Perioperative pain management for thoracic surgery: a narrative review of the literature

Abstract

The objective of this article was to review the evidence regarding multimodal analgesia drugs and regional block techniques in the context of thoracic surgery, with a special focus on video-assisted thoracic surgery (VATS).Background: Despite advances in surgical technique and the increased use of minimally invasive surgery, postoperative pain after thoracic surgery is still significant, especially in the first two postoperative days.Inadequate pain control leads to a reduced rate of pulmonary recovery which can lead to atelectasis, hypoxemia and pneumonia and is significantly linked to an increased incidence of chronic postsurgical pain.However, the optimal analgesic protocol that allows adequate postoperative pain control and facilitates fast recovery of this population has yet to be determined.Methods: An extensive review of articles published between January 1980 and November 2020 using different combinations of search terms that were relevant to the topic was conducted using PubMed search engine. All published full articles randomised controlled trials comparing the analgesic efficacy of a regional block or of a multimodal analgesic drug to a placebo in patients undergoing either thoracotomy or VATS were included in this review.Conclusions: Analgesic protocols in thoracic surgery must take into consideration the surgery that is being performed (VATS or thoracotomy) as well as patient's characteristics. Regional blocks are highly effective at providing good postoperative pain control although their duration is limited. Various non opioid analgesic drugs have been evaluated in order to address the various pain generators that cause postoperative pain after thoracic surgery, although none has become a clinical standard. Using a combined multimodal and regional analgesic protocol could improve postoperative pain control and decrease the use of parenteral opioids and their unwanted side effects. Recommendations on multimodal analgesic protocols are given based on the literature.

Clinical guideline on reversal of direct oral anticoagulants in patients with life-threatening bleeding: use of a urine dipstick

“…5 Due to these shortcomings of epidural analgesia, alternative regional analgesic methods with better safety profiles and comparable efficacy are now becoming more popular for postoperative thoracic analgesia: such techniques include paravertebral, intercostal, and more recently the erector spinae plane blocks. 6,7 These alternatives may just make epidural analgesia obsolete in the future, so the evaluation of a fading, less used method seems to be outdated. 5.…”

Disregarding the use of oral morphine is not justified yet

“…Complications of the epidural technique and adverse reactions to the epidural drugs are not reported, although these are well known and documented elsewhere 5 . Due to these shortcomings of epidural analgesia, alternative regional analgesic methods with better safety profiles and comparable efficacy are now becoming more popular for postoperative thoracic analgesia: such techniques include paravertebral, intercostal, and more recently the erector spinae plane blocks 6,7 . These alternatives may just make epidural analgesia obsolete in the future, so the evaluation of a fading, less used method seems to be outdated.…”