Risk-benefit perception of analgesia modalities in thoracotomy
decortication for empyema thoracis: A questionnaire on individual
practices and beliefs
Thoracic empyema remains a complex condition, with a chronically evolving inflammatory picture and
subsequent challenging management decisions. Post- or parapneumonic remains the leading cause (4060%), with 5-20% of all related effusions becoming empyemas. The complete process of development
normally takes 5-6 weeks, although the origin of the empyema can be difficult to determine.
There is a well-established triphasic nature to the disease, involving an early exudative phase (I), a
transitional or fibrinopurulent phase (II) and finally an organising or consolidative phase (III). The
principle of treatment is ultimately pus evacuation. It is generally considered that for stage III disease,
where the underlying lung is unable to expand due to the inflammatory coat, that open decortication is
the treatment modality of choice for symptomatic patients, if they are fit enough to tolerate it. The
procedure can double lung perfusion, increase vital capacity and FEV 1 and fills the chest cavity by lung
re-expansion.
Decortication is a procedure with significant morbidity and mortality of up to 6% has been
documented. With a reasonable proportion not exhibiting signs of systemic infection, despite known
empyema, a question remains relatively unanswered on the safety of epidural analgesia for these
patients, especially for the group of adults post-pneumonia, who may already have impaired function in
both lungs even before thoracotomy, with considerable postoperative risks and would therefore in
theory benefit from neuraxial analgesia.
This audit poll is to obtain some idea of individual anaesthetists’ practice for post-operative analgesia
in this challenging patient group and what factors (if any) would influence practice on neuraxial
blockade.
Please state your grade:
A) Do you routinely anaesthetise patients for thoracotomy?
B) What is your preferred choice for post-operative analgesia in these patients?
Opiate PCA
Intercostal nerve blocks
Single shot paravertebral block
Multiple paravertebral injections
Paravertebral catheterisation
Thoracic Epidural catheterisation
Intra-thecal morphin
Other – please specify
C) Have you anaesthetised patients for decortication via thoracotomy?
D) What is your preferred choice for post-operative analgesia in these patients?
Opiate PCA
Intercostal nerve blocks
Single shot paravertebral block
Multiple paravertebral injections
Paravertebral catheterisation
Thoracic Epidural catheterisation
Intra-thecal morphin
Other – please specify
E) Could you rate the safety of analgesia options for this group of patients as a whole?
Analgesia modality
Opiate PCA
Intercostal nerve blocks
Single shot paravertebral block
Multiple paravertebral injections
Paravertebral catheterisation
Thoracic Epidural catheterisation
Intra-thecal morphine
Other – please specify
Low risk
Medium risk
High risk
F) Could you rate the effectiveness of the same analgesia options for this group of
patients as a whole?
Analgesia modality
Poorly
effective
Reasonably
effective
Very
effective
Opiate PCA
Intercostal nerve blocks
Single shot paravertebral block
Multiple paravertebral injections
Paravertebral catheterisation
Thoracic Epidural catheterisation
Intra-thecal morphine
Other – please specify
G) Would you personally consider neuraxial blockade for this patient group?
H) Which, if any, of the following would you consider a contra-indication to thoracic
epidural in patients with confirmed empyema?
1) Signs of systemic sepsis: Fever > 38’C, WCC > 12, 000/mm3, heart rate > 90/min,
respiratory rate > 20/min)
2) No systemic sepsis but: Fever > 38’C and WCC > 12,000/mm3
3) No systemic sepsis or fever but: WCC >12,000/mm3
4) No systemic sepsis, apyrexial with normal WCC
I) If signs of sepsis existed, are there any patient groups that you would still consider
thoracic epidural in?
Paediatric patient
Fit, young adult
Elderly patient
Co-existing lung disease
Ongoing pneumonia
Post pneumonia
Post lung resection
Post lung resection with bronchopleural fistula
Post thoracic trauma
J) What would be your preferred method of epidural insertion if neuraxial block was
undertaken?
Midline approach
Paramedian, same side as empyema
Paramedian, opposite side as empyema
No preference – same as usual practice
Would never insert an epidural in this patient group
K) How would you manage a bloody tap on epidural insertion?
1) Re-site epidural?
2) Abandon procedure?
Many thanks for your participation in this audit.
Paul Harris MBChB FRCA
Consultant Anaesthetist, Auckland City Hospital, New Zealand
References:
1) Molnar TF. Current surgical treatment of thoracic empyema in adults. Eur J Cardiothorac Surg. 2007
Sep;32(3):422-30
2) Kotzé A, Hinton W, Crabbe DC, Carrigan BJ. Audit of epidural analgesia in children undergoing
thoracotomy for decortication of empyema. Br J Anaesth 2007 May;98(5):662-6