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Liu Y, Pan B, Liu J, Zhang J. Early administration of ketorolac after cardiac surgery and postoperative complications: Analysis of the MIMIC-IV database. Clin Transl Sci 2024; 17:e13907. [PMID: 39102873 DOI: 10.1111/cts.13907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 06/26/2024] [Accepted: 07/24/2024] [Indexed: 08/07/2024] Open
Abstract
Inflammation may contribute to postoperative cardiac complications and ketorolac, an anti-inflammatory agent inhibiting cyclooxygenase (COX), shows promise in enhancing cardiac graft patency by suppressing endothelial cell proliferation in animal studies. However, the safety of postoperative ketorolac use remains controversial. This study investigates the association between early ketorolac application and complications following cardiac surgery. Data from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database fueled this retrospective cohort study. The primary outcome is a composite of mortality, pulmonary insufficiency, severe acute kidney injury (AKI), hemorrhage or hematoma, infection, cardiogenic shock, and cerebrovascular infarction postcardiac surgery. Propensity score matching (PSM; 1:1 match, caliper 0.2), multivariate logistic regression, interaction stratification analysis, pairwise algorithmic, and overlap weight model analyses were employed. Following inclusion and exclusion criteria, 7143 patients who underwent valvular surgery or coronary artery bypass grafting (CABG) were included. PSM created a balanced cohort of 3270 individuals (1635 in the ketorolac group). The matched cohort exhibited an 8.1% overall rate of postoperative complications, with a lower composite outcome rate in patients receiving ketorolac within 48 h of surgery compared with those without (PSM, OR 0.70 [95% CI, 0.54-0.90]). Consistent associations were observed in total cohort analyses, sensitivity, and subgroup analyses. Early ketorolac use within 48 h post-CABG or valvular procedures in adults is independently associated with a lower incidence of composite postoperative adverse events. Prospective trials are warranted to assess causality.
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Affiliation(s)
- Yi Liu
- Department of Anesthesiology, Shanghai Cancer Center, Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Bo Pan
- Department of Anesthesiology, Shanghai Cancer Center, Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jie Liu
- Department of Vascular and Endovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Jun Zhang
- Department of Anesthesiology, Shanghai Cancer Center, Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Eisenbraun A, Schroeder D, Schaff HV, Martin E, Wittwer ED. A Single-Center Retrospective Comparison of Opioid Based and Multimodal Analgesic Regimens in Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00168-4. [PMID: 37003853 DOI: 10.1053/j.jvca.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/13/2023] [Accepted: 03/01/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVES To compare the outcomes of 2 multimodal analgesic regimens with an opioid-based one. DESIGN A 2-stage, retrospective study. SETTING A large tertiary-care facility. PARTICIPANTS Adult cardiac surgical patients. INTERVENTIONS Patients received one of three regimens: opioid-only or 2 multimodal regimens. The opioid regimen included intraoperative fentanyl and patient-controlled analgesia pumps. Multimodal regimen 1 included preoperative extended-release oxycodone, intraoperative ketamine infusion, and postoperative morphine suppository. Multimodal regimen 2 included intraoperative methadone and dexmedetomidine infusion. MEASUREMENTS AND MAIN RESULTS Outcomes measured included opioid use, pain scores, time to tracheal extubation, postoperative antiemetic use as a surrogate marker for postoperative nausea and vomiting (PONV), age, sex, surgical procedure(s), body mass index, time to first bowel movement, intensive care unit length of stay (LOS), and hospital LOS. Intraoperative median oral morphine equivalents (OMEs) declined from 425 mg (314, 518) to 150 mg (75, 150) and 230 mg (160, 240), p < 0.001, in multimodal regimens 1 and 2, respectively, compared with the opioid-only regimen. Predischarge opioid use was reduced from a median OME of 7.5 mg (0, 22.5) to 5 mg (0, 22.5) and 0 mg (0, 15.0), p < 0.001, in multimodal regimens 1 and 2, respectively. Pain scores were reduced in the multimodal regimen 2 for hours 0 to 6 (estimated difference = -1.5, 95% CI -1.8 to -1.2, p < 0.001) compared with the opioid-only regimen. The PONV treatment was reduced in multimodal regimen 1 versus the opioid-based or multimodal regimen 2 (53% v 64% and 62%), and time to tracheal extubation was clinically equivalent across all regimens: 4.2 (2.8, 6.0), 3.6 (2.3, 5.7), and (3.0, 6.2) hours for the opioid and multimodal regimens 1 and 2, respectively. CONCLUSIONS Multimodal analgesic regimens, particularly when incorporating methadone and dexmedetomidine, significantly reduced total and predischarge opioid use in cardiac surgical patients.
