New approaches and old controversies to postoperative pain control following cardiac surgery

Evaluation of Analgesic Drug Therapy for Postoperative Pain Management in Cardiovascular Surgery

Background

Cardiovascular surgery is usually associated with higher degree of postoperative pain that influences a patient's physical recovery. Multiple clinical measures have been taken to avoid overuse of opioid agents for postoperative pain management, which led to the development of clinical pathways for analgesic drug treatment using a multimodal approach.

Objective

To evaluate the effectiveness and safety of a multimodal postoperative analgesic drug pathway (ADP) for pain management following cardiovascular surgery.

Methods

This retrospective, controlled, nonrandomized study evaluated a postoperative ADP in patients undergoing cardiovascular surgery in a tertiary general hospital in Qingdao, China. Effectiveness and safety outcomes were compared before and after the implementation of the ADP. Outcome indicators included postoperative pain scores, consumption of opioids in analgesic pumps, and incidence of adverse events.

Results

Patients who underwent cardiovascular surgery from September to November 2021 before the implementation of the ADP (n = 193) and from September to November 2022 after the implementation of the ADP (n = 218) were enrolled. Pain scores were reduced on day 1, 3, and 5 after surgery and the reduction was most significant in mild pain (P < .001). Opioids in analgesic pumps consumption was also significantly reduced and there was decreased incidence of adverse events such as nausea and vomiting (P = .026), respiratory inhibition (P = .027), and dizziness and headache (P = .028) in cardiovascular surgery patients after implementation of the ADP.

Conclusions

Improved effectiveness and safety were observed following the implementation of the ADP. Multimodal analgesic ADP methodology can be effectively used for postoperative pain management in patients undergoing cardiovascular surgery.

Deep Parasternal Intercostal Plane Block for Intraoperative Pain Control in Cardiac Surgical Patients for Sternotomy: A Prospective Randomized Controlled Trial

OBJECTIVES

Sternotomy pain is common after cardiac surgery. The deep parasternal intercostal plane (DPIP) block is a novel technique that provides analgesia to the anterior chest wall. The aim of this study was to investigate the analgesic effect of bilateral DPIP blocks on intraoperative pain control in cardiac surgery.

DESIGN

This is a double-blinded, prospective randomized controlled trial (Oct 2020-Dec 2022).

SETTINGS

This study was conducted in a single institution, which is an academic university hospital.

PARTICIPANTS

Eighty-six elective cardiac surgical patients with median sternotomy were recruited.

INTERVENTIONS

Patients were randomly divided into DPIP or control group. Either 20ml 0.25% levobupivacaine or 0.9% normal saline was injected for the DPIP under ultrasound guidance after induction of general anaesthesia.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was intraoperative opioids consumption and hemodynamic changes at sternotomy. Secondary outcomes included postoperative morphine consumption, postoperative pain and time to tracheal extubation. Intraoperative opioids requirement was reduced from a median (IQR) intravenous morphine equivalence of 21.4mg (13.8-24.3mg) in control group to 9.5mg (7.3-11.2mg) in the DPIP group (P<0.001). Hemodynamic parameters were more stable in DPIP group at sternotomy, as evidenced by lower percentage increase in systolic, diastolic and mean arterial blood pressure from baseline. No difference was observed in time to tracheal extubation, postoperative morphine consumption, postoperative pain score and spirometry.

CONCLUSIONS

Bilateral DPIP block provides effective intraoperative analgesia and opioid-sparing. It may be included as part of the multimodal analgesia for enhanced recovery in cardiac surgery.

