{"id":3156,"date":"2021-05-19T14:46:31","date_gmt":"2021-05-19T11:46:31","guid":{"rendered":"https:\/\/www.esrahellas.gr\/?page_id=3156"},"modified":"2021-07-15T10:49:56","modified_gmt":"2021-07-15T07:49:56","slug":"thoracotomy","status":"publish","type":"page","link":"https:\/\/www.esrahellas.gr\/en\/prospect-recommendations\/thoracotomy\/","title":{"rendered":"Thoracotomy"},"content":{"rendered":"  <div id=\"page-header-1586609768\" class=\"page-header-wrapper\">\n  <div class=\"page-title dark featured-title\">\n\n    \n    <div class=\"page-title-inner container align-center flex-row medium-flex-wrap\" >\n              <div class=\"title-wrapper flex-col text-left medium-text-center\">\n          <h1 class=\"entry-title mb-0\">\n            Thoracotomy          <\/h1>\n        <\/div>\n                    <div class=\"title-content flex-col flex-right text-right medium-text-center\">\n        <div class=\"title-share pt-half pb-half\"><div class=\"social-icons share-icons share-row relative icon-style-fill\" ><a href=\"https:\/\/www.facebook.com\/sharer.php?u=https:\/\/www.esrahellas.gr\/en\/prospect-recommendations\/thoracotomy\/\" data-label=\"Facebook\" onclick=\"window.open(this.href,this.title,'width=500,height=500,top=300px,left=300px'); return false;\" target=\"_blank\" class=\"icon primary button circle tooltip facebook\" title=\"Share on Facebook\" aria-label=\"Share on Facebook\" rel=\"noopener nofollow\"><i class=\"icon-facebook\" aria-hidden=\"true\"><\/i><\/a><a href=\"https:\/\/twitter.com\/share?url=https:\/\/www.esrahellas.gr\/en\/prospect-recommendations\/thoracotomy\/\" onclick=\"window.open(this.href,this.title,'width=500,height=500,top=300px,left=300px'); return false;\" target=\"_blank\" class=\"icon primary button circle tooltip twitter\" title=\"Share on Twitter\" aria-label=\"Share on Twitter\" rel=\"noopener nofollow\"><i class=\"icon-twitter\" aria-hidden=\"true\"><\/i><\/a><a href=\"mailto:?subject=Thoracotomy&body=Check%20this%20out%3A%20https%3A%2F%2Fwww.esrahellas.gr%2Fen%2Fprospect-recommendations%2Fthoracotomy%2F\" class=\"icon primary button circle tooltip email\" title=\"Email to a Friend\" aria-label=\"Email to a Friend\" rel=\"nofollow\"><i class=\"icon-envelop\" aria-hidden=\"true\"><\/i><\/a><a href=\"https:\/\/www.linkedin.com\/shareArticle?mini=true&url=https:\/\/www.esrahellas.gr\/en\/prospect-recommendations\/thoracotomy\/&title=Thoracotomy\" onclick=\"window.open(this.href,this.title,'width=500,height=500,top=300px,left=300px'); return false;\" target=\"_blank\" class=\"icon primary button circle tooltip linkedin\" title=\"Share on LinkedIn\" aria-label=\"Share on LinkedIn\" rel=\"noopener nofollow\"><i class=\"icon-linkedin\" aria-hidden=\"true\"><\/i><\/a><\/div><\/div>      <\/div>\n    <\/div>\n\n     \n<style>\n#page-header-1586609768 {\n  margin-bottom: 20px;\n}\n<\/style>\n  <\/div>\n    <\/div>\n  \n<div class=\"row align-middle\"  id=\"row-633519029\">\n\n\t<div id=\"col-1556052320\" class=\"col medium-4 small-12 large-4\"  >\n\t\t\t\t<div class=\"col-inner\"  >\n\t\t\t\n\t\t\t\n\t<div class=\"img has-hover x md-x lg-x y md-y lg-y\" id=\"image_1476645021\">\n\t\t\t\t\t\t\t\t<div class=\"img-inner dark\" >\n\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"200\" height=\"66\" src=\"https:\/\/www.esrahellas.gr\/wp-content\/uploads\/2021\/05\/LOGO-PROSPECT-1.jpg\" class=\"attachment-large size-large\" alt=\"\" \/>\t\t\t\t\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\n<style>\n#image_1476645021 {\n  width: 100%;\n}\n<\/style>\n\t<\/div>\n\t\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\n\t\n\n\t<div id=\"col-1693867203\" class=\"col medium-8 small-12 large-8\"  >\n\t\t\t\t<div class=\"col-inner\"  >\n\t\t\t\n\t\t\t\n<h3>Thoracotomy &#8211; PROSPECT<\/h3>\n<p>GUIDELINES &#8211; RECOMMENDATIONS<br \/>Procedure Specific Postoperative Pain Management<\/p>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\n\t\n<\/div>\n<div class=\"row\"  id=\"row-819820047\">\n\n\t<div id=\"col-1217953441\" class=\"col small-12 large-12\"  >\n\t\t\t\t<div class=\"col-inner\"  >\n\t\t\t\n\t\t\t\n<p><strong>GUIDELINES &#8211; RECOMMENDATIONS<\/strong><\/p>\n<p><strong>Procedure Specific Postoperative Pain Management<\/strong><\/p>\n<p><a href=\"http:\/\/www.postoppain.org\/\">www.postoppain.org<\/a><\/p>\n<p><strong>THORACOTOMY<\/strong><\/p>\n<p><strong>SUMMARY RECOMMENDATIONS<\/strong><\/p>\n<p><strong>PATIENT ADVICE<\/strong><\/p>\n<p>For more information: <a href=\"http:\/\/www.postoppain.org\/content.aspx?nid=56130\">click here<\/a> or <a href=\"http:\/\/www.postoppain.org\/extraPage.aspx?epid=4\">click here<\/a><\/p>\n<p>It is essential that patients undergoing thoracotomy be informed about what to expect after surgery, as an understanding of the procedure as well as realistic expectations of pain and rehabilitation can promote recovery and return to normal activity. Patients undergoing thoracotomy may suffer from very severe acute postoperative pain if analgesia is not managed appropriately. Pulmonary function is impaired as a result of thoracic surgery, and may be worsened by the effects of pain. Therefore, during the early postoperative period following thoracic surgery, pain control and maintenance of pulmonary function are the major goals. Thoracotomy is associated with a number of postoperative complications; the risk of pulmonary complications may be reduced by adequate analgesia as well as physiotherapy. Co-operation with chest physiotherapy, deep breathing exercises and coughing should be emphasized as important ways for patients to improve healing and prevent pneumonia. For pre-operative improvement of pulmonary function, patients should be given intermittent physiotherapy of the lung and general physical exercises, and be advised to stop smoking. (Click here for further information: <a href=\"http:\/\/www.postoppain.org\/extraPage.aspx?epid=4\" target=\"_blank\" rel=\"nofollow noopener noreferrer\">Peri-operative patient advice<\/a>)<\/p>\n<p><strong>PATIENT ASSESSMENT<\/strong><\/p>\n<p>For more information: <a href=\"http:\/\/www.postoppain.org\/content.aspx?nid=56132\">click here<\/a> or <a href=\"http:\/\/www.postoppain.org\/extraPage.aspx?epid=5\">click here<\/a><\/p>\n<p>Many patients undergoing thoracotomy will have significant comorbidities. Therefore, pre-operative assessment is essential to determine whether the benefits of surgery outweigh any risk from postoperative complications, which may be increased by poor general health. Peri-operative analgesia must be planned accordingly, to make use of the most appropriate regional analgesic techniques, depending on patient risk factors and anticipated requirement for analgesia.<\/p>\n<p><strong>Algorithm for the Management of Postoperative Pain following Thoracotomy:<\/strong> <a href=\"http:\/\/www.postoppain.org\/image.aspx?imgid=432\">click here<\/a><\/p>\n<p><strong>Not Recommended for Thoracotomy:<\/strong> <a href=\"http:\/\/www.postoppain.org\/image.aspx?imgid=461\">click here<\/a><\/p>\n<p><strong>PROSPECT THORACOTOMY SUBGROUP<\/strong><\/p>\n<p>For each review, a Subgroup of the PROSPECT Working Group performs an initial evaluation of the evidence and also drafts clinical practice statements and recommendations, which are then discussed by the whole Working Group before a final consensus is reached. The Subgroup may sometimes include a non-Working Group member, to provide additional expertise in the procedure being reviewed.