Mitigating the impact of acute and chronic post-thoracotomy pain

Ultrasound-guided serratus anterior plane block versus paravertebral block on postoperation analgesia and safety following the video-assisted thoracic surgery: A prospective, randomized, double-blinded non-inferiority clinical trial

BACKGROUND

Both the anesthetic efficacy of ultrasound-guided serrate anterior plane block (SAPB) and the ultrasound-guided paravertebral block (PVB) in alleviating postoperative pain have been well concerned. This study primarily aims to evaluate whether the ultrasound-guided SAPB and ultrasound-guided PVB can provide comparable analgesia for video-assisted thoracic surgery. Secondarily, the safety and clinical satisfaction of the two blocks are evaluated.

METHODS

It was a prospective, randomized, double-blinded non-inferiority clinical trial involving 99 patients with lung nodules receiving video-assisted thoracic surgery with ultrasound-guided SAPB or PVB on T4 and T7 vertebra using 0.375% ropivacaine at 3 mg/kg. The Visual Analogue Scale (VAS) scores at rest and cough at 24 h/48 h postoperatively and the incidence and severity of chronic pain at 3 and 6 months postoperatively were the primary outcome. Secondary outcomes included the complications and block application time of two kinds of blocks, and consumption of sufentanil as an analgesic rescue.

RESULTS

A total of 92 eligible patients were recruited, including 46 in the SAPB group and 46 in the PVB group. No significant differences in VAS scores at rest and cough at first 48 h, 3 months, and 6 months postoperatively between the SAPB group and PVB group were detected (all P > 0.05). The SAPB group had fewer complications and higher patient satisfaction(P＜0.05).

CONCLUSION

The ultrasound-guided SAPB was not inferior to PVB in alleviating postoperative pain following the VATS with fewer complications and higher patient satisfaction.

Patients after lung resection heading to the high-dependency unit: a cost-effectiveness study for managing lung cancer patients

Background

Recently, most thoracic surgery units allocate patients post lung resection to high-dependency units (HDU) rather than the old trend of intensive care units (ITU). The aim of the study is to assess the safety and efficacy of such a policy. We compared a single group of patients who underwent lobectomies who were admitted to ITU before March 2011 and patients whom their destination was to HDU after that date. Preoperative factors and postoperative outcomes were compared.

Results

A total of 408 patients were studied, 203 post-lobectomy patients were admitted routinely to ITU before March 2011, while 205 patients were admitted to HDU after that date. The mean postoperative length of stay in ITU was 1.2 days while in HDU was 1.1 days. In-hospital mortality for the ITU group was 2.5% (n = 5) while in the HDU group was 1.4% (n = 3) (p = 0.43). ITU readmission was observed in 6.5% (n = 13) in the ITU group and 4.3% (n = 9) in the HDU group (p = 0.31). Total complications were present in 39% in the ITU group and 33% in the HDU group (p = 0.16). The total estimated cost of one ITU day per patient is 850 GBP in comparison with 430 GBP for the HDU group (p = 0.007). The incremental cost-effectiveness ratio of the HDU stay per year was US $32.130/QALY.

Conclusion

The high-dependency unit is a safe destination for post-lobectomy patients. The same concept may apply to all thoracotomy patients. Hospitals could adopt such a policy which offers a better financial option without jeopardizing the level of patient care or outcome.

Dexamethasone and postoperative analgesia in minimally invasive thoracic surgery: a retrospective cohort study

BACKGROUND

Dexamethasone is commonly used for the prevention of postoperative nausea and vomiting (PONV), and recent reviews suggest a role for dexamethasone in postoperative analgesia. The aim of this study is to evaluate the efficacy of dexamethasone as an analgesic adjuvant in minimally invasive thoracic surgery. Primary outcome was morphine consumption 24 h after surgery; secondary outcomes were pain control, measured as numeric rating scale (NRS), glycemic changes, PONV, and surgical wound infection.

