Knowledge Key:
Arguments against Arguments againste
Arguments for Arguments for
Prospect Recommendation Prospect Recommendation
Clinical Practice Clinical Practice
Transferable Evidence Transferable Evidence
Procedure Specific Evidence Procedure Specific Evidence

Pre-Operative

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Systemic Analgesia

PROSPECT Recommendations

  • Conventional NSAIDs are not recommended pre-operatively in thoracotomy due to the risk of bleeding (transferable evidence, Grade B) and because pre-operative administration is of no additional benefit compared with postoperative administration alone (Grade A)

Clinical Practice

  • Caution is required when conventional NSAIDs are used in patients receiving epidural analgesia concomitantly with medications for thromboprophylaxis, due to the risk of spinal haematoma

Transferable Evidence from Other Procedures

  • Conventional NSAIDs have proven analgesic efficacy in a variety of surgical procedures Barden et al 2004
  • A meta-analysis of randomised controlled trials that was performed to evaluate the risk of morphine-related adverse effects in patients treated with NSAIDs demonstrated that NSAIDs decreased the incidence of nausea, vomiting and sedation, but not pruritis, urinary retention or respiratory depression Marret et al 2005
  • Randomised trials in healthy volunteers have shown that conventional NSAIDs are associated with a higher incidence of upper gastrointestinal ulceration compared with COX-2 selective inhibitors for short-term use Harris et al 2001
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo Greer et al 1999
  • Meta-analyses of randomised, controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with control Marret et al 2003
  • Pre-operative conventional NSAIDs significantly increased peri-operative blood loss in patients undergoing total hip arthroplasty compared with other analgesic agents in four out of five studies An et al 1991 Click here for more information
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused reversible platelet dysfunction Niemi et al 1997
  • A large randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery Forrest et al 2002
  • A randomised clinical trial showed that the conventional NSAID diclofenac was associated with significantly greater intra-operative blood loss than the COX-2-selective inhibitor rofecoxib in patients undergoing abdominal or vaginal hysterectomy or breast surgery Hegi et al 2004
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease Stevenson 2004
  • Conventional NSAIDs and COX-2 selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of conventional NSAIDs or COX-2 selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • Conventional NSAIDs and COX-2 selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Conventional NSAIDs and COX-2 selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies Gajraj 2003

Thoracotomy-specific Evidence

PROSPECT Recommendations

  • Pre-operative systemic clonidine is not recommended because limited evidence from thoracotomy shows no analgesic benefit (Grade A), transferable evidence shows inconsistent analgesic benefit (Grade B), and because of potential side-effects (Grade D)
  • Despite positive transferable evidence, pre-operative systemic dexmedetomidine is not recommended at this time because procedure-specific evidence is lacking, and because of potential side-effects (Grade D)

Clinical Practice

  • The risk/benefit ratio for clonidine and dexmedetomidine is unclear. Potential side effects include hypotension, sedation, dizziness and bradycardia

Transferable Evidence from Other Procedures

  • Intravenous clonidine given before skin incision, or before peritoneal incision, was superior to fentanyl given before skin incision for postoperative analgesic outcomes in open colonic resection De Kock et al 1994 Click here for more information
  • Intravenous dexmedetomidine administered before hand or abdominal surgery reduced intra- and/or postoperative analgesic requirements compared with control in four studies (n=40, n=30, n=30, n=60) Esmaoglu et al 2005
  • Pre-operative clonidine provided no consistent significant benefit over placebo for reducing postoperative pain scores in abdominal hysterectomy; and results for other postoperative pain outcomes were mixed Dimou et al 2003 Click here for more information
  • Intravenous dexmedetomidine administered before hand or abdominal surgery did not significantly reduce pain scores compared with control in two studies (n=30, n=60) Jacobson et al 1983
  • In one study, intravenous dexmedetomidine administered before hand surgery induced decreases in blood pressure and heart rate that were mainly abolished within 4 h of surgery (n=30) Jaakola 1994
  • Study Information Dimou et al 2003 Click here for more information

