Effect of pre-emptive ketamine on sensory changes and postoperative pain after thoracotomy: comparison of epidural and intramuscular routes

Opioid-Free Versus Opioid-Based Anesthesia on Postoperative Pain After Thoracoscopic Surgery: The Use of Intravenous and Epidural Esketamine

BACKGROUND

The effectiveness and safety of opioid-free anesthesia (OFA) regimens in distinct types of surgeries remain controversial. In this study, we investigated whether OFA could reduce the occurrence of chronic postoperative pain in patients receiving video-assisted thoracoscopic surgery (VATS).

METHODS

We conducted a 2-center, randomized, controlled trial from September 2021 to January 2022. A total of 162 lung tumor patients scheduled to undergo VATS were randomly divided into an opioid-based anesthesia (OA) group and an OFA group. The OA group received general anesthesia combined with thoracic epidural block using morphine, while the OFA group received general anesthesia combined with thoracic epidural block using esketamine. Patient-controlled epidural analgesia (PCEA) was used after surgery (ropivacaine and morphine for the OA group versus ropivacaine and esketamine for the OFA group). The primary end point was chronic pain rates at 3 months after VATS, which were analyzed using a logistic regression model. The secondary end points were chronic pain rates at 6 months, acute pain rates at 24 hours and 48 hours postoperatively, postoperative side effects, and perioperative variables.

RESULTS

The final analysis included 159 patients. Acute postoperative pain at 24 hours occurred in 0 of the 79 (0%) patients in the OA group and 10 of the 80 (17.5%) patients in the OFA group (odds ratio, 52.14; 95% confidence interval [CI], 6.47-420.10; P < .001). Acute postoperative pain at 48 hours occurred in 3 of the 79 (3.8%) patients in the OA group and 2 of the 80 (2.5%) patients in the OFA group (odds ratio, 2.07; 95% CI, 0.99-4.32; P = .053). In this study, none of the patients had moderate or severe pain in either group at 3 and 6 months postsurgically. Mild chronic postoperative pain at 3 months occurred in 27 of the 79 (34.2%) patients in the OA group and 14 of the 80 (17.5%) patients in the OFA group (odds ratio, 3.52; 95% CI, 1.49-8.31; P = .004). At 6 months, mild chronic pain still occurred in 23 of the 79 (29.1%) patients in the OA group and 9 of the 80 (11.3%) patients in the OFA group (odds ratio, 5.55; 95% CI, 2.01-15.33; P = .001). In addition, the OFA group included fewer patients with side effects, including nausea, vomiting, and pruritus, within 48 hours after surgery.

CONCLUSIONS

Replacement of opioids by esketamine, intraoperatively as intravenous injection and epidural infusion and postoperatively as epidural infusion, reduces the incidence of mild chronic postoperative pain and side effects in patients after VATS.

Efficacy of preemptive intercostal nerve block on recovery in patients undergoing video-assisted thoracic lobectomy

BACKGROUND

Preemptive intercostal nerve block (pre-ICNB) achieves the same analgesic effects as postoperative ICNB (post-ICNB) remains unclear. This study aimed to evaluate the efficacy of preemptive ICNB on perioperative outcomes for patients undergoing video-assisted thoracic surgery (VATS).

METHODS

This was a randomized, open-label study (ChiCTR2200055667) from August 1, 2021, to December 30, 2021. Eligible patients scheduled for lobectomy for lung cancer were allocated into the pre-ICNB group and the post-ICNB group. The postoperative pain evaluation, patient rehabilitation, and opioid consumption were observed.