<\/p>\n<p>For the thoracotomy review, the Subgroup members were:<\/p>\n<ul>\n<li>Professor Francis Bonnet<\/li>\n<\/ul>\n<ul>\n<li>Professor Girish Joshi<\/li>\n<\/ul>\n<ul>\n<li>Mr Rajesh Shah (Consultant thoracic surgeon, Wythenshawe Hospital, Manchester, UK)<\/li>\n<\/ul>\n<p><strong>GRADES OF RECOMMENDATIONS<\/strong><\/p>\n<p>The recommendations of the PROSPECT Working Group are graded A\u2013D, based on the level of evidence from the studies, which is in accordance with the Oxford Centre for Evidence-Based Medicine (<a href=\"http:\/\/www.postoppain.org\/reference.aspx?rid=747\" target=\"_blank\" rel=\"nofollow noopener noreferrer\">CEBM 2005<\/a>). In the context of PROSPECT, recommendations based on procedure-specific evidence are grade A (randomised clinical trials), those based on transferable evidence are grade B (randomised clinical trials) or grade C (retrospective studies or case series) and those based on clinical practice are grade D. (<a href=\"http:\/\/www.postoppain.org\/extraPage.aspx?epid=10\" target=\"_blank\" rel=\"nofollow noopener noreferrer\">Click here for further information on levels of evidence and grades of recommendation<\/a>).<\/p>\n<p>PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.<\/p>\n<p><strong>SUMMARY RECOMMENDATIONS<\/strong><\/p>\n<p>Pre-, intra- and postoperative interventions have been evaluated for the management of postoperative pain following thoracotomy. Unless otherwise stated, \u2018pre-operative\u2019 refers to interventions applied before surgical incision, \u2018intra-operative\u2019 refers to interventions applied after incision and before wound closure, \u2018postoperative\u2019 refers to interventions applied at or after wound closure. The following peri-operative interventions for thoracotomy have been reviewed:<\/p>\n<p><strong>PREOPERATIVE PERIOD<\/strong><\/p>\n<p><strong>Recommended<\/strong><\/p>\n<p><em>Regional Analgesia<br \/><\/em><\/p>\n<ul>\n<li>Thoracic epidural LA + strong opioid as a bolus before surgery (Grade A), continued as an infusion\n<ul>\n<li>epinephrine in the epidural solution is recommended if a low dose of epidural LA and\/or opioid is used (Grade B)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>Paravertebral block with LA (bolus pre-operatively or at the end of surgery, followed by continuous infusion), as an alternative to thoracic epidural analgesia (Grade A)<\/li>\n<\/ul>\n<ul>\n<li>Single bolus spinal strong opioid as part of a multi-analgesic regimen, when thoracic epidural analgesia and paravertebral block are not possible (Grade A)<\/li>\n<\/ul>\n<p><strong>Not recommended<\/strong><\/p>\n<p><em>Systemic Analgesia<\/em><\/p>\n<ul>\n<li>\n<p>alpha &#8211; 2 Adrenergic Receptor Agonists<\/p>\n<ul>\n<li>Clonidine (Grade A)<\/li>\n<li>Dexmedetomidine (Grade D)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>\n<p>Corticosteroid (Grade D)<\/p>\n<\/li>\n<li>\n<p>Conventional NSAIDs (Grade A)<\/p>\n<\/li>\n<li>\n<p>COX-2 Selective Inhibitors (Grade D)<\/p>\n<\/li>\n<li>\n<p>Ketamine (Grade D)<\/p>\n<\/li>\n<li>\n<p>Gabapentin \/ Pregabalin (Grade D)<\/p>\n<\/li>\n<li>\n<p>Strong Opioids (Grade A)<\/p>\n<\/li>\n<\/ul>\n<p><em>Regional Analgesia<\/em><\/p>\n<ul>\n<li>\n<p>Lumbar epidural strong opioid is not recommended as the first choice of epidural technique based on evidence that the thoracic epidural route may provide superior analgesia to the lumbar epidural route (Grade A). However, there is procedure-specific evidence that lumbar epidural hydrophilic strong opioid reduces pain compared with systemic analgesia.