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Makkad B, Heinke TL, Sheriffdeen R, Khatib D, Brodt JL, Meng ML, Grant MC, Kachulis B, Popescu WM, Wu CL, Bollen BA. Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2. Anesth Analg 2023; 137:26-47. [PMID: 37326862 DOI: 10.1213/ane.0000000000006506] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.
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Affiliation(s)
- Benu Makkad
- From the Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Timothy Lee Heinke
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Raiyah Sheriffdeen
- Department of Anesthesiology, Medstar Washington Hospital Center, Washington, DC
| | - Diana Khatib
- Department of Anesthesiology, Weil Cornell Medical College, New York, New York
| | - Jessica Louise Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bessie Kachulis
- Department of Anesthesiology, Columbia University, New York, New York
| | - Wanda Maria Popescu
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher L Wu
- Department of Anesthesiology, Hospital of Special Surgery, Weill Cornell Medical College, New York, New York
| | - Bruce Allen Bollen
- Missoula Anesthesiology, Missoula, Montana
- The International Heart Institute of Montana, Missoula, Montana
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Aternali A, Slepian PM, Clarke H, Ladha KS, Katznelson R, McRae K, Seltzer Z, Katz J. Presurgical distress about bodily sensations predicts chronic postsurgical pain intensity and disability 6 months after cardiothoracic surgery. Pain 2022; 163:159-169. [PMID: 34086627 DOI: 10.1097/j.pain.0000000000002325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/19/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Chronic postsurgical pain (CPSP) and disability after cardiothoracic surgery are highly prevalent and difficult to treat. Researchers have explored a variety of presurgical risk factors for CPSP and disability after cardiothoracic surgery, including one study that examined distress from bodily sensations. The current prospective, longitudinal study sought to extend previous research by investigating presurgical distress about bodily sensations as a risk factor for CPSP and disability after cardiothoracic surgery while controlling for several other potential psychosocial predictors. Participants included 543 adults undergoing nonemergency cardiac or thoracic surgery who were followed over 6 months postsurgically. Before surgery, participants completed demographic, clinical, and psychological questionnaires. Six months after surgery, participants reported the intensity of CPSP on a 0 to 10 numeric rating scale and pain disability, measured by the Pain Disability Index. Multinomial logistic regression analyses were conducted to evaluate the degree to which presurgical measures predicted pain outcomes 6 months after surgery. The results showed that CPSP intensity was significantly predicted by age and presurgical scores on the Symptom Checklist-90-Revised Somatization subscale (Nagelkerke R2 = 0.27, P < 0.001), whereas chronic pain disability was only predicted by presurgical Symptom Checklist-90-Revised Somatization scores (Nagelkerke R2 = 0.29, P < 0.001). These findings demonstrate that presurgical distress over bodily sensations predicts greater chronic pain intensity and disability 6 months after cardiothoracic surgery and suggest that presurgical treatment to diminish such distress may prevent or minimize CPSP intensity and disability.
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Affiliation(s)
- Andrea Aternali
- Department of Psychology, York University, Toronto, ON, Canada
| | - P Maxwell Slepian
- Department of Psychology, York University, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Hance Clarke
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
- Centre for the Study of Pain, University of Toronto, Toronto, ON, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
- Department of Anesthesia and Pain Management, St. Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Rita Katznelson
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - Karen McRae
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
| | - Ze'ev Seltzer
- Centre for the Study of Pain, University of Toronto, Toronto, ON, Canada
- Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany
| | - Joel Katz
- Department of Psychology, York University, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada
- Centre for the Study of Pain, University of Toronto, Toronto, ON, Canada
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McGillion MH, Henry S, Busse JW, Ouellette C, Katz J, Choinière M, Lamy A, Whitlock R, Pettit S, Hare J, Gregus K, Brady K, Dvirnik N, Yang SS, Parlow J, Dumerton-Shore D, Gilron I, Buckley DN, Shanthanna H, Carroll SL, Coyte PC, Ebrahim S, Isaranuwatchai W, Guerriere DN, Hoch J, Khan J, MacDermid J, Martorella G, Victor JC, Watt-Watson J, Howard-Quijano K, Mahajan A, Chan MTV, Clarke H, Devereaux PJ. Examination of psychological risk factors for chronic pain following cardiac surgery: protocol for a prospective observational study. BMJ Open 2019; 9:e022995. [PMID: 30826789 PMCID: PMC6398732 DOI: 10.1136/bmjopen-2018-022995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Approximately 400 000 Americans and 36 000 Canadians undergo cardiac surgery annually, and up to 56% will develop chronic postsurgical pain (CPSP). The primary aim of this study is to explore the association of pain-related beliefs and gender-based pain expectations on the development of CPSP. Secondary goals are to: (A) explore risk factors for poor functional status and patient-level cost of illness from a societal perspective up to 12 months following cardiac surgery; and (B) determine the impact of CPSP on quality-adjusted life years (QALYs) borne by cardiac surgery, in addition to the incremental cost for one additional QALY gained, among