RESULTS

A total of 81 patients were included. When compared with the post-ICNB group, the pre-ICNB group had a lower proportion of hypertension comorbidity (P = 0.023), significantly lower total consumption of morphine milligram equivalents (MMEs) (P = 0.016), shorter extubation time (P = 0.019). The pre-ICNB group has similar Numeric Rating Scales (NRS) scores of dynamic pain in the post-anesthesia care unit (PACU), postoperative 6 h, 12 h, 24 h, and 48 h (P > 0.05), and had simialr scores of Bruggrmann Comfort Scale (BCS) in postoperative 6 h, 12 h, 24 and 48 h (P > 0.05). The scores of the Mini-mental state examination (MMSE) and Ramsay in the pre-ICNB group were comparable to those in the post-ICNB group, except the scores of MMSE and Ramsay in postoperative 6 h were lower (P = 0.048 and P = 0.019). The pain evaluation in the 1-month follow-up was comparable with that in the post-ICBN group (P > 0.05).

CONCLUSIONS

Pre- ICNB is equally efficacious in perioperative pain management as post-ICNB, and pre-ICNB significantly reduces intra-operative opioid consumption, providing faster recovery in PACU.

TRIAL REGISTRATION

Registered in the Chinese Clinical Trial Register (ChiCTR2200055667).

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).

Subcutaneous ketamine prolongs the analgesic effect of local infiltration of plain Bupivacaine in children undergoing inguinal herniotomy

Background

Inguinal herniotomy is one of the commonest paediatric surgical procedures at the University of Benin Teaching Hospital. Incisional infiltration with plain bupivacaine has been used to provide postoperative analgesia for this procedure but with a short duration of action, 4–6 hours.

Aims/Objectives

The aim of this study therefore was to evaluate the efficacy of subcutaneous ketamine on post-operative analgesia in children undergoing unilateral inguinal herniotomy

Methods

Forty-six (46) ASA I or II patients aged three to seven years scheduled for unilateral inguinal herniotomy were recruited. The patients were randomized to receive surgical wound site infiltration with plain bupivacaine plus subcutaneous injection of ketamine for group I or surgical wound site infiltration plain bupivacaine plus 2ml of saline subcutaneously for group II at the end of surgery. Data obtained were analyzed using SPSS version 20. Continuous data were compared using student t-test while categorical data were compared using Chi-square or Fisher's exact test. P-value <0.05 was considered statistically significant.

Results

In group, I, the mean time to first analgesic request was 667.7 minutes (11.12 hours) and in group II, it was 371.3 minutes (6.2 hours) with p<0.001. The pain scores were better and more favourable in group I from the 8th hour and above of the assessment period. The mean post-operative analgesic consumption in 24 hours was less in group I (19.35±5.4mg) than in group II (27.32±5.8 mg) with p-value <0.001.

Conclusion

The study showed that subcutaneous ketamine prolonged the analgesic effect of plain bupivacaine surgical wound site infiltration in children undergoing unilateral inguinal herniotomy.

Paravertebral Block Versus Preemptive Ketamine Effect on Pain Intensity after Posterolateral Thoracotomies: A Randomized Controlled Trial

Severe postoperative pain affects most patients after thoracotomy and is a risk factor for post-thoracotomy pain syndrome (PTPS). This randomized controlled trial compared preemptively administered ketamine versus continuous paravertebral block (PVB) versus control in patients undergoing posterolateral thoracotomy. The primary outcome was acute pain intensity on the visual analog scale (VAS) on the first postoperative day. Secondary outcomes included morphine consumption, patient satisfaction, and PTPS assessment with Neuropathic Pain Syndrome Inventory (NPSI). Acute pain intensity was significantly lower with PVB compared to other groups at four out of six time points. Patients in the PVB group used significantly less morphine via a patient-controlled analgesia pump than participants in other groups. Moreover, patients were more satisfied with postoperative pain management after PVB. PVB, but not ketamine, decreased PTPS intensity at 1, 3, and 6 months after posterolateral thoracotomy. Acute pain intensity at hour 8 and PTPS intensity at month 3 correlated positively with PTPS at month 6. Bodyweight was negatively associated with chronic pain at month 6. Thus, PVB but not preemptively administered ketamine decreases both acute and chronic pain intensity following posterolateral thoracotomies.

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.

