Post-thoracotomy pain after thoracic epidural analgesia: a prospective follow-up study

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1 Acta Anaesthesiol Scand 2003; 47: Copyright # Acta Anaesthesiol Scand 2003 Printed in Denmark. All rights reserved ACTA ANAESTHESIOLOGICA SCANDINAVICA ISSN Post-thoracotomy pain after thoracic epidural analgesia: a prospective follow-up study E. TIIPPANA, E.NILSSON and E. KALSO Department of Anaesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland Background: Pain becomes chronic in 22 67% of patients who undergo a thoracotomy. Thoracic epidural analgesia (TEA) has replaced less invasive methods to manage postoperative pain. We wanted to find out if active use of TEA, combined with extended pain management at home, reduces the incidence of chronic post-thoracotomy pain. Methods: All consecutive thoracotomy patients during a 16-month period were included. On the ward, pain was measured daily by VAS during rest and coughing and the consumption of analgesics was registered. The patients were interviewed one week after discharge by telephone and by a questionnaire after 3 and 6 months to find out how much pain they had. Results: A total of 114 patients were recruited. The data were analysed from 89 patients who had had TEA and 22 who had had other methods. TEA was effective in alleviating pain at rest and during coughing. In the TEA patients the incidence of chronic pain of at least moderate severity was 11% and 12% at 3 and 6 months, respectively. One week after discharge 92% of all patients needed daily pain medication. Conclusions: TEA seems effective in controlling evoked postoperative pain, but technical problems occurred in 24% of the epidural catheters. The incidence of chronic pain was lower compared with previous studies where TEA was not used. The patients had significant pain and needed regular pain medication and instructions during the first week after discharge. Extended postoperative analgesia up to the first week at home is warranted. Accepted for publication 21 October 2002 Key words: chronic postsurgery pain; post-thoracotomy pain; thoracic epidural analgesia; thoracotomy. # Acta Anaesthesiologica Scandinavica 47 (2003) THORACOTOMY is one of the most painful operations (1 5). Post-thoracotomy pain is a combination of nociceptive and neuropathic pain. Part of the pain is wound pain, part of it is due to stretching of the thorax and part due to manipulation of lungs and pleura. Also the shoulder joint that has been stretched duringtheoperationmaybepainfulforseveraldays. The small joints of the vertebrae and ribs become easily displaced while being manipulated and they also fracture easily. Thick drains may cause severe pain by applying pressure to intercostal nerves. Also the sympathetic fibres from the pleura can be involved (4 8). One of the long-term complications of thoracotomy is chronic post-thoracotomy pain. It is defined as pain on the chest around the incision scar that persists for longer than 2 months postoperatively, or that recurs after having disappeared for a while, but that is not related to the recurrence of a tumour or to an infection (6, 9 11). According to various studies, the incidence of this pain is 22 67% (6, 9 15). Pain is severe in 5 25% of these patients (9, 14). The chronic pain disturbs daily activities of almost half of the patients, sleep is disturbed in one quarter of them (9). It has been suggested that the development of chronic post-thoracotomy pain can be prevented by treating acute postoperative pain effectively (1, 6, 9, 13, 15) and by using good surgical techniques (16, 17). According to several studies, thoracic epidural analgesia (TEA) is superior to less invasive methods in the management of acute post-thoracotomy pain. Today it can be considered a gold standard (2, 8, 15, 16, 18 25). Usually a combination of a local anaesthetic (bupivacaine, ropivacaine) and an opioid (fentanyl, morphine) is used (18, 19, 25 27). This study had two purposes: first, to investigate whether effective postoperative pain management with TEA can reduce the risk of chronic postthoracotomy pain and second, to find out how the patients manage at home during the first week after 433

