Fast-track coronary artery bypass grafting surgery under general anesthesia with remifentanil and spinal analgesia with morphine and clonidine

Pain management after cardiac surgery via median sternotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations

BACKGROUND

Pain after cardiac surgery via median sternotomy can be difficult to treat, and if inadequately managed can lead to respiratory complications, prolonged hospital stays and chronic pain.

OBJECTIVES

To evaluate available literature and develop recommendations for optimal pain management after cardiac surgery via median sternotomy.

DESIGN

A systematic review using PROcedure-SPECific Pain Management (PROSPECT) methodology.

ELIGIBILITY CRITERIA

Randomised controlled trials and systematic reviews published in the English language until November 2020 assessing postoperative pain after cardiac surgery via median sternotomy using analgesic, anaesthetic or surgical interventions.

DATA SOURCES

PubMed, Embase and Cochrane Databases.

RESULTS

Of 319 eligible studies, 209 randomised controlled trials and three systematic reviews were included in the final analysis. Pre-operative, intra-operative and postoperative interventions that reduced postoperative pain included paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), intravenous magnesium, intravenous dexmedetomidine and parasternal block/infiltration.

CONCLUSIONS

The analgesic regimen for cardiac surgery via sternotomy should include paracetamol and NSAIDs, unless contraindicated, administered intra-operatively and continued postoperatively. Intra-operative magnesium and dexmedetomidine infusions may be considered as adjuncts particularly when basic analgesics are not administered. It is not clear if combining dexmedetomidine and magnesium would provide superior pain relief compared with either drug alone. Parasternal block/surgical site infiltration is also recommended. However, no basic analgesics were used in the studies assessing these interventions. Opioids should be reserved for rescue analgesia. Other interventions, including cyclo-oxygenase-2 specific inhibitors, are not recommended because there was insufficient, inconsistent or no evidence to support their use and/or due to safety concerns.

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.

Current Status of Neuraxial and Paravertebral Blocks for Adult Cardiac Surgery

Cardiac surgeries are known to produce moderate to severe pain. Pain management has traditionally been based on intravenous opioids. Poorly controlled pain can result in increased incidence of respiratory complications such as atelectasis and pneumonia leading to prolonged intubation and intensive care unit length of stay and subsequent prolonged hospital stay. Adequate perioperative analgesia improves hemodynamics and immunologic responses, which would result in better outcomes after cardiac surgery. Opioid sparing "Enhanced Recovery After Surgery" protocols are increasingly being incorporated into cardiac surgeries. This will reduce opioid requirements and opioid-related side effects and facilitate fast-tracking of patients. Regional analgesia can be provided by neuraxial blocks, fascial plane blocks, peripheral nerve blocks, or simply by the infiltration of the wound with local anesthetics for cardiac surgery. Neuraxial analgesia is provided through epidural, spinal, and paravertebral routes. Though they are being replaced by peripheral fascial plane blocks, epidural and spinal analgesia are still being used in some centers. In this article, neuraxial forms of analgesia are focused. We sought to review epidural analgesia and its impact in suppressing hemodynamic stress response, reducing pulmonary complications, and development of chronic pain. The relationship between intraoperative heparinization and potential neuraxial hematoma is discussed. Other neuraxial options such as spinal and paravertebral analgesia and their usefulness, benefits, and limitations are also reviewed.

Procedural sedation and analgesia for percutaneous high-tech cardiac procedures

The interest in percutaneous high-tech cardiac procedures has increased in recent years together with its safety and efficacy. In fragile patients, procedural sedation and analgesia are used to perform most of the procedures. General anesthesia remains the technique of choice during the team learning curve and might be required in selected patients or in emergent situations. Despite the high costs of percutaneous high-tech cardiac procedures, the decrease in length of hospital stays, rate of intensive care admission and complications, balance the increase in devices costs. In fragile patients who undergo percutaneous high tech cardiac procedures, the primary role of the anesthesiologist is to prevent the need for postprocedural intensive care unit and complications rate. Starting from the experience of a large university third level hospital we identified the eight most commonly performed contemporary percutaneous high tech cardiac procedures (ventricular tachycardia and atrial fibrillation ablation, protected percutaneous coronary intervention, transcatheter aortic valve implantation, MitraClip® (Abbott Laboratories; Abbott Park, IL, USA), percutaneous patent foramen ovale closure, left atrial appendage closure, and dysfunctional lead extraction), discuss the role of procedural sedation and analgesia in this setting, and explore future perspectives.

Intraoperative Remifentanil Infusion and Postoperative Pain Outcomes After Cardiac Surgery-Results from Secondary Analysis of a Randomized, Open-Label Clinical Trial

DESIGN

Report of secondary pain outcomes from a prospective, randomized, open-label clinical trial that compared remifentanil and fentanyl on perioperative hyperglycemic response in cardiac surgery.