Pre-Emptive Analgesia with Ketamine for Relief of Postoperative Pain After Surgical Removal of Impacted Mandibular Third Molars

PURPOSE

In this study we assessed the clinical efficacy of sub-mucosal injection of ketamine at sub-anesthetic dose of 0.5 mg/kg on post-operative pain, swelling and trismus following surgical extraction of impacted mandibular third molars.

METHODS

Forty bilaterally symmetrical impacted mandibular third molars in 20 patients who required surgical removal were included in the study. Within the same individual, one of the sites received a test medication whereas the other site was used as control. All patients received nerve blocks with local anesthetic (2 % lignocaine hydrochloride with 1:80,000 adrenaline); the Test group received sub-mucosal infiltration of 0.5 mg/kg of ketamine hydrochloride (without preservative) around the impacted mandibular third molar and along the incision line, while the Placebo group received normal saline infiltration, 10 min before placement of the incision.

RESULTS

The pain scores on VAS at 30 min, 1, 4, 12 h and 1 day post-operatively was significantly lower in the Test group than in the Placebo group (p < .05). With respect to facial swelling and mouth opening the Test group and Placebo group showed overall no statistically significant difference (p > .05) on the 1st, 3rd and 7th post-operative days.

CONCLUSION

The sub-mucosal injection of 0.5 mg/kg ketamine administered before surgical removal of impacted mandibular third molars was found to be effective in significantly reducing post-operative pain for the first 24 h.

Is pre-emptive administration of ketamine a significant adjunction to intravenous morphine analgesia for controlling postoperative pain? A randomized, double-blind, placebo-controlled clinical trial

OBJECTIVES

To evaluate if the pre-emptive administration of ketamine would potentiate the effect of intravenous morphine analgesia in the management of post-thoracotomy pain.

METHODS

This was a unicentre, double-blind, placebo-controlled, parallel-group, prospective study. Patients were randomly assigned to receive 1 mg/kg ketamine (ketamine group) or an equivalent dose of normal saline (placebo group) before thoracotomy in 1:1 ratio. All patients received postoperatively intravenous morphine administration as additional analgesic regimen. Primary end-point was the pain relief measured with Visual Analogue Scale at rest. The secondary end-points were the reduction of inflammatory response expressed by plasma C-reactive protein levels, the morphine consumption and the rate of side effects. The measurements were carried out 6, 12, 24, 36 and 48 hours postoperatively.

RESULTS

A total of 75 patients were randomized of whom 38 were allocated to ketamine group and 37 to placebo group. Baseline characteristics were comparable. Ketamine compared with placebo group showed a significant reduction of pain scores (P = 0.01), C-reactive protein (P < 0.001) and morphine consumption (P < 0.001). No acute psychological side effects related to the use of ketamine were registered.

CONCLUSIONS

The administration of ketamine before surgery may be an effective adjunct to intravenous morphine analgesia in acute post-thoracotomy pain management. In ketamine group, satisfaction of pain relief was significantly higher with a significant reduction of inflammatory response and morphine consumption compared with placebo group. Our results, if confirmed by larger studies, may be of clinical relevance in situations where epidural analgesia or other analgesic procedures different from systemic opioid analgesia are unavailable or contraindicated.

Ketamine in outpatient arthroscopic shoulder surgery: Effects on postoperative pain, hemodynamic stability and process times

Background

Pain after arthroscopic shoulder surgery is often severe, and establishing a pain treatment regimen that does not delay discharge can be challenging. The reported ability of ketamine to prevent opioid-induced hyperalgesia has not been investigated in this particular setting.

Methods

300 adult patients scheduled for shoulder arthroscopy under general anesthesia were recruited for this observational clinical trial and were allotted to either receive 1mg/kg IV bolus of ketamine before surgery (ketamine group, KG) or to a control group (CG) without ketamine. NRS pain scores were obtained on the operative day and on postoperative days 1 and 2 and compared between groups. Secondary variables were blood pressure, heart rate, process times, satisfaction with the anesthetic and unwanted effects.