RESULTS

We performed a retrospective cohort study considering 70 patients who underwent elective lobectomy, segmentectomy, or wedge resection surgery with a mini-thoracotomy approach or video-assisted thoracoscopic surgery (VATS). All patients received the same locoregional techniques and short-acting opioids during surgery; 46 patients received dexamethasone at induction. There were no significant differences in morphine consumption at 24 h (p = 0.09) and in postoperative pain scores. Nevertheless, a higher frequency of rescue therapy (p = 0.01) and a tendency for a higher attempted-PCA pushes count were observed in patients who did not receive dexamethasone. No cases of surgical wound infections were detected, and the incidence of PONV was similar in the two groups. Postoperative glycemia was transiently higher in the dexamethasone group (p = 0.004), but the need of hypoglycemic therapy was not significantly different.

CONCLUSIONS

Preoperative administration of dexamethasone did not cause a significant reduction in morphine consumption, but appears to be safe and plays a role in a multimodal anesthesia approach for patients undergoing elective minimally invasive thoracic surgery.

AAAPT Diagnostic Criteria for Acute Thoracic Surgery Pain

Patients undergoing thoracic surgery experience particular challenges for acute pain management. Availability of standardized diagnostic criteria for identification of acute pain after thoracotomy and video assisted thoracic surgery (VATS) would provide a foundation for evidence-based management and facilitate future research. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the United States Food and Drug Administration, the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) formed the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) initiative to address absence of acute pain diagnostic criteria. A multidisciplinary working group of pain experts was invited to develop diagnostic criteria for acute thoracotomy and VATS pain. The working group used available studies and expert opinion to characterize acute pain after thoracotomy and VATS using the 5-dimension taxonomical structure proposed by AAAPT (i.e., core diagnostic criteria, common features, modulating factors, impact/functional consequences, and putative mechanisms). The resulting diagnostic criteria will serve as the starting point for subsequent empirically validated criteria. PERSPECTIVE ITEM: This article characterizes acute pain after thoracotomy and VATS using the 5-dimension taxonomical structure proposed by AAAPT (ie, core diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms).

Readmission After Lobectomy for Lung Cancer: Not All Complications Contribute Equally

OBJECTIVE

The aim of this study was to identify independent predictors of hospital readmission for patients undergoing lobectomy for lung cancer.

SUMMARY BACKGROUND DATA

Hospital readmission after lobectomy is associated with increased mortality. Greater than 80% of the variability associated with readmission after surgery is at the patient level. This underscores the importance of using a data source that includes detailed clinical information.

METHODS

Using the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD), we conducted a retrospective cohort study of patients undergoing elective lobectomy for lung cancer. Three separate multivariable logistic regression models were generated: the first included preoperative variables, the second added intraoperative variables, and the third added postoperative variables. The c statistic was calculated for each model.

RESULTS

There were 39,734 patients from 277 centers. The 30-day readmission rate was 8.2% (n = 3237). In the final model, postoperative complications had the greatest effect on readmission. Pulmonary embolus {odds ratio [OR] 12.34 [95% confidence interval (CI),7.94-19.18]} and empyema, [OR 11.66 (95% CI, 7.31-18.63)] were associated with the greatest odds of readmission, followed by pleural effusion [OR 7.52 (95% CI, 6.01-9.41)], pneumothorax [OR 5.08 (95% CI, 4.16-6.20)], central neurologic event [OR 3.67 (95% CI, 2.23-6.04)], pneumonia [OR 3.13 (95% CI, 2.43-4.05)], and myocardial infarction [OR 3.16 (95% CI, 1.71-5.82)]. The c statistic for the final model was 0.736.

CONCLUSIONS

Complications are the main driver of readmission after lobectomy for lung cancer. The highest risk was related to postoperative events requiring a procedure or medical therapy necessitating inpatient care.

Effects of Polymorphisms in the Serotonin Transporter Promoter-Linked Polymorphic Region on Postthoracotomy Pain Severity

Purpose

Serotonin (5-HT) is highly associated with pain modulation. The human 5-HT transporter (5-HTT) gene (SLC6A4) features several polymorphisms in its promoter region (5-HTTLPR) that affect the 5-HTT expression. The S allele of 5-HTTLPR induces low 5-HT tone, and it may influence the modulation of chronic pain. Meanwhile, pain occurs in 40–50% of patients after thoracic surgery, and its mechanism remains under investigation. This study assessed the role of 5-HTTLPR polymorphisms in postthoracotomy pain severity.

