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Background: Post thoracotomy ipsilateral shoulder pain (PTISP) is a distressing and highly prevalent problem after thoracic surgery and has not received much attention despite the incidence as high as 85%. Objectives: To study the effect of phrenic nerve infiltration with Ropivacaine compared to paracetamol infusion on PTISP in thoracotomy patients with epidural analgesia as standard mode of incisional analgesia in both the groups. Study Design: Prospective Randomised and Double Blind Study. Methods: 126 adult patients were divided randomly into 2 groups, “Group A (Phrenic Nerve Infiltration Group) received 10 mL of 0.2% Ropivacaine close to the diaphragm into the periphrenic fat pad” and “Group B (Paracetamol Infusion Group) received 20mg/kg paracetamol infusion” 30 minutes prior to chest closure respectively. A blinded observer assessed the patients PTISP using the VAS score at 1, 4, 8, 12 and 24 hours (h) postoperatively. The time and number of any rescue analgesic medication were recorded. Results: PTISP was relieved significantly in Group A (25.4℅) as compared to Group B (61.9℅), with significantly higher mean duration of analgesia in Group A. The mean time for first rescue analgesia was significantly higher in Group A (11.1 ± 7.47 hours) than in Group B (7.40 ± 5.30 hours). The number of rescue analgesic required was less in Group A 1.6 ± 1.16 as compared to Group B 2.9 ± 1.37 (P value <0.5). Conclusions: Phrenic Nerve Infiltration significantly reduced the incidence and delayed the onset of PTISP as compared to paracetamol infusion and was not associated with any adverse effects.
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Objective A rat model of chronic post-thoracotomy pain is used to study whether acute pain and pre-operative diffused noxious inhibitory controls(DNIC) can predict chronic pain and how DNIC changes when pain maintains.Methods Rats were randomly divided into three groups:naive group,sham group and model group.DNIC was constantly assessed in individual rats,along with each animal's mechanical hyperalgesia and cold allodynia after thoracotomy.Results In model group,the incidence of chronic post-thoracotomy pain was 55%(11 of 20),which was named CPTP group,and the other 9 rats without chronic pain was defined as non-CPTP group.The pre-operative DNIC was significantly weaker in CPTP group with lower mechanical threshold on 6 days after surgery and higher cold sensitivity on 6 days after surgery comparing with non-CPTP group.In the acute pain phase (day 3),DNIC was decreased in both CPTP group and non-CPTP group as compared with pre-operative period.Besides,DNIC was recovered in non-CPTP group while kept impaired in CPTP group on 21 days after surgery.Conclusions Pre-operatively assessed DNIC efficiency and acute post-operative pain intensity were two independent predictors for CPTP.DNIC was decreased both in acute pain and chronic state,while returned to normal when pain sense was normal.
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Introducción: la toracotomía es una de las incisiones quirúrgicas más dolorosas. La exposición quirúrgica de la cavidad torácica causa daño a múltiples estructuras nociceptivas en la pared del tórax y las vísceras cardiopulmonares. Existe una alta incidencia de dolor posoperatorio agudo y crónico que puede retardar la recuperación y causa la invalidez a largo plazo. La prevención y tratamiento del dolor después de la toracotomía es un desafío que puede requerir una variedad de intervenciones y es de vital importancia para minimizar las complicaciones pulmonares. Objetivo: exponer las estrategias para la prevención y tratamiento de este tipo de dolor. Métodos: revisión exhaustiva de la literatura disponible en cuanto a las estrategias basadas en evidencias para la prevención y tratamiento del dolor post-toracotomía. Resultados: el tratamiento subóptimo del dolor después de la toracotomía tiene consecuencias importantes, en especial en los pacientes con limitada reserva pulmonar siendo la más frecuente e importante la disfunción pulmonar. Se exponen los principios generales del tratamiento del dolor post-toracotomía y se abordan las técnicas actuales para su control. Conclusiones: la analgesia epidural torácica es actualmente el estándar para la analgesia tras la cirugía de tórax y en ausencia de contraindicaciones todos los pacientes programados para la cirugía torácica deben tener colocado un catéter epidural torácico preoperatorio.