Thoracotomy-specific Evidence

PROSPECT Recommendations

  • Despite positive transferable evidence on reduction of pain and PONV from other procedures, pre-operative corticosteroids are not recommended for thoracotomy due to limited procedure-specific evidence (Grade D)

Clinical practice

  • Much of the transferable evidence for efficacy of corticosteroids in reduction of PONV and for pain relief is based on short-stay surgery

Transferable Evidence from Other Procedures

  • A single prophylactic dose of corticosteroid is anti-emetic compared with placebo, when there is a high risk of PONV, in a wide range of surgical procedures Henzi et al 2000
  • Pre-operative dexamethasone (8 mg) reduced pain, fatigue, nausea and vomiting, and duration of convalescence, compared with placebo in patients undergoing laparoscopic cholecystectomy Bisgaard et al 2003
  • Intravenous methylprednisolone (125 mg) given one day after orthopaedic surgery reduced pain and opioid consumption compared with placebo (n=50) Romundstad et al 2004

Thoracotomy-specific Evidence

  • A pre-operative intravenous bolus of methylprednisolone reduced VAS pain scores compared with placebo at rest at 4 h and day 1, and on coughing at 4 and 8 h and day 2, (p<0.05), but not on days 3 and 4 (n=36) Bigler et al 1996
  • A pre-operative intravenous bolus of methylprednisolone was associated with similar pulmonary function (FVC, FEV, PEF) compared with placebo (n=36) Bigler et al 1996
  • Study details Bigler et al 1996 Click here for more information

PROSPECT Recommendations

  • COX-2-selective inhibitors are not recommended pre-operatively because there is no procedure-specific evidence that pre-operative administration is of more benefit than postoperative administration (Grade D)

Clinical Practice

  • None cited

Transferable Evidence from Other Procedures

  • Peri-operative use of rofecoxib (50 mg at 24 h and at 1 to 2 h before total knee arthroplasty, followed by 50 mg daily for 5 days postoperatively, and 25 mg for another 8 days), as part of a multi-analgesic regimen, reduced pain, opioid use, vomiting, sleep disturbance and improved knee range of motion, compared with placebo (n=68) Buvanendran et al 2003
  • COX-2-selective inhibitors provide similar postoperative analgesia to conventional NSAIDs Rømsing et al 2004
  • Randomised trials in healthy volunteers have shown that COX-2 selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use Harris et al 2001
  • Studies in healthy volunteers demonstrated that COX-2 selective inhibitors had no effect on platelet aggregation Greenberg et al 2000
  • Pre-operative administration of oral rofecoxib 25 mg once daily did not increase intra- or postoperative blood loss when compared with placebo, in patients undergoing total knee arthroplasty Reuben et al 2002
  • A randomised clinical trial showed that the COX-2-selective inhibitor rofecoxib was associated with significantly less intra-operative blood loss than the conventional NSAID diclofenac in patients undergoing abdominal or vaginal hysterectomy or breast surgery Hegi et al 2004
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function Bavbek et al 2004
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following noncardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062) Nussmeier et al 2006
  • Two clinical trials showed that in patients who had undergone CABG surgery COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo Nussmeier et al 2005
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents EMEA 2004a
  • Conventional NSAIDs and COX-2 selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible O'Connor et al 2003
  • Short-term use of COX-2 selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients Cheng et al 2004
  • COX-2 selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication Cheng et al 2004
  • Although there is some concern that COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting Blomme et al 2003
  • Conventional NSAIDs and COX-2 selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies Gajraj 2003

Thoracotomy-specific Evidence

  • None cited

PROSPECT Recommendations

  • Low-dose ketamine cannot be recommended at this time due to a lack of procedure-specific evidence (Grade D), although analgesic data from other procedures are promising

Clinical Practice

  • Ketamine may be of benefit for prevention of chronic pain conditions following thoracotomy, where 40–60% patients may develop chronic pain and/or allodynia. Additionally, it may be of benefit in patients who have opioid tolerance. Ketamine is most often used after induction of GA, but before incision (pre-operatively)