those who develop CPSP compared with those who do not. METHODS AND ANALYSES In this prospective cohort study, 1250 adults undergoing cardiac surgery, including coronary artery bypass grafting and open-heart procedures, will be recruited over a 3-year period. Putative risk factors for CPSP will be captured prior to surgery, at postoperative day 3 (in hospital) and day 30 (at home). Outcome data will be collected via telephone interview at 6-month and 12-month follow-up. We will employ generalised estimating equations to model the primary (CPSP) and secondary outcomes (function and cost) while adjusting for prespecified model covariates. QALYs will be estimated by converting data from the Short Form-12 (version 2) to a utility score. ETHICS AND DISSEMINATION This protocol has been approved by the responsible bodies at each of the hospital sites, and study enrolment began May 2015. We will disseminate our results through CardiacPain.Net, a web-based knowledge dissemination platform, presentation at international conferences and publications in scientific journals. TRIAL REGISTRATION NUMBER NCT01842568.
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Affiliation(s)
- Michael H McGillion
- School of Nursing, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
- Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Shaunattonie Henry
- School of Nursing, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
- Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jason W Busse
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Carley Ouellette
- School of Nursing, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
- Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Joel Katz
- Department of Psychology, York University, Toronto, Ontario, Canada
| | - Manon Choinière
- Centre de recherche de Centre hospitalier de l'Université de Montreal, Montreal, Quebec, Canada
| | - Andre Lamy
- Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Richard Whitlock
- Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shirley Pettit
- Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jacqueline Hare
- Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Krysten Gregus
- Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Katheryn Brady
- Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Nazari Dvirnik
- Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Stephen Su Yang
- Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Joel Parlow
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Ian Gilron
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - D Norman Buckley
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Harsha Shanthanna
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Sandra L Carroll
- School of Nursing, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Peter C Coyte
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Shanil Ebrahim
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Wanrudee Isaranuwatchai
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Denise N Guerriere
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Hoch
- Department of Public Health Sciences, University of California, Davis, Davis, California, USA
| | - James Khan
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Joy MacDermid
- School of Physical Therapy, Western University, London, Ontario, Canada
| | | | - J Charles Victor
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Judy Watt-Watson
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Kimberly Howard-Quijano
- Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Aman Mahajan
- Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Matthew T V Chan
- Department of Anesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hance Clarke
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - P J Devereaux
- Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Linden W, Young S, Ignaszewski A, Con A, Terhaag S, Campbell T. Psychosocial and medical predictors of 1-year functional outcome in male and female coronary bypass recipients. HEART AND MIND 2019. [DOI: 10.4103/hm.hm_64_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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McGillion M, Yost J, Turner A, Bender D, Scott T, Carroll S, Ritvo P, Peter E, Lamy A, Furze G, Krull K, Dunlop V, Good A, Dvirnik N, Bedini D, Naus F, Pettit S, Henry S, Probst C, Mills J, Gossage E, Travale I, Duquette J, Taberner C, Bhavnani S, Khan JS, Cowan D, Romeril E, Lee J, Colella T, Choinière M, Busse J, Katz J, Victor JC, Hoch J, Isaranuwatchai W, Kaasalainen S, Ladak S, O'Keefe-McCarthy S, Parry M, Sessler DI, Stacey M, Stevens B, Stremler R, Thabane L, Watt-Watson J, Whitlock R, MacDermid JC, Leegaard M, McKelvie R, Hillmer M, Cooper L, Arthur G, Sider K, Oliver S, Boyajian K, Farrow M, Lawton C, Gamble D, Walsh J, Field M, LeFort S, Clyne W, Ricupero M, Poole L, Russell-Wood K, Weber M, McNeil J, Alpert R, Sharpe S, Bhella S, Mohajer D, Ponnambalam S, Lakhani N, Khan R, Liu P, Devereaux PJ. Technology-Enabled Remote Monitoring and Self-Management - Vision for Patient Empowerment Following Cardiac and Vascular Surgery: User Testing and Randomized Controlled Trial Protocol. JMIR Res Protoc 2016; 5:e149. [PMID: 27480247 PMCID: PMC4999307 DOI: 10.2196/resprot.5763] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/16/2016] [Accepted: 05/19/2016] [Indexed: 12/27/2022] Open
Abstract
Background Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT—VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom. Objective Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT). Methods CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise—death, myocardial infarction, and nonfatal stroke— all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups. Results Study start-up is underway and usability testing is scheduled to begin in the fall of 2016. Conclusions Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS.