Results

Pain severity did not differ significantly between the groups at any time. Propofol injection rate and cumulative dose were higher in the KG. Heart rates and blood pressures were similar. Time to emergence and time in PACU were longer and vomiting was more frequent in patients given ketamine.

Conclusion

Preoperative low-dose ketamine added to a general anesthetic does not reduce perioperative pain after outpatient shoulder arthroscopy. It increases procedural times and the incidence of PONV.

Ketamine: use in anesthesia

The role of ketamine anesthesia in the prehospital, emergency department and operating theater settings is not well defined. A nonsystematic review of ketamine was performed by authors from Australia, Europe, and North America. Results were discussed among authors and the final manuscript accepted. Ketamine is a useful agent for induction of anesthesia, procedural sedation, and analgesia. Its properties are appealing in many awkward clinical scenarios. Practitioners need to be cognizant of its side effects and limitations.

Causes and prevention of chronic postsurgical pain

PURPOSE OF REVIEW

Surgical incision invariably causes some measure of nerve damage and inflammatory response that, in most cases, heals quickly without long-term negative consequence. However, a subset of these patients go on to develop lasting neuropathic pain that is difficult to treat and, in many cases, prevents the return to normal activities of life. It remains unknown why two patients with identical surgical interventions may go on to develop completely divergent pain phenotypes or no pain at all. Aggressive, early analgesic therapy has been shown to reduce the incidence of chronic postsurgical pain (CPSP), but no specific regional anesthetic technique or systemic pharmacologic therapy has been shown to prevent CPSP.

RECENT FINDINGS

Inflammation and glial cell activation have recently been shown to be just as important in the transition from normal acute pain to pathologic chronic pain as nerve injury itself and that central sensitization may not be solely due to repetitive nociceptive firing at the time of nerve injury. This has opened a number of new therapeutic possibilities for prevention of CPSP.

SUMMARY

Here, we discuss the causes of CPSP and current useful preventive strategies in the perioperative period. We also discuss future potential disease-modifying treatments of CPSP.

Prevention of chronic pain after surgical nerve injury: amputation and thoracotomy

Although techniques for acute pain management have improved in recent years, a dramatic reduction in the incidence and severity of chronic pain following surgery has not occurred. Amputation and thoracotomy, although technically different, share the commonalities of unavoidable nerve injury and the frequent presence of persistent postsurgical neuropathic pain. The authors review the risk factors for the development of chronic pain following these surgeries and the current evidence that supports analgesic interventions. The inconclusive results from many preemptive analgesic studies may require us to reconceptualize the perioperative treatment period as a time of gradual neurologic remodeling.

Opioid-induced hyperalgesia in a mice model of orthopaedic pain: preventive effect of ketamine

BACKGROUND

The aim of this study was to assess the preventative effect of ketamine on the exaggerated postoperative pain observed in sufentanil-treated mice and its ability to improve the analgesic effectiveness of morphine during the postoperative period in an orthopaedic model of pain.

METHODS

In this study, we assessed the effects of ketamine on sufentanil enhancement of pain behaviour induced by fracture and the effects of ketamine on postoperative morphine-induced analgesia. Three tests were used to assess pain behaviour: von Frey filament application, hot-plate test, and a subjective pain scale.

RESULTS

When administered 1 day after surgery in mice treated with sufentanil on D0 (before surgery), morphine induced an analgesic effect as observed by the nociceptive threshold increase in saline- and ketamine-treated mice. Morphine was more effective in ketamine-treated (1 and 50 mg kg(-1)) mice.

CONCLUSIONS

Our results suggest that pre-emptive use of ketamine is useful in orthopaedic surgery in this mice model to diminish short- and long-term hyperalgesia, but also to improve morphine effectiveness leading to a better mobilization and more rapid rehabilitation.