Patients and Methods

A total of 178 patients undergoing pneumonectomy were enrolled. The genotypes of 5-HTTLPR were divided into two groups: S/S group and S/L or L/L group. Linear mixed-effects models were used to assess the association between 5-HTTLPR genotypes and the numerical rating scale (NRS) score change over time.

Results

Among the participants, data were obtained for 162 patients. The genotype distribution was as follows: S/S, 67.3%; S/L or L/L, 32.7%. No significant difference in patient characteristics was found between the genotype groups. There was no significant interaction between the 5-HTTLPR genotypes and the NRS score change over time (p = 0.842).

Conclusion

Polymorphisms in 5-HTTLPR were not associated with postthoracotomy pain severity.

Association Between Sternotomy Versus Thoracotomy and the Prevalence and Severity of Chronic Postsurgical Pain After Mitral Valve Repair: An Observational Cohort Study

OBJECTIVE

Investigate differences in the prevalence and severity of chronic postsurgical pain (CPSP) after cardiac surgery via thoracotomy versus sternotomy are not well-understood.

DESIGN

An observational cohort study.

SETTING

A tertiary care hospital.

PARTICIPANTS

Four hundred twenty-eight patients (sternotomy: 192 patients, thoracotomy: 236 patients) who underwent mitral valve repair.

INTERVENTIONS

A questionnaire about the severity of surgical wound pain evaluated with a numerical rating scale (NRS) was sent. NRS responses for current pain, peak pain in the last four weeks, and average pain in the last four weeks were evaluated.

MEASUREMENTS AND MAIN RESULTS

The main outcomes were the severity of CPSP evaluated using NRS and the prevalence of CPSP. CPSP was defined as pain >0 that developed after a surgical procedure. During the median follow-up of 29 months, 79 patients complained of CPSP. (sternotomy: 15 patients, thoracotomy: 64 patients). Multivariate ordinal logistic regression showed that NRS responses for current pain (adjusted odds ratio [aOR], 3.17; 95% confidence interval [CI] 1.64-6.12; p = 0.001), peak pain in the last four weeks (aOR, 2.00; 95% CI 1.11-3.61; p = 0.021), and average pain in the last four weeks (aOR, 2.21; 95% CI 1.31-3.72; p = 0.003) were significantly higher in patients who underwent thoracotomy. Multivariate logistic regression showed that thoracotomy was an independent predictor of CPSP (aOR, 3.63; 95% CI 1.67-7.88; p = 0.001).

CONCLUSIONS

The prevalence and severity of CPSP were higher among patients who underwent mitral valve repair via thoracotomy than sternotomy.

Postoperative Thoracic Pain Treatment: Serratus Anterior or Erector Spinae Plane Block?

BACKGROUND

 Thoracic surgery is one of the most painful surgeries. Effective analgesia is important in postoperative pain management. In this study, we aimed to compare the two new fascial block techniques.

METHODS

 A total of 107 patients who underwent thoracic surgery between October 2018 and November 2019 were retrospectively evaluated. The study included 59 patients in the serratus anterior plane block (SAPB) group and 48 patients in the erector spinae plane block (ESPB) group. Both groups were administered 30 mL of 0.25% bupivacaine and their morphine consumption was evaluated by a patient-controlled analgesia (PCA) method during the 2nd, 6th, 12th, 24th, and 48th postoperative hours. Pain was measured with the visual analog scale (VAS). Intraoperative mean arterial pressure (MAP) and heart rate (HR) were recorded.

RESULTS

 During the first 24 hours, VAS values were significantly lower in the ESPB group (p < 0.05). Moreover, morphine consumption was significantly lower in the ESPB group in the 24th and 48th hours (p < 0.05). Intraoperative remifentanil consumption was also significantly lower in the ESPB group (p < 0.05). Intraoperative MAP in the ESPB group was found to be significantly lower after the 4th hour. HR was similar in both groups.

CONCLUSION

 ESPB was more effective compared with SAPB in postoperative thoracic pain management.

Analgesic Effectiveness of Perioperative Ultrasound-Guided Serratus Anterior Plane Block Combined with General Anesthesia in Patients Undergoing Video-Assisted Thoracoscopic Surgery: A Systematic Review and Meta-analysis

Objective

To investigate whether perioperative ultrasound-guided serratus anterior plane block (SAPB) combined with general anesthesia is more effective and safer than current analgesic techniques for postoperative analgesia after video-assisted thoracoscopic surgery (VATS).

