Post-thoracotomy pain after thoracic epidural analgesia: a prospective follow-up study

BACKGROUND: Pain becomes chronic in 22-67% of patients who undergo a thoracotomy. Thoracic epidural analgesia (TEA) has replaced less invasive methods to manage postoperative pain. We wanted to find out if active use of TEA, combined with extended pain management at home, reduces the incidence of chronic post-thoracotomy pain. METHODS: All consecutive thoracotomy patients during a 16-month period were included. On the ward, pain was measured daily by VAS during rest and coughing and the consumption of analgesics was registered. The patients were interviewed one week after discharge by telephone and by a questionnaire after 3 and 6 months to find out how much pain they had. RESULTS: A total of 114 patients were recruited. The data were analysed from 89 patients who had had TEA and 22 who had had other methods. TEA was effective in alleviating pain at rest and during coughing. In the TEA patients the incidence of chronic pain of at least moderate severity was 11% and 12% at 3 and 6 months, respectively. One week after discharge 92% of all patients needed daily pain medication. CONCLUSIONS: TEA seems effective in controlling evoked postoperative pain, but technical problems occurred in 24% of the epidural catheters. The incidence of chronic pain was lower compared with previous studies where TEA was not used. The patients had significant pain and needed regular pain medication and instructions during the first week after discharge. Extended postoperative analgesia up to the first week at home is warranted.     

Cost drivers in patient-controlled epidural analgesia for postoperative pain management after major surgery

In this retrospective study, we determined efficiency, treatment length, and resource use for postoperative pain management with patient-controlled epidural analgesia (PCEA) in 350 consecutive patients undergoing major abdominal, thoracic, gynecological, or orthopedic surgery. Average pain scores on a visual analog scale were 16 +/- 23 and 9 +/- 16 (visual analog scale range, 0 to 100) on postoperative Days 1 and 3, respectively, and were similar among groups. The treatment length was 4.9 +/- 2.2 days in general surgical, 5.2 +/- 3.1 days in gynecological, and 4.5 +/- 2.8 days in orthopedic patients. The total volumes of the mixture of local anesthetic and opioid received epidurally were 707 +/- 507 mL, 770 +/- 576 mL, and 593 +/- 456 mL in the general surgical, gynecological, and orthopedic groups, respectively. The average total costs for all groups for the full treatment course with PCEA were 447 +/- 218 per case (1 equals approximately US dollar 1). Fifty-one percent of these costs were staff costs, 20% were costs for the applied drugs, 15% were costs for PCEA pumps and pump material, and 13% were costs for the initial catheter insertion. In the light of these costs and the availability of less costly alternatives, measurements for cost containment by using PCEA are recommended. Because treatment length is the main cost driver both for drug and staff costs, close monitoring of treatment length and a predefined migration path to alternative techniques after PCEA should be considered. IMPLICATIONS: Patient-controlled epidural analgesia is increasingly used as first-line treatment for postoperative pain management. In this study, costs and cost drivers are analyzed for the first time for this new technique, based on 350 cases of pain therapy after major surgery in a university hospital.     

Optimal dose of fentanyl for postoperative epidural analgesia after thoracic surgery

BACKGROUND: We investigated the dose of fentanyl in ropivacaine for epidural anesthesia that will provide effective analgesia with minimal side effects after thoracic surgery. METHODS: Sixty patients scheduled to undergo thoracic surgery were randomly allocated to four groups according to fentanyl dose in epidural analgesia: group R (0 microg x hr(-1); n = 15), group F1 (5 microg x hr(-1); n = 15), group F2 (10 microg x hr(-1); n = 15) and group F3 (15 microg x hr(-1); n = 15). Pain scores (visual analogue scale: VAS) were assessed at 1, 3, 6, 12, 24, and 48 hrs after surgery. Degrees of satisfaction regarding pain relief and complications during a period of 48 hrs after surgery were compared. RESULTS: Pain scores in group F3 were significantly lower than those in the other groups at 3, 6, and 12 hrs after surgery. The number of postoperative analgesics used in group R was significantly more than the numbers used in other groups. The incidences of side effects were similar in the four groups. CONCLUSIONS: We conclude that continuous epidural administration of more than 15 microg x hr(-1) of fentanyl in ropivacaine provides pain relief and few side effects after thoracic surgery.     