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Setälä P, Kalliomäki ML, Järvelä K, Huhtala H, Sisto T, Puolakka P. Postoperative hyperalgesia does not predict persistent post-sternotomy pain; observational study based on clinical examination. Acta Anaesthesiol Scand 2016; 60:520-8. [PMID: 26659097 DOI: 10.1111/aas.12659] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 08/15/2015] [Accepted: 10/08/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Persistent post-sternotomy pain is a common problem, but the risk of developing it varies among patients. We sought to find out whether the risk of persistent post-sternotomy pain could be predicted by measuring the area of acute sensory dysfunction around the sternotomy wound. The secondary aim was to determine risk factors for persistent post-sternotomy pain. PATIENTS AND METHODS Hundred patients who were scheduled to undergo elective coronary artery bypass surgery were recruited to the study. Patients were excluded if they had undergone previous cardiac surgery or if they lacked co-operation. Preoperative pain scores were determined and the patients filled in questionnaires about depression, anxiety, and pain. The area of sensory dysfunction around the sternotomy wound was assessed by pin prick on postoperative day 4. The presence of persistent post-sternotomy pain was determined at a follow-up evaluation at 4-6 months after surgery. RESULTS The sizes of the area of hyperalgesia or overall sensory dysfunction were not associated with persistent post-sternotomy pain. Independent risk factors for persistent post-sternotomy pain were found to be smoking and high pain score on postoperative day 1. The prevalence of persistent post-sternotomy pain in our study population was 38% analyzed by only the questionnaire and 15% according to the clinical examination. CONCLUSION Measuring the area of hyperalgesia in the acute phase does not give any additional information on the risk of developing a persistent post-sternotomy pain. We do thus not recommend measuring the area in this particular group of patients. Evaluation of pain by only a questionnaire risks to overestimate the presence of persistent post-sternotomy pain as compared to clinical examination.
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Affiliation(s)
- P. Setälä
- Department of Anaesthesia; Tampere University Hospital; Tampere Finland
| | - M.-L. Kalliomäki
- Department of Anaesthesia; Tampere University Hospital; Tampere Finland
| | - K. Järvelä
- Heart Center; Tampere University Hospital; Tampere Finland
| | - H. Huhtala
- School of Health Sciences; University of Tampere; Tampere Finland
| | - T. Sisto
- Heart Center; Tampere University Hospital; Tampere Finland
| | - P. Puolakka
- Department of Anaesthesia; Tampere University Hospital; Tampere Finland
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Guimarães-Pereira L, Farinha F, Azevedo L, Abelha F, Castro-Lopes J. Persistent Postoperative Pain after Cardiac Surgery: Incidence, Characterization, Associated Factors and its impact in Quality of Life. Eur J Pain 2016; 20:1433-42. [PMID: 26988335 DOI: 10.1002/ejp.866] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cardiac surgery (CS) ranks among the most frequently performed interventions worldwide and persistent postoperative pain (PPP) has been recognized as a relevant clinical outcome in this context. We aimed to evaluate its incidence, characteristics, associated factors and patient's quality of life (QoL). METHODS Observational prospective study conducted in patients undergoing CS in a tertiary university hospital. PPP was defined as persistent pain after surgery with higher than 3 months' duration, after excluding other causes of pain. We used a set of questionnaires for data collection: Pain Catastrophizing Scale, Duke Health Profile, Brief Pain Inventory Short Form, McGill Pain Questionnaire Short Form, Douleur Neuropathique en 4 Questions and standardized questions regarding pain periodicity. RESULTS A total of 288 patients have completed the study and 43% presented PPP assessed at 3 months (PPP3M); out of which 84% were not under any treatment. PPP patients reported significantly lower QoL, and a neuropathic pain (NP) component was present in 50% of them. Younger age, female gender, higher body mass index, catastrophizing, coronary artery bypass graft, osteoarthritis, history of previous surgery (excluding sternotomy) and moderate to severe acute postoperative pain were independent predictors of PPP3M. CONCLUSION This is the first study comprehensively describing PPP after CS and identifying NP in half of them. Our results support the important role that PPP plays after CS in considering its interference in patients' daily life and their lower QoL, which deserves the attention of health care professionals in order to improve prevention, assessment and treatment of these patients. WHAT DOES THIS STUDY ADD?: This study comprehensively describes persistent postoperative pain (PPP) after cardiac surgery (CS) and identifies neuropathic pain (NP) in half of them. Our results support the important role that PPP plays after CS in considering its interference in patients' daily life and their lower quality of life.