Methods

PubMed, the Cochrane Library, and EMBASE were searched for clinical trials published up to July 31, 2019. Outcomes, including operative duration, postoperative pain scores, postoperative analgesia use, patient satisfaction with analgesia, time to chest tube removal, length of stay, and adverse effects were analyzed.

Results

Four clinical trials, including 262 patients, met inclusion criteria. Ultrasound-guided SAPB reduced pain scores at zero, 15, 30, 45, and 60 minutes in the postoperative anesthesia care unit (all P &lt; 0.05) and at one, two, six, 12, and 24 hours in the ward (all P &lt; 0.001). Additionally, postoperatively, morphine consumption at 15 and 30 minutes, overall morphine consumption, and total consumption (morphine plus tramadol) were significantly lower in the SAPB cohort (P  &lt; 0.05). Similarly, postoperative tramadol consumption at one, two, six, 12, and 24 hours was also lower in this cohort (all P  &lt; 0.05). The postoperative consumption of fentanyl, tramadol, and total morphine in patient-controlled analgesia (PCA) at 24 hours was significantly reduced (P &lt; 0.05). Moreover, SAPB provided better patient satisfaction with analgesia (P = 0.0038). However, no statistically significant difference was found in duration of operation, time to chest tube removal, length of stay, or side effects (all P &gt; 0.05).

Conclusions

Perioperative ultrasound-guided SAPB combined with general anesthesia provided more effective postoperative analgesia after VATS. However, no significant advantage was found regarding side effects.

Patient-Reported Chronic Pain Outcomes After Lung Transplantation

Chronic pain after lung transplantation is a significant concern, in particular given the heterogeneity of the patient population and the challenges of achieving adequate pain control amid concerns related to complex immunosuppressant regimens and the possibility of respiratory depression. We undertook a patient-reported outcomes (PRO) survey administered via our electronic health care portal to examine the postoperative incisional pain prevalence in a cohort of lung transplant recipients at a single, high-volume center where bilateral thoracosternotomy is the preferred surgical approach. The Patient Reported Outcomes Measurement Information System (PROMIS) Global Health and Pain Intensity short forms were sent to a total of 173 lung transplant recipients who were more than 2 months postsurgery at the time of the study. A total of 64 patients responded to both PROMIS surveys (response rate 38%). In the cohort of survey respondents, we observed a chronic pain incidence of 58% after lung transplantation (median pain score 1/10) and an overall good quality of life score (median score 4/5); however, only 9.4% reported moderate-severe pain (pain score ≥5/10). Survey nonrespondents had higher rates of pretransplant opioid and psychiatric medication use compared with respondents. In this study, we demonstrated the feasibility of using an electronic PRO survey for assessing postoperative pain outcomes after lung transplantation. However, measuring pain outcomes using this type of tool highlights issues of response rate and potential selection bias. Larger studies are needed to adequately assess the risk and predictors of chronic pain after lung transplantation and its impact on quality of life.

Ultrasound-guided continuous serratus anterior plane block: dexmedetomidine as an adjunctive analgesic with levobupivacaine for post-thoracotomy pain. A prospective randomized controlled study

Purpose: The study aimed to evaluate the analgesic efficiency of dexmedetomidine (DEX) when added to levobupivacaine in continuous ultrasound-guided serratus anterior plane block (SAPB) performed at the end of major thoracic surgery.

Methods: This randomized, double-blind trial included 50 adults undergoing thoracic surgery. Continuous SAPB was performed at the end of surgery. Patients were randomized into two groups. Group L (n=25) received levobupivacaine only while Group DL (n=25) received a mixture of levobupivacaine and DEX. All patients received intravenous (IV) paracetamol every 8 hrs. Morphine IV was given according to VAS score of pain as a 5 mg loading dose. The primary outcome measure was postoperative pain intensity. Secondary outcome measures were postoperative morphine consumption and adverse effects.