Continuous epidural analgesia with bupivacaine-fentanyl versus patient-controlled analgesia with i.v. morphine for postoperative pain relief after knee ligament surgery

BACKGROUND: Both epidural analgesia and intravenous patient-controlled analgesia (PCA) have been found efficacious after various types of surgery. We compared the efficacy, safety, side effects and patient satisfaction of these methods in a randomized double-blind fashion after elective anterior cruciate ligament reconstruction of the knee. METHODS: Fifty-six patients had an epidural catheter placed at the L2-L3 interspace. Spinal anaesthesia with 15 mg of plain bupivacaine 5 mg/ml was performed at the L3-L4 interspace. After surgery the patients were randomly divided into three groups: 19 received a continuous epidural infusion with bupivacaine 1 mg/ml and fentanyl 10 mg/ml (F10), 19 patients received bupivacaine 1 mg/ml and fentanyl 5 microg/ml (F5) and 18 patients received saline (S). The rate of the epidural infusions was 0.1 ml kg(-1) h(-1). Each patient could also use an intravenous (i.v.) PCA device with 40 microg/kg bolus doses of morphine with a lockout period of 10 min and a maximum dose 240 microg kg(-1) h(-1). At the end of surgery ketoprofen 100 mg i.v. was given and continued orally three times a day. Patients were assessed for pain with a visual analogue scale (VAS) at rest and during activity, side effects and satisfaction at 3, 9 and 20 h. RESULTS: Both epidural infusions (F10, F5) provided better analgesia than epidural saline plus i.v. PCA (S) (P<0.05). There was slightly less nausea in the S group (NS). In spite of the difference in the quality of pain relief, there was no difference between the groups in patient satisfaction regarding analgesic therapy. CONCLUSION: Epidural infusion of fentanyl (1 microg kg(-1) h(-1) or 0.5 microg kg(-1) h(-1)) and bupivacaine (0.1 mg kg(-1) h(-1)) provided better pain relief but more side effects than intravenous morphine patient-controlled analgesia after knee ligament surgery. Almost all patients in all groups were satisfied with their pain relief.     

Lumbar versus thoracic epidural buprenorphine for postoperative analgesia following coronary artery bypass graft surgery

BACKGROUND: Thoracic epidural analgesia (TEA) is reported to provide effective analgesia following cardiac surgery. We compared the effect of buprenorphine (BN) through the lumbar and thoracic epidural routes for postoperative analgesia following coronary artery bypass graft surgery (CABG). METHODS: Forty patients with normal left ventricular ejection fraction scheduled for CABG were randomly divided into two groups, the TEA group (n = 19) and the lumbar epidural analgesia (LEA) group (n = 20). For postoperative pain relief they received epidural BN 0.15 mg at the first demand for pain relief following extubation. A top-up dose of BN 0.15 mg was administered in cases where visual analogue scale (VAS) score was > 3 at 1 h after first dose. Subsequent breakthrough pain was treated with 30 mg intramuscular ketorolac tromethamine (ketorolac). Pain assessed by VAS score on a 0-10 scale, respiratory rate, FEV1, FVC, mean arterial blood pressure, cardiac index, PaO2 and PaCO2 were measured at frequent intervals. Side effects of epidural opioids were noted. RESULTS: Both groups were comparable in demographic characteristics, had similar VAS scores from 1 to 24 h postoperatively, required similar amounts of intramuscular ketorolac for break-through pain and had comparable pulmonary functions and side effects. CONCLUSION: This study shows that BN by the lumbar epidural route for analgesia after CABG compares favourably with the same drug through the thoracic route in terms of quality of analgesia and incidence of side effects.     

