Post-thoracotomy analgesia.

Pain relief has come a long way in 20 years. Many aspects of the relief of pain of thoracic surgery must be rationalized and modernized to meet the demands placed on services and subject to new dynamics. To place the present state of practice and knowledge in the context of an anticipation that such attitudes will impact on and, ultimately, drive services for relief of pain, the key issues of safety, defining and measuring quality, and giving value for money must be addressed. Rationing is the impetus; the exercise to be conducted by those interested in the field of thoracic pain relief is to recognize that not all patients can have or require five-star services and gold standard techniques but are entitled to an equally high quality and measure of pain relief. Newer drugs, such as clonidine, ropivacaine, and modified local anesthetics, are on the horizon; old drugs, such as ketamine, are being revisited. Their place in the field will become apparent only if the ways that outcome measures are presented are more uniform and standard. Disaggregation analysis, pain profiling, a revisitiation of respiratory restoration factor, and optimization modeling are suggested ways forward to meet the clinical and organizationally holistic population forces being generated on the cusp of the third millennium. Increasingly, we live in a world defined by guidelines and protocols. The challenge is ensuring that these measure up to the watchwords--effective, safe, affordable.