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

Abstract

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 patientcontrolled 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 patientcontrolled 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 postthoracotomy pain. We suggest that studies on effective drug dosages for providing subpleural analgesia are necessary.RESUMO CONTEXTO E OBJETIVO: Dor pós-toracotomia é severa e intensa, causada por trauma de nervos periféricos, músculos e costelas. O objetivo foi comparar analgesia subpleural (SPA) com analgesia epidural torácica (TEA) em pacientes submetidos à toracotomia. TIPO DE ESTUDO E LOCAL: Estudo randomizado no Hospital Educação e Pesquisa de Numune, em Ancara, Turquia. MÉTODOS: Trinta pacientes com o estado físico I-III da Sociedade Americana de Anestesiologistas foram agendados para toracotomia diagnóstica eletiva e escolhidos aleatoriamente para receber, num período de 24 horas, SPA ou TEA, ambas controladas pelo próprio paciente, para controle da dor pós-toracotomia. Os dois grupos receberam mistura de 3 ug/ml de fentanil com solução de 0,05% de bupivacaína por meio de bomba de analgesia controlada pelo paciente. Foi administrada analgesia de resgate por via intravenosa, com 100 mg de tramadol, nos dois grupos. No pós-operatório, a escala visual analógica foi utilizada para medir presença de dor durante a tosse ou em repouso, ao longo de 24 horas. RESULTADOS: No grupo SPA, todos os pacientes necessitaram de analgesia de resgate. Cinco pacientes (33%) necessitaram de analgesia de resgate no grupo TEA (P < 0,05). Os pacientes com SPA exibiram pontuações superiores na escala visual analógica, em repouso e ao tossir, em comparação aos que receberam TEA. Nenhum dos pacientes teve quaisquer efeitos...

Timelog-Based Approach to Early Post-Thoracotomy Pain in Lung Cancer Surgery

“…25 Although conflicting results existed in the literature, TEA proved its efficacy over conventional analgesia and other regional techniques. [1][2][3][6][7][8][9]26,27 Reducing the requirement for rescue analgesics, sustained mode of action and relatively low incidence of serious procedurerelated complications are the main advantages of TEA, which made it accepted as the gold standard method. 1,6,9 Along with these, TEA has superiority over conventional analgesia through preserving cardiopulmonary functions, diminishing stress response, facilitating the recovery of gastrointestinal motility and improving immune function.…”

“…[1][2][3][6][7][8][9]26,27 Reducing the requirement for rescue analgesics, sustained mode of action and relatively low incidence of serious procedurerelated complications are the main advantages of TEA, which made it accepted as the gold standard method. 1,6,9 Along with these, TEA has superiority over conventional analgesia through preserving cardiopulmonary functions, diminishing stress response, facilitating the recovery of gastrointestinal motility and improving immune function. 5,7,9,11,12 Nevertheless, the risk of irreversible neural damage (~1:10000 in the literature) and relatively high frequency of other treatable conditions like hypotension raised the necessity of developing less invasive techniques.…”

“…A VAS score lower than 4 was defined as tolerable pain as previously described. 2,9,14 For scores equal to or over 4, patients treated with TEA received an additional bolus dose of 10 ml 0.1% bupivacaine. Infusion rate was also increased by 2 ml/hour.…”

“…1,5,6 Thoracic epidural analgesia (TEA), paravertebral blockade, intercostal neural blockade, and subpleural analgesia can be listed as the main regional analgesia techniques. 3,[6][7][8][9][10] Thoracic epidural analgesia is accepted as the gold standard and has a proven advantage regarding influence on physiologic response and efficacy as compared to other techniques. 1,6,9,11,12 The main purpose of our study was to determine the predictors of significant pain (including the method of analgesia) during surgical critical care follow-up of post-thoracotomy patients in a single tertiary center.…”

“…3,[6][7][8][9][10] Thoracic epidural analgesia is accepted as the gold standard and has a proven advantage regarding influence on physiologic response and efficacy as compared to other techniques. 1,6,9,11,12 The main purpose of our study was to determine the predictors of significant pain (including the method of analgesia) during surgical critical care follow-up of post-thoracotomy patients in a single tertiary center. We aimed to highlight the entity of time-log instead of technical issues and patient-related factors considering the fact that relevant variables which might provoke or alleviate the perception of pain were not persistent throughout the early postoperative period.…”