Continuous postoperative epidural analgesia in management of postoperative surgical pain

In the last fifteen months we have used continuous postoperative epidural analgesia after open urologic surgery and herein report our experience with the first 64 patients. Incisional pain was completely eliminated in 96 percent of patients. Epidural analgesia diminished pain-related pulmonary complications without sedation. Complications were tolerable and manageable. Hypotension due to sympathetic blockade responds to intravenous fluid administration. Urinary retention is avoidable if the epidural infusion is discontinued prior to removing the urethral catheter. Itching is an undesirable consequence observed by 20 percent of patients when morphine is used.     

Ultrasound-guided erector spinae plane block versus thoracic epidural analgesia: Postoperative pain management after Nuss repair for pectus excavatum

Aim of the StudyPostoperative pain management is a significant challenge in patients undergoing Nuss repair for pectus excavatum chest wall deformity. Therapeutic anesthetic options primarily include patient-controlled intravenous analgesia, thoracic epidural analgesia (TEA), and cryoanalgesia. However, TEA is limited to inpatient use and both TEA and cryoanalgesia can result in neurologic injury. The novel technique of ultrasound-guided erector spinae plane regional analgesia has been used recently in our patients undergoing the Nuss repair and has shown impressive pain relief, but without the potential complications of other modalities. Erector spinae plane block (ESPB) postoperative pain management outcomes were studied as compared to TEA.MethodsThirty consecutive patients with severe pectus excavatum undergoing Nuss repair and placement of ultrasound-guided ESPB were each paired to a historical cohort control patient with TEA postoperative pain management. The cohort patient match was defined by age (± 2 years), gender, and CT pectus index (± 15%). Study variables included hospital length of stay (LOS), pain scores, and pain medication usage.ResultsPain scores as measured by area under the curve per hour (Day 1: 2.72 (SD = 1.37) vs. 3.90 (SD = 1.81), P = 0.006; Day 2: 2.83 (SD = 1.32) vs. 3.97 (SD = 1.82), P = 0.007) and oral morphine equivalent (OME) pain medication usage (Day 1: 11.9 (SD = 4.9) vs 56.0 (SD = 32.2), P < 0.001; Day 2: 14.7 (SD = 7.1) vs. 38.0 (SD = 21.7), P < 0.001) were higher for the first two postoperative days in the ESPB group. However, mean hospital LOS was nearly one day shorter for ESPB patients (3.78 (SD = 0.82) vs. 2.90 (SD = 0.87), P < 0.001) who were discharged home with the catheter in place until removal, typically at 5–7 days postoperatively.ConclusionUltrasound-guided ESPB is thus a feasible, safe, and effective alternative to TEA in postoperative pain management after Nuss repair and results in decreased hospital stay.Level of evidenceIII     

Interpleural or thoracic epidural analgesia for pain after thoracotomy. A double blind study

The analgetic effect of bupivacaine given epidurally or interpleurally after thoracotomy was investigated in a randomized, double blind, placebo controlled study. 32 patients with both an epidural and an interpleural catheter, were randomized to receive either interpleural or epidural analgesia. The interpleural group was given bupivacaine 5 mg ml^-1 with 5 microgram epinephrine as a 30 ml interpleural bolus, followed by a continuous infusion starting at a rate of 7 ml per hour and epidurally a bolus of 0.9% NaCl followed by a continuous infusion of 0.9% NaCl. The epidural group was given bupivacaine 3.75 mg–ml^-1 with 5 microgram epinephrine as a 5 ml epidural bolus, followed by a continuous infusion starting at a rate of 5 ml per hour and interpleurally a bolus of 0.9% NaCl followed by a continuous infusion of 0.9% NaCl. The draining tubes were clamped during the injection of the interpleural bolus and 15 min afterwards. Adequacy of pain relief was evaluated with the Prins–Henry pain scale. Morphine requirement was registered, there was no difference between the groups in painscores or need for additional morphine.     

