Göğüs Cerrahisinde Ağrı Yönetimi
Synopsis
Pain occurring after thoracic surgery is extremely severe, and inadequate control can lead to respiratory complications such as atelectasis and pneumonia, delayed mobilization, deep vein thrombosis, and chronic conditions like Post-Thoracotomy Pain Syndrome (PTPS). The pathophysiology of this pain involves nociceptive somatic stimuli arising from damage to intercostal nerves, pleura, and ribs, as well as visceral mechanisms mediated via vagal and phrenic pathways, and the stimulation of NMDA receptors. Factors such as female gender, younger age, preoperative opioid use, and trocar trauma during VATS significantly increase a patient's pain risk. Effective pain management is achievable only through a multimodal approach that begins preoperatively with patient education and continues throughout the perioperative period. In systemic treatment, combining NSAIDs, the NMDA antagonist ketamine, opioids delivered via patient-controlled analgesia (PCA), paracetamol, and gabapentinoids effectively reduces opioid consumption and adverse effects. Regarding regional techniques, while thoracic epidural analgesia (TEA) remains the traditional gold standard, lower-risk alternatives such as thoracic paravertebral block (TPVB), ultrasound-guided erector spinae plane block (ESPB), and serratus anterior plane block (SAPB) are increasingly preferred to minimize complications like epidural hematoma. Ultimately, multimodal analgesia combining systemic and regional methods improves early postoperative comfort while playing a critical role in preventing the development of chronic post-thoracotomy pain.
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