Impact of an Enhanced Recovery after Surgery Protocol on Postoperative Outcomes in Cardiac Surgery

Background: Enhanced recovery after surgery (ERAS) protocols are perioperative care pathways designed to achieve early recovery after procedures. ERAS protocols have shown shortened recovery time, and lower opioid utilization and postoperative complication rates. Evidence to support the use of ERAS protocols is robust, however, minimal data exists in cardiac surgery patients. Methods: This observational cohort compared adults receiving post-operative care after coronary artery bypass or valve procedures who received an ERAS protocol containing acetaminophen, gabapentin, and methocarbamol to historical controls. The primary outcome of this study was postoperative opioid use during the first 72-hours following cardiac surgery. Secondary outcomes included length of stay, average pain scores 72-hours postoperatively, and incidence of opioid-related complications. Results: Total cumulative 72-hour post-operative opioid consumption showed a trend toward reduction in opioid use in patients who received the ERAS protocol vs the historic control group [75.8 mg vs 105.4 mg oral morphine equivalents (P = .09)]. Median postoperative lengths of stay and pain scores were similar between groups. Opioid related complications including constipation and respiratory depression occurred more frequently in the control group compared to the ERAS group [47.7% vs 60.5% (P < .05) and 57.1% vs 62.7% (P < .05) respectively]. Conclusions: Use of an ERAS protocol shows a promising trend toward less postoperative opioid use in cardiac surgery patients. Lower rates of opioid-related adverse events, including constipation and respiratory depression, were observed in the ERAS protocol group. This study indicates that ERAS protocols have a potential role for cardiac surgery patients postoperatively.

Retrospective Evaluation of Fascial Plane Blocks in Cardiac Surgery With Median Sternotomy in a Tertiary Hospital

BACKGROUND AND AIM

Cardiac surgery typically causes moderate to severe postoperative pain and discomfort. Inadequate pain management in the early postoperative period leads to pulmonary complications. The length of intensive care unit (ICU) stay and the hospital is typically prolonged. As a component of multimodal analgesia regimens, fascial plane blocks have become more popular. In our clinic, serratus anterior plane blocks (SAPB), pectoral nerve blocks (PECS I-II), and pectointercostal nerve fascial plane blocks (PIFB) are performed by ultrasonography. We wished to evaluate the postoperative visual pain scale, initial additional analgesic agent requirement time, extubation time, morbidity and mortality in patients who underwent open heart surgery with fascial plane blocks.

MATERIALS AND METHODS

Forty-eight patients over 18 years who underwent open heart surgery with sternotomy between 01 September 2021 and 15 June 2022 were evaluated retrospectively. Only patients with chest wall blocks placed at the end of surgery were included in the study. In Group 1, the PECS II block was placed on the chest tube side and bilateral PIFBs were placed at the end of surgery in the operating room. In Group 2, SAPB was placed on the chest tube side and bilateral PIFBs were placed at the end of surgery. Data regarding patient demographics, anesthesia method applied, amount of opioid used intraoperatively, cardiopulmonary bypass time, anesthesia and surgery time, postoperative extubation time, mechanical ventilation time, Visual Analogue Scale (VAS) of patients at rest and movement at 6th, 12th, 18th, 24th, 48th hours post-extubation, time to and type of first postoperative analgesic, postoperative complications, length of cardiac intensive care unit (CICU) stay and hospital length of stay were recorded from hospital records.

RESULTS

 The data of a total of 46 patients (Group 1: PECS II block + PIFB, n=20; Group 2: SAPB+ PIFB, n=26) were analyzed retrospectively. There was no difference in demographic variables between the groups. Intraoperative opioid usage, operation time, Cardiopulmonary bypass time, postoperative mechanical ventilation time, extubation time, ICU discharge time, and length of hospital stay were not statistically different between the groups. The first rescue analgesic requirement time was longer in group 2 than in group 1 but not statistically significant (18.76±15.36 h vs 12.62±10.61 h, p=0.162). The post-extubation VAS scores at rest and movement at the 6th hour were significantly lower in group 2 than in group 1 (1.73±1.28 vs 3.15±2.10, respectively, p=0.02).

CONCLUSION

In our study, the VAS scores at the 6th hour were lower in SAPB + PIFB group than in PECS II + PIFB group. As these blocks can be easy to apply, we thought these combinations could be an alternative for pain relief in cardiac surgery. Prospective randomized studies are needed with a large number of patients.