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Gibson CM, Hall B, Kwon HI, Davis S, Bradford D, Howard ML. Safety and Efficacy of Indomethacin for Reducing Chest Tube Duration After Coronary Artery Bypass Grafting Surgery. J Pharm Technol 2022; 38:148-154. [PMID: 35600275 PMCID: PMC9116119 DOI: 10.1177/87551225221074588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) contain a boxed warning for use in coronary artery bypass graft (CABG) surgery due to increased risk of thrombotic events, but recent research has challenged the assumption that these risks are a class effect. One anecdotal indication for NSAIDs in CABG is reducing chest tube output. Objective: The primary objective of this retrospective study was to determine whether indomethacin was associated with reduced duration of chest tube insertion after CABG surgery, defined as total chest tube duration in controls versus duration of chest tube insertion after the first dose of indomethacin in the treatment group. Secondary objectives were comparisons of daily reductions in chest tube output volume, length of stay, and safety between groups. Methods: In this retrospective, single-center case-control review, adult patients who received indomethacin after CABG were matched 1:1 to control patients based on age, sex, concomitant valve surgery, and, when possible, diabetes status. Results: Thirty-two patients were included. The mean age was 56 years and 75% were men. The primary outcome measure was 94 hours among control patients and 82.8 hours among indomethacin patients (P = 0.041). Insignificant mean reductions in daily chest tube output were observed prior to and after indomethacin initiation (38.7 vs 87.7 mL/day, P > 0.05). Conclusion: In this small, single-center study, indomethacin appeared safe and possibly effective for reducing chest tube duration after CABG surgery. Future large, prospective, randomized studies should be conducted to confirm the results.
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Affiliation(s)
- Caitlin M. Gibson
- Department of Pharmacotherapy and
Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond,
VA, USA
- Department of Pharmacotherapy, College
of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX,
USA
| | - Brenton Hall
- Department of Pharmacy, JPS Health
Network, Fort Worth, TX, USA
| | | | - Sondra Davis
- Department of Pharmacy, Medical City
Arlington, Arlington, TX, USA
| | - Darien Bradford
- Department of Surgery, Medical City
Arlington, Arlington, TX, USA
| | - Meredith L. Howard
- Department of Pharmacotherapy, College
of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX,
USA
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Nazarnia S, Subramaniam K. Nonopioid Analgesics in Postoperative Pain Management After Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2021; 25:280-288. [PMID: 33899581 DOI: 10.1177/1089253221998552] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Opioid analgesia is still considered the standard of practice for cardiac surgery. In recent years, combinations of several nonnarcotic analgesics and regional analgesia have shown promise in restricting opioid use during and after cardiac surgery. Ketamine infusion, dexmedetomidine infusion, acetaminophen, ketorolac, and gabapentin are useful adjuvants in cardiac anesthesia practice and have opioid-sparing properties. The beneficial effects of nonnarcotic multimodal analgesia on intraoperative stress response, recovery profile, postoperative pain, and persistent opioid use after cardiac surgery are yet to be established, and further randomized clinical trials are required.
