Thoracotomy 2015

Thoracotomy-Specific Evidence

Please click here for Paravertebral block study details

Thoracotomy-Specific Evidence

Arguments for 

• IV bolus of magnesium sulphate followed by infusion (30 mg/kg plus 10 mg/kg/h up to 24 h) compared with control resulted in a significant delay to first analgesic demand (p<0.05) and a significantly lower total epidural dose of fentanyl and bupivacaine over 24 h (p<0.05) (Gupta et al. 2011, n=60, LoE 1).

Epidural analgesia: Adjuvants and other agents study details. Click here for more information

PROSPECT Recommendations 

• The use of magnesium as an adjuvant to TEA is not recommended (GoR A) based on limited procedure-specific evidence

Thoracotomy-Specific Evidence

Arguments for PVB

• A systematic review and meta-analysis of 10 randomised trials comparing PVB with TEA (LA ± strong opioid) for thoracotomy found no significant difference for postop pain scores or morphine use. However, meta-analysis showed a significant benefit of PVB for reducing postop pulmonary complications, urinary retention, PONV and hypotension, as well as the incidence of regional block failure (Davies et al. 2006, n=520, LoE1).
• A review and metaregression of 25 trials, totalling 763 patients, looked at efficacy and safety of different techniques for PVB to determine whether LA dose influenced the quality of analgesia from PVB. Use of higher doses of bupivacaine was found to predict lower pain scores at all time points up to 48 h and was predictive of faster recovery of pulmonary function by 72 h. CI of LA predicted lower pain scores compared with intermittent boluses and the use of adjuvant clonidine or fentanyl, pre-emptive PVB, and the addition of patient-controlled opioids to PVB did not improve analgesia (Kotzé et al. 2009, n=762, LoE 1).
• A Best Evidence Topic was written to understand if paravertebral block (PVB) was as effective as epidural analgesia for pain management in patients undergoing thoracic surgery. Six studies were reviewed, it was concluded that PVB is at least as effective as epidural analgesia for pain control post-thoracotomy, and has a better side-effect profile and a lower complication rate than epidural analgesia (Scarci et al. 2010, LoE 3).
• A meta-analyses of eight studies was conducted, using the PRISMA method, to study the effectiveness of continuous TEA and PVB for pain management after thoracotomy as well as the incidence of adverse effects. There were no statistically significant differences in pain relief after thoracotomy between TEA and PVB. PVB showed a lower incidence of side effects with reduced frequency of urinary retention and hypotension (Júnior et al. 2013, LoE 1).
• A systematic review and meta-analysis of 12 clinical trials (n=541) compared thoracic PVB with TEA in thoracotomy for lung surgery. VAS at rest and during activity at 4-8, 24 and 48 h postop were similar in both the PVB and TEA groups. Hypotension and urinary retention are more common in the TEA group (Baidya et al. 2014, n=541, LoE 1).
• A meta-analysis comparing the analgesic efficacy and side effects of PVBl compared with TEA in thoracotomy reviewed 18 studies (n=777). There was no significant difference in pain scores between PVB and TEA at 4–8, 24, 48 h, and the rates of pulmonary complications and morphine usage during the first 24 h were also similar. PVB was better than TEA in reducing the incidence of urinary retention (p<0.0001), nausea and vomiting (p=0.01), hypotension (p<0.00001), and rates of failed block were lower in the PVB group (p=0.01) (Ding et al. 2014, n=777, LoE 1).

PVB versus TEA study details. Click here for more information

Clinical Practice 

Arguments for

• Thoracic epidural strong opioid alone may be used when there is a contra-indication for thoracic epidural LA, such as hypotension due to excessive blood loss
• Thoracic epidural LA alone may be used when opioid-associated side effects are a problem

Arguments against 

• Use of heparin or conventional NSAIDs may increase the risk of spinal haematoma due to epidural analgesia

PROSPECT Recommendations 

• Paravertebral block with LA, as a bolus followed by a continuous infusion for 2–3 days, is recommended, based on evidence that the technique provides comparable postoperative analgesia to thoracic epidural with LA (GoR A), and may be associated with fewer adverse effects (GoR A)
• PVB block with LA is recommended as the first choice for thoracic surgery due to a lower incidence of complications, compared to thoracic epidural .
• Paravertebral block cannot be recommended in preference to thoracic epidural with LA plus opioid, and vice versa, because of limited data
• There are not enough data to recommend a specific concentration or volume of LA

Thoracotomy-Specific Evidence

Arguments against 

• In patients undergoing lung surgery, single intercostal nerve block plus IV PCA with morphine is not as effective as patient-controlled EDA with respect to pain control and restoration of pulmonary function (Meierhenrich et al. 2011, n=83, LoE 1).

Intercostal nerve block study details. Click here for more information

Clinical Practice 

• Infusion techniques for intercostal nerve blocks are more convenient for use in clinical practice and adequate analgesia is more likely to be maintained than with intermittent bolus administration

PROSPECT Recommendations 

• Intercostal nerve block with LA (bolus at the end of surgery, followed by continuous infusion) is recommended, if thoracic epidural analgesia and paravertebral block are not possible (GoR D)

Thoracotomy-Specific Evidence

Arguments for 

• Extrapleural (PVB) block using ropivacaine is equivalent to continuous epidural block in VATS, in terms of postop VAS scores at rest and during movement, total dose of IV morphine, supplemental NSAIDs and side effects (Hotta et al. 2011, n=40, LoE 1).

Arguments against 

• Subpleural analgesia is not superior to TEA in terms of VAS at rest and on coughing at all time points (p<0.05) (Kanazi et al. 2012, n=42, LoE 1)

Interpleural nerve blocks study details. Click here for more information

PROSPECT Recommendations 

• Interpleural LA is not recommended due to lack of efficacy (GoR A) as well as potential toxicity associated with high absorption (GoR D)

Thoracotomy-Specific Evidence

Arguments for 

• Intercostal cryoanalgesia was superior to control for postop pain scores at all time points and for consumption of pethidine on day 1 postop (p<0.001) (Momenzadeh et al. 2011, n=60, LoE 1)
• Cryoanalgesia was superior to control for postop pain scores at rest and on coughing at all time points and for total PCA morphine consumption (p<0.001) (Sepsas et al. 2013, n=50, LoE 1)

Arguments against

• A systematic review of 12 studies showed that cryoanalgesia alone is not superior to other methods of postop pain relief after thoracotomy (Khanbhai et al. 2013. LoE 1, 12 studies).

Cryoanalgesia study details. Click here for more information

Clinical Practice 

Arguments against 

• Cryoanalgesia may increase the incidence of chronic pain and neuralgia

PROSPECT Recommendations

• Cryoanalgesia is not recommended due to the risk of neuropathic pain (GoR A), and inconsistent results for analgesia compared with control (GoR A)