Analgesic efficacy and risk of low-to-medium dose intrathecal morphine in patients undergoing cardiac surgery: An updated meta-analysis

Background

To evaluate the analgesic efficacy and risk of low-to-medium dose intrathecal morphine (ITM) (i.e., ≤0.5 mg) following cardiac surgery.

Methods

Medline, Cochrane Library, Google scholar and EMBASE databases were searched from inception to February 2022. The primary outcome was pain intensity at postoperative 24 h, while the secondary outcomes included intravenous morphine consumption (IMC), extubation time, hospital/intensive care unit (ICU) length of stay (LOS), and ITM-associated side effects (e.g., respiratory depression). Subgroup analysis was performed on ITM dosage (low: <0.3 mg vs. medium: 0.3–0.5 mg).

Results

Fifteen RCTs involving 683 patients published from 1988 to 2021 were included. Pooled results showed significantly lower postoperative 24-h pain scores [mean difference (MD) = −1.61, 95% confidence interval: −1.98 to −1.24, p < 0.00001; trial sequential analysis: sufficient evidence; certainty of evidence: moderate] in the ITM group compared to the controls. Similar positive findings were noted at 12 (MD = −2.1) and 48 h (MD = −1.88). Use of ITM was also associated with lower IMC at 24 and 48 h (MD: −13.69 and −14.57 mg, respectively; all p < 0.05) and early tracheal extubation (i.e., 48.08 min). No difference was noted in hospital/ICU LOS, and nausea/vomiting in both groups, but patients receiving ITM had higher risk of pruritus (relative risk = 2.88, p = 0.008). There was no subgroup difference in IMC except a lower pain score with 0.3–0.5 mg than <0.3 mg at postoperative 24 h. Respiratory depression events were not noted in the ITM group.

Conclusion

Our results validated the analgesic efficacy of low-to-medium dose ITM for patients receiving cardiac surgery without increasing the risk of respiratory depression.

Intravenous Lidocaine Infusion Reduce Post-operative Pain and Length of Hospital in Elderly Patients Undergoing Surgery: Meta-analysis of Randomized Controlled Trials

Objective. It is debated wheter intravenous (IV) lidocaine improves post-operative pain and has other potential benefits in elderly patients. This systematic review and meta-analysis aimed to estimate the effect of perioperative continuous IV lidocaine in elderly patients undergoing surgery. Method. PubMed/Medline, Web of Science, Embase, and CENTRAL databases (through OVID SP) were searched independently until October 10, 2020 by two authors. We included all randomized controlled trials that compared the effect of continuous IV lidocaine and any placebo or no treatment in elderly patients after surgery. Primary outcomes were length of hospital stay and post-operative pain score. Results. Eighteen studies (988 patients) were included. Meta-analysis suggested that IV lidocaine reduced the post-operative pain scores 2 hours (standardized mean difference [SMD]: −1.58, 95% confidence interval [CI]: −2.03 to −1.13), 4 hours (SMD:−1.20, 95% CI: −2.02 to −.39), 8 hours (SMD:−.82, 95% CI: −1.51 to −.13), 12 hours (SMD:−.66, 95% CI: −1.28 to −.04), and 24 hours (SMD:−.42, 95% CI: −.72 to −.12) post-operatively. Moreover, those patients given IV lidocaine had a shorter length of hospital stay (MD: −.24, 95% CI: −.71 to −.23) and required fewer opioid drugs (SMD: −.31, 95% CI: −.31 to −.01). Conclusion. The evidence suggested that IV lidocaine significantly reduced post-operative pain intensity and opioid consumption and shortened the length of hospital stay in elderly patients. IV lidocaine decreased the incidence of post-operative nausea while it could not reduce the incidence of post-operative vomiting and accelerate the recovery of gastrointestinal function.

Can Continuous Local Anesthetic Infusion After Median Sternotomy Reduce Opioid Use?

