Acta Anaesthesiol Scand 1992: 36: 96-100
Pain after thoracic surgery E. KALSO, K. PERTTUNEN and S. KAASINEN Department of Anaesthesia, Helsinki University Central Hospital, Helsinki, Finland
In order to evaluate postoperative pain treatment following thoracic surgery, 214 medical records of patients who were operated during 1986-1988 were examined. Nurses’ comments concerning pain and the amounts of analgesics given during the 2 postoperative days were recorded. The 150 patients who were still alive i n December 1989 were sent a postal questionnaire which asked about the pain and the efficacy of pain relief they had received after their operation. They were also asked if they still had pain which they connected to the thoracotomy and if any attempts had been made to treat that pain. The mean consumption of intramuscular oxycodone was 38 mg during the 1st and 33 mg during the 2nd postoperative day. The administration of nonsteroidal anti-inflammatory drugs significantly reduced the opioid consumption on the second but not on the first postoperative day. In 30% of the patients’ charts there were no remarks on pain, in 10% there was a mention of no pain, in 40% pain was mentioned and in 20% the patient was reported to have severe pain. During the first postoperative week little pain was experienced by 60% of the patients, considerable pain by 35% and excruciating pain by 5% of the patients being interviewed. The postoperative pain relief was rated as good in 60% of the answers, satisfactory in 38% and poor in 2%. Persistent post-thoracotomy pain lasting for more than 6 months was reported by 44% of the patients, of whom 66% had received treatment for the pain. Received 12 Januay, accepted for publication 10 3.b 1991
K y words: Pain: postoperative, chronic; surgery: thoracic.
About 70% of patients experience severe pain following thoracic surgery, and the pain may last longer than after abdominal or orthopaedic surgery (1). Pain in the thorax will prevent patients from breathing and coughing, resulting in pulmonary complications (2). Post-thoracotomy pain responds to opioids better than pain following upper abdominal surgery, but the required doses may be high (3) and the side effects, especially respiratory depression, are conspicuously deleterious in these patients. The immediate post-thoracotomy pain usually disappears by 5 months, but may persist even longer or reappear after a painfree period, usually indicating recurrent or persistent tumour or infection (4). The aim of this study was to evaluate the incidence and treatment of both acute and persistent post-thoracotomy pain.
PATIENTS AND METHODS Patient charts All 214 charts of the patients who had undergone thoracotomies during 1986-1988 in the 111 Department of Surgery, Helsinki University Central Hospital, were examined in order to find out how much analgesic the patients were prescribed and how much they received during the recovery room period and during the first and
second postoperative day on the ward. Nurses’ comments were analysed for comments on postoperative pain. Interview by a letter A letter was sent to the 150 surviving patients and they were asked to answer the following questions: I. Would you rate the pain you experienced, in spite of the pain killers that you were given, during the first week after your operation as minor, considerable or excruciating? 2. Was the pain relief you were given good, satisfactory or poor? 3. If you were not satisfied with the pain treatment, would you have liked higher doses of analgesics, shorter intervals between doses, local anaesthetic blocks or something else (could you please drfine)? 4. Did you have pain at home? 5. If you had pain at home, did it last for less than 3 months, from 3 to 6 months or for more than 6 months? 6. Do you still have pain that you think is due to the operation? 7. Have you received any treatment for your pain? 8. If you have received treatment, have you been given ordinary pain killers, strong analgesics, other drugs, local anaesthetic blocks, acupuncture, cryotherapy ( = freezing of a nerve), physiotherapy or something else (please tick as appropriate and define if necessary)? 9. Could you please describe the painful area by indicating i t on the enclosed diagram, using the following symbols to describe your pain: x x x = ache, 0 0 0 = burning pain, = = = =tenderness and I11 = numbness. Statistical analysis Student’s t-test for unpaired data was used for between-group comparisons of demographic data. The consumption of analgesics, esti-
97
PAIN AFTER THORACIC SURGERY
Table 1 Characteristics of the patients and the postoperative pain treatment. Mean values f s.e.mean are given. There were no statistically significant differences between the patients who either had or did not have persistent post-thoracotomy pain.