Results: Analgesia was satisfactory in the two groups up to 24 hrs. VAS score was significantly lower in group DL compared to group L between 6 and 24 hrs postoperatively. Total morphine consumption was significantly lower in group DL compared to group L (p<0.001). Up to 12 hrs postoperatively, sedation score was significantly lower in group DL compared to group L. Afterwards, all patients were fully alert. All values of mean arterial pressure and heart rate were within the clinically accepted ranges. There were no recorded cases of hypotension or bradycardia in the whole studied group.

Conclusions: Continuous SAPB with levobupivacaine plus DEX seems to be a promising analgesic alternative following thoracotomy. Combined with IV paracetamol, this approach provided adequate analgesia and proper sedation.

Trial registration: ISRCTN registry; study ID: ISRCTN35517318

Preoperative dexamethasone for acute post-thoracotomy analgesia: a randomized, double-blind, placebo-controlled study

Background

The analgesic effects of dexamethasone have been reported previously, and the present study determined the effects of preoperative dexamethasone on postoperative pain in patients who received thoracotomy.

Methods

Forty patients participated in this randomized, double-blind study. All patients received either dexamethasone via a 0.1 mg/kg intravenous bolus before anesthetic induction or an equal volume of saline. Postoperative analgesia was provided to both groups via epidural patient-controlled analgesia (PCA), which consisted of 250 μg of sufentanil in 250 mL of ropivacaine (0.18%) for 72 h. The primary outcome was the cumulative consumption of epidural PCA at postoperative 24 and 72 h. The secondary outcomes were the pain intensity scores during resting and coughing at postoperative 24 and 72 h, quality of recovery, total amount of rescue analgesics required, and length of hospital stay.

Results

No significant differences was observed in the consumption of epidural PCA between the control and dexamethasone infusion groups at 24 h (63.6 [55.9–72.7] vs. 68.5 [60.2–89.0] ml, P = 0.281) and 72 h (199.4 [172.4–225.1] vs. 194.7 [169.1–252.2] ml, P = 0.890). Moreover, there was no significant difference in the pain intensity scores during resting and coughing at postoperative 24 and 72 h, quality of recovery, total amount of rescue analgesics required, and length of hospital stay.

Conclusion

A single intravenous administration of dexamethasone during the preoperative period does not reduce opioid consumption and post-thoracotomy pain.

Trial registration

The study was registered at http://cris.nih.go.kr (KCT0000359) and was conducted from December 2011 to October 2012.

Effects of progressive muscle relaxation training on sleep and quality of life in patients with pulmonary resection

BACKGROUND

The inadequate quality and nature of sleep is a commonly reported problem among hospitalized patients. The purpose of this study is to examine the effects of progressive muscle relaxation training program on sleep quality, sleep state, pain, and quality of life in patients who underwent pulmonary resection.

METHODS

Our study was planned as a single-blind prospective randomized controlled trial. The study was conducted on 26 patients who underwent surgery by using posterolateral thoracotomy method. Progressive muscle relaxation training were given to the training group with a therapist two times a day. Sleep quality, daytime sleeping, pain, and quality of life were respectively evaluated in the morning before the surgery and 1 week after the surgery by using Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, visual analogue scale, and Euro Quality of Life-5D (EQ-5D).

RESULTS

There is no significant difference between preoperative groups in the total Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Euro Quality of Life-5D, and visual analogue scale scores (p > 0.05). The intra-group change in the study group showed a significant deterioration in the Euro Quality of Life-5D and visual analogue scale scores (p < 0.05). There was a significant deterioration in the total Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, EQ-5D, and visual analogue scale scores in the control group (p < 0.05). The Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Euro Quality of Life-5D scores showed significant improvements in the relaxation training group after treatment at 1 week (p < 0.05).

CONCLUSIONS

Progressive muscle relaxation prevents a decline in patient-reported sleep quality following pulmonary resection.

Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series

Background and aims

Post thoracotomy pain syndrome (PTPS) remains a common complication of thoracic surgery with significant impact on patients’ quality of life. Management usually involves a mul¬tidisciplinary approach that includes oral and topical analgesics, performing appropriate interventional techniques, and coordinating additional care such as physiotherapy, psychotherapy and rehabilitation. A variety of interventional procedures have been described to treat PTPS that is inadequately managed with systemic or topical analgesics. Most of these procedures are technically complex and are associated with risks and complications due to the proximity of the targets to neuraxial structures and pleura. The ultrasound-guided erector spinae plane (ESP) block is a novel technique for thoracic analgesia that promises to be a relatively simple and safe alternative to more complex and invasive techniques of neural blockade. We have explored the application of the ESP block in the management of PTPS and report our preliminary experience to illustrate its therapeutic potential.