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Affiliation(s)
- Soheyla Nazarnia
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Ochroch J, Usman A, Kiefer J, Pulton D, Shah R, Grosh T, Patel S, Vernick W, Gutsche JT, Raiten J. Reducing Opioid Use in Patients Undergoing Cardiac Surgery - Preoperative, Intraoperative, and Critical Care Strategies. J Cardiothorac Vasc Anesth 2020; 35:2155-2165. [PMID: 33069556 DOI: 10.1053/j.jvca.2020.09.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/01/2020] [Accepted: 09/09/2020] [Indexed: 02/08/2023]
Abstract
Patients undergoing cardiothoracic surgery are exposed to opioids in the operating room and intensive care unit and after hospital discharge. Opportunities exist to reduce perioperative opioid use at all stages of care and include alternative oral and intravenous medications, novel intraoperative regional anesthetic techniques, and postoperative opioid-sparing sedative and analgesic strategies. In this review, currently used and investigational strategies to reduce the opioid burden for cardiothoracic surgical patients are explored.
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Affiliation(s)
- Jason Ochroch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Asad Usman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse Kiefer
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Danielle Pulton
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ro Shah
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Taras Grosh
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William Vernick
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse Raiten
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Nejim B, Weaver ML, Locham S, Al-Nouri O, Naazie IN, Malas MB. Intravenous ketorolac is associated with reduced mortality and morbidity after open abdominal aortic aneurysm repair. Vascular 2020; 29:15-26. [PMID: 32576118 DOI: 10.1177/1708538120914454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The role of non-steroidal anti-inflammatory drugs in aortic aneurysm disease has been debated. Animal studies demonstrated that intrathecal ketorolac reduces the inflammatory response associated with aortic clamping. However, no human-subject study evaluated this association. Therefore, we sought to explore the effects of ketorolac use in open abdominal aortic aneurysm repair. METHODS The Premier Healthcare Database (June 2009-March 2015) was inquired to capture patients who underwent open abdominal aortic aneurysm repair for non-ruptured abdominal aortic aneurysm, identified via International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Intravenous ketorolac was coded as any or none. Outcomes were in-hospital mortality, cardiac, respiratory, renal, neurological, and hemorrhagic complications. Multivariable logistic regression coarsened exact matching followed by conditional fixed-effect regression modeling were performed. RESULTS A total of 6394 patients were identified (ketorolac: 806; 12.6%). Patients who received ketorolac were younger and less likely to have hypertension (76.1% vs. 79.3%), diabetes mellitus (12.5% vs. 17.4%), or chronic kidney disease (8.3% vs. 21.4%; all p values ≤ .033). There was no significant difference in medication use including oral non-steroidal anti-inflammatory drugs and malignant or musculoskeletal diseases. Mortality, respiratory, and renal complications were less prevalent with ketorolac (2.5% vs. 4.9%, 25.2% vs. 34.6%, 10.0% vs. 21.1%; p ≤ .002). Ketorolac was associated with lower adjusted odds for those events: 0.58 (0.36-0.93), 0.53 (0.42-0.68), and 0.72 (0.60-0.86), respectively (all p values ≤ .025). There was no association with neurological, cardiac, or hemorrhagic complications. The findings were replicated by coarsened exact matching analysis. CONCLUSION This study demonstrated 40% mortality reduction with intravenous ketorolac following open abdominal aortic aneurysm repair. The survival benefit could be due to its anti-inflammatory and opioid-sparing properties. This is evident by its protective effect against respiratory outcomes. The lack of association with the classical non-steroidal anti-inflammatory drugs-related cardiac and hemorrhagic complication could be attributable to the short-term use of ketorolac compared with non-steroidal anti-inflammatory drugs chronic use.