Sex (F/M) Age (years) Weight (kg) Yo of patients operated for a malignancy % of patients given an intrathoracic i.c. block % of patients having an epidural block Dose of i.m. oxycodone (mg) prescribed for the ward Amount of oxycodone given ( m g ) - in the recovery room - during the 1. postop. day - during the 2. postop. day % of patients given nonsteroidal anti-inflammatory drugs - in the recovery room - during the 1. postop. day - durinn the 2. postop. day
All patients N = 207
Patients with persistent post-thoracotomy pain N = 59
Patients without persistent post-thoracotomy pain N = 75
691138 57.2 ( f 0.9) 71.9 ( f 1.0) 85% 96% 2Yo 8.9 ( t 0 . 1 3 )
2 1/38 57.1 ( f 1.6) 72.2 (t 1.6) 84% 97% 2% 8.9 ( f 0.2)
27/48 55.8 ( f 1.7) 71.8 (k 1.9) 78% 95% 1% 8.9 ( k 0 . 2 )
10.8 (t0.7) 38.1 (k 1.0) 32.6 ( k 1.3)
11.0 (t 1.1) 40.5 ( f 1.6) 33.8 ( f 2.3)
9.9 ( k 1.0) 38.2 ( t 1.7) 33.9 ( 2.2)
31% 51% 48 %
34% 54% 42%
25% 43% 43%
mations of pain and pain relief were compared with the MannWhitney’s U-test, Kruskall-Wallis and Spearman rank correlation tests. PcO.05 was regarded as statistically significant.
and the pain treatment they received during the first 2 postoperative days are shown in Table 1. There were no statistically significant differences in these parameters between the patients who still had pain and those who were free from pain. The distributions of opioid consumption during the recovery room period and the 1st and 2nd postoperative days are shown in Fig. 1. There was a statistically significant correlation between the consumption of opioids in the recovery room and during the 1st postoperative day and between the opioid consumption during the 1st and the 2nd postoperative days. Oxycodone was administered to all patients except for two, who were given morphine as the primary opioid. In addition, buprenorphine was given to 6% of the patients and pethidine to 2% of the patients. No opioids were given to 0.5% of the patients on the 1st postoperative day and to 10% of the patients on the 2nd postoperative day. Nonsteroidal anti-inflammatory drugs (NSAIDs), mainly diclofenac or indomethacin, were given to 51% of the patients (Table 1). The mean consumption of oxycodone was significantly ( P < O . O O O l ) less on the 2nd postoperative day in the group of patients who had been given NSAIDs (27.0_+1.9 mg, s.e.mean) compared to those who had not been given NSAIDs (37.7 f 1.6 mg, s.e.mean). The administration of NSAIDs made no difference to the oxycodone consumption on the 1st postoperative day, the mean daily doses f s.e.mean of oxycodone being 38.7 1.3 mg (NSAIDs given) and 37.9 f 1.4 mg (no NSAIDs given). Litalgina (metamizol. natr. 500 mg + pitofen-HC1 2 mg in 1 ml) was given to 35% of the patients. Almost every patient (96%) had an intrathorac-
RESULTS Of the total of 214 medical records, seven were excluded either because the patient had died or had had a reoperation within 2 postoperative days. A letter was sent to 150 surviving patients, of whom 89% answered and returned the questionnaire. The mean time from the surgery to the return of the questionnaire was 30.3 months (range 15-48 months). Of these patients, 44% reported that they still had pain which they connected to the thoracotomy. The characteristics of the patients
150
Recoveryroom
2nd postop. day
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I z 0 0-10 10-20 20-30 30-40 40-50 50-60 60-70 70-90
Oxycodone (mg) Fig. 1. Consumption of oxycodone during the recovery mom period and during the 1st and 2nd postoperative days after thoracic surgery.
