Prevalence of chronic post-thoracotomy pain in patients with traumatic multiple rib fractures in South Korea: a cross-sectional study

Mechanisms inherent in acute-to-chronic pain after surgery - risk, diagnostic, predictive, and prognostic factors

PURPOSE OF REVIEW

Pain is an expected consequence of a surgery, but it is far from being well controlled. One major complication of acute pain is its risk of persistency beyond healing. This so-called chronic post-surgical pain (CPSP) is defined as new or increased pain due to surgery that lasts for at least 3 months after surgery. CPSP is frequent, underlies a complex bio-psycho-social process and constitutes an important socioeconomic challenge with significant impact on patients' quality of life. Its importance has been recognized by its inclusion in the eleventh version of the ICD (International Classification of Diseases).

RECENT FINDINGS

Evidence for most pharmacological and non-pharmacological interventions preventing CPSP is inconsistent. Identification of associated patient-related factors, such as psychosocial aspects, comorbidities, surgical factors, pain trajectories, or biomarkers may allow stratification and selection of treatment options based on underlying individual mechanisms. Consequently, the identification of patients at risk and implementation of individually tailored, preventive, multimodal treatment to reduce the risk of transition from acute to chronic pain is facilitated.

SUMMARY

This review will give an update on current knowledge on mechanism-based risk, prognostic and predictive factors for CPSP in adults, and preventive and therapeutic approaches, and how to use them for patient stratification in the future.

Analgesic Effects of Continuous Wound Infusion Combined with Intravenous Patient-Controlled Analgesia for Thoracic Surgery: A Retrospective Study

Continuous wound infusion analgesia (CWA) with local anesthetics is a loco-regional anesthetic approach for multimodal analgesia management in surgical procedures. This study analyzed whether the combination of intravenous patient-controlled analgesia (PCA) and CWA would be more effective than PCA alone for postoperative analgesia and in preventing chronic postsurgical pain syndrome (PSPS) after thoracic surgeries. We enrolled 166 patients after propensity score matching, the PCA alone (PCA group, n = 83) and the combination of PCA and CWA (PCA-CWA group, n = 83), through a review of electronic medical records. The primary endpoint was the numeric rating scale (NRS) at postoperative days 1, 2, 3, 4, and 5. The secondary endpoint was the presence of PSPS at 3 and 6 months postoperatively. The NRS were lower in the PCA-CWA group than in the PCA group throughout the postoperative period (p < 0.001). The sedation incidence was lower in the PCA-CWA group (1.2%) than in the PCA group (9.6%) (p = 0.034), and there was no significant difference in other postoperative complications or in the incidence of PSPS (p = 1.000). The combination of intravenous PCA and CWA is an effective postoperative analgesic modality for thoracic surgery.

Incidence and Influencing Factors of Chronic Postthoracotomy Pain in Lung Tumor Patients

OBJECTIVES

To estimate the incidence of chronic postthoracotomy pain (CPTP) in lung tumor patients and to explore the influencing factors of the intensity of CPTP.

METHODS

Lung tumor patients who underwent video-assisted thoracoscopic surgery (VATS) or thoracotomy were consecutively recruited from October 2016 to December 2017 at Yunnan Cancer Hospital. All the eligible patients were interviewed via telephone at the end of the third month after surgeries to identify the presence of CPTP. The potential influencing factors of CPTP, including pre-, intra-, and postoperative variables, were collected from medical records. A cumulative logit regression model was used to identify the independent influencing factors of the intensity of CPTP.

RESULTS

Three hundred and forty-three patients completed a telephone interview. The estimated overall incidence of CPTP was 67.6% (95% of confidence interval, 95% CI: 62.4%, 72.6%) in lung tumor patients; 70.8% (95% CI: 63.8%, 77.1%) in benign patients and 63.5% (95% CI: 55.2%, 71.3%) in malignant patients; and 78.1% (95% CI: 66.0%, 87.5%) in open chest and 65.2% (95% CI: 59.3%, 70.8%) in VATS. Cumulative logit regression models (intensity order, NRS, 0 ⟶ 1-3 ⟶ 4-) revealed independent influencing factors of CPTP to be patients with diabetes (OR = 0.32; 95% CI: 0.14, 0.76), usage of VATS (OR = 0.47; 95% CI: 027, 0.82), and the amount of intraoperative blood loss (OR = 1.09; 95% CI: 1.00, 1.19).

CONCLUSIONS

A high incidence of CPTP is detected in lung tumor patients following the thoracic operation. Patients with diabetes and using VATS are the independent protective factors of the intensity of CPTP, and the increasing amount of intraoperative blood loss is an independent risk factor of the intensity of CPTP.

Clinical Update on Patient-Controlled Analgesia for Acute Postoperative Pain

Patient-controlled analgesia (PCA) is an effective method for controlling acute pain, including postoperative pain in adults and in children from five years of age, pain resulting from labor, trauma, or other medical situations, or chronic and malignant pain. The treatment consists of a mini-computer-controlled infusion pump permitting the administration of on-demand, continuous, or combined doses of analgesic (mainly opioid) variations in response to therapy, which allows pain to be significantly controlled. Intravenous (IV)-PCA minimizes individual pharmacodynamics and pharmacokinetic differences and is widely accepted as a reference method for mild or severe postoperative pain. IV-PCA is the most studied route of PCA; other delivery methods have been extensively reported in the literature. In addition, IV-PCA usually voids the gap between pain sensation and analgesic administration, permitting better recovery and fewer side effects. The most commonly observed complications are nausea and vomiting, pruritus, respiratory depression, sedation, confusion and urinary retention. However, human factors such as pharmacy preparation and device programming can also be involved in the occurrence of these complications, while device failure is much less of an issue.