Thoracotomy 2015

Thoracotomy-Specific Evidence

Arguments for 

• Infusion of bupivacaine into the surgical wound resulted in significant decreases in pain scores at rest (p<0.001) and after coughing (p=0.01) compared with saline alone and a reduction in additional morphine intake (p=0.03) and ketorolac (p=0.01) during the entire postop period (Fiorelli et al. 2016, n=55, LoE 1)

Arguments against 

• Wound infusion with ropivacaine was inferior to PVB with ropivacaine with regards to VAS on cough (p<0.05) and median morphine consumption (p<0.001) in the 24 h postop period. There was no difference between groups for VAS at rest (Zhang et al. 2015, n=61, LoE1).

Wound infiltration or infusion study details. Click here for more information

PROSPECT Recommendations 

• Wound infiltration is not recommended after thoracotomy (GoR A) because insufficient procedure-specific evidence

Thoracotomy-Specific Evidence

Arguments for 

• A study comparing thoracic epidural bupivacaine with and without opioid to a continuous paravertebral infusion of bupivacaine showed that analgesia on all postoperative days was superior in the thoracic epidural group receiving bupivacaine plus hydromorphone, but was similar in the epidural and continuous paravertebral groups receiving bupivacaine alone (Grider et al. 2012, n=75, LoE 1)
• A study comparing anterior thoracotomy (AT) with posterolateral thoracotomy (PT) with either a bolus or CI of levobupivacaine showed no significant differences between treatments in terms of mean VAS scores or rescue analgesia requirement (Fibla et al. 2015, n=80, LoE 1).

Arguments against

• In a study of 47 patients with contraindication to epidural anaesthesia randomised to receive either CI of 0.5% ropivacaine or saline, there was no significant difference between groups in terms of VAS at rest and on coughing, mean postoperative morphine consumption and incidence of morphine-related side effects (Helms et al. 2011, n=40, LoE 1).

Paravertebral block study details. Click here for more information

Clinical Practice 

Arguments for 

• A paravertebral block can be used in combination with other analgesic techniques, as part of a multimodal analgesic regimen
• Paravertebral LA may be administered as a bolus at the end of surgery

Arguments against 

• Paravertebral block is used less frequently than epidural analgesia in clinical practice

PROSPECT Recommendations 

• Paravertebral block with LA, continuous infusion (GoR A) is recommended as the first choice for thoracic surgery due to its lower complication rate.

Thoracotomy-Specific Evidence

Arguments for 

• Low-dose ketamine combined with lower-dose morphine resulted in comparable pain control compared with the standard morphine dose alone, with fewer adverse side effects and reduced morphine consumption (p<0.01) (Nesher et al. 2009, n=41, LoE 1).

IV PCA ketamine study details. Click here for more information

PROSPECT Recommendations 

• Low-dose ketamine cannot be recommended at this time due to a lack of procedure-specific evidence (GoR D)

Thoracotomy-Specific Evidence

Arguments against 

• Treatment with PCEA using fentanyl and bupivacaine combination was superior to IVPCA using morphine in terms of rescue analgesia requirement (p<0.05), pain relief at rest and on coughing (p<0.05), sedation scores and side effects (Behera et al. 2009, n=30, LoE 1)

PCA morphine study details. Click here for more information

PROSPECT Recommendations 

• Intravenous PCA strong opioid, if regional analgesic techniques fail or are not possible (GoR D)
• Weak opioids for moderate- (VAS>30<50 mm) or low- (VAS≤30 mm) intensity pain in the late postoperative period, only if conventional NSAIDs/COX-2-selective inhibitors plus paracetamol are insufficient or contra-indicated (GoR D)