A randomised double blind trial of the effect of pre-emptive epidural ketamine on persistent pain after lower limb amputation

Persistent pain has been reported in up to 80% of patients after limb amputation. The mechanisms are not fully understood, but nerve injury during amputation is important, with evidence for the crucial involvement of the spinal N-methyl d-aspartate (NMDA) receptor in central changes. The study objective was to assess the effect of pre-emptively modulating sensory input with epidural ketamine (an NMDA antagonist) on post-amputation pain and sensory processing. The study recruited 53 patients undergoing lower limb amputation who received a combined intrathecal/epidural anaesthetic for surgery followed by a randomised epidural infusion (Group K received racemic ketamine and bupivacaine; Group S received saline and bupivacaine). Neither general anaesthesia nor opioids were used during the peri-operative period. Pain characteristics were assessed for 12 months. The primary endpoint was incidence and severity of post-amputation pain. Persistent pain at one year was much less in both groups than in comparable studies, with no significant difference between groups (Group K=21% (3/14) and 50% (7/14); and Group S=33% (5/15) and 40% (6/15) for stump and phantom pain, respectively). Post-operative analgesia was significantly better in Group K, with reduced stump sensitivity. The intrathecal/epidural technique used, with peri-operative sensory attenuation, may have reduced ongoing sensitisation, reducing the overall incidence of persistent pain. The improved short-term analgesia and reduced mechanical sensitivity in Group K may reflect acute effects of ketamine on central sensitisation. Longer term effects on mood were detected in Group K that requires further study.

Molecular interaction in the mouse PAG between NMDA and opioid receptors in morphine-induced acute thermal nociception

Previous evidence demonstrates that low dose morphine systemic administration induces acute thermal hyperalgesia in normal mice through microOR stimulation of the inositol signaling pathway. We investigated the site of action of morphine and the mechanism of action of microOR activation by morphine to NMDA receptor as it relates to acute thermal hyperalgesia. Our experiments show that acute thermal hyperalgesia is blocked in periaqueductal gray with the microOR antagonist CTOP, the NMDA antagonist MK801 and the protein kinase C inhibitor chelerythrine. Therefore, a site of action of systemically administered morphine low dose on acute thermal hyperalgesic response appears to be located at the periaqueductal gray. At this supraspinal site, microOR stimulation by systemically morphine low dose administration leads to an increased phosphorylation of specific subunit of NMDA receptor. Our experiments show that the phosphorylation of subunit 1 of NMDA receptor parallels the acute thermal hyperalgesia suggesting a role for this subunit in morphine-induced hyperalgesia. Protein kinase C appears to be the key element that links microOR activation by morphine administration to mice with the recruitment of the NMDA/glutamatergic system involved in the thermal hyperalgesic response.

Genetic susceptibility and development of chronic non-malignant back pain

Previous data indicate that persistent pain states often involve sensitization within the central nervous system (CNS). Many recently described human genetic variants may affect these central processes. Genetic variability influences both synthesis and function of proteins affecting the plasticity of the CNS. Hence, individual genetic variability may be important to understand the development of many persistent pain conditions including chronic nonmalignant back pain. In this review we argue that genotyping of each patient may be a valuable complement to diagnosis of back disorders. This may be important for future prescription of medicine to individuals predisposed for persistent pain. Increased understanding of genetic variability may also improve multidisciplinary and cognitive-behavioral approaches to management of persistent pain. Translation of this information from the laboratory into clinical application will be important for future prevention as well as treatment of long-lasting non-malignant pain conditions.

Improved postoperative analgesia with coadministration of preoperative epidural ketamine and midazolam

STUDY OBJECTIVE

To assess postoperative pain regulation and pharmacokinetic effects of preoperative administration of ketamine and midazolam.

DESIGN

Double-blind, randomized clinical study.

SETTING

University hospital.

PATIENTS

46 ASA physical status I and II patients (age, 26-58 yrs), scheduled for gastrectomy.

INTERVENTIONS

Patients were randomly assigned to three treatment groups: a preoperative epidural injection of 10 mL (1) ketamine (0.5 mg/kg) solution (Ket group); (2) ketamine (0.5 mg/kg) plus midazolam (0.05 mg/kg) solution (KM group); or (3) normal saline solution (Ctr group).