<\/p>\n<\/li>\n<li>\n<p>Intercostal nerve block with LA, as a single pre-operative injection (Grade D)<\/p>\n<\/li>\n<li>\n<p>Intercostal clonidine (Grade D)<\/p>\n<\/li>\n<li>\n<p>Pre-operative LA injection in the planned site of incision  (Grade A)<\/p>\n<\/li>\n<\/ul>\n<p><strong>INTRAOPERATIVE PERIOD<\/strong><\/p>\n<p><strong>Recommended<\/strong><\/p>\n<p><em>Regional Analgesia<\/em><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li>Thoracic epidural infusion of LA + strong opioid, continuous infusion (Grade A)\n<ul>\n<li>epinephrine in the epidural solution is recommended if a low dose of epidural LA and\/or opioid is used (Grade B)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li style=\"list-style-type: none;\">\n<ul>\n<li>Paravertebral block with LA (bolus pre-operatively or at the end of surgery, followed by continuous infusion), as an alternative to thoracic epidural analgesia (Grade A)<\/li>\n<\/ul>\n<\/li>\n<li style=\"list-style-type: none;\">\n<ul>\n<li>Intercostal nerve block with LA (bolus at the end of surgery, followed by continuous infusion), if thoracic epidural analgesia and paravertebral block are not possible (Grade D)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>Not Recommended<\/strong><\/p>\n<p><em>Systemic Analgesia<\/em><\/p>\n<ul>\n<li>\n<p>Conventional NSAIDs (Grade D)<\/p>\n<\/li>\n<li>\n<p>COX-2 Selective Inhibitors (Grade D)<\/p>\n<\/li>\n<li>\n<p>Ketamine (Grade D)<\/p>\n<\/li>\n<li>\n<p>Gabapentin \/ Pregabalin (Grade D)<\/p>\n<\/li>\n<\/ul>\n<p><em>Regional Analgesia<\/em><\/p>\n<ul>\n<li>\n<p>Lumbar epidural strong opioid is not recommended as the first choice of epidural technique based on evidence that the thoracic epidural route may provide superior analgesia to the lumbar epidural route (Grade A). However, there is procedure-specific evidence that lumbar epidural hydrophilic strong opioid reduces pain compared with systemic analgesia.<\/p>\n<\/li>\n<li>\n<p>Addition of dextran to intercostal LA solution (Grade A)<\/p>\n<\/li>\n<li>\n<p>Intercostal phenol (Grade D)<\/p>\n<\/li>\n<li>\n<p>Interpleural strong opioid (Grade D)<\/p>\n<\/li>\n<li>\n<p>Cryoanalgesia (Grade A)<\/p>\n<\/li>\n<\/ul>\n<p><em>Analgesia for Shoulder Pain<\/em><\/p>\n<ul>\n<li>\n<p>Phrenic nerve block (Grade D)<\/p>\n<\/li>\n<\/ul>\n<p><em>Operative Techniques<\/em><\/p>\n<ul>\n<li>\n<p>The operative technique used should depend on factors other than pain (Grade D)<\/p>\n<\/li>\n<\/ul>\n<p><strong>POSTOPEARTIVE PERIOD<\/strong><\/p>\n<p><strong>Recommended<\/strong><\/p>\n<p><em>Systemic Analgesia<\/em><\/p>\n<ul>\n<li>\n<p>Conventional NSAIDs, if regional analgesia is inadequate (Grade A)<\/p>\n<\/li>\n<li>\n<p>COX-2-selective inhibitors, if regional analgesia is inadequate (Grade B)<\/p>\n<\/li>\n<li>\n<p>Intravenous PCA strong opioid, if regional analgesic techniques fail or are not possible (Grade D)<\/p>\n<\/li>\n<li>\n<p>Weak opioids for moderate- (VAS>30<50 mm) or low- (VAS\u00a330 mm) intensity pain in the late postoperative period, only if conventional NSAIDs\/COX-2-selective inhibitors plus paracetamol are insufficient or contra-indicated (Grade D)<\/p>\n<\/li>\n<li>\n<p>Paracetamol, if regional analgesia is inadequate, as part of a multianalgesic regimen (Grade D)<\/p>\n<\/li>\n<\/ul>\n<p><em>Regional Analgesia<\/em><\/p>\n<ul>\n<li>\n<p>Thoracic epidural LA + strong opioid, continuous infusion for 2\u20133 days (Grade A)<\/p>\n<ul>\n<li>epinephrine in the epidural solution is recommended if a low dose of epidural LA and\/or opioid is used (Grade B)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>\n<p>Paravertebral block with LA, continuous infusion for 2\u20133 days, as an alternative to thoracic epidural analgesia (Grade A)<\/p>\n<\/li>\n<li>\n<p>Intercostal nerve block with LA, continuous infusion for 2\u20133 days, if thoracic epidural analgesia and paravertebral block are not possible (Grade D)<\/p>\n<\/li>\n<\/ul>\n<p><strong>Not Recommended<\/strong><\/p>\n<p><em>Systemic Analgesia<\/em><\/p>\n<ul>\n<li>\n<p>alpha-2 adrenergic