Introduction

Effective treatment of postoperative pain due to median sternotomy speeds up hemodynamic healing of patients. For this purpose, opioids with a wide range of side effects are widely used at high doses. The aim of this study is to investigate the effect of continuous local anesthetic (bupivacaine) infusion on opioid use on cardiac surgery patients undergoing median sternotomy.

Methods

A total of 215 patients undergoing isolated coronary artery bypass grafting surgery were included in the study; and 105 patients who underwent parasternal continuous local anesthetic infusion (0.5% bupivacaine at 4 mL/h, for 48h) were determined as local anesthesia group and other patients were as control group. The primary outcomes evaluated between the groups in the postoperative period were pain scores (VAS: Visual Analogic Score, PHHPS: Prince Henry Hospital Pain Score) and the number of opioids used. Secondary outcomes were mechanical ventilation time, intensive care unit and hospital stay duration, development of atrial fibrillation and atelectasis.

Results

Postoperative pain was found to be significantly lower in the local anesthesia group compared to the control group (VAS: 3 ± 1.9 vs 6.4 ± 1.8, p < 0.001; PHHPS: 0.9 ± 0.8 vs 1.62 ± 0.82, p < 0.001). As a result of this, opioid drug use was significantly lower in the local anesthesia group compared to the control group (0 (0 - 4) vs 1 (0 - 8), p < 0.001). Mechanical ventilation time, intensive care unit and hospital stay duration, and development of atelectasis were significantly lower in the local anesthesia group. In terms of the development of atrial fibrillation, no significant difference was found between the groups.

Conclusion

Parasternal continuous local anesthetic infusion reduces postoperative opioid use and speeds up hemodynamic healing by preventing possible side effects of opioids. It is a simple and effective method in the treatment of postoperative pain due to median sternotomy.

[SBA 2020: Regional anesthesia guideline for using anticoagulants update]

The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology (SBA) 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative revision, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.

Comparing the effects of ketorolac and Paracetamol on postoperative pain relief after coronary artery bypass graft surgery. A randomized clinical trial

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.

Preoperative oral methadone for postoperative pain in patients undergoing cardiac surgery: A randomized double-blind placebo-controlled pilot

Background: Inadequately controlled sternotomy pain after cardiac surgery can lead to delayed recovery and patient suffering. Preoperative intravenous methadone is effective for reducing both postoperative pain and opioid consumption. Despite ease of administration, the effects of preoperative oral methadone are not well described in the literature.

Aims: This pilot study investigated the effect of preoperative oral methadone on pain scores, analgesia requirements, and opioid-induced side effects.

Methods: A randomized double-blind placebo-controlled model was used with sampling of patients undergoing sternotomy for isolated coronary artery bypass graft (CABG) surgery (ClinicalTrials.gov registration no. NCT02774499). Participants were randomized to receive oral methadone (0.3 mg/kg) or oral placebo prior to entering the operating room. The primary outcome was pain scores on a 0–10 Verbal Rating Scale. Secondary outcomes included morphine requirements using patient-controlled analgesia (PCA), time to extubation, level of sedation, and side effects such as nausea, vomiting, pruritus, hypoventilation, and hypoxia over a 72-h monitoring time.

Results: Twenty-one patients completed the study. Oral methadone did not reduce pain scores in the methadone group (P = 0.08). However, postoperative morphine requirement during the first 24 h was reduced by a mean of 23 mg in the methadone group (mean difference, −23; 99% confidence interval [CI], 37–13 mg; P < 0.005). No reduction in pain scores or PCA morphine was observed beyond 24 h postoperatively. There was no difference in incidence of opioid-related side effects between groups throughout the postoperative period.

Conclusions: Though preoperative oral methadone did not reduce pain scores, morphine requirements were reduced in the first 24 h post-CABG.

Optimising pain management protocols following cardiac surgery: A protocol for a national quality improvement study

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Severe pain is associated with tachyarrhythmias, shallow breathing and poor recovery.