Transferable Evidence from Other Procedures

  • Studies of intravenous or neuraxial ketamine in a variety of surgeries, including abdominal, gynaecological, orthopaedic, gastric, hepatic, and genitor-urinary surgery, showed a reduction in postoperative pain and opioid use when used as an adjunct to morphine Bell et al 2005

Thoracotomy-specific Evidence

  • Pre-operative intramuscular ketamine reduced PCEA morphine use, but not PCEA bupivacaine use, compared with placebo (p<0.001) (n=40) Ozyalcin et al 2004
  • Pre-operative intramuscular ketamine reduced the areas of pin-prick hyperalgesia at 1 month (p=0.008), brush allodynia at 2 and 15 days and at 1 month (p<0.05), and pressure hyperalgesia at 2 days (p<0.05), compared with placebo (n=40) Ozyalcin et al 2004
  • Study details Ozyalcin et al 2004 Click here for more information

PROSPECT Recommendations

  • Gabapentin/pregabalin cannot be recommended at this time due to a lack of procedure-specific evidence (Grade D), although analgesic data from other procedures are promising

Clinical Practice

  • Gabapentin may be of benefit for prevention of chronic pain conditions following thoracotomy, where 40–60% of patients may develop chronic pain and/or allodynia

Transferable Evidence from Other Procedures

  • Studies of gabapentin and pregabalin in mastectomy, abdominal surgery, laparoscopic cholecystectomy, spinal surgery, knee surgery, ear-nose-throat surgery, and nephrectomy showed reductions in postoperative pain and supplementary analgesic requirements for at least 24 h Dahl et al 2004
  • One study showed no significant benefit of gabapentin 800 mg for reducing pain or opioid use compared with placebo in spinal surgery (n=60) Radhakrishnan et al 2005

Thoracotomy-specific Evidence

  • None cited

PROSPECT Recommendations

  • Systemic strong opioids are not recommended as premedication to provide postoperative analgesia, based on evidence for a lack of postoperative analgesic benefit (Grade A), and because of potential side-effects (Grade B)

Clinical Practice

  • None cited

Transferable Evidence from Other Procedures

  • Strong opioids are associated with adverse effects, including nausea, vomiting, sedation, confusion, paralytic ileus and urinary retention Wheeler et al 2002

Thoracotomy-specific Evidence

Epidural Analgesia

PROSPECT Recommendations

  • Pre- and intra-operative thoracic epidural LA plus strong opioid is recommended based on a reduction in pain compared with postoperative administration alone (Grade A)
  • Thoracic epidural LA plus strong opioid is recommended as a pre-operative bolus followed by an infusion continued for 2–3 days postoperatively, based on a reduction in pain compared with systemic analgesia (Grade A, see Postoperative Epidural Analgesia section)
  • There are not enough data to recommend one specific combination of LA and opioid over another
  • There are not enough data to recommend a specific concentration or volume of LA and strong opioid
  • There are not enough data to recommend lipophilic opioids in preference to hydrophilic opioids or vice versa, in combination with LA

Clinical Practice

  • Thoracic epidural strong opioid alone may be used when there is a contra-indication for thoracic epidural LA, such as hypotension due to excessive blood loss
  • Thoracic epidural LA alone may be used when opioid-associated side-effects are a problem
  • Use of heparin or conventional NSAIDs may increase the risk of spinal haematoma due to epidural analgesia

Transferable Evidence from Other Procedures

  • A meta-analysis of randomised controlled trials found that both continuous epidural infusion and PCEA analgesia provided superior postoperative analgesia compared with intravenous PCA analgesia Wu et al 2005
  • A meta-analysis found that continuous epidural infusion provided superior analgesia and reduced the incidence of pruritis compared with PCEA analgesia, but was associated with a higher incidence of PONV and motor block Wu et al 2005
  • A meta-analysis of randomised controlled trials found that epidural analgesia significantly decreased the incidence of pulmonary morbidity compared with systemic opioids Ballantyne et al 1998 Click here for more information
  • Epidural administration of strong opioids is associated with side effects including pruritis, PONV, urinary retention, and respiratory depression Chaney 1995

