Audit of postoperative pain management after open thoracotomy and the incidence of chronic postthoracotomy pain in more than 500 patients at a tertiary center

doi:10.1016/j.jclinane.2016.10.011

Journal of Clinical Anesthesia

Volume 36, February 2017, Pages 174-177

https://doi.org/10.1016/j.jclinane.2016.10.011 Get rights and content

Highlights

•
Poorly controlled acute postoperative pain predisposes to persistent pain.
•
Chronic postthoracotomy pain remains a major challenge.
•
Current preventative strategies have been disappointing.
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There is a need for identifying patients at risk for chronic postthoracotomy.
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A way forward may be multi-interventional strategies in high-risk patients.

Abstract

Study objective

To evaluate the quality of postoperative pain relief during the first 3 days after surgery and to evaluate with the incidence of persistent pain at 6 months after surgery.

Design

Retrospective single-center audit.

Setting

University hospital.

Patients

Five hundred four patients who underwent thoracotomy.

Interventions

Review of patient records, questionnaire, and telephone review.

Results

Of the 364 survivors, 306 were contacted. Five or more episodes of severe pain (numerical rating scale >6/10 at rest or movement) during the first 72 hours after surgery occurred in 133 patients. Persistent postsurgical pain at 6 months was present in 82% (109/133) of these patients. Patient satisfaction with acute postoperative pain management was excellent (36%), good (43%), and fair or poor (21%).The incidence of postthoracotomy pain was 56% (mild 32%, moderate 18%, and severe 6%).

Conclusions

Poorly controlled acute postoperative pain correlated with persistent postsurgical pain at 6 months. In view of such a high incidence in thoracotomy patients, preventative strategies assume great significance.

Introduction

Persistent pain is a recognized complication after several surgical procedures. A recognized cause of persistent postsurgical pain is poorly controlled immediate postoperative pain. Open thoracotomy can induce significant pain during the immediate postoperative period. Patients undergoing thoracotomy also have one of the greatest incidences of chronic postoperative pain and disability among all the surgical procedures [1]. The International Association for the Study of Pain defines chronic postthoracotomy pain (CPTP) as pain that persists or recurs along a thoracotomy scar for more than 2 months after surgery [2]. The incidence of CPTP is approximately between 30%-60% [1], [2], [3], [4], [5]. The CPTP has features of neuropathic pain in more than 3 quarters of patients [6]. Chronic neuropathic pain is a complex condition that has a profound effect on both quality of life and health care expenditures [7]. In view of such a high incidence of CPTP in thoracotomy patients, preventative strategies assume great significance. This condition remains a challenge for clinicians as a variety of treatment and prevention strategies have yielded disappointing results [8], [9], [10]. We performed a retrospective evaluation of the quality of pain relief during the immediate postoperative period and present our audit of 504 patients in a tertiary center over a 2-year period postthoracotomy.

Section snippets

Methods

The audit was performed in 2 phases. A retrospective audit was performed on data collected on a cohort of adult patients who underwent thoracotomy over a 2-year (May 2010-April 2012) period at Glenfield Hospital, University Hospitals of Leicester. A telephonic survey was then conducted on the survivors with a complete pain assessment questionnaire. This joint departmental (Anaesthesia and Thoracic Surgery) audit was discussed and registered with Clinical Audit, Safety, and Effectiveness,

Results

A total of 504 patients underwent open posterolateral thoracotomy during the audit period. There were 364 survivors and we were able to contact 306 patients (84%).

Epidural analgesia was provided in 95% patients (289/306). Epidural failure rate was 27% over the 72-hour period. Seventeen patients received PCA with morphine due to patient refusal for thoracic epidural analgesia.

During telephone review, it emerged that 5 or more episodes of severe pain (numerical rating scale >6/10 at rest or

Discussion

Our retrospective audit reveals that three-fourths of patients undergoing open thoracotomy were satisfied with the acute postoperative pain management. However, more than a third of patients contacted reported 5 or more episodes of severe pain during the first 72 hours after surgery. The incidence of CPTP in this cohort was high (82%) when compared with the overall incidence of CPTP (56%). This confirms the importance of adequate pain control in the immediate postoperative period.