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98
E. KALSO ET AL.
Table 2 Patients' estimation of the severity of pain and of the efficacy of pain relief during the first postoperative week. The postoperative pain was significantly more severe in the group of patients with persistent post-thoracotomy pain than in the group without persistent post-thoracotomy pain ( P
Pain after thoracic surgery E. KALSO, K. PERTTUNEN and S. KAASINEN Department of Anaesthesia, Helsinki University Central Hospital, Helsinki, Finland
In order to evaluate postoperative pain treatment following thoracic surgery, 214 medical records of patients who were operated during 1986-1988 were examined. Nurses’ comments concerning pain and the amounts of analgesics given during the 2 postoperative days were recorded. The 150 patients who were still alive i n December 1989 were sent a postal questionnaire which asked about the pain and the efficacy of pain relief they had received after their operation. They were also asked if they still had pain which they connected to the thoracotomy and if any attempts had been made to treat that pain. The mean consumption of intramuscular oxycodone was 38 mg during the 1st and 33 mg during the 2nd postoperative day. The administration of nonsteroidal anti-inflammatory drugs significantly reduced the opioid consumption on the second but not on the first postoperative day. In 30% of the patients’ charts there were no remarks on pain, in 10% there was a mention of no pain, in 40% pain was mentioned and in 20% the patient was reported to have severe pain. During the first postoperative week little pain was experienced by 60% of the patients, considerable pain by 35% and excruciating pain by 5% of the patients being interviewed. The postoperative pain relief was rated as good in 60% of the answers, satisfactory in 38% and poor in 2%. Persistent post-thoracotomy pain lasting for more than 6 months was reported by 44% of the patients, of whom 66% had received treatment for the pain. Received 12 Januay, accepted for publication 10 3.b 1991
K y words: Pain: postoperative, chronic; surgery: thoracic.
About 70% of patients experience severe pain following thoracic surgery, and the pain may last longer than after abdominal or orthopaedic surgery (1). Pain in the thorax will prevent patients from breathing and coughing, resulting in pulmonary complications (2). Post-thoracotomy pain responds to opioids better than pain following upper abdominal surgery, but the required doses may be high (3) and the side effects, especially respiratory depression, are conspicuously deleterious in these patients. The immediate post-thoracotomy pain usually disappears by 5 months, but may persist even longer or reappear after a painfree period, usually indicating recurrent or persistent tumour or infection (4). The aim of this study was to evaluate the incidence and treatment of both acute and persistent post-thoracotomy pain.
PATIENTS AND METHODS Patient charts All 214 charts of the patients who had undergone thoracotomies during 1986-1988 in the 111 Department of Surgery, Helsinki University Central Hospital, were examined in order to find out how much analgesic the patients were prescribed and how much they received during the recovery room period and during the first and
second postoperative day on the ward. Nurses’ comments were analysed for comments on postoperative pain. Interview by a letter A letter was sent to the 150 surviving patients and they were asked to answer the following questions: I. Would you rate the pain you experienced, in spite of the pain killers that you were given, during the first week after your operation as minor, considerable or excruciating? 2. Was the pain relief you were given good, satisfactory or poor? 3. If you were not satisfied with the pain treatment, would you have liked higher doses of analgesics, shorter intervals between doses, local anaesthetic blocks or something else (could you please drfine)? 4. Did you have pain at home? 5. If you had pain at home, did it last for less than 3 months, from 3 to 6 months or for more than 6 months? 6. Do you still have pain that you think is due to the operation? 7. Have you received any treatment for your pain? 8. If you have received treatment, have you been given ordinary pain killers, strong analgesics, other drugs, local anaesthetic blocks, acupuncture, cryotherapy ( = freezing of a nerve), physiotherapy or something else (please tick as appropriate and define if necessary)? 9. Could you please describe the painful area by indicating i t on the enclosed diagram, using the following symbols to describe your pain: x x x = ache, 0 0 0 = burning pain, = = = =tenderness and I11 = numbness. Statistical analysis Student’s t-test for unpaired data was used for between-group comparisons of demographic data. The consumption of analgesics, esti-
97
PAIN AFTER THORACIC SURGERY
Table 1 Characteristics of the patients and the postoperative pain treatment. Mean values f s.e.mean are given. There were no statistically significant differences between the patients who either had or did not have persistent post-thoracotomy pain.