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Affiliation(s)
- Besma Nejim
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - M Libby Weaver
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Satinderjit Locham
- Department of Surgery, Johns Hopkins University, Baltimore, MD, USA.,Department of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Omar Al-Nouri
- Department of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Isaac N Naazie
- Department of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Mahmoud B Malas
- Department of Surgery, University of California San Diego, La Jolla, CA, USA
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Javaherforooshzadeh F, Abdalbeygi H, Janatmakan F, Gholizadeh B. Comparing the effects of ketorolac and Paracetamol on postoperative pain relief after coronary artery bypass graft surgery. A randomized clinical trial. J Cardiothorac Surg 2020; 15:80. [PMID: 32393370 PMCID: PMC7216617 DOI: 10.1186/s13019-020-01125-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/28/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Pain management after coronary artery bypass graft (CABG) surgery remains challenging. Objective This study aimed to compare the effects of Ketorolac and Paracetamol on postoperative CABG pain relief. Method This double-blind randomized clinical trial study was conducted in Ahvaz, Iran, from September 2018–December 2019. Two consecutive groups of 60 patients undergoing elective on-pump coronary artery bypass graft surgery. Intervention The patients were divided into 0.5 mg/kg of ketorolac mg/dl and 10 mg/kg of Paracetamol after surgery for pain management. Primary outcomes were: visual analog pain scale (VAS) at the time point immediately after extubation (baseline) and at 6, 12, 24 and 48 h and the total dose of morphine consumption. Secondary outcomes included the hemodynamic variables, weaning time, chest tube derange, in-hospital mortality and myocardial infarction. Statistical analysis: The data were analyzed using SPSS version 22(SPSS, Chicago, IL). The Mann-Whitney U-test was used to compare demographic data, VAS scores, vital signs, and side effects. Repeated measurements were tested within groups using Friedman’s ANOVA and the Wilcoxon rank-sum test. Values were expressed as means ± standard deviations. Statistical significance was defined as a p-value < 0.05. Results Compared with baseline scores, there were significant declines in VAS scores in both groups throughout the time sequence (P< 0.05). The statistical VAS score was slightly higher in the Paracetamol group at most time points, except for the time of 6 h. However, at 24 and 48 h, the VAS score in group Paracetamol was significantly higher than in group Ketorolac. There were no significant differences between groups about hemodynamic variables. Conclusion The efficacy of ketorolac is comparable to that of Paracetamol in postoperative CABG pain relief. Trial registry IRCT20150216021098N5. Registered at 2019-09-12.
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Affiliation(s)
- Fatemeh Javaherforooshzadeh
- Department of Cardiac Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Hasan Abdalbeygi
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Farahzad Janatmakan
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Behnam Gholizadeh
- Atherosclerosis Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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A Review of Perioperative Analgesic Strategies in Cardiac Surgery. Int Anesthesiol Clin 2018; 56:e56-e83. [PMID: 30204605 DOI: 10.1097/aia.0000000000000200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Brand J. Sedation and Analgesia. PHARMACEUTICAL SCIENCES 2017. [DOI: 10.4018/978-1-5225-1762-7.ch019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Patients in the cardiothoracic intensive care unit (CTICU) are subject to numerous physical and mental stresses. While most of these cannot be completely eliminated, intensivists have many tools in their armamentarium to alleviate patients' pain and suffering. This chapter will consider the importance of analgesia and sedation in the CTICU and the relevant consequences of over- or under-treatment. We will examine the tools available for monitoring and titrating analgesia and sedation in critically ill patients. The major classes of medications available will be reviewed, with particular attention to their clinical effects, metabolism and excretion, and hemodynamic characteristics. Lastly, experimental evidence will be assessed regarding the best strategies for treatment of pain and agitation in the CTICU, including use of non-pharmacologic adjuvants.