Our audit

Acknowledgment

The authors would like to sincerely thank Mr David Waller (consultant thoracic surgeon) and Mr Apostolos Nakas (consultant thoracic surgeon) for their wholehearted support for this audit.

References (24)

H. Kehlet et al.
Persistent postsurgical pain: risk factors and prevention
Lancet
(2006)
G. Niraj et al.
Persistent postoperative pain: where are we now?
Br J Anaesth
(2011)
C. Duale et al.
Perioperative ketamine does not prevent chronic pain after thoracotomy
Eur J Pain
(2009)
M.A.H. Steegers et al.
Only half of the chronic pain after thoracic surgery shows a neuropathic component
J Pain
(2008)
A. Johansen et al.
Persistent postsurgical pain in general population: prevalence and predictors in the Tromso study
Pain
(2012)
L. Nikolajsen et al.
The influence of preamputation pain on postamputation stump and phantom pain
Pain
(1997)
K. Wildgaard et al.
Quantitative sensory testing of persistent pain after video-assisted thoracic surgery lobectomy
Br J Anaesth
(2012)
E. Kalso
Persistent post-surgery pain: research agenda for mechanisms, prevention, and treatment
Br J Anaesth
(2013)
International Association for the Study of Pain Subcommittee of Taxonomy
Classification of chronic pain
Pain
(1986)
N. Mongardon et al.
Assessment of chronic pain after thoracotomy: a 1-year prevalence study
Clin J Pain
(2011)

K. Wildgaard et al.

Chronic postthoracotomy pain: a critical review of pathogenic mechanisms, and strategies for prevention

Eur J Cardiothorac Surg

(2009)

W.A. Pluijms et al.

Chronic postthoracotomy pain: a retrospective study

Acta Anaesthesiol Scand

(2006)