Influence of thoracic epidural analgesia on postoperative pain relief and ileus after laparoscopic colorectal resection

Background  Thoracic epidural analgesia (TEA) provides superior analgesia with a lower incidence of postoperative ileus when compared with systemic opiate analgesia in open colorectal surgery. However, in laparoscopic colorectal surgery the role of TEA is not well defined. This prospective observational study investigates the influence of TEA in laparoscopic colorectal resections. Methods  All patients undergoing colorectal resection between November 2004 and February 2007 were assessed for inclusion into a prospective randomized trial investigating the influence of bisacodyl on postoperative ileus. All patients treated by laparoscopic resection from this collective were eligible for the present study. Primary endpoints were use of analgesics and visual analogue scale (VAS) pain scores. Secondary endpoint concerned full gastrointestinal recovery, defined as the mean time to the occurrence of the following three events (GI-3): first flatus passed, first defecation, and first solid food tolerated. Results  75 patients underwent laparoscopic colorectal resection, 39 in the TEA group and 36 in the non-TEA group. Patients with TEA required significantly less analgesics (metamizol median 3.0 g [0–32 g] versus 13.8 g [0–28 g] (p < 0.001); opioids mean 12 mg [±2.8 mg standard error of mean, SEM] versus 103 mg [±18.2 mg SEM] (p < 0.001). VAS scores were significantly lower in the TEA group (overall mean 1.67 [± 0.2 SEM] versus 2.58 [±0.2 SEM]; p = 0.004). Mean time to gastrointestinal recovery (GI-3) was significantly shorter (2.96 [±0.2 SEM] days versus 3.81 [±0.3 SEM] days; p = 0.025). Analysis of the subgroup of patients with laparoscopically completed resections showed corresponding results. Conclusion  TEA provides a significant benefit in terms of less analgesic consumption, better postoperative pain relief, and faster recovery of gastrointestinal function in patients undergoing laparoscopic colorectal resection.     

Patient-controlled epidural analgesia after abdominal surgery: ropivacaine versus bupivacaine.

In this randomized, double-blinded study we sought to assess the analgesic efficacy of ropivacaine and bupivacaine in combination with sufentanil and the efficacy of ropivacaine alone after major abdominal surgery. Sixty patients undergoing major abdominal surgery received standardized general anesthesia combined with epidural thoracic analgesia. They were allocated to one of three groups: the BS group received postoperative patient-controlled epidural analgesia with 0.125% bupivacaine plus 0.5 microg/mL sufentanil; the RS group received 0.125% ropivacaine plus 0.5 microg/mL sufentanil; and the R group received 0.2% ropivacaine, with the patient-controlled epidural analgesia device set at bolus 2-3 mL and background infusion 3-5 mL/h. Visual analog scale scores were significantly lower during coughing in the BS group compared with the RS and R groups and in the RS group compared with the R group. The BS group required significantly less local anesthetic (milligrams per day) during the first three postoperative days compared with the RS and R groups, and the RS group, significantly less than the R group. No major side effects were noted in any group. We conclude that, after major abdominal surgery, thoracic epidural analgesia was more effective with bupivacaine than with ropivacaine when these two local anesthetics are used in a mixture with sufentanil. Ropivacaine alone was less effective than ropivacaine in combination with sufentanil. IMPLICATIONS: After major abdominal surgery, thoracic epidural analgesia was more effective with 0.125% bupivacaine than with 0.125% ropivacaine when these two local anesthetics were used in a mixture with 0.5 microg/mL sufentanil. Ropivacaine 0.2% alone was less effective than 0.125% ropivacaine combined with sufentanil.     