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Affiliation(s)
- Jordan Brand
- San Francisco VA Medical Center, USA & University of California – San Francisco, USA
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11
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Howard ML, Warhurst RD, Sheehan C. Safety of Continuous Infusion Ketorolac in Postoperative Coronary Artery Bypass Graft Surgery Patients. PHARMACY 2016; 4:pharmacy4030022. [PMID: 28970395 PMCID: PMC5419367 DOI: 10.3390/pharmacy4030022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/30/2016] [Accepted: 06/21/2016] [Indexed: 12/02/2022] Open
Abstract
Background:Continuous infusion ketorolac is sometimes utilized for analgesia in postoperative coronary artery bypass graft (CABG) patients despite contraindications for use. Limited literature surrounds this topic; therefore, this study was conducted to evaluate the safety of this practice. Methods: This retrospective cohort study evaluated the primary outcome of mortality and secondary outcomes of incidence of bleeding and myocardial infarction (MI). All patients who underwent isolated CABG surgeries and received continuous infusion ketorolac during the study period were included. An equal number of randomly selected isolated CABG patients served as control patients. Electronic medical records and the Society of Thoracic Surgeons (STS) database were utilized to determine baseline characteristics and outcomes; Results: One hundred and seventy-eight patients met inclusion; 89 in each group. More patients in the control group underwent on-pump surgeries (78.6% vs. 29.2%, p = 0.01) and had higher STS risk scores (1.1% vs. 0.6%, p = 0.003). There was no difference in mortality between the ketorolac group and control group (2.2% vs. 3.3%, p = 0.605). Additionally, no patients experienced a MI and there was no difference in bleeding incidence (5.5% vs. 6.7%, p = 0.58); Conclusions: No association was found between continuous infusion ketorolac and increased risk of mortality, MI, or bleeding events in postoperative CABG patients. Considerations to differences in baseline characteristics must be made when interpreting results.
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Affiliation(s)
- Meredith L Howard
- University of North Texas System College of Pharmacy, 3500 Camp Bowie Blvd, Fort Worth, TX 76107, USA.
| | - Robert D Warhurst
- Department of Pharmacy, Indiana University Health, Saxony Hospital, 13000 E. 136th St., Fishers, IN 46037, USA.
| | - Courtney Sheehan
- Department of Pharmacy, Indiana University Health, Methodist Hospital, 1701 N. Senate Ave., AG401, Indianapolis, IN 46202, USA.
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Martín Gutiérrez E, Castaño Ruiz M, Gualis Cardona JA, Martínez Comendador JM, Otero Sáiz J, Maiorano P. Doble terapia antiagregante en el postoperatorio de cirugía coronaria: revisión bibliográfica. CIRUGIA CARDIOVASCULAR 2016. [DOI: 10.1016/j.circv.2015.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care. Crit Care Med 2015; 43:1477-97. [PMID: 25962078 DOI: 10.1097/ccm.0000000000001059] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient. DATA SOURCE AND SYNTHESIS Narrative review of relevant English-language peer-reviewed medical literature. CONCLUSIONS Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.
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Kulik A, Bykov K, Choudhry NK, Bateman BT. Non-steroidal anti-inflammatory drug administration after coronary artery bypass surgery: utilization persists despite the boxed warning. Pharmacoepidemiol Drug Saf 2015; 24:647-53. [PMID: 25907164 DOI: 10.1002/pds.3788] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/20/2015] [Accepted: 03/20/2015] [Indexed: 11/09/2022]
Abstract
PURPOSE In 2005, the US Food and Drug Administration (FDA) issued a boxed warning against the administration of non-steroidal anti-inflammatory drugs (NSAIDs) after coronary artery bypass graft (CABG) surgery because of cardiovascular safety concerns. We assessed utilization rates before and after the advisory and evaluated predictors of NSAID administration following CABG. METHODS We assembled a cohort of 277,576 patients who underwent CABG from 2004 to 2010. Temporal trends in NSAID exposure were evaluated, and predictors of postoperative NSAID use were identified using generalized estimating equations. RESULTS Over the study period, 92,938 CABG patients (33.5%) received NSAIDs following surgery. The frequency of NSAID administration declined steadily over time, from a peak of 38.9% in 2004 to a low of 29.0% in 2010 (p < 0.0007). Ketorolac was the most frequent NSAID prescribed, commonly on the first postoperative day. Surgery performed after the boxed warning was independently associated with a 20% lower odds of NSAID administration [odds ratio (OR): 0.80; p = 0.0003]. Other factors that predicted a lower odds of NSAID use following surgery included a history of renal disease (OR: 0.33; p < 0.0001) and liver disease (OR: 0.66; p < 0.0001), and the need for concurrent valve surgery (OR: 0.78; p < 0.0001). A mammary graft at the time of surgery increased the odds of NSAID administration (OR: 1.23; p < 0.0001). CONCLUSIONS The frequency of NSAID administration after CABG has declined since the FDA advisory, yet many patients continue to receive them in recent years. Our data highlight the need for future research initiatives to further define the risks associated with NSAID use in this population.