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Thoracic surgery is associated with one of the highest rates of chronic postsurgical pain (CPSP) among all surgical subtypes. Chronic postsurgical pain carries significant medical, psychological, and economic consequences, and further interventions are needed to prevent its development. This study aimed to determine the prevalence, characteristics, and risk factors associated with CPSP after thoracic surgery.
A prospective cohort study.
Single-center tertiary care hospital.
This study included 285 adult patients who underwent thoracic surgery at Toronto General Hospital in Toronto, Canada, between 2012 and 2020.
Demographic, psychological, and clinical data were collected perioperatively, and follow-up evaluations were administered at 3, 6, and 12 months after surgery to assess CPSP. Chronic postsurgical pain was reported in 32.4%, 25.4%, and 18.2% of patients at 3, 6, and 12 months postoperatively, respectively. Average CPSP pain intensity was rated to be 3.37 (SD 1.82) at 3 months. Features of neuropathic pain were present in 48.7% of patients with CPSP at 3 months and 71% at 1 year. Multivariate logistic regression models indicated that independent predictors for CPSP at 3 months were scores on the Hospital Anxiety and Depression Scale (adjusted odds ratio [aOR] of 1.07, 95% CI of 1.02 to 1.14, p = 0.012) and acute postoperative pain (aOR of 2.75, 95% CI of 1.19 to 6.36, p = 0.018).
None.
Approximately 1 in 3 patients will continue to have pain at 3 months after surgery, with a large proportion reporting neuropathic features. Risk factors for pain at 3 months may include preoperative anxiety and depression and acute postoperative pain.
Opioid Requirements After Intercostal Cryoanalgesia in Thoracic Surgery
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Complete recovery after thoracic surgery generally takes several weeks to months. Prior research has demonstrated that inadequate treatment of acute pain may precipitate chronic pain,4,5 which further highlights the importance of effective pain management. Strategies aimed at reducing opioid consumption and associated risk for the dependency include minimally invasive surgical (MIS) techniques6 for limiting tissue trauma2 and surgical stress.7
The optimal approach to pain management after thoracic surgery remains poorly defined. The purpose of this study was to examine the association between intercostal nerve cryoanalgesia and postoperative opioid requirements after thoracic surgery.
We conducted a single-center retrospective review of all patients who underwent unilateral thoracic surgery for pulmonary pathology from June 2017 to August 2019. Patients receiving intercostal nerve cryoanalgesia were compared with standard analgesia. The primary outcome was total oral morphine equivalent consumption during hospitalization, at discharge, and 90 d postoperatively. Secondary outcomes included pain scores and pulmonary function measured on postoperative days 1 and 3, at discharge, and postoperative complications. Planned subgroup analysis by opioid exposure and surgical approach was performed.
The Wilcoxon rank-sum test demonstrated significantly less inpatient opioid use for cryoanalgesia patients (45 versus 305 mg, P < 0.001), regardless of opioid history (naïve: 22.5 versus 209.8 mg, P < 0.001; tolerant: 159.5 versus 1043 mg, P < 0.001) and minimally invasive approach (opioid naïve: 26.2 versus 209.8 mg, P < 0.001; tolerant: 158.5 versus 1059 mg, P < 0.001). Opioid-naïve patients required fewer discharge opioids (50 versus 168 mg; P < 0.05). Cryoanalgesia lowered daily pain scores (P < 0.001) and showed a trend toward lower 90-d opioid prescriptions and higher pulmonary function scores. There was no difference in postoperative complications (P = 0.31).
Our results suggest an association between intercostal nerve cryoanalgesia and reduced inpatient opioid requirements and pain in opioid-naïve and tolerant patients. Pulmonary function, 90-d opioid prescriptions, and adverse events were no different between groups. It may serve as a useful adjunct for opioid-sparing pain management in thoracic surgery.
Persistent and acute postoperative pain after cardiac surgery with anterolateral thoracotomy or median sternotomy: A prospective observational study
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The persistence of pain up to 3 months after surgery does no longer constitutes a physiologic response and is defined chronic or persistent [5]. Moderate-to-severe APP (numerical rating scale (NRS) ≥ 4) [6,7] during the first 72 h after surgery has been reported to increase the risk of significant persistent postoperative pain (PPP) impacting daily activities and quality of life [8–14]. The reported incidence of postoperative pain after cardiac surgery varies significantly and ranges between 49% and 90% for APP and 21% and 67% for PPP at 3 to 12 months [3,12,15,16].
The primary objective of this study was to compare the association between cardiac surgical approach (thoracotomy vs. sternotomy) and incidence of persistent postoperative pain at 3 months. Secondary objectives were the incidence and intensity of persistent pain at 6 and 12 months, acute postoperative pain, analgesic requirement and its side effects.
Single-center, prospective, observational study. Recruitment between December 2017 and August 2018.
Perioperative care at university-affiliated tertiary care centre.