Bupivacaine 0.125% improves continuous postoperative epidural fentanyl analgesia after abdominal or thoracic surgery

The addition of 0.125% and 0.25% bupivacaine to continuous postoperative epidural infusions of fentanyl, in a 10 μg · ml^?1 concentration, were studied in 39 patients following abdominal or thoracic surgery in prospective, random, double-blind fashion. Patients received an initial bolus of 0.1 ml · kg^?1 of the the study solution and an infusion of 6 ml · hr^?1 which was titrated to maintain analgesia (VAS < 40). Assessments of pain (VAS), pulmonary function (pH, PaCO₂, and bowel function (time to flatus or po fluids) were made until the second postoperative morning. There was a difference among the three groups in analgesia (means VAS scores) over time (P < 0.01), with the fentanyl-alone group producing less analgesia than the 0.125% bupivacaine group (P < 0.01). There was no difference in the average infusion rates, postoperative pulmonary function, or bowel function. The incidence of side effects including somnolence, nausea and vomiting, and pruritus was also similar. Fewer patients in the 0.125% bupivacaine group than in the 0.25% group developed a transient sensory loss to pinprick and ice (3 vs 10, P < 0.001). Four patients in both bupivacaine groups had leg weakness, those in the 0.125% were all a Bromage 1 score, while in the 0.25% group one had a Bromage 1, one a Bromage 2, and two Bromage 3 scores. The addition of 0.125% bupivacaine improves the analgesia of epidural infusions of fentanyl (10 μg · ml^?1) when used following abdominal or thoracic surgery and results in minimal sensorimotor disturbance.     

Intramuscular low-dose ketamine versus pethidine for postoperative pain treatment after thoracic surgery

In a double-blind prospective study the effects of low-dose intramuscular ketamine (1 mg/kg) were compared to pethidine (1 mg/kg) in the treatment of pain after pulmonary surgery. Thirty patients were admitted to the study and postoperatively randomized to either a ketamine or a pethidine group. The analgesic effect was evaluated using a scale ranging from 0 to 10, where 0 denoted no pain and 10 severe pain. We did not find any significant difference between the analgesic effect of ketamine and pethidine; however, the duration of action of ketamine appeared to be slightly longer. Throughout the study PaCO2 was significantly lower in the ketamine group. PaO2 increased through the study in both groups and was significantly higher after 2 h. Heart rates increased significantly only in the pethidine group. Mean arterial pressures remained unchanged and the respiratory frequencies were similar in the two groups. The incidence of adverse reactions was low and not significantly different between the groups. The findings indicate that low-dose intramuscular ketamine is a potent analgesic for postoperative analgesia following thoracic surgery and that it has no respiratory depressive effect.     

Bupivacaine 0.1% does not improve postoperative epidural fentanyl analgesia after abdominal or thoracic surgery

Epidural infusions of fentanyl, in a 10 micrograms.ml-1 concentration, combined with bupivacaine 0.1% were compared with epidural infusions of fentanyl alone for postoperative analgesia following abdominal or thoracic surgery. There were no detectable differences between the two groups in analgesia (mean visual analogue scale pain scores ranging between 15-35 mm), average infusion rates of 7-9 ml.hr-1, and serum fentanyl concentrations which reached 1-2 ng.ml-1. There was no difference in postoperative pulmonary function (pH, PaCO2, SaO2), or bowel function (time to flatus or po fluids). The incidence of side-effects including somnolence, nausea and vomiting, pruritus and postural hypotension was also similar. Of the patients receiving fentanyl and bupivacaine 0.1%, three developed a transient unilateral sensory loss to pinprick and ice, and two of these patients had unilateral leg weakness equal to a Bromage 1 score. The addition of bupivacaine 0.1% does not improve epidural infusions of fentanyl using a 10 micrograms.ml-1 concentration following abdominal or thoracic surgery.     

