POSTOPERATIVE PAIN MANAGEMENT FOR VIDEO ASSISTED THORACOSCOPIC SURGERIES

Abstract

SUMMARY P ain control after surgery is one of the corner stones in anesthetic management of patients undergoing thoracic surgery. The provision of good effective post-operative analgesia is important and is regarded by some as the core business of anesthesia and a fundamental human right. Effective analgesia can reduce pulmonary complications, morbidity and mortality. It is unlikely that a single technique will optimally fulfill these objectives for all patients. Analgesia should be tailored to the specific patient and aim to minimize mortality, patient suffering, pulmonary complications and other morbidity. VATS has made tremendous progress during the last decade. The advances in endoscopic technology, with sophisticated endoscopic instruments and endoscopic telescope, allow the replacement of thoracotomy in many indications. With video-assisted thoracoscopic surgeries (VATS) the extent of the surgical incision is limited and early post-operative pain can be reduced. These benefits may be reduced by the use of larger-diameter instruments and/or the twisting of surgical instruments against the ribs causing injury to the intercostal nerves and bruising or even fracturing of the ribs. Multimodal analgesia, defined as the use of a variety of analgesic medication and techniques that target different mechanisms of action in the peripheral and/or central nervous system (which might also be combined with non-pharmacological interventions) might have additive or synergistic effects and more effective pain relief compared with single-modality interventions. Anesthesiologists should provide patient and family-centered, individually tailored education to the patient including information on treatment options for management of postoperative pain, and document the plan and goals for postoperative pain management. Experience with a wide range of analgesic techniques is helpful as it enables the implementation of an appropriate technique. Thoracic epidurals are associated with a risk of permanent injury and this risk has orders of magnitude greater than the risks associated with lumbar epidural administered in parturient. The most frequent disabling complications are epidural hematomas. Current anticoagulant and antiplatelet medication increases the risk of epidural. Impaired coagulation is less of a contraindication to thoracic paravertebral block, particularly when they are inserted under direct vision.High spinal anesthesia has analgesic effect limited to 24 hours. Serious complications are rare with paravertebral block technique. Recent studies and its systemic analysis have suggested that paravertebral blocking techniques are more effective at reducing pulmonary complications than thoracic epidurals. Intercostal block is an excellent choice for analgesic purposes. Advantages of intraoperative intercostal catheter placement include direct visualization under thoracoscope, which can help to avoid intercostal vessels injury. The use of TENS at paravertebral dermatomes corresponding to the surgical incision and/or acupoints has also been reported to improve postoperative pain management. Because this technique cause few if any adverse effects, its use as an adjunct to conventional pharmaceutical approaches should be considered as part of multimodal analgesic regimens in the future. Patients undergoing minithoracotomy for minimally invasive thoracic surgery benefit from cryoablation of the intercostal nerve at the completion of surgery. Using of cognitive–behavioral modalities, acupuncture, music, cold therapy massage, and/ or other physical modalities consider being safe and aiding the multimodal principal of pain management.