MEASUREMENTS

Analgesic effects were evaluated by Visual Analog Scale (VAS) pain scores at rest, time to first request for analgesic (TFA), and morphine consumption during the initial postoperative time of 48 hours. Plasma concentration of ketamine in the Ket group and the KM group was measured by high-performance liquid chromatography, and the elimination half-life of ketamine was calculated.

MAIN RESULTS

Compared with the Ctr group, the Ket and KM groups had lower VAS pain scores, longer TFA, and lower morphine consumption. The KM group had the longest TFA and the lowest morphine consumption of the three groups. The KM group also had higher plasma concentrations of ketamine 90 to 240 minutes after injection, and a longer elimination half-life of ketamine, than did the Ket group.

CONCLUSIONS

Preoperative epidural coadministration of a low dose of ketamine with midazolam is more effective in relieving postoperative pain than using ketamine alone. In addition, epidural midazolam prolongs the elimination of ketamine.

Perioperative uses of low-dose ketamine for pain management

The purpose of this article is to explore the most current literature regarding perioperative pain management uses of low-dose ketamine. Research has demonstrated significant reductions in postoperative pain scores as well as opioid consumption with low-dose ketamine administration without side effects associated with its induction doses. The availability of S(+)-ketamine with double the analgesic potency of ketamine will create even more reason for its use.

Effects of preoperative epidural administration of racemic ketamine for analgesia in sheep undergoing surgery

OBJECTIVE

To investigate the effects of preoperative epidural administration of racemic ketamine to provide analgesia in sheep undergoing experimental hind limb orthopedic surgery.

ANIMALS

12 adult sheep (weight range, 51.4 to 67.2 kg).

PROCEDURE

Sheep were anesthetized with guaifenesin, thiopental, and isoflurane; after induction of anesthesia, sheep received a lumbosacral epidural injection of ketamine (1 mg/kg; n = 6) or saline (0.9% NaCl) solution (1 mL/7 kg; 6 [control group]). Respiratory and cardiovascular variables were recorded before and at intervals during and for 6 hours after anesthesia. During that 6-hour postoperative period, analgesia was evaluated subjectively with a numeric ranking scale that included assessments of comfort, posture, movement, and response to wound palpation; buprenorphine was administered when a score > 3 (maximum score, 10) was achieved. Rectal temperature, heart and respiratory rates, and lameness were evaluated daily for 2 weeks after surgery.

RESULTS

At all evaluations, cardiovascular and respiratory variables were comparable between the 2 groups. Compared with control sheep, time to first administration of rescue analgesic was significantly longer and total dose of buprenorphine administered during the 6- hour postoperative period was significantly decreased for ketamine-treated sheep. During the second week following surgery, ketamine-treated sheep had significantly less lameness than control sheep.

CONCLUSIONS AND CLINICAL RELEVANCE

In sheep undergoing hind limb surgery, preoperative epidural administration of ketamine appears to provide analgesia in the immediate postoperative period and has residual analgesic effects, which may contribute to more rapid return of normal function in surgically treated limbs.

Pain management for pediatric thoracic surgery

PURPOSE OF REVIEW

Pain management after thoracic surgery in children presents the challenge of providing adequate analgesia without excessive sedation, and maintaining adequate respiratory function in the face of compromise resulting from existing pathology, surgical trauma, single-lung ventilation and postoperative ventilation-perfusion abnormalities. In the pediatric population, pain assessment and reporting present additional challenges. The number and complexity of surgical procedures, including video-assisted thoracoscopic procedures, is increasing in the pediatric population. There is a need to explore pain management for these types of patients.

RECENT FINDINGS

There are effective and safe strategies whereby analgesia can be provided to this pediatric population. This review will outline the progress that has been made in this field, including the use of regional techniques. The routine use of caudal catheters in neonates and infants for thoracic surgical procedures and the use of electrical guidance of epidural catheters, the 'Tsui' technique, are reviewed.

SUMMARY

These techniques, applied within a comprehensive pain management strategy, can be extremely beneficial in the care of the pediatric thoracic patient.