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Our protocol was effective at reducing post-cardiac surgery pain in a single centre.

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It consists of pre-operative gabapentin and dividing patients based on risk of pain.

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High-risk group receive PCA along with paracetamol and codeine given to all patients.

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Centres will undertake a baseline audit, then implement a protocol and re-audit pain.

Pain following cardiac surgery is a multifaceted phenomenon resulting from a number of mechanisms. High-levels of post-operative pain are associated with cardiovascular and respiratory complications and adequate pain management is crucial for enabling fast recovery. However, adequate pain control is complex, a challenge that stems from a combination of poor reporting of pain, significant variation amongst patients and the side-effects of strong, particularly opioid, analgesics. An initial audit at our hospital demonstrated high-levels of post-operative pain following cardiac surgery and a protocol was therefore devised by the anaesthetic department for cardiac surgical pain management. The protocol stratified patients into high- or low-risk of pain based on the presence of risk factors for pain and utilised a combination of pre-operative one-off dose of gabapentin, intra-operative opioid infusion and post-operative multimodal analgesia with paracetamol, weak and strong opioids. Additionally, patients at high-risk of pain also received patient controlled analgesia. Use of this protocol was associated with improved pain scores on the first three post-operative days. We have devised this study to test for reproducibility of the benefit experienced at our hospital at a larger multicentre level. After acquiring pre-existing post-operative pain management strategies through an initial survey, local study leads will undertake a baseline audit. Local study leads will then lead a 4-week period of protocol implementation. Trusts with official pain management protocols will be given the option to re-circulate their pre-existing protocols. Subsequently, pain scores during post-operative days 1–3 will be re-audited.

Pain process of patients with cardiac surgery-Semantic annotation of electronic patient record data

AIMS AND OBJECTIVES

To describe and compare the pain process of the patients' with cardiac surgery through nurses' and physicians' documentations in the electronic patient records.

BACKGROUND

Postoperative pain assessment and management should be documented regularly, to ensure optimal pain care process for patients. Despite availability of evidence-based guidelines, pain assessment and documentation remain inadequate.

DESIGN

A retrospective patients' record review.

METHODS

The original data consisted of the electronic patient records of 26,922 patients with a diagnosed heart disease. A total of 1,818 care episodes of patients with cardiac surgery were selected from the data. We used random sampling to obtain 280 care episodes for annotation. These 280 care episodes contained 2,156 physician reports and 1,327 days of nursing notes. We developed an annotation manual and schema, and then, we manually conducted semantic annotation on care episodes, using the Brat annotation tool. We analysed the annotation units using thematic analysis. Consolidated criteria for reporting qualitative research guideline was followed in reporting where appropriate in this study design.

RESULTS

We discovered expressions of six different aspects of pain process: (a) cause, (b) situation, (c) features, (d) consequences, (e) actions and (f) outcomes. We determined that five of the aspects existed chronologically. However, the features of pain were simultaneously existing. They indicated the location, quality, intensity, and temporality of the pain and they were present in every phase of the patient's pain process. Cardiac and postoperative pain documentations differed from each other in used expressions and in the quantity and quality of descriptions.

CONCLUSION

We could construct a comprehensive pain process of the patients with cardiac surgery from several electronic patient records. The challenge remains how to support systematic documentation in each patient.

RELEVANCE TO CLINICAL PRACTICE

The study provides knowledge and guidance of pain process aspects that can be used to achieve an effective pain assessment and more comprehensive documentation.

Assessment and pathophysiology of pain in cardiac surgery

Analysis of the problem of surgical pain is important in view of the fact that the success of surgical treatment depends largely on proper pain management during the first few days after a cardiosurgical procedure. Postoperative pain is due to intraoperative damage to tissue. It is acute pain of high intensity proportional to the type of procedure. The pain is most intense during the first 24 hours following the surgery and decreases on subsequent days. Its intensity is higher in younger subjects than elderly and obese patients, and preoperative anxiety is also a factor that increases postoperative pain. Ineffective postoperative analgesic therapy may cause several complications that are dangerous to a patient. Inappropriate postoperative pain management may result in chronic pain, immunosuppression, infections, and less effective wound healing. Understanding and better knowledge of physiological disorders and adverse effects resulting from surgical trauma, anesthesia, and extracorporeal circulation, as well as the development of standards for intensive postoperative care units are critical to the improvement of early treatment outcomes and patient comfort.