202 adults scheduled for cardiac surgery. Patients with chronic pain or behavioural disorder were excluded.
Thoracotomy (n = 106) and sternotomy (n = 96).
Pain scores and pain medication requirements from extubation until hospital discharge. Persistent postoperative pain was assessed using a telephone questionnaire.
Incidence and intensity of pain was not significantly different between thoracotomy or sternotomy either in the short- or in the long-term follow-up. Incidence of persistent postoperative pain showed no differences between groups (30.2 vs 22.9% at 3 months (p = 0.297), 10.4 vs 7.3% at 6 months (p = 0.364) and 7.5 vs 7.3% at 12 months (p = 0.518) in thoracotomy and sternotomy group). A significant decrease of pain incidence was observed between 3 and 6 months (p < 0.001) but not between 6 and 12 months (p = 0.259) in both groups. ANOVA of repeated measures adjusted for confounding variable showed a decrease of acute pain intensity over time (p = 0.001) with no difference between groups (p = 0.145). Acute pain medication requirements were not different between the groups (p = 0.237 for piritramide and p = 0.743 for oxycodone) with no difference in their side effects.
Our study showed no difference in short- or long-term pain in patients undergoing anterolateral thoracotomy or median sternotomy. Both groups showed a decrease in persistent postoperative pain incidence between 3 and 6 months without any significant changes at 12 months.
From acute postoperative pain to chronic postsurgical pain: Still a lot to learn
2020, Douleurs
Depuis la mise en évidence des douleurs chroniques post-chirurgie (DCPC), les études cliniques rétrospectives et prospectives n’ont pas cessé de questionner la valeur prédictive de la douleur postopératoire (DPO) aiguë. Il semble cependant que le lien DPO-DCPC soit loin d’être évident et probablement ne soit pas un lien de causalité. Bien que l’intensité et la durée de la DPO soient des facteurs de risque reconnus, de nombreux patients endurent encore actuellement une DPO sévère mais ne vont pas développer pour autant de DCPC. Ces observations soulignent les limites actuelles de l’évaluation et de la compréhension de la DPO aiguë. Parmi l’évolution et les progrès dans ce domaine, l’utilisation des trajectoires de douleur, qui mettent en évidence le caractère dynamique de la DPO, a permis une meilleure approche de sa résolution. De plus, l’observation du fait que le lien entre DPO-DCPC ne soit pas nécessairement un continuum a souligné l’importance et la valeur prédictive de la douleur dite « sub-aiguë ou douleur transitionnelle » dans le développement des DCPC. En résumé, une approche différente de la douleur aiguë (c.-à.-d, au-delà des scores d’intensité) qui prend en considération le patient dans sa globalité et dans son devenir (douleur sub-aiguë) est peut-être la clé d’une meilleure prédiction et donc d’une prévention plus efficace des douleurs chroniques post-chirurgie.
Since the first publication about chronic postsurgical pain, both retrospective and prospective studies have questioned the relationship between acute postoperative pain and CPSP as well as the predictive value of acute postoperative pain. Actually, the link is far from evident and probably there is no causal relationship. Although both the intensity and the duration of severe unrelieved acute postoperative pain are well known risk factors to develop CPSP, a significant number of patients still experience severe postoperative pain but will not develop CPSP. These observations clearly demonstrate the limits and incoherences involved in the evaluation of acute postoperative pain. Not only the intensity but also the characteristics of acute postoperative pain should be questioned in relation with the type of surgery to assess their predictive value. Among the progress in the field, the use of pain trajectories, which underlines the dynamic character of pain, has allow a better vision of postoperative pain resolution. Further, the observation of the fact that the link between acute postoperative pain and CPSP is not always a continuum has highlighted the importance and possible predictive value of subacute pain, also called transitional pain, in the development of CPSP. To summarize, a different approach of acute postoperative pain, i.e. beyond the intensity scores and taking into account a global approach centered on the patient and his outcome (subacute pain) is perhaps a key for a better prediction and an improved prevention of CPSP development.
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Original ContributionAudit of postoperative pain management after open thoracotomy and the incidence of chronic postthoracotomy pain in more than 500 patients at a tertiary center

Highlights

Abstract

Study objective

Design

Setting

Patients

Interventions

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgment

Lancet

Br J Anaesth

Eur J Pain

J Pain

Pain

Pain

Br J Anaesth

Br J Anaesth

Classification of chronic pain

Pain

Assessment of chronic pain after thoracotomy: a 1-year prevalence study

Clin J Pain

Chronic postthoracotomy pain: a critical review of pathogenic mechanisms, and strategies for prevention

Eur J Cardiothorac Surg

Chronic postthoracotomy pain: a retrospective study

Acta Anaesthesiol Scand

Original Contribution
Audit of postoperative pain management after open thoracotomy and the incidence of chronic postthoracotomy pain in more than 500 patients at a tertiary center