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.<sup>14 Conacher I.D. Pain relief after thoracotomy Br J Anaesth 1990 ;  65 : 806

Cliccare qui per andare alla sezione Riferimenti</sup> 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.<sup>5 Brichon P.Y., Pison C., Chaffanjon P. , e al. Comparison of epidural analgesia and cryoanalgesia in thoracic surgery Eur J Cardiothorac Surg 1994 ;  8 : 482  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 13 Conacher I.D. Neuralgia after cryoanalgesia for thoracotomy Lancet 1986 ;  1 : 277  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 42 Miguel R., Hubbell D. Pain management and spirometry following thoracotomy: A prospective, randomized study of four techniques J Cardiothorac Vasc Anesth 1993 ;  7 : 529  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> Restoration of function, in terms of pulmonary function tests, was the only realistic outcome measure. Bromage<sup>6 Bromage P.R. Spirometry in assessment of analgesia after abdominal surgery: A method of comparing analgesic drugs Br Med J 1955 ;  2 : 589  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> 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.<sup>6 Bromage P.R. Spirometry in assessment of analgesia after abdominal surgery: A method of comparing analgesic drugs Br Med J 1955 ;  2 : 589  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup>

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.<sup>14 Conacher I.D. Pain relief after thoracotomy Br J Anaesth 1990 ;  65 : 806

Cliccare qui per andare alla sezione Riferimenti, 17 Cook T.M., Riley R.H. Analgesia following thoracotomy: A survey of Australian practice Anaesth Intensive Care 1997 ;  25 : 520

Cliccare qui per andare alla sezione Riferimenti, 20 Doyle E., Bowler G.M. Preemptive effect of multimodal analgesia in thoracic surgery Br J Anaesth 1998 ;  80 : 147

Cliccare qui per andare alla sezione Riferimenti, 21 Eng J., Sabnathan S. Post-thoracotomy analgesia Journal of Royal College of Surgeons of Edinburgh 1993 ;  38 : 62

Cliccare qui per andare alla sezione Riferimenti, 36 Kalso E., Pertunnen K., Kaasinen S. Pain after thoracic surgery Acta Anaesthesiol Scand 1992 ;  36 : 96  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 39 Kruger M., Sandler A.N. Post-thoracotomy pain control Current Opinion in Anaesthesiology 1999 ;  12 : 55  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti, 53 Salzer G.M., Kingler P., Kingler A. , e al. Pain treatment after thoracotomy: Is it a special problem? Ann Thorac Surg 1997 ;  63 : 1411  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> 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.<sup>65 Wright C.D., Wain J.C., Grillo H.C. , e al. Pulmonary lobectomy patient care pathway: A model to control cost and maintain quality Ann Thorac Surg 1997 ;  64 : 299  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> Statutory regulations and bodies, now being commissioned in many democracies, will probe for evidence-base, quality, and financial efficiency.