2 E. Tiippana et al. discharge. In our previous surveys on chronic postthoracotomy pain the patients had conservative methods of pain management (9, 12). However, during the last few years TEA has become the treatment of choice for managing thoracotomy pain in our department. Patients and methods For the prospective follow-up study all consecutive patients who underwent a thoracotomy between April 1999 and August 2000 were enrolled. The study was not randomized or controlled, because the choice of the method of pain relief was made by the anaesthetist in charge. The study was approved by the local ethics committee and all patients gave an informed consent. The patient characteristics are described in Table 1. Thoracic epidural analgesia (TEA) was considered as the standard treatment (Table 2). The second alternative was i.v.-pca with oxycodone (5 mg ml 1,mean single dose 3 mg, lock-out time 15 min) in addition to an intrathoracic intercostal block with 5 mg ml 1 of bupivacaine ml at the end of surgery. Four patients were treated conventionally with intramuscular opioids. In addition, the patients were given oral analgesics (paracetamol or non-steroidal antiinflammatory drugs) regularly. All patients were prescribed ibuprofen or paracetamol, and tramadol for home. The epidural catheter was inserted usually the day before surgery. The location of the catheter was confirmed with a test dose of 4 ml of lignocaine 20 mg ml 1 with epinephrine. The infusion was started in the postanaesthesia care unit (PACU). The infusion rate was adjusted between 3 and 8 ml aiming at VAS < 4 while coughing. The drug combination in the continuous infusions was mostly 1mg ml 1 of bupivacaine and 0.01 mg ml 1 of fentanyl; 10 patients had 1.8 mg ml 1 of ropivacaine (see Table 2 for details). Table 1 Characteristics of all patients who entered the study Sex (F/M) 42/69 Age (years) (21 81) Weight (kg) (45 125) Height (cm) ( ) Primary disease (other than the diagnosis for surgery) none 50 (45%) cardiovascular 33 (30%) respiratory (e.g. asthma, COPD) 16 (14%) musculoskeletal 5 (5%) neurologic 6 (5%) psychiatric (including alcohol abuse) 2 (2%) endocrine (e.g. thyroid, diabetes) 9 (8%) Malignant/benign 72/39 Surgery explorative thoracotomy þ biopsy 24 (22%) lobectomy 31 (28%) resection/extirpation 30 (27%) pneumectomy 11 (10%) pleurectomy/decortication 18 (16%) Operation side (dx/sin) Acute pain treatment other 11 (10%) 58/53 thoracic epidural analgesia (TEA) 89 (80%) i.v.-pca þ ic-block 18 (16%) intrathoracic intercostal block þ i.m. opioids 4 (4%) Number of patients having reoperation within 7 days 4 (4%) between 1 and 6 months 2 (2%) Drainage (duration, days) 5.4 3(2 18) Postoperative hospitalization (duration, days) 8.0 4(3 26) Number of patients who died after the operation between 1 and 3 months 4 (4%) between 3 and 6 months 5 (5%) Mean SD (range) are given; n ¼

3 Post-thoracotomy pain after TEA Table 2 Characteristics of thoracic epidural analgesia (n ¼ 89) Placement of the catheter Th (29%) Th (42%) Th (25%) other location 4 (4%) Infusion rate (ml/h); mean SD (range) (3 8) Doses of bupivacaine/fentanyl (mg 24 h 1 ); mean SD (range) operation day (72 384)/ ( ) 1.p.o.d (40 384)/ ( ) 2.p.o.d (18 288)/ ( ) 3.p.o.d (30 384)/ ( ) 4.p.o.d (12 288)/ ( ) Duration of the epidural treatment (days); mean SD (range) (3 23) Pain treatment rated by the patient as good 87% satisfactory 13% poor 0% Adverse effects none 50 (56%) catheter complications (see below) 17 (19%) pruritus 12 (13%) nausea 13 (15%) dizziness 4 (4%) drowsiness 3 (3%) hallucinations, nightmares 4 (4%) hypotension 2 (2%) urinary retention (which needed catheterization) 8 (9%) Treatment stopped prematurely (on the 1 3 p.o.d) total number 21 (24%) because of catheter complications* 17 (19%) because of adverse effects** 4 (4%) LMWH (dalteparine) during TEA 29 (33%) *One patient removed the catheter himself in a confused state, in one case a nurse cut the catheter by accident, the catheter slipped out in 15 patients. **One patient had previous back problems and felt the catheter uncomfortable, two patients had unbearable nausea, one patient had difficult urinating problems. Oral non-steroidal anti-inflammatory drugs (NSAIDs) or paracetamol were given from the first postoperative day. A weak opioid (tramadol or paracetamol with codeine) was started when TEA or i.v.-pca was stopped. The Acute Pain Service visited the patients daily. Pain was measured three times a day with the VAS during rest and while coughing. On the day of discharge the patients were given a prescription for the analgesics (ibuprofen 600 mg or paracetamol 1 g t.i.d., and tramadol 100 mg t.i.d) and they were encouraged to call the Acute Pain Service nurse when needed. A week after discharge all patients were interviewed over the phone using a structured questionnaire and 3 and 6 months later, with a mailed questionnaire. No reminders were sent. Statistical analysis Student s t-test (unpaired, two-tailed) was used. P < 0.05 was considered statistically significant. Results The final number of patients analysed was 111. Three patients were excluded from the final analysis because they were reoperated within a week of the thoracotomy. Of the 111 patients 89 had TEA, 18 had i.v.