POST-THORACOTOMY ANALGESIA - 03/09/11
Résumé |
Analgesia for patients with pain of thoracic surgical origin is examined from an organizational perspective. Conventional approaches are discussed in the light of the dynamics that are driving managed healthcare resources in global economies. Not all patients can expect to receive gold standard techniques within five-star environments, but each individual is entitled to receive a similar measure of quality pain relief. This aim should be the prime one of those charged with providing pain relief services.
A state-of-the-art review from 2 decades ago could be made by describing the application of local anesthetics to the intercostal space at the time of surgery and, more exotically, into the epidural space with percutaneously sited catheters after surgery.14 The bulk of patients had as-required prescriptions of opiates, probably by intramuscular injection; few received nonsteroidal anti-inflammatory drugs (NSAIDs) by mouth or rectally. There was interest in the use of a cryoprobe for intercostal nerve blockade, but recognition that it caused post-thoracotomy neuralgia led to the demise as a pain-relief technique.5, 13, 42 Restoration of function, in terms of pulmonary function tests, was the only realistic outcome measure. Bromage6 proposed the measure, respiration restoration factor, an index that reflected the recent knowledge that reduction in pain levels counteracted the restrictive effects of surgery on chest wall mechanics and led to a reduction in what was regarded as an obligatory effect of thoracotomy, by way of which almost all surgery was conducted.6
Since then, there has been an analgesic revolution, notably in the use of neuraxial opioids. With technologic advances, such as sophisticated delivery systems that can be patient-operated, there has been an explosion of alternatives for relieving the suffering of thoracic trauma and surgically induced pain.14, 17, 20, 21, 36, 39, 53 As an outcome measure, improved function waned with the rise of pain analog scoring systems, a concept of opioid sparing, and with detecting and preempting changes in surrogate markers of pain found in the biochemistry of stress.
North America has been slower than Europe to recognize that the legacy of tobacco on an elderly population demographic is the creation of an epidemic of cigarette smoking–related pulmonary disease that rivals cardiovascular disease. By 2020, obstructive airways disease will be the fourth largest killing condition. Lung cancer is now the third commonest cancer in Western democracies. In many cases, surgery is the only option with a chance of cure, and requires considerable investment from the economy. Practice increasingly is viewed from a consumerist, rather than medical, perspective because of the politicization of the funding of managed healthcare systems. Pain-relief services are not immune from scrutiny from various directions.65 Statutory regulations and bodies, now being commissioned in many democracies, will probe for evidence-base, quality, and financial efficiency.
Le texte complet de cet article est disponible en PDF.Plan
| Address reprint requests to Ian D. Conacher, MD, MB, Department of Thoracic Anaesthesia, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Freeman Road, Newcastle upon Tyne, NE7 7DN, United Kingdom |
Vol 19 - N° 3
P. 611-625 - septembre 2001 Retour au numéro
Article précédent
- ANESTHESIA CONSIDERATIONS FOR LUNG VOLUME REDUCTION SURGERY
- Edda M. Tschernko
Bienvenue sur EM-consulte, la référence des professionnels de santé.
L’accès au texte intégral de cet article nécessite un abonnement.
Déjà abonné à cette revue ?