If you are having a chest tube, thoracotomy, pleurodesis, etc. this is the seminar for you.
Dr. Hammam Akbik is the Pain Service Director at the University of Cincinnati and it is no surprise that he was voted the best pain physician in Cincinnati for 2006-2007. He spoke to us last year about Pain Management. He shows such respect for the patient and made it clear that we are never at the end of the road in pain management. There is always hope. No one should ever be allowed to live in pain for the rest of their life.
There are several possible reasons for post thoracotomy, post pleurodesis pain that becomes chronic: 1) tissue destruction from the disease, 2) trauma to the intercostal nerve which can occur if the surgeon is not careful and puts a retractor on the nerve that runs on the bottom edge of the rib where the nerve is located, 3) scar formation after surgery that pulls on the lung, 4) rib fracture either from surgery or from extreme bouts of coughing, 4) costochondrial separation (a separation in the costochondrial joint. It can also come from a large chest tube if it is put on the lower edge of the ribs or after a significant bout of pneumonia that results in scar tissue.
The pain can sometimes last for months to years.
The best treatment for pain occurs in being pre-emptive. Medication often takes hours to be fully effective and should be done well prior to the procedure so that pain does not get started in the first place.
The placement of an epidural 24 hours prior to surgery decreases the chances of severe pain 75%. Pain control can be continuous and/or under patient control. The problem with only patient control is that when you sleep, no medication is delivered. The epidural requires the placement of a catheter in the back in the epidural space around the spinal cord in an area with the margin of error being 4-6 mm. If you cannot get a pre-emptive epidural he recommends going to another hospital.
Many different drugs can be administered through the epidural so if you don't respond to one drug, it should be discarded and another tried. Every patient responds differently to the drugs.
If you are not finding relief from your pain even after leaving the hospital, there are several other possibilities. There are Intra/Sub-Pleural catheters that can be left in place for a few days to weeks. Nerve blocks and steroids are also a possibility. It might be that once the nerve regenerates, you will no longer have pain.
Another possibility is a Port-A-Cath into the epidural space that can be inserted in the office.
Local anasthetics can be delivered by a catheter into the wound for up to 6 days. You can adjust the rate of delivery and pull it out yourself when used up.
TENS units can be used to alter your perception of the pain so it is tolerable.
If all these possibilities fail a catheter can be implanted into the spine or a spinal cord stimulator which emits an electrical field can be tried.
A question was asked about bedside pleurodesis which many know can be extremely painful. This is a situation where the pre-pleurodesis should be used followed by several days of post-pleurodesis pain control.
I think most of us would agree that we would like to each have our own clone of Dr. Akbik that to help us with our pain management issues!
Mary Harbaugh
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Wish I would have had this info from 1993 on. Thanks so much!!!
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