Thoracotomy-specific Evidence

  • Four of six studies showed that pre-/intra-operative thoracic epidural LA ± strong opioid reduced pain scores compared with control Neustein et al 2002 Click here for more information
  • Pre-operative thoracic epidural sufentanil was superior to intravenous sufentanil for reducing pain scores at 1 h (p<0.005) and 2 h (p<0.025) (n=22) Rosseel et al 1988
  • Pre-operative thoracic epidural sufentanil was superior to intravenous sufentanil for reducing the dose of sufentanil required during surgery (p<0.005) but not for reducing the number of sufentanil doses required (n=22) Rosseel et al 1988
  • Pre-operative thoracic epidural sufentanil was superior to intravenous sufentanil for extending the time until first analgesic request (p<0.05) (n=22) Rosseel et al 1988
  • Two studies reported that pre-/intra-operative thoracic epidural bupivacaine plus morphine was similar to control for the incidence of: vomiting (all patients received postoperative epidural analgesia) (n=46) Senturk et al 2002
  • Pre-operative thoracic epidural sufentanil was associated with lower PaCO compared with intravenous sufentanil, at 2 h (p<0.025) but not at 1 h (n=22) Rosseel et al 1988
  • Three of five studies reported that pre-/intra-operative thoracic epidural LA ± strong opioid was similar to control for the rate of epidural infusion required or indomethacin use Aguilar et al 1996 Click here for more information
  • Intra-operative thoracic epidural bupivacaine plus fentanyl was not associated with an increase in physical activity after discharge compared with control (both groups received postoperative epidural analgesia; n=120) Ochroch et al 2002
  • Pre-operative thoracic epidural sufentanil was similar to intravenous sufentanil for the incidence of PONV (n=22) Rosseel et al 1988
  • Study details Aguilar et al 1996 Click here for more information

PROSPECT Recommendations

  • Pre-operative lumbar epidural strong opioid is not recommended as the first choice of epidural technique, based on evidence that the thoracic epidural route is more effective for pain relief following thoracotomy (Grade A, see Postoperative Epidural Analgesia). However, there is procedure specific evidence that lumbar epidural hydrophilic strong opioid reduces pain compared with systemic analgesia (see Postoperative Epidural Analgesia)

Clinical Practice

  • Infusion techniques are more convenient for use in clinical practice and adequate analgesia is more likely to be maintained than with bolus administration of lumbar epidural strong opioid
  • Use of heparin or conventional NSAIDs may increase the risk of spinal haematoma due to epidural analgesia

Transferable Evidence

  • A meta-analysis of randomised controlled trials found that both continuous epidural infusion and PCEA analgesia provided superior postoperative analgesia compared with intravenous PCA analgesia Wu et al 2005
  • A meta-analysis found that continuous epidural infusion provided superior analgesia and reduced the incidence of pruritis compared with PCEA analgesia, but was associated with a higher incidence of PONV and motor block Wu et al 2005
  • A meta-analysis of randomised controlled trials found that epidural analgesia significantly decreased the incidence of pulmonary morbidity compared with systemic opioids Ballantyne et al 1998 Click here for more information
  • Epidural administration of strong opioids is associated with side effects including pruritis, PONV, urinary retention, and respiratory depression Chaney 1995

Thoracotomy-specific Evidence

  • Pre-incisional administration of lumbar epidural fentanyl was not significantly different from post-incisional administration for reducing pain scores at 2, 4, 12, 24 and 48 h; pre-incision administration was superior only at 6 h (p<0.04) (n=30) Katz et al 1992
  • Pre-incisional administration of lumbar epidural fentanyl was superior to post-incisional administration for reducing PCA morphine requirements during 12–24 h (p<0.008), but there was no significant difference during 0–12 h and 24–48 h (n=30) Katz et al 1992
  • Study details Katz et al 1992 Click here for more information