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Affiliation(s)
- Luís Guimarães-Pereira
- Department of Anesthesiology, Centro Hospitalar São João, Oporto, Portugal. .,Department of Health Information and Decision Sciences & Center for Health Technology and Services Research, Faculty of Medicine of the University of Porto, Oporto, Portugal.
| | - Filomena Farinha
- Department of Anesthesiology, Centro Hospitalar São João, Oporto, Portugal
| | - Luís Azevedo
- Department of Health Information and Decision Sciences & Center for Health Technology and Services Research, Faculty of Medicine of the University of Porto, Oporto, Portugal
| | - Fernando Abelha
- Department of Anesthesiology, Centro Hospitalar São João, Oporto, Portugal.,Department of Surgery, Faculty of Medicine of the University of Porto, Oporto, Portugal
| | - José Castro-Lopes
- Department of Experimental Biology, Faculty of Medicine of the University of Porto, Oporto, Portugal
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Persson AKM, Pettersson FD, Dyrehag LE, Åkeson J. Prediction of postoperative pain from assessment of pain induced by venous cannulation and propofol infusion. Acta Anaesthesiol Scand 2016; 60:166-76. [PMID: 26373922 DOI: 10.1111/aas.12634] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/17/2015] [Accepted: 08/21/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Postoperative pain may lead to delayed mobilization, persisting pain, and psychosocial distress. There are no simple and reliable techniques for prediction of postoperative pain. This study was designed to evaluate if pain induced by venous cannulation or propofol injection can be used to predict postoperative pain. METHODS This prospective study included 180 patients scheduled for laparoscopic cholecystectomy. Pain intensity associated with peripheral venous cannulation and administration of propofol preoperatively and pain intensity, and use of opioid postoperatively was recorded. RESULTS Patients scoring cannulation-induced pain intensity > 2.0 VAS units were given postoperative opioid more often (65% vs. 36%; P < 0.001), earlier (12 min vs. 90 min; P < 0.001), and in higher doses (4.8 mg vs. 0 mg; P < 0.001), and also reported higher levels of postoperative pain intensity (5.8 vs. 2.9 VAS units; P < 0.001). There were also significant (P < 0.01) correlations with postoperative pain intensity (rs = 0.24), time to opioid administration (rs = -0.26), and total dose of opioid (rs = 0.25). Propofol-induced pain intensity correlated significantly (P < 0.05) with postoperative pain intensity (rs = 0.19). CONCLUSION Pain intensity associated with venous cannulation and propofol infusion can easily be evaluated at bedside before surgery without specific equipment or training. Patients scoring > 2.0 VAS units on venous cannulation were found to have 3.4 times higher risk of postoperative pain after laparoscopic cholecystectomy. Low pain intensity associated with venous cannulation and propofol infusion indicate lower risk of postoperative pain.