The role of intraoperative interventions to minimise chronic postsurgical pain

Chronic postsurgical pain (CPSP) is the most common complication following surgery, with increasing evidence of both its prevalence and severity. While awareness of the various risk factors for this long-term condition is also increasing, effective prevention remains elusive. In this review, we describe the increasing evidence for preventive or 'protective' strategies. Controversies and conflicting human data are presented along with suggestions for improved future study.

Intraoperative Methadone for the Prevention of Postoperative Pain

Background:

The intensity of pain after cardiac surgery is often underestimated, and inadequate pain control may be associated with poorer quality of recovery. The aim of this investigation was to examine the effect of intraoperative methadone on postoperative analgesic requirements, pain scores, patient satisfaction, and clinical recovery.

Methods:

Patients undergoing cardiac surgery with cardiopulmonary bypass (n = 156) were randomized to receive methadone (0.3 mg/kg) or fentanyl (12 μg/kg) intraoperatively. Postoperative analgesic requirements were recorded. Patients were assessed for pain at rest and with coughing 15 min and 2, 4, 8, 12, 24, 48, and 72 h after tracheal extubation. Patients were also evaluated for level of sedation, nausea, vomiting, itching, hypoventilation, and hypoxia at these times.

Results:

Postoperative morphine requirements during the first 24 h were reduced from a median of 10 mg in the fentanyl group to 6 mg in the methadone group (median difference [99% CI], −4 [−8 to −2] mg; P &lt; 0.001). Reductions in pain scores with coughing were observed during the first 24 h after extubation; the level of pain with coughing at 12 h was reduced from a median of 6 in the fentanyl group to 4 in the methadone group (−2 [−3 to −1]; P &lt; 0.001). Improvements in patient-perceived quality of pain management were described in the methadone group. The incidence of opioid-related adverse events was not increased in patients administered methadone.

Conclusions:

Intraoperative methadone administration resulted in reduced postoperative morphine requirements, improved pain scores, and enhanced patient-perceived quality of pain management.

Comparison of electroacupuncture and morphine-mediated analgesic patterns in a plantar incision-induced pain model

Electroacupuncture (EA) is a complementary therapy to improve morphine analgesia for postoperative pain, but underlying mechanism is not well-known. Herein, we investigated EA-induced analgesic effect in a plantar incision (PI) model in male Sprague-Dawley rats. PI was performed at the left hind paw. EA of 4 Hz and high intensity or sham needling was conducted at right ST36 prior to PI and repeated for another 2 days. Behavioral responses to mechanical and thermal stimuli, spinal phospho-ERK, and Fos expression were all analyzed. In additional groups, naloxone and morphine were administered to elucidate involvement of opioid receptors and for comparison with EA. EA pretreatment significantly reduced post-PI tactile allodynia for over 1 day; repeated treatments maintained analgesic effect. Intraperitoneal naloxone could reverse EA analgesia. Low-dose subcutaneous morphine (1 mg/kg) had stronger inhibitory effect on PI-induced allodynia than EA for 1 h. However, analgesic tolerance appeared after repeated morphine injections. Both EA and morphine could equally inhibit PI-induced p-ERK and Fos inductions. We conclude that though EA and morphine attenuate postincision pain through opioid receptor activations, daily EA treatments result in analgesic accumulation whereas daily morphine injections develop analgesic tolerance. Discrepant pathways and mechanisms underlying two analgesic means may account for the results.