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Affiliation(s)
- Alexander Kulik
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Lynn Heart and Vascular Institute, Boca Raton Regional Hospital, and Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Katsiaryna Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Niteesh K Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Engoren M, Schwann TA, Jewell E, Neill S, Benedict P, Likosky DS, Habib RH. Is Transfusion Associated With Graft Occlusion After Cardiac Operations? Ann Thorac Surg 2015; 99:502-8. [DOI: 10.1016/j.athoracsur.2014.09.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 09/10/2014] [Accepted: 09/19/2014] [Indexed: 02/01/2023]
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16
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Oliveri L, Jerzewski K, Kulik A. Black Box Warning: Is Ketorolac Safe for Use After Cardiac Surgery? J Cardiothorac Vasc Anesth 2014; 28:274-9. [DOI: 10.1053/j.jvca.2013.07.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Indexed: 11/11/2022]
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17
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Lauretti GR, Righeti CCF, Mattos AL. Intrathecal ketorolac enhances intrathecal morphine analgesia following total knee arthroplasty. J Anaesthesiol Clin Pharmacol 2013; 29:503-8. [PMID: 24249988 PMCID: PMC3819845 DOI: 10.4103/0970-9185.119155] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Total knee arthroplasty represents one of the most painful surgeries. The aim of the study was to compare analgesia and adverse effects of intrathecal (IT) ketorolac versus IT morphine, versus the combination of IT ketorolac and morphine. Materials and Methods: After ethical approval and patient consent, 80 patients undergoing knee arthroplasty were randomized to one of 4 groups. All groups received 15 mg IT bupivacaine plus IT test drug (2 ml). The control group (CG) received saline as IT test drug. The morphine group (MG) received IT 200 g morphine, the ketorolac group (KG) IT 2 mg ketorolac and the morphine-ketorolac group (MKG) 200 g morphine + 2 mg ketorolac as test drugs. Pain and adverse effects were evaluated. P > 0.05 was considered significant. Results: The MG and KG were similar in their times to time to first rescue analgesic (440 ± 38 min and 381 ± 44 min, respectively). Both groups were longer when compared to the CG (170 ± 13 min) (P > 0.01). The MG and KG had lesser ketoprofen consumption compared to the CG (P > 0.05). The time to first rescue analgesic was longer to the MKG (926 ± 222 min) (15 h) compared to CG (P > 0.001) and to the MG and the KG (P > 0.01). MKG displayed lesser ketoprofen consumption compared to MG and KG (P > 0.05) and to the CG (P > 0.02). Conclusions: The data suggest a role for spinal ketorolac and morphine in orthopaedic surgery because this combination of agents provided 15 h of analgesia compared to 7 h after each drug alone, with no significant side-effects.
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Affiliation(s)
- Gabriela R Lauretti
- Department of Biomechanics, Medicine and Rehabilitation of Members, Teaching Hospital, School of Medicine of Ribeirão Preto, University of São Paulo, Brazil
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Petricevic M, Biocina B. Does ketorolac improve graft patency after coronary artery bypass grafting? Ann Thorac Surg 2012; 93:2121-2; author reply 2122-3. [PMID: 22632527 DOI: 10.1016/j.athoracsur.2011.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 11/01/2011] [Accepted: 12/06/2011] [Indexed: 10/28/2022]
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