Multimodal approach to pain management in thoracic surgery

Authors

DOI:

https://doi.org/10.30978/GS-2023-1-21

Keywords:

NSAIDs, enhanced recovery after surgery, multimodal analgesia, postoperative pain

Abstract

The American Cancer Society estimated that 68,820,000 men and 61,360,000 women in the United States of America would die from lung and bronchial cancer in 2022, which is equal to 21% of all cancer deaths. Patients who undergo thoracotomy have a higher risk of postoperative complications due to the severe pain syndrome that typically develops after surgery. Even though there has been extensive research on the advantages and disadvantages of various perioperative analgesia techniques, the search for the best and safest still continues.

Objective — to improve the results of perioperative anesthesia in patients undergoing thoracotomy by choosing the optimal method of analgesia.

Materials and methods. A total of 59 patients with lung cancer who underwent thoracotomy at the communal non‑profit enterprise «Kyiv City Clinical Hospital No 17» from 2018 to 2020 were included in an open‑label noncommercial randomized controlled clinical trial. Patients were divided into 2 groups: the multimodal analgesia (MA) group (32 patients) and the epidural analgesia (EA) group (27 patients). According to the concept of preemptive analgesia, patients in the MA group received 1000 mg of paracetamol and 50 mg of dexketoprofen intravenously 1 hour before surgery. In the postoperative period, dexketoprofen and paracetamol were administered every 8 hours in combination with epidural analgesia. During postoperative epidural analgesia, patients received 40 mg of a 2% lidocaine solution through a catheter inserted into the epidural space (Th5—Th6) and a ropivacaine 2 mg/mL (3—14 mL/h) infusion. Patients in the EA group received only epidural analgesia in the postoperative period. After placement of an epidural catheter in the epidural space (Th5—Th6), they had an injection of 40 mg of a 2% lidocaine solution and an epidural infusion of ropivacaine 2 mg/ml (3—14 mL/h).

Results. The study groups did not demonstrate a statistically significant difference in terms of age, hight, weight, a grade of anesthesiological risk (ASA), blood loss, surgery duration, and surgical volume (р >0,05). The level of analgesia was assessed using the numerological rating scale (NRS) after 3, 6, 24, and 32 hours after surgery. Every research stage revealed a significant difference in the level of pain syndrome between the study groups (p<0.05). Patients in the EA group experienced more severe pain syndrome than those in the MA group. Consequently, 7 patients (26%) in the EA group were anesthetized with morphine 10 mg intramuscularly compared to 3 patients (9%) in the MA group.

Conclusions. In patients undergoing thoracic surgery, a multimodal analgesic approach, which includes the use of COX‑2 and COX‑3 inhibitors in combination with epidural analgesia, has been shown to produce better analgesia compared to epidural anesthesia alone. The beneficial effect of multimodal analgesia was seen in a significant difference (p<0.05) in the intensity of pain syndrome between the study groups in the early postoperative period after thoracotomy.

References

Algera MH, Olofsen E, Moss L, et al. Tolerance to opioid-induced respiratory depression in chronic high-dose opioid users: a model-based comparison with opioid-naïve individuals. Clin Pharmacol Ther. 2021 Mar;109(3):637-45. http://doi.org/10.1002/cpt.2027. Epub 2020 Oct 5.

American Cancer Society. Cancer Facts & Figures 2022. Information and Resources about for Cancer: Breast, Colon, Lung, Prostate, Skin. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2022.html

Apfelbaum J, Chen C, et al. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003 Aug;97(2):534-40. http://doi.org/10.1213/01.ANE.0000068822.10113.9E

Baldo BA. Toxicities of opioid analgesics: respiratory depression, histamine release, hemodynamic changes, hypersensitivity, serotonin toxicity. Arch Toxicol. 2021 Aug;95(8):2627-42. http://doi.org/10.1007/s00204-021-03068-2. Epub 2021 May 11.

Carr DB, Goudas LC. Acute pain. Lancet. 1999 Jun;353(9169):2051-8. http://doi.org/10.1016/S0140-6736(99)03313-9.

CDC. Centers for Disease Control and Prevention. What are the risk factors for lung cancer? https://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm

Chauvin M. Prise en charge post-opératoire. La douleur après l’intervention chirurgicale [Postoperative patient management. Pain after surgical intervention]. Presse Med. 1999 Jan 30;28(4):203-11. (In French)

Dunn LK, Durieux ME, Nemergut EC. Non-opioid analgesics: Novel approaches to perioperative analgesia for major spine surgery. Best Pract Res Clin Anaesthesiol. 2016;30:79-89.

Fiorelli A, Morgillo F, Milione R, et al. Control of post-thoracotomy pain by transcutaneous electrical nerve stimulation: effect on serum cytokine levels, visual analogue scale, pulmonary function and medication. Eur J Cardiothorac Surg. 2012 Apr;41(4):861-8; discussion 868. http://doi.org/10.1093/ejcts/ezr108.

