Pre-operative - ESRA
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Thoracotomy 2015

Pre-operative

Thoracotomy-Specific Evidence 

Arguments for 

  •  In a study comparing TEA levobupivacaine plus IV dexketoprofen analgesia (PED), TEA levobupivacaine alone (PE) or control (no epidural/IV analgesia pre- or intra op (C)), lower VAS scores were found in group PED at 24 h (p<0.05) and 48 h (p=0.08) postop and before discharge (p<0.001). Comparable VAS scores were found at 1 and 3 months and a lower score at 6 months (p<0.05) (Comez et al. 2015, n=60, LoE 1).

Conventional NSAIDs study information, click here

PROSPECT Recommendations 

  • Preoperative administration of conventional NSAIDs is not recommended because pre-operative administration is of no additional benefit compared with postoperative administration alone (GoR A)

Thoracotomy-Specific Evidence

Arguments for 

  • Administration of celecoxib the evening before surgery, the morning before surgery, then twice a day for 48 h resulted in pain scores significantly lower at rest (p=0.026) and on coughing (p=0.021) in group C compared with placebo (Senard et al. 2010, n=36, LoE 1).

COX-2 selective inhibitors study details. Click here for more information

PROSPECT Recommendations

  • COX-2-selective inhibitors are not recommended pre-operatively because there is no procedure-specific evidence that pre-operative administration is of more benefit than postoperative administration (GoR D)

Thoracotomy-Specific Evidence

Arguments for

  • Preoperative administration of IV clonidine, infused with using a syringe pump over 30 min before surgery resulted in lower VAS scores on coughing at 30, 60 and 120 min after surgery, with VAS scores comparable until 24 h postop. The time to first request for fentanyl postop was longer (p<0.05) and the average amount of fentanyl requested was lower (p=0.03) in the group receiving preoperative clonidine (Samantaray et al. 2012, n=58, LoE 1)

Alpha-2-adrenergic antagonists study details click here more information 

Clinical Practice 

Arguments against 

  • The risk/benefit ratio for clonidine and dexmedetomidine is unclear. Potential side effects include hypotension, sedation, dizziness and bradycardia

PROSPECT Recommendations

  • Pre-operative systemic clonidine is not recommended because limited evidence from thoracotomy shows no analgesic benefit (GoR A) and because of potential side-effects (GoR D)

Thoracotomy-Specific Evidence

Arguments for 

  • Systemic administration of lidocaine could reduce morphine requirements, postoperative pain and intraoperative propofol requirement of patients undergoing thoracic surgery after propofol-remifentanil-based anaesthesia. (Cui et al. 2010, n=40, LoE 1)

Lidocaine study details. Click here for more information

PROSPECT Recommendations

  • Systemic administration of lidocaine is recommended when regional analgesia is not possible for any reason (GoR B)

Thoracotomy-Specific Evidence

Arguments against 

  • The administration of 1200 mg gabapentin 2 h before surgery followed by increasing doses over 5 days postop (600 mg for day 1; 900 mg for day 2; and 1200 mg for days 3–5) was not superior to placebo for treating acute or chronic post-thoracotomy pain (Grosen et al. 2014, n=104, LoE 1).
  • A single preoperative oral dose of 600 mg gabapentin did not reduce pain scores or opioid consumption following elective thoracotomy compared with placebo, and did not confer any analgesic benefit as part of multimodal analgesia that included TEA (Kinney et al. 2012, n=120, LoE 1).
  • Pre-emptively administered PO gabapentin, 1200 mg, did not reduce the incidence or severity of post-thoracotomy shoulder pain compared with placebo, in patients receiving TEA (Huot et al. 2008, n=51, LoE 1)

Gabapentin study details. Click here for more information

Clinical Practice 

Arguments for

  • Gabapentin may be of benefit for prevention of chronic pain conditions following thoracotomy, where 40–60% of patients may develop chronic pain and/or allodynia

PROSPECT Recommendations

  • Gabapentin/pregabalin cannot be recommended due to limited procedure-specific evidence (GoR A)

 

 

Thoracotomy-Specific Evidence

Arguments for 

Arguments against

Pre-incisional ketamine is not recommended:

– based on specific evidence (D’Alonzo et al. 2011, Yazigi et al. 2012)

– based on the prevention of chronic pain after thoracic surgery (Joseph et al. 2012)

  • There is no evidence to recommend epidural ketamine instead of IV ketamine (Tena et al. 2014)
  • There is no evidence documenting that repeated administration is preferable to a single bolus (D’Alonzo et al. 2011)

Ketamine study details. Click here for more information

Clinical Practice 

Arguments for 

  • Ketamine may be of benefit for prevention of chronic pain conditions following thoracotomy, where 40–60% patients may develop chronic pain and/or allodynia. Additionally, it may be of benefit in patients who have opioid tolerance. Ketamine is most often used after induction of GA, but before incision (pre-operatively)