PROSPECT recommendations

  • Thoracic epidural corticosteroid is not recommended because there are limited data (Grade D)
  • Epidural epinephrine is recommended if a low dose of epidural LA and/or opioid is used (Grade B)

Clinical Practice

  • None cited

Transferable Evidence from Other Procedures

  • Three studies in major thoracic or abdominal surgery showed that addition of epinephrine 1.5–2 µg/ml to thoracic epidural local anaesthetic plus strong opioid reduced pain intensity Niemi et al 1998 Click here for more information
  • Epinephrine 1.5–2 µg/ml was associated with reduced frequency of pruritis (p<0.002; n=36) Niemi et al 2003

Thoracotomy-specific evidence

  • Addition of epinephrine to thoracic epidural strong opioid was superior to epidural strong opioid alone for reducing use of epidural fentanyl, and for extending the duration of analgesia Baron et al 1996 Click here for more information
  • Postoperative epidural methylprednisolone did not significantly reduce pain scores at rest and on mobilisation, or total morphine requirement over 48 h, compared with placebo (n=24) Blanloeil et al 2001
  • Postoperative epidural methylprednisolone did not significantly reduce the incidence of PONV compared with placebo (n=24) Blanloeil et al 2001
  • Addition of epinephrine to postoperative thoracic epidural strong opioid did not significantly reduce pain scores compared with epidural strong opioid alone Baron et al 1996 Click here for more information
  • Addition of epinephrine to postoperative thoracic epidural strong opioid did not significantly reduce the incidence of PONV compared with epidural strong opioid alone (n=34; n=23) Baron et al 1996
  • Addition of epinephrine to postoperative thoracic epidural strong opioid was associated with similar pulmonary function to epidural strong opioid alone: FEV (n=23) Baron et al 1996
  • Study details Blanloeil et al 2001 Click here for more information

Spinal Analgesia

PROSPECT Recommendations

  • A pre-operative single bolus of spinal strong opioid is recommended as part of a multi-analgesic regimen (Grade A), when epidural analgesia or paravertebral block are not possible for any reason (Grade D)
  • Spinal opioids are recommended in preference to intravenous PCA opioids, based on a greater reduction in pain for up to 24 hours, with no difference in respiratory function (Grade A)
  • Thoracic epidural LA plus opioid is recommended in preference to spinal strong opioid based on evidence that the analgesic effect of thoracic epidural analgesia has a longer duration than 24 h (Grade A, see Postoperative Epidural Analgesia)

Clinical Practice

  • Hydrophilic opioids provide a longer duration of analgesia than lipophilic opioids

Transferable Evidence

  • A meta-analysis of randomised controlled trials in coronary artery bypass surgery found that spinal analgesia combined with general anaesthesia decreased pain scores and systemic morphine use compared with general anaesthesia alone Liu et al 2004
  • Spinal administration of strong opioids is associated with side effects including pruritis, PONV, urinary retention, and respiratory depression Chaney 1995
  • A meta-analysis found that spinal analgesia combined with general anaesthesia in coronary artery bypass surgery increased the incidence of pruritis compared with general anaesthesia alone Liu et al 2004
  • In a systematic review, spinal morphine in patients undergoing caesarean section was shown to increase the relative risk of postoperative pruritis, nausea and vomiting compared with control; increasing the dose of morphine increased the relative risk of postoperative nausea and vomiting Dahl et al 1999