receptor antagonists<\/p>\n<ul>\n<li>dexmedetomidine (Grade D)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>\n<p>Ketamine (Grade D)<\/p>\n<\/li>\n<li>\n<p>Gabapentin\/pregabalin (Grade D)<\/p>\n<\/li>\n<li>\n<p>Paracetamol alone for high intensity pain (VAS\u00b350 mm) (Grade B)<\/p>\n<\/li>\n<\/ul>\n<p><em>Regional Analgesia<\/em><\/p>\n<ul>\n<li>\n<p>Lumbar epidural strong opioid is not recommended as the first choice of epidural technique based on evidence that the thoracic epidural route may provide superior analgesia to the lumbar epidural route (Grade A). However, there is procedure-specific evidence that lumbar epidural hydrophilic strong opioid reduces pain compared with systemic analgesia.<\/p>\n<\/li>\n<li>\n<p>Thoracic epidural corticosteroid (Grade D)<\/p>\n<\/li>\n<li>\n<p>Repeated spinal analgesia (grade D)<\/p>\n<\/li>\n<li>\n<p>Interpleural LA (Grade A)<\/p>\n<\/li>\n<\/ul>\n<p><em>Alternative Analgesic Techniques<\/em><\/p>\n<ul>\n<li>\n<p>Auricular acupuncture (Grade D)<\/p>\n<\/li>\n<li>\n<p>TENS (Grade D)<\/p>\n<\/li>\n<\/ul>\n<p><em>Analgesia for Shoulder Pain<\/em><\/p>\n<ul>\n<li>\n<p>Suprascapular nerve block (Grade D)<\/p>\n<\/li>\n<\/ul>\n<p><em>Analgesia for Chest Tube Removal<\/em><\/p>\n<ul>\n<li>\n<p>Ice pack (Grade A)<\/p>\n<\/li>\n<li>\n<p>Interpleural local anaesthestic (Grade A)<\/p>\n<\/li>\n<li>\n<p>Topical local anaesthetic (Grade D)<\/p>\n<\/li>\n<\/ul>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\n\t\n<\/div>\n\t<div id=\"gap-1106257181\" class=\"gap-element clearfix\" style=\"display:block; height:auto;\">\n\t\t\n<style>\n#gap-1106257181 {\n  padding-top: 30px;\n}\n<\/style>\n\t<\/div>\n\t\n<div class=\"social-icons share-icons share-row relative full-width text-center\" ><a href=\"https:\/\/www.facebook.com\/sharer.php?u=https:\/\/www.esrahellas.gr\/en\/prospect-recommendations\/thoracotomy\/\" data-label=\"Facebook\" onclick=\"window.open(this.href,this.title,'width=500,height=500,top=300px,left=300px'); return false;\" target=\"_blank\" class=\"icon primary button circle tooltip facebook\" title=\"Share on Facebook\" aria-label=\"Share on Facebook\" rel=\"noopener nofollow\"><i class=\"icon-facebook\" aria-hidden=\"true\"><\/i><\/a><a href=\"https:\/\/twitter.com\/share?url=https:\/\/www.esrahellas.gr\/en\/prospect-recommendations\/thoracotomy\/\" onclick=\"window.open(this.href,this.title,'width=500,height=500,top=300px,left=300px'); return false;\" target=\"_blank\" class=\"icon primary button circle tooltip twitter\" title=\"Share on Twitter\" aria-label=\"Share on Twitter\" rel=\"noopener nofollow\"><i class=\"icon-twitter\" aria-hidden=\"true\"><\/i><\/a><a href=\"mailto:?subject=Thoracotomy&body=Check%20this%20out%3A%20https%3A%2F%2Fwww.esrahellas.gr%2Fen%2Fprospect-recommendations%2Fthoracotomy%2F\" class=\"icon primary button circle tooltip email\" title=\"Email to a Friend\" aria-label=\"Email to a Friend\" rel=\"nofollow\"><i class=\"icon-envelop\" aria-hidden=\"true\"><\/i><\/a><a href=\"https:\/\/www.linkedin.com\/shareArticle?mini=true&url=https:\/\/www.esrahellas.gr\/en\/prospect-recommendations\/thoracotomy\/&title=Thoracotomy\" onclick=\"window.open(this.href,this.title,'width=500,height=500,top=300px,left=300px'); return false;\" target=\"_blank\" class=\"icon primary button circle tooltip linkedin\" title=\"Share on LinkedIn\" aria-label=\"Share on LinkedIn\" rel=\"noopener nofollow\"><i class=\"icon-linkedin\" aria-hidden=\"true\"><\/i><\/a><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":3105,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-blank.php","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-3156","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.0 - 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