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Perioperative Pain Management

Varuna Manoo, Alexander McLaren-Blades, Hance Clarke, Alexander Huang
Perioperative Pain Management is a topic covered in the Pearson's General Thoracic.

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Key Points

  • Lower morbidity and mortality rates in thoracic surgery have been attributed, in part, to more effective management of perioperative pain.
  • Thoracic epidural catheters, paravertebral nerve catheters, or intercostal nerve catheters may be used to provide safe and effective perioperative analgesia. Local anesthetic agents may be delivered through these catheters via a continuous infusion. Thoracic epidural catheters may also be used to administer neuraxial opioids combined with the local anesthetic.
  • Multimodal analgesia combines neuronal blockade, opioids, non-steroidal anti-inflammatory agents, and other adjuvant medications (e.g., clonidine, dexmedetomidine) and directs therapy at multiple anatomic and pharmacologic sites of action to provide the best analgesia possible with minimal adverse side effects.
  • Newer pain management modalities now include myofascial plane blocks, which may provide effective analgesia, while having fewer procedural risks.
  • Chronic post thoracic surgery pain, as well as long-term opioid dependence after thoracic surgery, are two growing issues needing early identification and management.

One of the several curious entities recorded in Viking literature is the grotesque and fear inspiring execution of King Aelle. Ivar the Boneless is said to have avenged the death of his father, Ragnarr Lodbrok, by delivering what is called the ‘Blood Eagle’ to this ill-fated royal. Apart from death, this ritual was meant to torture, as the executioner cut through to the ribs, severed them from the spine on each side and then pulled the lungs through the openings to create a pair of ‘wings’ as the victim died[1].

It is not difficult to imagine why such an extreme approach to punishment might have been reserved for the few least worthy of individuals in Viking society, especially when one considers that incisions to the chest wall – whether executional or surgical - are known to be some of the most painful to man.

For thoracic surgery patients, peri-operative pain, morbidity and mortality are inextricably linked. The trend toward lower morbidity and mortality rates in thoracic surgery has paralleled the improvement in postoperative analgesic techniques, and evidence supports the concept that at least a part of the reported improvement can be attributed to more effective management of postoperative pain (Table 1) [2],[3],[4],[5]. Enhanced Recovery After Surgery (ERAS) programs demand increasingly elegant approaches to analgesia[6]. Chronic pain in this population also often emerges from poorly controlled acute pain and can have a remarkably high incidence of up to 50% at 3 to 6 months post-surgery[7].

Table 1: Trends in Perioperative Mortality After Lung Cancer Surgery

Author (Year)

Patients

Mortality (%)

Analgesic Technique

Nakahara[2], et al (1988)

All risks

6.4

IV/IM

Licker[3], et al (1999)

All risks

4.8

IV/IM/LEA

Cerfolio[4], et al (1996)

High-risk

2.4

LEA/TEA

Licker[3], et al (1999)

All risks

2.1

TEA

Licker[5], et al (2006)

High-Risk

2.4

TEA

IM, intramuscular; IV, intravenous; LEA, lumbar epidural analgesia; TEA, thoracic epidural analgesia.

Modified from Conacher ID, Slinger PD: Pain management. In Kaplan J, Slinger P (eds): Thoracic Anesthesia, 3rd ed. New York, Churchill Livingstone, 2003.

To adequately grasp the concept of pain management and its importance however, it is imperative that one first understands the mechanisms by which pain is generated, as well as the untoward systemic effects that arise from it.

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Key Points

  • Lower morbidity and mortality rates in thoracic surgery have been attributed, in part, to more effective management of perioperative pain.
  • Thoracic epidural catheters, paravertebral nerve catheters, or intercostal nerve catheters may be used to provide safe and effective perioperative analgesia. Local anesthetic agents may be delivered through these catheters via a continuous infusion. Thoracic epidural catheters may also be used to administer neuraxial opioids combined with the local anesthetic.
  • Multimodal analgesia combines neuronal blockade, opioids, non-steroidal anti-inflammatory agents, and other adjuvant medications (e.g., clonidine, dexmedetomidine) and directs therapy at multiple anatomic and pharmacologic sites of action to provide the best analgesia possible with minimal adverse side effects.
  • Newer pain management modalities now include myofascial plane blocks, which may provide effective analgesia, while having fewer procedural risks.
  • Chronic post thoracic surgery pain, as well as long-term opioid dependence after thoracic surgery, are two growing issues needing early identification and management.

One of the several curious entities recorded in Viking literature is the grotesque and fear inspiring execution of King Aelle. Ivar the Boneless is said to have avenged the death of his father, Ragnarr Lodbrok, by delivering what is called the ‘Blood Eagle’ to this ill-fated royal. Apart from death, this ritual was meant to torture, as the executioner cut through to the ribs, severed them from the spine on each side and then pulled the lungs through the openings to create a pair of ‘wings’ as the victim died[1].

It is not difficult to imagine why such an extreme approach to punishment might have been reserved for the few least worthy of individuals in Viking society, especially when one considers that incisions to the chest wall – whether executional or surgical - are known to be some of the most painful to man.

For thoracic surgery patients, peri-operative pain, morbidity and mortality are inextricably linked. The trend toward lower morbidity and mortality rates in thoracic surgery has paralleled the improvement in postoperative analgesic techniques, and evidence supports the concept that at least a part of the reported improvement can be attributed to more effective management of postoperative pain (Table 1) [2],[3],[4],[5]. Enhanced Recovery After Surgery (ERAS) programs demand increasingly elegant approaches to analgesia[6]. Chronic pain in this population also often emerges from poorly controlled acute pain and can have a remarkably high incidence of up to 50% at 3 to 6 months post-surgery[7].

Table 1: Trends in Perioperative Mortality After Lung Cancer Surgery

Author (Year)

Patients

Mortality (%)

Analgesic Technique

Nakahara[2], et al (1988)

All risks

6.4

IV/IM

Licker[3], et al (1999)

All risks

4.8

IV/IM/LEA

Cerfolio[4], et al (1996)

High-risk

2.4

LEA/TEA

Licker[3], et al (1999)

All risks

2.1

TEA

Licker[5], et al (2006)

High-Risk

2.4

TEA

IM, intramuscular; IV, intravenous; LEA, lumbar epidural analgesia; TEA, thoracic epidural analgesia.

Modified from Conacher ID, Slinger PD: Pain management. In Kaplan J, Slinger P (eds): Thoracic Anesthesia, 3rd ed. New York, Churchill Livingstone, 2003.

To adequately grasp the concept of pain management and its importance however, it is imperative that one first understands the mechanisms by which pain is generated, as well as the untoward systemic effects that arise from it.

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Last updated: May 19, 2020