Thoracotomy-specific Evidence

  • Pre-operative single bolus spinal sufentanil was superior to control for reducing pain scores: at rest at 0 and 2 h (p<0.05), but not during 4–24 h; and on coughing during 0–4 h (p<0.05) (one treatment arm; n=29) Liu et al 2001
  • Four studies showed that pre-operative single bolus spinal morphine was superior to control for reducing pain scores Cohen et al 1993 Click here for more information
  • Two studies showed that pre-operative single bolus spinal sufentanil plus morphine was superior to control for reducing pain scores Liu et al 2001 Click here for more information
  • Pre-operative single bolus spinal sufentanil was superior to control for reducing supplementary analgesic requirements: titrated morphine dose and total 24-h morphine dose (p<0.05) (one treatment arm; n=29) Liu et al 2001
  • Pre-operative single bolus spinal morphine was superior to control for reducing supplementary analgesic requirements Liu et al 2001 Click here for more information
  • Single bolus spinal strong opioid (lipophilic and hydrophilic combined) was superior to control for reducing supplementary analgesic requirements Liu et al 2001 Click here for more information
  • Pre-operative spinal morphine was associated with similar or superior pulmonary function compared with control Bowler et al 2002 Click here for more information
  • Pre-operative single bolus spinal strong opioid (lipophilic and hydrophilic combined) did not significantly increase the time to first use of PCA analgesia compared with control (n=30) Mason et al 2001
  • Pre-operative single bolus spinal sufentanil did not reduce the incidence of PONV compared with control (one treatment arm; n=29) Liu et al 2001
  • Pre-operative single bolus spinal morphine did not reduce the incidence of PONV compared with control (one treatment arm, n=29) Liu et al 2001
  • Pre-operative single bolus spinal strong opioid (lipophilic and hydrophilic combined) did not reduce the incidence of PONV compared with control (one treatment arm; n=29) Liu et al 2001
  • Pre-operative single bolus spinal strong opioid (lipophilic and hydrophilic combined) was similar to placebo for outcomes of pulmonary function tests: PEFR, FEV, FVC (n=30) Mason et al 2001
  • Study details Liu et al 2001 Click here for more information

Analgesic Peripheral Nerve Blocks

PROSPECT Recommendations

  • Paravertebral block with LA is recommended as an alternative to thoracic epidural LA plus strong opioid, based on evidence that the technique provides comparable postoperative analgesia and may be associated with fewer adverse effects (Grade A; see also Postoperative Paravertebral Block)

Clinical Practice

  • A paravertebral block can be used in combination with other analgesic techniques, as part of a multimodal analgesic regimen
  • Paravertebral LA may be administered as a bolus before surgery
  • Paravertebral block is used less frequently than epidural analgesia in clinical practice

Transferable Evidence from Other Procedures

  • Paravertebral block improved pain relief, reduced opioid use and was associated with improved pulmonary function compared with placebo in pleurectomy Mozell et al 1991
  • Four studies in breast surgery found that paravertebral block was associated with analgesic benefits compared with control Kairaluoma et al 2004 Click here for more information
  • Bilateral paravertebral block combined with general anaesthesia reduced pain scores, supplementary analgesic use, and the incidence of PONV, compared with general anaesthesia alone in laparoscopic cholecystectomy (n=60) Naja et al 2004

Thoracotomy-specific Evidence

  • Pre-operative paravertebral block was superior to control for reducing pain scores during 0–48 h (no statistical analyses) (seven treatment arms; n=56) Richardson et al 1994
  • Pre-operative paravertebral block was superior to control for reducing supplementary opioid use during 0–24 h (no statistical analysis) (seven treatment arms; n=56) Richardson et al 1994
  • Pre-operative paravertebral block was associated with superior pulmonary function (FVC, FEV1 and PEFR) compared with control (no statistical analysis) (seven treatment arms; n=56) Richardson et al 1994
  • Pre-operative multi-analgesic regimens including paravertebral bupivacaine were superior to analgesic regimens including only systemic morphine or diclofenac with no paravertebral bupivacaine for reducing pain scores during 0–48h and the use of supplementary opioids during 0–24 h (no statistical analysis) (n=56) Richardson et al 1994
  • Pre-operative multi-analgesic regimens including paravertebral bupivacaine were superior to systemic morphine or diclofenac, alone or in combination, and were associated with superior pulmonary function (FVC, FEV1 and PEFR) to no pre-operative treatment (n=56) Richardson et al 1994
  • Study details Richardson et al 1994 Click here for more information