Gelman D, Gelmanas A, Urbanaitė D, Tamošiūnas R, Sadauskas S. Role of multimodal analgesia in the evolving enhanced recovery after surgery pathways. Medicina (Kaunas). 2018 Apr 23;54(2):20. http://doi.org/10.3390/medicina54020020.

Gerner P. Postthoracotomy pain management problems. Anesthesiol Clin. 2008 Jun;26(2):355-67. http://doi.org/10.1016/j.anclin.2008.01.007

Global Burden of Disease [database].Washington, DC: Institute of Health Metrics; 2019. IHME, accessed 17 July 2021.

Horlocker TT, Vandermeuelen E, Kopp SL, et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Reg Anesth Pain Med. 2018 Apr;43(3):263-309. http://doi.org/10.1097/AAP.0000000000000763.

Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. National Academies Press; 2011. 382 p.

Iyer A, Yadav S. Postoperative care and complications after thoracic surgery. in principles and practice of cardiothoracic surgery. Intech Open; 2013. https://doi.org/10.5772/55351

Jin J, Min S, Chen Q, Zhang D. Patient-controlled intravenous analgesia with tramadol and lornoxicam after thoracotomy: A comparison with patient-controlled epidural analgesia. Medicine (Baltimore). 2019 Feb;98(7):e14538. http://doi.org/10.1097/MD.0000000000014538. PMID: 30762794; PMCID: PMC6408084.

Kehlet H, Dahl JB. The value of «multimodal» or «balanced analgesia» in postoperative pain treatment. Anesthesia & Analgesia. 1993 Nov;77(5):1048-56.

Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008 Aug;248(2):189-98. http://doi.org/10.1097/SLA.0b013e31817f2c1a. PMID: 18650627.

Kissin I. Preemptive analgesia. Anesthesiology Anesthesiology. 2000 Oct;93(4):1138-43. http://doi.org/10.1097/00000542-200010000-00040.

Mercadante S. Opioid analgesics adverse effects: the other side of the coin. Curr Pharm Des. 2019;25(30):3197-202. http://doi.org/10.2174/1381612825666190717152226.

Møiniche S, Kehlet H, Dahl JB. A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief: the role of timing of analgesia. Anesthesiology. 2002 Mar;96(3):725-41. http://doi.org/10.1097/00000542-200203000-00032

Montes A, Roca G, Sabate S, Lao JI, Navarro A, et al; GENDOLCAT Study Group. Genetic and Clinical Factors Associated with Chronic Postsurgical Pain after Hernia Repair, Hysterectomy, and Thoracotomy: A Two-year Multicenter Cohort Study. Anesthesiology. 2015 May;122(5):1123-41. http://doi.org/10.1097/ALN.0000000000000611

Moran BL, Myburgh JA, Scott DA. The complications of opioid use during and post-intensive care admission: A narrative review. Anaesth Intensive Care. 2022 Mar;50(1-2):108-26. http://doi.org/10.1177/0310057X211070008. Epub 2022 Feb 16.

Muñoz de Cabo C, Hermoso Alarza F, Cossio Rodriguez AM, Martín Delgado MC. Perioperative management in thoracic surgery. Med Intensiva (Engl Ed). 2020 Apr;44(3):185-191. English, Spanish. http://doi.org/10.1016/j.medin.2019.10.012. Epub 2019 Dec 20. PMID: 31870510.

Rawal N. Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med. 2012;37(3):310-7. http://doi.org/10.1097/AAP.0b013e31825735c6.

Sostres C, Gargallo CJ, Arroyo MT, Lanas A. Adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs, aspirin and coxibs) on upper gastrointestinal tract. Best Pract Res Clin Gastroenterol. 2010 Apr;24(2):121-32.

Sung, H, Ferlay, J, Siegel, RL, Laversanne, M, Soerjomataram, I, Jemal, A, Bray, F. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021:71:209-249. https://doi.org/10.3322/caac.21660

Tan M, Law LS, Gan TJ. Optimizing pain management to facilitate Enhanced Recovery after Surgery pathways. Can J Anesth. 2015;62:203-18. [CrossRef] [PubMed]

Upp J, Kent M, Tighe PJ. The evolution and practice of acute pain medicine. Pain Med. 2013 Jan;14(1):124-44. http://doi.org/10.1111/pme.12015.

Vane JR. Inhibition of prostaglandin synthesis as a mechanism of action for aspirin-like drugs. Nat New Biol. 1971 Jun 23;231(25):232-5.

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Published

2023-04-13

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1.
Poniatovska H, Dubrov S. Multimodal approach to pain management in thoracic surgery. ЗХ [Internet]. 2023Apr.13 [cited 2024Dec.9];(1):21-7. Available from: http://generalsurgery.com.ua/article/view/276882

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Original Research