Methods

The ESP block was performed in a pain clinic setting in a cohort of 7 patients with PTPS following thoracic surgery with lobectomy or pneumonectomy for lung cancer. The blocks were performed with ultrasound guidance by injecting 20–30mL of ropivacaine, with or without steroid, into a fascial plane between the deep surface of erector spinae muscle and the transverse processes of the thoracic vertebrae. This paraspinal tissue plane is distant from the pleura and the neuraxis, thus minimizing the risk of complications associated with injury to these structures. The patients were followed up by telephone one week after each block and reviewed in the clinic 4–6 weeks later to evaluate the analgesic response as well as the need for further injections and modification to the overall analgesic plan.

Results

All the patients had excellent immediate pain relief following each ESP block, and 4 out of the 7 patients experienced prolonged analgesic benefit lasting 2 weeks or more. The ESP blocks were combined with optimization of multimodal analgesia, resulting in significant improvement in the pain experience in all patients. No complications related to the blocks were seen.

Conclusion

The results observed in this case series indicate that the ESP block may be a valuable therapeutic option in the management of PTPS. Its immediate analgesic efficacy provides patients with temporary symptomatic relief while other aspects of chronic pain management are optimized, and it may also often confer prolonged analgesia.

Implications

The relative simplicity and safety of the ESP block offer advantages over other interventional procedures for thoracic pain; there are few contraindications, the risk of serious complications (apart from local anesthetic systemic toxicity) is minimal, and it can be performed in an outpatient clinicsetting. This, combined with the immediate and profound analgesia that follows the block, makes it an attractive option in the management of intractable chronic thoracic pain. The ESP block may also be applied to management of acute pain management following thoracotomy or thoracic trauma (e.g. rib fractures), with similar analgesic benefits expected. Further studies to validate our observations are warranted.

The efficacy of serratus anterior plane block in analgesia for thoracotomy: a retrospective study

PURPOSE

A multimodal analgesic approach is necessary for post-thoracotomy pain, which can be severe. Intravenous access, central and peripheral nerve blocks are frequently used. The aim of this study was to evaluate the efficacy of serratus anterior plane block (SAPB) in the management of post-thoracotomy pain.

METHODS

A total of 40 patients who underwent thoracotomy between January 2014 and January 2016 were retrospectively analyzed. The patients were divided into two groups: Group M (intravenous patient-controlled analgesia morphine; n = 20) and Group S (intravenous patient-controlled analgesia morphine + SAPB; n = 20). The Visual Analogue Scale (VAS) was used for pain evaluation at the 1st, 2nd, 4th, 6th, 8th, 12th and 24th postoperative hours and morphine consumption was evaluated at the 6th, 12th and 24th postoperative hours. Secondary outcomes were additional analgesic requirement, side effects, the Ramsay Sedation Scale (RSS) scores, block onset time and block level.

RESULTS

The VAS scores and the amount of morphine consumed at the 6th, 12th and 24th hours were found to be significantly lower in Group S than in Group M (P < 0.001). No statistically significant difference was found in the rate of side effects, including nausea, vomiting, pruritus, respiratory depression, bradycardia and hypotension, and RSS outcomes between the groups.

CONCLUSION

Our study suggests that SAPB is an effective adjuvant treatment option for thoracotomy analgesia.

Post-thoracotomy pain syndrome and sensory disturbances following thoracotomy at 6- and 12-month follow-ups

Background

Persistent pain affects a large proportion of patients after thoracotomy and is associated with sensory disturbances. The objective of this prospective study was to investigate the time course of pain and sensory disturbances over a 12-month period.

Methods

Patients scheduled for thoracotomy were recruited. Data were collected on the day before surgery, including baseline characteristics and the presence of any preoperative pain. At 6- and 12-month follow-ups, data on pain were collected using the Brief Pain Inventory-Short Form, and perceived sensory disturbances around the thoracotomy scar were recorded from a self-exploration test.