Sex (F/M) Age (years) Weight (kg) Yo of patients operated for a malignancy % of patients given an intrathoracic i.c. block % of patients having an epidural block Dose of i.m. oxycodone (mg) prescribed for the ward Amount of oxycodone given ( m g ) - in the recovery room - during the 1. postop. day - during the 2. postop. day % of patients given nonsteroidal anti-inflammatory drugs - in the recovery room - during the 1. postop. day - durinn the 2. postop. day
All patients N = 207
Patients with persistent post-thoracotomy pain N = 59
Patients without persistent post-thoracotomy pain N = 75
691138 57.2 ( f 0.9) 71.9 ( f 1.0) 85% 96% 2Yo 8.9 ( t 0 . 1 3 )
2 1/38 57.1 ( f 1.6) 72.2 (t 1.6) 84% 97% 2% 8.9 ( f 0.2)
27/48 55.8 ( f 1.7) 71.8 (k 1.9) 78% 95% 1% 8.9 ( k 0 . 2 )
10.8 (t0.7) 38.1 (k 1.0) 32.6 ( k 1.3)
11.0 (t 1.1) 40.5 ( f 1.6) 33.8 ( f 2.3)
9.9 ( k 1.0) 38.2 ( t 1.7) 33.9 ( 2.2)
31% 51% 48 %
34% 54% 42%
25% 43% 43%
mations of pain and pain relief were compared with the MannWhitney’s U-test, Kruskall-Wallis and Spearman rank correlation tests. PcO.05 was regarded as statistically significant.
and the pain treatment they received during the first 2 postoperative days are shown in Table 1. There were no statistically significant differences in these parameters between the patients who still had pain and those who were free from pain. The distributions of opioid consumption during the recovery room period and the 1st and 2nd postoperative days are shown in Fig. 1. There was a statistically significant correlation between the consumption of opioids in the recovery room and during the 1st postoperative day and between the opioid consumption during the 1st and the 2nd postoperative days. Oxycodone was administered to all patients except for two, who were given morphine as the primary opioid. In addition, buprenorphine was given to 6% of the patients and pethidine to 2% of the patients. No opioids were given to 0.5% of the patients on the 1st postoperative day and to 10% of the patients on the 2nd postoperative day. Nonsteroidal anti-inflammatory drugs (NSAIDs), mainly diclofenac or indomethacin, were given to 51% of the patients (Table 1). The mean consumption of oxycodone was significantly ( P < O . O O O l ) less on the 2nd postoperative day in the group of patients who had been given NSAIDs (27.0_+1.9 mg, s.e.mean) compared to those who had not been given NSAIDs (37.7 f 1.6 mg, s.e.mean). The administration of NSAIDs made no difference to the oxycodone consumption on the 1st postoperative day, the mean daily doses f s.e.mean of oxycodone being 38.7 1.3 mg (NSAIDs given) and 37.9 f 1.4 mg (no NSAIDs given). Litalgina (metamizol. natr. 500 mg + pitofen-HC1 2 mg in 1 ml) was given to 35% of the patients. Almost every patient (96%) had an intrathorac-
RESULTS Of the total of 214 medical records, seven were excluded either because the patient had died or had had a reoperation within 2 postoperative days. A letter was sent to 150 surviving patients, of whom 89% answered and returned the questionnaire. The mean time from the surgery to the return of the questionnaire was 30.3 months (range 15-48 months). Of these patients, 44% reported that they still had pain which they connected to the thoracotomy. The characteristics of the patients
150
Recoveryroom
2nd postop. day
m
.-e
c)
loo
c)
a a
(r
0 L
3
50
I z 0 0-10 10-20 20-30 30-40 40-50 50-60 60-70 70-90
Oxycodone (mg) Fig. 1. Consumption of oxycodone during the recovery mom period and during the 1st and 2nd postoperative days after thoracic surgery.
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98
E. KALSO ET AL.
Table 2 Patients' estimation of the severity of pain and of the efficacy of pain relief during the first postoperative week. The postoperative pain was significantly more severe in the group of patients with persistent post-thoracotomy pain than in the group without persistent post-thoracotomy pain ( P