Comparison of effects of epidural bupivacaine and intravenous meperidine analgesia on patient recovery following elective abdominal aortic surgery

Background

The efficacy of epidural anesthesia and analgesia in management of perioperative stress has been established. Perioperative pain management strategies decrease surgical complications and aid recovery. In this study, we aimed to document and compare the efficacy of epidural bupivacaine and intravenous meperidine on recovery of patients with elective abdominal aortic surgery performed under general anesthesia.

Material/Methods

Patients undergoing elective abdominal aortic surgery between February 2009 and November 2011 were studied prospectively. Patients were randomized into epidural bupivacaine (n=40) and intravenous meperidine (n=40) groups regarding postoperative analgesia strategy. The preoperative demographic characteristics, perioperative outcomes, postoperative adverse effects of analgesia strategy, time to initiate oral intake, sedation scores, visual analogue scale results, and mobility scores were compared.

Results

The mean ages of the patients were 61.7±8.1 in the epidural group and 59.4±9.7 in the intravenous group (p>0.05). The preoperative demographic characteristics of the patients were comparable between the groups. There were no statistically significant differences between groups regarding anesthesia times, intubation times, intensive care unit stay, hospital length of stay, postoperative vomiting, and postoperative cardiac, renal, and cerebral complications. Postoperative nausea was more prevalent in the meperidine group (p<0.05). In the epidural group, time to begin oral intake was shorter, sedation scores and visual analogue scale results were lower, and mobility scores were higher (p<0.05 each).

Conclusions

Epidural analgesia allowed earlier recovery compared to intravenous analgesia in patients undergoing elective abdominal aortic surgery, but did not affect postoperative outcomes and complications.

The effects of intrathecal morphine on patient-controlled analgesia, morphine consumption, postoperative pain and satisfaction scores in patients undergoing gynaecological oncological surgery

OBJECTIVE

Gynaecological oncological surgery (GOS) includes a wide variety of surgical procedures and postoperative pain is a major concern. This study compared the impact of intrathecal morphine (ITM) plus patient-controlled analgesia (PCA) with PCA alone on morphine consumption, pain relief and patient satisfaction after GOS.

METHODS

Sixty women undergoing GOS under general anaesthesia were randomized to receive either 0.3 mg ITM or placebo. On arrival at the postanaesthesia care unit each patient received a morphine PCA pump. The three primary outcome measures were pain, patient satisfaction scores evaluated using a 100-mm visual analogue scale and cumulative PCA morphine consumption.

RESULTS

No significant differences were observed in the demographic data. Cumulative PCA morphine consumption was significantly lower in the ITM group compared with the control group. Fatigue scores were lower in the ITM group compared with the control group but did not reach statistical significance. Pain, sedation and patient satisfaction scores, and the rate of side-effects were similar for the two groups.

CONCLUSIONS

Administering ITM in GOS could improve postoperative analgesia and reduce morphine consumption without serious side-effects.

[Evaluation of the postoperative acute pain after heart surgery]

INTRODUCTION

Pain is one of the main symptoms reported by patients who have had heart surgery.

OBJECTIVES

To describe the pain and explain the possible association among demographics, psychological and biological variables of the patients subjected to heart surgery with pain intensity during the postoperative in the ICU.

PATIENTS AND METHOD

A descriptive, longitudinal study conducted between February 2008 and January 2009 on patients subjected to heart surgery with admission to the ICU of the Hospital of Navarra was conducted. A preoperatory interview was made with registration of sociodemographic, biological and psychological variables. Pain intensity was monitored during the first 48 hours of ICU stay with the Verbal Numeric Scale (VNS) of pain. Accepted level of significance was p<0.05.

RESULTS

A sample of 69 patients with mean age of 62, 26% women and 74% men was included. A superior statistical association was found between postoperative pain levels for age<65 years, bypass grafting with internal mammary artery and preoperatory anxiety variables. There was a significant increase in analgesic consumption for incomes>1400 €/month, bypass grafting with internal mammary artery and preoperatory anxiety.