PROSPECT Recommendations

  • Single pre-operative injection with LA for intercostal nerve block is not recommended based on limited evidence (Grade D)

Clinical Practice

  • Infusion techniques for intercostal nerve blocks are more convenient for use in clinical practice and adequate analgesia is more likely to be maintained than with intermittent bolus administration

Transferable Evidence

  • Two studies in open cholecystectomy and one study in upper abdominal surgery showed that intercostal nerve block did not significantly reduce pain scores compared with control (n=37, n=40, n=66) Maidatsi et al 1998
  • In open cholecystectomy, intercostal nerve block reduced supplementary opioid use compared with control in one study (n=37) Maidatsi et al 1998
  • A meta-analysis found that intercostal nerve block tended to reduce the incidence of pulmonary complications, but these differences did not achieve statistical significance. There were no significant differences in surrogate measures of pulmonary function (FEV1, FVC, and PEFR) Ballantyne et al 1998
  • The incidence of pneumothorax following intercostal nerve block in thoracic and upper abdominal surgery has been reported in the range of 0.073% to 19% Shanti et al 2001

Thoracotomy-specific Evidence

  • Intercostal bupivacaine pH 4.1 and pH 6.9 were similar for pain scores and supplementary morphine use during 0–36 h (n=20) Swann et al 1991
  • Pre-operative administration of an analgesic regimen including intercostal LA was superior to postoperative administration for reducing pain scores Doyle et al 1998 Click here for more information
  • Pre-operative and postoperative administration of an analgesic regimen including intercostal LA were similar for postoperative supplementary analgesic requirements Doyle et al 1998 Click here for more information
  • Intramuscular morphine plus rectal indomethacin plus intercostal bupivacaine did not significantly reduce pain scores at rest or on movement compared with placebo (n=30) Kavanagh et al 1994
  • Intramuscular morphine plus rectal indomethacin plus intercostal bupivacaine significantly reduced PCA morphine use during 0–6 h (p<0.03) but increased cumulative morphine use during 0–72 h (p<0.05), compared with placebo (n=30) Kavanagh et al 1994
  • Intramuscular morphine plus rectal indomethacin plus intercostal bupivacaine was associated with similar pulmonary function parameters to placebo (FVC, FEV1 and PaCO2) (n=30) Kavanagh et al 1994
  • Pre-operative and postoperative administration of an analgesic regimen including systemic morphine and diclofenac plus intercostal bupivacaine were similar for the duration of hospital stay (n=30) Doyle et al 1998
  • Study details Swann et al 1991 Click here for more information

PROSPECT Recommendations

  • Intercostal clonidine, in combination with LA, is not recommended, due to limited evidence (Grade D)

Clinical Practice

  • Clonidine may prolong the intercostal nerve block
  • Clonidine is not routinely used because it is associated with an increased risk of hypotension, sedation, dizziness and bradycardia

Transferable Evidence

  • None cited

Thoracotomy-specific Evidence

  • Intercostal LA plus clonidine significantly reduced pain scores compared with LA alone, during 1–4 h after arrival in the PACU (p<0.05), but there was no significant difference during 5–8 h (n=26) Tschernko et al 1998
  • Intercostal LA plus clonidine was superior to LA alone, for reducing PCA piritramide requirements during 1–5 h after arrival in PACU (p<0.05), but not during 6–8 h, and total opioid use at 24 h (p<0.005), but there was no significant difference at 48 h (n=26) Tschernko et al 1998
  • Intercostal LA plus clonidine was associated with increased PaO2 during 1–4 h (p<0.05), but not during 5–8 h, compared with LA alone (n=26) Tschernko et al 1998
  • Study details Tschernko et al 1998 Click here for more information

Local anaesthetic techniques

PROSPECT Recommendations

  • Pre-operative LA injection in the planned site of incision is not recommended based on procedure-specific evidence that shows a lack of analgesic efficacy (Grade A)

Clinical Practice

  • None cited

Transferable Evidence

  • None cited

Thoracotomy-specific Evidence