Background: thoracotomy is one of the most painful surgical incisions. The surgical exposure of the thoracic cavity causes damage to multiple structures in the nociceptive chest wall and cardiopulmonary viscera. There is a high incidence of chronic and acute postoperative pain that can delay the recovery and cause long-term disability. The prevention and treatment of post-thoracotomy pain is a challenge that may require a variety of surgeries and is of vital importance to minimize pulmonary complications. Objective: to show strategies for the prevention and treatment of this type of pain. Methods: a detailed review of the available literature in relation to evidence-based strategies for the prevention and treatment of post-thoracotomy pain was made. Results: the suboptimal treatment of post-thoracotomy pain has important implications, especially in patients with limited pulmonary reserve, being pulmonary dysfunction the most frequent and important one. The general principles for the treatment of post-thoracotomy pain and current techniques to deal with its control are shown. Conclusions: thoracic epidural analgesia is currently the standard analgesia after a thoracic surgery and in the absence of contraindications, all patients scheduled for this type of surgery should have been placed a preoperative thoracic epidural catheter.
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To compare the outcomes of thoracic epidural block with thoracic paravertebral block for thoracotomy in pediatric patients. A prospective double-blind study. 60 pediatric patients aged 1-24 months, ASA II, III scheduled for thoracotomy were randomly allocated into two groups. After induction of general anesthesia, thoracic epidural catheter was inserted in group E (epidural) patients and thoracic paravertebral catheter was inserted in group P (paravertebral) patients. Post operative pain score was recorded hourly for 24 hours. Plasma cortisol level was recorded at three time points. Tidal breathing analysis was done preoperatively and 6 hours postoperatively. Analgesia, serum cortisol level, and pulmonary function parameters were comparable in the two groups. However, failure rate (incorrect placement of catheter) was significantly higher in epidural group than in paravertebral group (7% versus 0%, respectively). The complications were also significantly higher in epidural group (vomiting 14.8%, urine retention 11.1% and hypotension 14.8%) than paravertebral group (0%, 0%, and 3.6%, respectively). We conclude that both thoracic paravertebral block and thoracic epidural block results in comparable pain score and pulmonary function after thoracotomy in pediatric patients; the paravertebral block is associated with significantly less failure rate and side effects.
Subject(s)
Anesthesia, Epidural/methods , Cardiac Catheters , Cardiac Surgical Procedures/methods , Humans , Infant , Infant, Newborn , Pain, Postoperative/etiology , Treatment Outcome , Thoracotomy/methodsABSTRACT
Post-thoracotomy pain is so severe that may lead to postoperative complications, such as sputum retention, atelectasis, pneumonia and respiratory failure. These complications are associated with shallow breathing and inability to cough due to pain. To reduce postoperative pulmonary complications and improve respiratory mechanics, effective pain relief is essential. Among the many methods, epidural administrations of narcotics or local anesthetics have been shown to provide profound relief of postoperative pain. Forty-five patients undergoing thoracotomy were randomized into three groups based on a postoperative pain regimen as indi-cated: Group I; intermittent intramusculal injections of nalbuphine 0.2mg/kg for pain control(n= 15) Group II; intermittent epidural injections of mixtures of 0.2% bupivacaine and fentanyl 3 ug/ ml (n=15) Group III: continuous epidural infusion of mixtures of 0.2% bupivacaine and fentanyl 3 ug/ml at a rate of 4-5 ml/hr with supplementation on pain complaint. We evaluated postoperative pain score at 30 minutes, 8 hours, 16 hours, 24 hours, 32 hours, 40 hours, and 48 hours after thoracotomy. And we observed the duration of analgesia and the incidence of systemic side effects of three methods. The results were as follows; 1) The pain score was significantly decreased in group III compared to group I and II<0. 05). 2) The mean duration of analgesia was significantly longer in group III compared to group I and II(p<0.05). 3) the number of case of systemie side effects in group I was one case of nausea and vomiting, in group II, two cases of mild hypotension, and one case of nausea and vomiting, pruritus, headache, and urinary retention each respectively and in group III, one case of ruinary retention.