CONCLUSIONS

Postoperative pain after heart surgery show significant individual variability. In our study, age, bypass grafting with internal mammary artery and preoperatory anxiety were shown as predictive variables of postoperative pain in patients undergoing heart surgery.

Intraoperative strategy in patients with extended involvement of mediastinal structures

The mediastinum is a virtual space containing several vital organs and structures. Biopsy and resection of lesions located within this region often require several considerations that bear on intraoperative strategy. To optimize outcome, clinicians must be able to predict which patients are at highest risk of anesthetic complications. Superior vena cava involvement, extensive compression of the airway, and pericardial effusion have a clear impact on the decision-making of the anesthetist and surgeon, who should plan together when forming the surgical strategy.

Analgesia best practice after cardiac surgery

Sources of pain after cardiac surgery include sternotomy, rib retraction, conduit harvest, and drain tubes sites. An analgesic regimen should consider individual patient characteristics, including age, preoperative history of pain and response to analgesics, comorbidities, and psychologic state. Intraoperative and postoperatively administered opioids remain the mainstay of therapy, but adjunctive analgesics such as paracetamol, nonsteroidal anti-inflammatory drugs and tramadol, and regional techniques, can reduce opioid consumption and opioid-induced respiratory depression. This may facilitate earlier tracheal extubation, mobilization, and recovery.

Use of continuous subcutaneous anesthetic infusion in cardiac surgical patients after median sternotomy

The use of opioid analgesics to control pain after median sternotomy in cardiac surgical patients is worldwide accepted and established. However, opioids have a wide range of possible side effects, concerning prolonged extubation time, gastrointestinal tract dyskinesia and urinary tract disorders mostly retention. All these may lead to a prolonged ICU stay or overall hospitalization time increase.

To determine whether a continuous subcutaneous regional anesthetic infusion delivered directly to the sternotomy site would result in decreased levels of postoperative pain and opioid requirements in cardiac surgical patients undergoing median sternotomy.

The continuous subcutaneous infusion (OnQ Painbuster system) was applied in 37 patients. 3 patients were exempted due to prolonged ICU stay. 29 patients underwent CABG, 5 had AVR, 1 MVR and modified Maze, 1 patient had a 3-valve repair due to endocarditis and another one had reconstruction of the left ventricle. Requirements of opioid analgesics were recorded for 96 hours after operation. Pain was assessed using the visual analog scale and the total postoperative hospital length of stay was also measured.

The postoperative pain was significantly diminished (0 – 3 at VAS). The mean postoperative length of stay was 5,8 days, rather improved compared to the average stay of 6,7 days.

Continuous subcutaneous infusion of ropivacaine directly at the median sternotomy significantly diminishes postoperative pain and the need for opioid analgesic use. Moreover, it seems to reduce overall postoperative length of stay for all cardiac surgical patients.

The influence of new antithrombotic drugs on regional anesthesia

PURPOSE OF REVIEW

Antithrombotic drugs are known to increase the risk of spinal epidural hematoma after neuraxial blockade. During the last few years, several new anticoagulants have been introduced, some of them more potent than the drugs currently available. More potency, however, may also indicate a higher risk of bleeding.

RECENT FINDINGS

Case series from the last few years indicate that spinal epidural hematoma is more common then previously estimated, with a prevalence from 1: 100,000 in obstetric patients to as high as 1: 3,600 in female orthopedic patients. In order to diminish this risk, most national societies have issued guidelines in which time intervals were established between administration of antithrombotic drugs and performance of neuraxial blockade.

SUMMARY

Guidelines are perceived to be capable of reducing the incidence of spinal epidural hematoma with the inherent risk of permanent paraplegia. These guidelines, however, will only be a valuable aid for clinicians if they are constantly updated and newer antithrombotic drugs are included. Although the resurge of peripheral nerve blocks may diminish patient hazards, deep nerve blocks such as lumbar sympathetic blockade are not devoid of serious complications and should probably be handled in the same way as neuraxial blockade.