lidocaine was perfused over a 3-day period following surgery. Patients also had access to morphine sulfate via patient-controlled analgesia. Eighteen consecutive posterolateral thoracotomies (in 17 patients) performed during a 6-month period were reviewed. Serum lidocaine exceeded the toxic level of 5 microgram/mL in only one patient, a 104.5-kg man who had a level of 5.9 micrograms/mL on postoperative day 2 but experienced no clinical toxicity. Pain was evaluated by verbal analog scores (0 = no pain and 10 = worst pain), which averaged 3.02, 3.14, and 2.8 in the 3 days following surgery. Mean total daily MS doses were 24.3, 37.75, and 34.32 mg (range, 0 to 94 mg). Sedation was scored on a 1 to 5 scale. Mean scores were 2.78, 2.56, and 2.6. No patient died or had a major respiratory complication. Continuous EPIB with lidocaine appears to be a promising adjuvant technique in the management of postthoracotomy pain. Effectiveness needs to be confirmed in a prospective randomized study.

Effect of interpleural administration of bupivacaine or lidocaine on pain and morphine requirement after esophagectomy with thoracotomy: a randomized, double-blind and controlled study

The purpose of the present study was to investigate the efficacy of interpleural (IP) analgesia with bupivacaine or lidocaine after esophageal surgery and to measure the plasma concentrations of bupivacaine and lidocaine after intermittent IP administrations. Two IP catheters were inserted percutaneously in the seventh intercostal space during operation. Patients in the bupivacaine group (Gr B) received 1 mg/kg of 0.5% bupivacaine with epinephrine 1:200000 in 20 mL of saline 0.9%, patients in the lidocaine group (Gr L) received 3 mg/kg of 2% lidocaine with epinephrine in 20 mL of saline 0.9%, and patients in the placebo group (Gr P) received 20 mL of saline 0.9% every 4 h during 2 days. Pain was assessed by visual analog scale (VAS) every 4 h at rest (VASR), after a deep breath or cough (VASC), at the thoracotomy (VAST), and at the laparotomy (VASL). Morphine consumption using a patient-controlled analgesia (PCA) device was recorded. There was no significant difference in the mean VASR, VASC, and VASL scores among the three groups. VAST scores were significantly lower in Gr B at 12, 16, 28, and 32 h when compared with Gr P and Gr L (P < 0.05). There was no statistical difference in mean VAST between Gr L and Gr P. Total consumption of morphine was lower in Gr B than in Gr P and Gr L (41.2 +/- 13 mg vs 66.1 +/- 21 mg in Gr P (P < 0.02) and 75.5 +/- 27 mg in Gr L (P < 0.01)), but were similar in Gr L when compared with Gr P.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intrapleural analgesia]

Interpleural analgesia, a recently devised method for postoperative analgesia, consists of the injection of a local anaesthetic into the pleural space. The technique of the catheter insertion is simple and derived from the threadening of an epidural catheter, using the same equipment. An unilateral analgesia is obtained with a rapid onset but not efficient enough for a surgical procedure. The area covered by analgesia includes the thorax and the upper part of the abdomen. No haemodynamic adverse effects occur and ventilatory function is rather improved. The main mechanism of analgesia is probably a retrograde intercostal nerve blockade. Although the exact dose and volume of local anaesthetic is still controversial, 20 to 30 mL of 0.5% bupivacaine is very likely the most convenient. Lidocaine may also be administered at the dose of 2 mg.kg-1 of a 2% solution. Main indications of interpleural analgesia are cholecystectomies and thorax trauma patients. Adverse effects and hazards are uncommon and include mainly pneumothorax and toxic effects of a local anaesthetic overdose.