-pca and the remaining four were given i.m. opioids. TEA was not used in these 22 patients because of technical difficulties while trying to insert an epidural catheter (n ¼ 4) or patient refusal (n ¼ 13). The reason for not using TEA in the remaining five patients is not known. The response rate was 100% at 1 week, 87% at 3 months and 80% at 6 months. The VAS-values of the TEA-patients at different follow-up times are seen in Fig. 1. The mean VAS pain intensity at rest was about 1/10 and during coughing /10. These results include the data from patients whose treatment was stopped prematurely (24%). These patients remained in the analysis as long as they had the epidural catheter (Table 2). 435

4 E. Tiippana et al. VAS (0 10) st p.o.d. 2nd p.o.d. 3rd p.o.d. 4th p.o.d. day when discharged 1week after discharge 3 months 6 months TEA at rest TEA when coughing Fig. 1. Mean pain intensity of patients treated with TEA at rest and when coughing (n ¼ at different time points). Patients whose TEA was prematurely stopped were excluded. Fentanyl was withdrawn from the solution in three cases because of pruritus. The i.v.-pca-patients had more pain in the early postoperative phase compared with the TEA-patients, particularly when coughing ( /10). One week after discharge 92% of the patients required analgesics daily. Ibuprofen 600 mg (76 patients) or paracetamol 1 g (20 patients) was taken regularly t.i.d. by 86% of the patients, whereas 71% took tramadol 100 mg t.i.d. According to the telephone interview 1 week after discharge, 89% of the patients did not experience any adverse effects from analgesics. Dizziness, nausea or tiredness was experienced by 9% of the patients taking tramadol and GI symptoms by 2% of those who took ibuprofen. Sixteen per cent of the patients felt that their prescription medication from the hospital was not sufficient and they were given new prescriptions. Twenty-one per cent required further instructions on how to take the pain medication. The same number of the patients also took advantage of the opportunity to call the pain management nurse when encountering problems. Nine per cent of the TEA-patients felt that they were discharged too early and that the change from the epidural to the oral pain treatment was too dramatic, indicating that they were too quickly transferred to oral analgesics and discharged home. Despite this, every fourth TEA-patient mentioned spontaneously that the epidural treatment had provided excellent pain relief. At 3 months, eight TEA-patients (11%) and four PCA-patients (29%) experienced chronic pain, which was defined as VAS 3/10 and as moderate, severe or excruciating on the verbal rating scale (VRS) (9, 18). This definition was chosen because mild pain did not disturb daily activities of the patients. However, mild pain interfered with certain more strenuous activities such as sports, etc. Forty per cent of both TEA- and i.v.-pca-patients were completely free of pain. Mild pain was experienced by 49% of the TEA- and 33% of the i.v.-pca patients at this point. Fifty per cent of the patients experienced pain in the wound region, 45% somewhere else on the chest, every third in the back and 50% had pain in more than one region. The pain was mostly tenderness or ache; numbness (45%), burning pain (10%) and lancinating pain (2%) as signs of possible intercostal neuralgia were also detected. The tendency of the pain to disturb daily activities can be seen in Fig. 2. Pain interrupted sleep in 20% of the patients. At six months, seven (12%) of the TEA patients and three (23%) of the i.v.-pca-patients experienced chronic pain. Only one patient experienced severe pain, none of the patients had excruciating pain. Twenty-one per cent of all the patients were taking analgesics daily and 15% on a weekly basis. NSAIDs were most commonly used, but weak opioids were needed by 20% of the patients still after 6 months. At 6months, 17% of the patients had experienced pain for less than 3 weeks, 17% from 3weeks to 2months and 16% for 2 to 5 months. When we compared patients with or without chronic pain 3 months after thoracotomy, we could not detect a significant difference in pain intensity on thedayofdischargebetweenthesegroups(p ¼ 0.5 at rest and 0.6 during coughing). Instead, the cumulative consumption of epidural fentanyl was somewhat higher on the first three postoperative days in those patients who had chronic pain at 3 months (P ¼ 0.06, when only those patients who had a functioning TEA for three p.o.d. were analysed) compared with those whowerefreeofpain. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 week n = 89 3 months n = 73 6 months n = 65 a lot quite a lot moderately little not at all Fig. 2. TEA patients: difficulties in daily life because of postthoracotomy pain at different follow-up points. All TEA-patients who answered are included. 436

5 Post-thoracotomy pain after TEA Discussion The main message of this prospective survey is that a combination of thoracic epidural analgesia and extended postoperative pain management at home may decrease the incidence of chronic post-thoracotomy pain. Another important piece of information is that more than 90% of the patients needed analgesics on a regular basis during the first week after discharge. A previous prospective study from the same department (9) reported an incidence of 30% of chronic postthoracotomy pain of at least moderate severity at 6 months. Matsunaga et al. (14), on the other hand, reported that 19% of the patients had pain that was stronger than moderate at 6 months. Using the same definition, 12% of the TEA-patients had chronic pain at 6 months in the present study. This suggests that patients who were treated with TEA and who had effective pain management at home experienced less frequently chronic pain, compared with the previous studies. Several studies (15, 19, 22, 28) have shown that TEA is more effective and causes less adverse effects than i.v.-pca in the management of acute postthoracotomy pain. In a recent study Sentürk et al. (15) compared preoperatively initiated TEA with postoperative TEA and i.v.-pca. Their results would indicate that TEA that covers the whole perioperative period in addition to the postoperative phase is significantly better than the other two methods. They also suggest that preoperatively initiated TEA would reduce the incidence of chronic pain at 6 months compared with i.v.-pca (15). Due to the small number of patients treated with i.v.-pca (n ¼ 18), the fact that the treatment allocation was not randomized and that the pain therapy was not standardized, no statistical comparisons can be made between the two treatments in the present study. The mean duration of the TEA in the present survey was 4.7 days. The drains often cause severe pain and the TEA should last until the drains are removed. A major complication of the TEA was that nearly one catheter in four came out during the 4 5day treatment. Perttunen et al. (9) and Katz et al. (13) have reported that higher consumption of analgesics during the acute post-thoracotomy period seems to be associated with more chronic post-thoracotomy pain. In the present study the cumulative consumption of epidural fentanyl was higher in the early postoperative phase in those patients who had chronic pain at 3 months. However, this result (P ¼ 0.06) was not statistically significant. Another important message from this study is that more attention needs to be paid to adequate pain management after the patients have been discharged. Only 8% of the patients managed without analgesics during the first week at home. The extended postthoracotomy pain treatment (86% with ibuprofen or paracetamol and 71% with tramadol) for up to 1 week after hospital discharge may also have played an important role in preventing the acute pain from becoming chronic. One patient in five also needed instructions on how to take the pain medication. A regular follow-up of the patients after discharge and a possibility to contact the hospital (acute pain service) on problems regarding pain management should be an integral part of high quality patient care. References 1. Richardson J, Smith T, Tsiamis A, Shah RD. Postthoracotomy pain (letter to the editor). Ann Thorac Surg 1998: 65: Sandler AN. Post-thoracotomy analgesia and perioperative outcome. Minerva Anestesiol 1999: 65: Salomäki T, Laitinen J, Nuutinen L. A randomized doubleblind comparison of epidural versus intravenous fentanyl infusion for analgesia after thoracotomy. Anesthesiology 1991: 75: Benedetti F, Vighetti S, Ricco CYM. 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