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Affiliation(s)
- A K M Persson
- Department of Clinical Sciences Malmö, Anesthesiology and Intensive Care Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
- Department of Anesthesiology and Intensive Care Medicine, Hallands Sjukhus Halmstad, Halmstad, Sweden
| | - F D Pettersson
- Karolinska Institute, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Stockholm, Sweden
| | - L-E Dyrehag
- Department of Anesthesiology and Intensive Care Medicine, Hallands Sjukhus Halmstad, Halmstad, Sweden
| | - J Åkeson
- Department of Clinical Sciences Malmö, Anesthesiology and Intensive Care Medicine, Lund University, Skåne University Hospital, Malmö, Sweden
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9
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Minimize the risk of chronic pain after cardiac surgery by treating acute postoperative pain. DRUGS & THERAPY PERSPECTIVES 2015. [DOI: 10.1007/s40267-015-0191-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gjeilo KH, Stenseth R, Klepstad P. Risk factors and early pharmacological interventions to prevent chronic postsurgical pain following cardiac surgery. Am J Cardiovasc Drugs 2014; 14:335-42. [PMID: 24934698 DOI: 10.1007/s40256-014-0083-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chronic postsurgical pain (CPSP) after cardiac surgery represents a significant clinical problem. The prevalence of CPSP varies widely between studies, but severe CPSP is present in less than 10% of the patients. Important differential diagnoses for CPSP after cardiac surgery are myocardial ischemia, sternal instability and mediastinitis. CPSP after cardiac surgery may be thoracic pain present at the site of the sternotomy or leg pain due to vein-graft harvesting. The CPSP can be neuropathic pain, visceral pain, somatic pain or mixed pain. Potential risk factors for CPSP are young age, female gender, overweight, psychological factors, preoperative pain, surgery-related factors and severe postoperative pain. In addition to standard postoperative analgesics, the use of N-methyl-D-aspartate (NMDA) antagonists, alpha-2 agonists, local anesthetics, gabapentinoids, and corticosteroids are all proposed to reduce the risk for CPSP after cardiac surgery. Still, no specific pharmacological therapy, cognitive therapy or physical therapy is established to protect against CPSP. The only convincing prevention of CSPS is adequate treatment of acute postoperative pain irrespective of method. Hence, interventions against acute pain, preferably in a step-wise approach titrating the interventions for each patient's individual needs, are essential concerning prevention of CPSP after cardiac surgery. It is also important that surgeons consider the risk for CPSP as a part of the basis for decision-making around performing a surgical procedure and that patients are informed of this risk.
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Affiliation(s)
- Kari Hanne Gjeilo
- Department of Cardiothoracic Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway,
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Choinière M, Watt-Watson J, Victor JC, Baskett RJF, Bussières JS, Carrier M, Cogan J, Costello J, Feindel C, Guertin MC, Racine M, Taillefer MC. Prevalence of and risk factors for persistent postoperative nonanginal pain after cardiac surgery: a 2-year prospective multicentre study. CMAJ 2014; 186:E213-23. [PMID: 24566643 DOI: 10.1503/cmaj.131012] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Persistent postoperative pain continues to be an underrecognized complication. We examined the prevalence of and risk factors for this type of pain after cardiac surgery. METHODS We enrolled patients scheduled for coronary artery bypass grafting or valve replacement, or both, from Feb. 8, 2005, to Sept. 1, 2009. Validated measures were used to assess (a) preoperative anxiety and depression, tendency to catastrophize in the face of pain, health-related quality of life and presence of persistent pain; (b) pain intensity and interference in the first postoperative week; and (c) presence and intensity of persistent postoperative pain at 3, 6, 12 and 24 months after surgery. The primary outcome was the presence of persistent postoperative pain during 24 months of follow-up. RESULTS A total of 1247 patients completed the preoperative assessment. Follow-up retention rates at 3 and 24 months were 84% and 78%, respectively. The prevalence of persistent postoperative pain decreased significantly over time, from 40.1% at 3 months to 22.1% at 6 months, 16.5% at 12 months and 9.5% at 24 months; the pain was rated as moderate to severe in 3.6% at 24 months. Acute postoperative pain predicted both the presence and severity of persistent postoperative pain. The more intense the pain during the first week after surgery and the more it interfered with functioning, the more likely the patients were to report persistent postoperative pain. Pre-existing persistent pain and increased preoperative anxiety also predicted the presence of persistent postoperative pain. INTERPRETATION Persistent postoperative pain of nonanginal origin after cardiac surgery affected a substantial proportion of the study population. Future research is needed to determine whether interventions to modify certain risk factors, such as preoperative anxiety and the severity of pain before and immediately after surgery, may help to minimize or prevent persistent postoperative pain.
