Ann Thorac Surg 2010;89:386. doi:10.1016/j.athoracsur.2009.11.083
© 2010 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited Commentary
Frederic W. Grannis, Jr, MD
Department of General and Oncologic Surgery, City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA 91010
(Email: fgrannis{at}coh.org).
I have witnessed major advances in the management of postoperative pain in the 40 years since my first posterolateral thoracotomy under the tutelage of "Jim" Clagett at Mayo Clinic. Postoperative analgesia circa 1970 was typically limited to intermittent intramuscular meperidine or morphine sulfate as needed. With this analgesic regimen, thoracotomy patients experienced severe pain. The combination of inadequate pain control and narcotic sedation resulted in a restriction of deep breathing, inefficient cough, and failure to clear secretions. The result was too often a downward spiral punctuated by atelectasis, pneumonia, respiratory failure, and death.
During the subsequent decades, multiple advances in postoperative analgesia have provided patients with safer, more comfortable recovery from thoracic operations. Introduction of continuous intravenous narcotic infusion pumps, combined with patient-controlled analgesia, improved pain control. In the 1980s, I adopted the method later reported by Sabanathan and colleagues [1] to add continuous paravertebral block analgesia. This method provided my patients improved pain control with a lower total narcotic dosage and less sedation [2]. Introduction and improvement of continuous infusion of epidural narcotics and local anesthetics, and patient-controlled epidural anesthesia, allowed deployment of multiple combinations of analgesia options by the surgeon and anesthesiologist. Today, improved patient comfort allows better respiratory effort and cough with lower morbidity and mortality.
Amr and colleagues [3], from Tanta University in Egypt, report their experience with a small, prospective randomized trial of 40 patients. One group received epidural bupivacaine and fentanyl before induction of anesthesia, whereas the second group did not receive the epidural infusion until after the operation.
They observed a statistically significant reduction in pain in the preoperative analgesia group both at rest and with cough, as well as a reduction in total narcotic dose and improvement in some pulmonary function indicators. Although the differences are statistically significant, they are relatively small. Some might question whether the provision of epidural analgesia before thoracotomy results in clinically significant improvement. The history of multiple advances in the management of pain after thoracotomy during the past few decades suggests to me that even small incremental improvements in pain control after operations combine over time to provide progressively more comfortable postoperative courses, leading to more rapid recovery and, most important, lower incidences of postoperative complications and death.
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References
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- Sabanathan S, Smith PJ, Pradhan GN, Hashimi H, Eng JB, Mearns AJ. Continuous intercostal nerve block for pain relief after thoracotomy Ann Thorac Surg 1988;46:425-426.[Abstract/Free Full Text]
- Sullivan E, Grannis Jr FW, Ferrell B, Dunst M. Continuous extrapleural intercostal nerve block with continuous infusion of lidocaine after thoracotomy. A descriptive pilot study. Chest 1995;108:1718-1723.[Abstract/Free Full Text]
- Amr YM, Yousef AA, Alzeftawy AE, Messbah WI, Saber AM. Effect of preincisional epidural fentanyl and bupivacaine on postthoracotomy pain and pulmonary function Ann Thorac Surg 2010;89:381-386.[Abstract/Free Full Text]
Related Article
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Effect of Preincisional Epidural Fentanyl and Bupivacaine on Postthoracotomy Pain and Pulmonary Function
- Yasser Mohamed Amr, Ayman Abd Al-Maksoud Yousef, Ashraf E. Alzeftawy, Wail I. Messbah, and Ahmed Mohamed Saber
Ann. Thorac. Surg. 2010 89: 381-385.
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