PROSPECT Recommendations

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

Thoracotomy-Specific Evidence

Arguments for

  • Thoracic epidural analgesia resulted in significantly lower VAS scores up to 24 h postop, along with beneficial hemodynamic effects when compared with lumbar epidural analgesia (Sagiroglu et al. 2014, n=120, LoE 1).
  • Thoracic epidural analgesia with bupivacaine plus fentanyl resulted in significantly lower VAS scores and better patient QoL compared with postop PCA with morphine (Ali et al. 2010, n=60, LoE 1).
  • Patients given thoracic epidural ropivacaine pre-op had lower VAS scores (p<0.05) at rest and on coughing at 24, 48 and 72 h postop, compared with patients given placebo or ropivacaine postop (Yang et al. 2015, n=84, LoE 1).
  • Significantly lower VAS scores (p<0.001) were seen in patients treated with 0.125% levobupivacaine plus 3 mg/mL fentanyl compared with lower (0.1%, 0.05%) doses of levobupivacaine (Tekelioglu et al. 2012, n=90, LoE 1).
  • Thoracic epidural analgesia with either levobupivacaine or bupivacaine provided comparable sensory block features, intraoperative haemodynamics, and postoperative analgesia for patients undergoing thoracic surgery (Cok et al. 2011, n=50, LoE 1).
  • Patients receiving high-dose remifentanil without epidural analgesia during surgery has a much higher incidence of chronic pain than those receiving low-dose remifentanil with epidural analgesia (Salengros et al. 2010, n=39, LoE 1).
  • There was no significant difference in VAS scores (p>0.05) in the 4–48 h postop, between varying concentrations of thoracic epidural bupivacaine plus fentanyl in patients undergoing thoracic surgery (Li et al. 2015, n=118).

Thoracic epidural analgesia 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

  • Thoracic epidural LA + strong opioid as a bolus before surgery (GoR A), continued as an infusion is recommended, if PVB is not used

Thoracotomy-Specific Evidence

Arguments for

  • Administration of epidural dexmedetomidine 1 μg/kg with bupivacaine 0.5% after induction of general anaesthesia resulted in significantly lower pain scores at all time points and significantly less requirement for rescue analgesia when compared with epidural bupivacaine 0.5% alone (Elhakim et al. 2010, n=50, LoE 1).
  • Epidural administration of magnesium sulphate did not significantly decrease the incidence or severity of CPOP, but did result in better pain relief at 12 (p=0.0461) and 24 h (p=0.0421) at rest compared with control (Lee et al. 2012, n=116, LoE 1).

Arguments against 

  • Addition of 50 mg/mL magnesium sulphate to TEA with 0.25% bupivacaine had no significant effect on postoperative pain scores compared with 0.25% bupivacaine alone but did decrease the need for postoperative rescue analgesia and incidence of postoperative shivering (Mohammad et al. 2015, 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…

  • Addition of intrathecal MgSO4 to morphine-fentanyl spinal analgesia resulted in comparable VAS scores both at rest and on coughing and lower morphine consumption at 0–12 h (p=0.006), 12–24 h (p<0.001) and 24–36 h (p<0.001) compared with control (Ouerghi et al. 2011, n=58, LoE 1).

Spinal analgesia: Adjuvants and other agentsstudy details. Click here for more information

PROSPECT Recommendations

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

Thoracotomy-Specific Evidence

Arguments against 

  • Patients receiving TEA with ropivacaine 0.2%+sufentanil had lower mean and maximal VAS scores than those receiving PVB with ropivacaine 0.5% +ITO (sufentanil+morphine). However, although VAS scores were statistically lower in the TEA compared with the PVB+ITO group at some observation points, the differences were small and of questionable clinical relevance (Dango et al. 2013, n=80, LoE 1)
  • There was no significant difference in VAS at rest and on coughing between patients receiving intrathecal morphine compared with paravertebral block with bupivacaine at 0, 1, 6, 12, 18, 24, and 48 h. Total bupivacaine consumption was significantly higher in the intrathecal morphine group over 48 h postop (p<0.01) (Zeid et al. 2012, n=40, LoE 1)

Clinical Practice 

Arguments for 

  • Hydrophilic opioids provide a longer duration of analgesia than lipophilic opioids

Arguments against

  • Spinal strong opioids may potentially increase the incidence of urinary retention and respiratory depression

Spinal analgesia: Spinal strong opioid study details. Click here for more information

PROSPECT Recommendations

  • Despite Grade A evidence of effectiveness, spinal strong opioid single bolus is not recommended because of clinical safety concerns (respiratory depression).
  • If no regional anaesthetic technique is possible, systemic opioid and non-opioid analgesia is recommended as rescue analgesia (GoR D)

Thoracotomy-Specific Evidence

Arguments for 

  • PVB (0.5% bupivacaine + 1:200,000 epinephrine) was superior to control (saline) for time to first analgesic request (p<0.05), postop pain scores at rest and coughing in 1st 4 h (p<0.01 at 0 h, p<0.05 at 1, 2, 4 h) and total morphine consumption (p<0.01) (Kaya et al. 2006, n=47, LoE 1)
  • PVB with multiple injections of 0.5% bupivacaine + 1:200,000 epinephrine was comparable to a single injection for postop pain scores, morphine consumption and time to first mobilisation. Time to onset of block was significantly faster in the single injection group (p=0.014) (Kaya et al. 2012, n=50, 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

Arguments against

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

PROSPECT Recommendations 

  • PVB with LA (bolus pre-operatively or at the end of surgery, followed by continuous infusion), is recomemended as an alternative to thoracic epidural analgesia (GoR A).
  • PVB with LA is recommended as the first choice for thoracic surgery due to a lower incidence of complications.