Different Anesthetic Techniques Associated with Different Incidences of Chronic Post-thoracotomy Pain: Low-Dose Remifentanil Plus Presurgical Epidural Analgesia is Preferable to High-Dose Remifentanil with Postsurgical Epidural Analgesia

• Published in: Journal of cardiothoracic and vascular anesthesia 2010-08, Vol.24 (4), p.608-616
• Main Authors: Salengros, Jean-Corentin, MD, Huybrechts, Isabelle, MD, Ducart, Anne, MD, Faraoni, David, MD, Marsala, Corinne, MD, Barvais, Luc, PhD, Cappello, Matteo, PhD, Engelman, Edgard, MD
• Format: Article
• Language: English
• Subjects: Aged; Analgesia, Epidural - adverse effects; Anesthesia & Perioperative Care; Anesthetics - administration & dosage; Chronic Disease; chronic pain; Critical Care; Dose-Response Relationship, Drug; Drug Therapy, Combination; epidural analgesia; Female; Follow-Up Studies; Humans; Incidence; Male; Middle Aged; Pain Measurement - drug effects; Pain Measurement - methods; Pain, Postoperative - epidemiology; Pain, Postoperative - etiology; Pain, Postoperative - prevention & control; Piperidines - administration & dosage; post-thoracotomy pain syndrome; Preoperative Care - methods; preventative analgesia; Prospective Studies; remifentanil; thoracic surgery; Thoracotomy - adverse effects
• ISSN: 1053-0770; 1532-8422
• DOI: 10.1053/j.jvca.2009.10.006

Objective To investigate the relationships between 2 anesthetic techniques, or the extent of allodynia around the surgical wound, and the occurrence of chronic post-thoracotomy pain. Design Prospective, randomized study. Setting A single-institution, university hospital. Participants Thirty-eight patients who underwent elective thoracotomy under general anesthesia. Interventions High-dose remifentanil (average effect-site concentration 5.61 ± 0.84 ng/mL) with epidural analgesia started and at the end of surgery or low-dose remifentanil (average effect site concentration 1.99 ± 0.02 ng/mL) with epidural analgesia with 0.5% ropivacaine started at the beginning of anesthesia. Measurements and Main Results Pain intensity and the extent of allodynia around the wound were measured during the hospital stay. The presence and intensity of residual pain were assessed 1, 3, and 6 months after surgery and at the end of the study (6-13 months, average 9 months). A DN4 neuropathic pain diagnostic questionnaire was conducted at the same times. In the high-dose group, the area with allodynia was three times larger than the area in the low-dose group. The increased allodynia was associated with a higher incidence of chronic pain (RR: 2.7-4.2) 3 and 6 months after surgery and at the end of the study (median follow-up: 9.5 months). Conclusions High-dose remifentanil (0.14-0.26 μg/kg/min) without epidural analgesia during surgery is associated with a large area of allodynia around the wound. These patients develop a much higher incidence of chronic pain than those receiving low-dose remifentanil with epidural analgesia during surgery.