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Strodl E, Kenardy J. A history of heart interventions moderates the relationship between psychological variables and the presence of chest pain in older women with self-reported coronary heart disease. Br J Health Psychol 2012; 18:687-706. [DOI: 10.1111/bjhp.12011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 10/30/2012] [Indexed: 01/24/2023]
Affiliation(s)
- Esben Strodl
- School of Psychology and Counselling; Queensland University of Technology; Kelvin Grove Queensland Australia
| | - Justin Kenardy
- School of Psychology; University of Queensland; St Lucia Queensland Australia
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van Gulik L, Ahlers S, van de Garde E, Bruins P, van Boven W, Tibboel D, van Dongen E, Knibbe C. Remifentanil during cardiac surgery is associated with chronic thoracic pain 1 yr after sternotomy. Br J Anaesth 2012; 109:616-22. [DOI: 10.1093/bja/aes247] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Sinatra R. Causes and Consequences of Inadequate Management of Acute Pain. PAIN MEDICINE 2010; 11:1859-71. [DOI: 10.1111/j.1526-4637.2010.00983.x] [Citation(s) in RCA: 283] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gjeilo KH, Klepstad P, Wahba A, Lydersen S, Stenseth R. Chronic pain after cardiac surgery: a prospective study. Acta Anaesthesiol Scand 2010; 54:70-8. [PMID: 19681771 DOI: 10.1111/j.1399-6576.2009.02097.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Chronic pain is a complication of several surgical procedures. The prevalence of chronic pain reported after cardiac surgery varies from 18% to 61%. However, most studies are retrospective, do not use validated instruments for pain measurement or include only pain at the sternum site. The aim of the present study was to assess chronic pain and health-related quality of life (HRQOL) after cardiac surgery. METHODS In a prospective, population-based study, we included 534 patients (413 males) and assessed chronic pain and HRQOL before, 6 months after, and 12 months after cardiac surgery. Pain was measured by the Brief Pain Inventory, while HRQOL was measured by the Short-Form 36 (SF-36). RESULTS Five hundred and twenty-one patients were alive 12 months after surgery; 462 (89%) and 465 (89%) responded after 6 and 12 months, respectively. Chronic pain was reported by 11% of the patients at both measurements. Younger age was associated with chronic pain [odds ratio 0.7 (95% confidence interval: 0.5-0.9)] at 12 months. Patients with chronic pain reported lower scores on seven of eight SF-36 subscales. DISCUSSION In conclusion, we observed a lower prevalence of chronic pain after cardiac surgery than in previous studies. Still, more than one out of 10 patients reported chronic pain after cardiac surgery. Chronic pain appears to affect HRQOL. Thus, given the large number of patients subjected to cardiac surgery, this study confirms that chronic pain after cardiac surgery is an important health care issue.
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Affiliation(s)
- K H Gjeilo
- St Elisabeth Department of Cardiothoracic Surgery, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
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Only half of the chronic pain after thoracic surgery shows a neuropathic component. THE JOURNAL OF PAIN 2008; 9:955-61. [PMID: 18632308 DOI: 10.1016/j.jpain.2008.05.009] [Citation(s) in RCA: 187] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 05/21/2008] [Accepted: 05/28/2008] [Indexed: 11/21/2022]
Abstract
UNLABELLED Chronic pain is a common complication after thoracic surgery. The cause of chronic post-thoracotomy pain is often suggested to be intercostal nerve damage. Thus chronic pain after thoracic surgery should have an important neuropathic component. The present study investigated the prevalence of the neuropathic component in chronic pain after thoracic surgery. Furthermore, we looked for predictive factors for prevalence and intensity of chronic pain. We contacted 243 patients who underwent a video-assisted thoracoscopy (VATS) or thoracotomy in the period between January 2004 and September 2006 by mail. Patients retrospectively received a questionnaire with the Dutch version of the PainDETECT Questionnaire, a validated screening tool for neuropathic pain. Results were analyzed from 204 patients (144 thoracotomies, 60 VATS). The prevalence of chronic pain was 40% after thoracotomy and 47% after VATS. Definite chronic neuropathic pain was present in 23% of the patients with chronic pain, with an additional 30% having probable neuropathic pain. Greater probability of neuropathic pain (ie, a higher total score of the PainDETECT) correlated with more intense chronic pain. Predictive factors for chronic pain were younger age (P = .01), radiotherapy (P = .043), pleurectomy (P = .04) and more extensive surgery (P < .001). PERSPECTIVE Up to half the chronic pain after thoracic surgery is not associated with a neuropathic component, which has not been reported to date. More extensive surgery and pleurectomy are predictive factors for chronic pain after thoracic surgery, suggesting a visceral component apart from nerve injury.
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