Results

At 12 months after surgery, 97 patients had complete data including baseline and 6-and 12-month measurements. Almost half of the patients reported post-thoracotomy pain at the follow-ups. However, 20% of the patients not reporting post-thoracotomy pain at 6 months did report it at 12 months. Between 40% and 60% of patients experienced some kind of sensory disturbance at 6 months. A small decline in some kind of sensory disturbance was reported by 20%–50% of patients at 12 months.

Conclusion

A proportion of patients experienced either resolved or delayed onset of pain. Sensory changes were strongly associated with post-thoracotomy pain syndrome, but were also present in a large proportion of patients without it.

Pain locations in the postoperative period after cardiac surgery: Chronology of pain and response to treatment

INTRODUCTION

Postoperative pain after cardiac surgery (CS) can be generated at several foci besides the sternotomy.

METHODS

Prospective descriptive longitudinal study on the chronological evolution of pain in 11 sites after CS including consecutive patients submitted to elective CS through sternotomy. The primary endpoints were to establish the main origins of pain, and to describe its chronological evolution during the first postoperative week. Secondary endpoints were to describe pain characteristics in the sternotomy area and to correlate pain intensity with other variables. Numerical Pain Rating Scale from 0 to 10 at rest and at movement on postoperative days 1, 2, 4 and 6. Numerical Pain Rating Scale>3 was considered moderate pain. Statistical analysis consisted in Mann-Whitney U-test, a Chi-squared, a Fisher exact text and Pearson's correlations.

RESULTS

Forty-seven patients were enrolled. In 4 of 11 locations pain was reported as Numerical Pain Rating Scale>3 (sternotomy, oropharynx, saphenectomy and musculoskeletal pain in the back and shoulders). Maximum intensity of pain on postoperative days 1 and 2 was reported in the sternotomy area, while on postoperative days 4 and 6 it was reported at the saphenectomy. Pain at rest and at movement differed considerably in the sternotomy, saphenectomy and oropharynx. Pain at back and shoulders and at central venous catheter entry were not influenced by movement. Pain in the sternotomy was mainly described as oppressive. Patients with arthrosis and younger patients presented higher intensity of pain (P=.004; P=.049, respectively).

CONCLUSIONS

Four locations were identified as the main sources of pain after CS: sternotomy, oropharynx, saphenectomy, and back and shoulders. Pain in different focuses presented differences in chronologic evolution and was differently influenced by movement.

Effect of parecoxib combined with thoracic epidural analgesia on pain after thoracotomy

BACKGROUND

Thoracotomy results in severe postoperative pain potentially leading to chronic pain. We investigated the potential benefits of intravenous parecoxib on postoperative analgesia combined with thoracic epidural analgesia (TEA).

METHODS

Eighty-six patients undergoing thoracic surgery were randomized into two groups. Patient-controlled epidural analgesia (PCEA) was used until chest tubes were removed. Patients received parecoxib (group P) or placebo (group C) intravenously just 0.5 h before the operation and every 12 h after operation for 3 days. The intensity of pain was measured by using a visual analogue scale (VAS) and recorded at 2, 4, 8, 24, 48, 72 h after operation. The valid number of PCA, the side effects and the overall satisfaction to analgesic therapy in 72 h were recorded. Venous blood samples were taken before operation, the 1(st) and 3(rd) day after operation for plasma cortisol, adrenocorticotropic hormone (ACTH), interleukin-6 and tumor necrosis factor-α level. The occurrence of residual pain was recorded using telephone questionnaire 2 and 12 months after surgery.

RESULTS

Postoperative pain scores at rest and on coughing were significantly lower with the less valid count of PCA and greater patient satisfaction in group P (P<0.01). Adverse effect and the days fit for discharge were comparable between two groups. The cortisol levels in placebo group were higher than parecoxib group at T2. The level of ACTH both decreased in two groups after operation but it was significantly lower in group P than that in group C. There were no changes in plasma IL-6 and TNF-α levels before and after analgesia at T1 and T2 (P>0.05). The occurrence of residual pain were 25% and 51.2% separately in group P and C 3 months postoperatively (P<0.05).

CONCLUSIONS

Intravenous parecoxib in multimodal analgesia improves postoperative analgesia provided by TEA, relieves stress response after thoracotomy, and may restrain the development of chronic pain.