Table 2. Summary of systemic analgesic options for acute perioperative pain control with benefits, cautions, and considerations for use in thoracotomy and thoracoscopic surgical approaches.

Drug	Benefits	Cautions	Thoracotomy	Thoracoscopy
Acetaminophen	Safe, synergistic with NSAIDs, effective for referred shoulder pain	Low-risk without significant adverse effects, caution if significant liver disease	Use unless contraindicated	Use unless contraindicated
NSAIDs	Opioid-sparing, synergistic with acetaminophen	Risk of bleeding, AKI, and GI mucosal damage	Use unless contraindicated	Use unless contraindicated
Ketamine	Opioid-sparing, synergistic with opioids, avoids respiratory depression	Hallucinations, nightmares	Consider in select patients (e.g., chronic pain on opioid therapy, contraindication to TEA)	Consider in select patients (e.g., chronic pain on opioid therapy, not candidate for other adjuncts)
Gabapentinoids	Possibly opioid-sparing, questionable clinical significance	Risk of sedation, respiratory depression with opioids	Avoid unless on prior to surgery	Avoid unless on prior to surgery
IV Lidocaine	Potential anti-inflammatory effect, pre-emptive topical effect	Risk of local anesthetic systemic toxicity	Consider if not using regional local anesthetics, but unclear benefit	Consider if not using regional local anesthetics, but unclear benefit
Dexamethasone	Opioid-sparing analgesic effects, PONV prophylaxis	Hyperglycemia	Use unless contraindicated	Use unless contraindicated
Opioids	Analgesia	Respiratory depression, sedation, constipation, tolerance, dependence	Use as needed (e.g., PCA, oral opioids with IV for breakthrough pain)	Use as needed (e.g., PCA, oral opioids with IV for breakthrough pain)

NSAID, non-steroidal anti-inflammatory drug; AKI, acute kidney injury; GI, gastrointestinal; TEA, thoracic epidural analgesia; PONV, post-operative nausea and vomiting; PCA, patient-controlled analgesia; IV, intravenous.