Posterior quadratus lumborum block versus epidural analgesia for postoperative pain management after open radical cystectomy: A randomized clinical trial

Background

In open abdominal surgery, continuous epidural analgesia is commonly used method for postoperative analgesia. However, ultrasound (US)-guided fascial plane blocks may be a reasonable alternative.

Methods

In this randomized controlled trial, we compared posterior quadratus lumborum block (QLB) with epidural analgesia for postoperative pain after open radical cystectomy (ORC). Adult patients aged 18–85 with bladder cancer (BC) scheduled for open RC were randomized in two groups. Exclusion criteria were complicated diabetes mellitus type I, lack of cooperation, and persistent pain for reasons other than BC. In one group, a bilateral US-guided single injection posterior QLB was performed with 3.75 mg/ml ropivacaine 20 ml/side. In the other group, continuous epidural analgesia with ropivacaine was used. Basic analgesia was oral paracetamol 1000 mg three times daily, and long-acting opioid twice daily in both groups. All patients had patient-controlled rescue analgesia with oxycodone. Postoperative cumulative rescue opioid consumption was recorded for the day of surgery, and the following 2 postoperative days (POD 0–2). Secondary outcomes were postoperative pain and nausea and vomiting.

Results

In total, 20 patients (QLB), and 19 patients (epidural analgesia) groups, were included in the analyses. Cumulative rescue opioid consumption on POD 0, being of duration 9–12 h, was 14 mg (7.6–33.3) in the QLB group versus 6.1 mg (2.0–16.1) in the epidural analgesia group, p = 0.089, and as doses, 8 doses (3.6–15.7) versus 4 doses (1.3–8.5), p = .057. On POD 1 consumption was 25.3 mg (11.0–52.9) versus 18.0 mg (14.4–43.7), p = .749, and as doses 12 (5.5–23.0) versus 10 (8–20), p > .9, respectively. On POD 2 consumption was 19.1 mg (7.9–31.0) versus 18.0 mg (5.4–27.6) p = .749, and as doses 8.5 (5.2–14.7) versus 11 (3.0–18.0) p > .9, respectively.

Conclusion

Opioid consumption did not differ significantly between posterior QLB and an epidural infusion with ropivacaine for the first 2 postoperative days following RC. Trial registration: ClinicalTrials.gov identifier NCT03328988.     

Patient-controlled epidural analgesia (PCEA) for postoperative pain control after lumbar spine surgery

Spine surgery remains one of the most common procedures for patients with a wide variety of spine disorders. Postoperative pain after major spine surgery is moderate to severe. We retrospectively reviewed 245 medical records of adult patients undergoing major spine surgery who received either patient-controlled epidural analgesia based on local anesthetics and opioids or patient-controlled intravenous analgesia as postoperative pain management. Several outcomes were analyzed including pain intensity, opioid consumption, time to endotracheal extubation, the incidence of deep venous thrombosis, and length of stay in the hospital. We found that the use of patient-controlled epidural analgesia provided better postoperative analgesia [median (quartiles) verbal analog scale score of 4 (3, 5) vs. 5 (3, 6)] and decreased the amount of opioid consumption postoperatively [median of 0 mg (0, 3) vs. 35 mg (0, 150)] compared with patient-controlled intravenous analgesia. Also, a substantially higher number of patients in the patient-controlled intravenous group required opioids as rescue analgesia. Incidences of deep venous thrombosis, operating room extubation, and length of stay in the hospital were not associated with the analgesic technique. The results of this study suggest that the use of neuroaxial analgesia for the management of postoperative pain associated with major spine surgery may have some beneficial properties over intravenous analgesia. The use of a reduced amount of opioids by patients with epidural analgesia may be relevant because of potential fewer side effects mainly in elderly patients. Several limitations related to the retrospective nature of the study are described. Prospective randomized-controlled trials are needed to understand and elucidate the optimum regimen of postoperative pain management after major spine surgery.