SETTING

Single institution, tertiary university hospital.

PARTICIPANTS

The study comprised 116 adult elective cardiac surgical patients.

INTERVENTIONS

Participants were randomly assigned to receive either intermittent fentanyl boluses (F) or continuous remifentanil infusion (R) intraoperatively.

MEASUREMENTS AND MAIN RESULTS

Postoperative pain was evaluated with pain scores every 6 hours for 48 hours. Pain threshold to mechanical stimuli was measured around the sternotomy incision at 48 and 96 hours. The development of chronic pain was assessed using the numeric rating scale at 1, 3, 6, and 12 months after discharge. The final analysis included 106 patients. Pain scores and wound hyperalgesia were not significantly different postoperatively between the groups. The incidence of chronic pain at 3 months was comparable in both groups (61% in group F v 58% in group R; p = 0.79). Pain of more-than-mild degree was seen in 13 (32%) patients in group F and 8 (19%) in group R (p = 0.25) at 3 months. Median pain scores were not significantly different between the groups at 1, 3, 6, and 12 months after discharge from the hospital.

CONCLUSIONS

The present study's findings suggested that intraoperative remifentanil infusion does not significantly worsen pain outcomes in patients undergoing elective cardiac surgery.

Impact of intrathecal morphine analgesia on the incidence of pulmonary complications after cardiac surgery: a single center propensity-matched cohort study

Background

Acute pain and systemic opioids may both negatively impact respiratory function after cardiac surgery. This study analyzes the local practice of using intrathecal morphine analgesia (ITMA) with minimal parenteral opioid administration in cardiac surgery, specifically the impact on postoperative pulmonary complications (PPCs).

Methods

Data from adult patients who underwent elective cardiac surgery between January 2002, and December 2013 in a single center were analyzed. Propensity scores estimating the likelihood of receiving ITMA were used to match (1:1) patients with ITMA and patients with intravenous analgesia (IVA). Primary outcome was PPCs, a composite endpoint including pneumonia, adult respiratory distress syndrome, and any type of acute respiratory failure. Secondary outcomes were in-hospital mortality, cardiovascular complications, and length of stay in the intensive care unit (ICU) and hospital.

Results

From a total of 1′543 patients, 920 were treated with ITMA and 623 with IVA. No adverse event consequent to the spinal puncture was reported. Propensity score matching created 557 balanced pairs. The occurrence of PPCs in patients with ITMA was 8.1% vs. 12.8% in patients with IVA (odds ratio, 0.6; 95% CI, 0.40–0.89; p = 0.012). Fewer patients with ITMA had a prolonged stay in the ICU (> 4 days; 16.5% vs. 21.2%, p = 0.047) or in the hospital (> 15 days; 25.5% vs. 31.8%. p = 0.024). In-hospital mortality and cardiovascular complications did not differ significantly between the two groups.

Conclusion

In this study involving cardiac surgical patients, ITMA was safely applied and was associated with fewer PPCs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-017-0398-z) contains supplementary material, which is available to authorized users.

Fast-track cardiac care for adult cardiac surgical patients

BACKGROUND

Fast-track cardiac care is a complex intervention involving several components of care during cardiac anaesthesia and in the postoperative period, with the ultimate aim of early extubation after surgery, to reduce length of stay in the intensive care unit and in the hospital. Safe and effective fast-track cardiac care may reduce hospital costs. This is an update of a Cochrane review first published in 2003, updated in 2012 and updated now in 2016.

OBJECTIVES

To determine the safety and effectiveness of fast-track cardiac care compared with conventional (not fast-track) care in adult patients undergoing cardiac surgery. Fast-track cardiac care intervention includes administration of low-dose opioid-based general anaesthesia or use of a time-directed extubation protocol, or both.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 5), MEDLINE (January 2012 to May 2015), Embase (January 2012 to May 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL; January 2012 to May 2015) and the Institute for Scientific Information (ISI) Web of Science (January 2012 to May 2015), along with reference lists of articles, to identify additional trials. We applied no language restrictions.

SELECTION CRITERIA

We included all randomized controlled trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement) that compared fast-track cardiac care and conventional (not fast-track) care groups. We focused on the following fast-track interventions, which were designed for early extubation after surgery: administration of low-dose opioid-based general anaesthesia during cardiac surgery and use of a time-directed extubation protocol after surgery. The primary outcome was risk of mortality. Secondary outcomes included postoperative complications, reintubation within 24 hours of surgery, time to extubation, length of stay in the intensive care unit and in the hospital, quality of life after surgery and hospital costs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted study data. We contacted study authors for additional information. We calculated a Peto odds ratio (OR) for risk of mortality and used a random-effects model to report risk ratio (RR), mean difference (MD) and 95% confidence intervals (95% CIs) for all secondary outcomes.

MAIN RESULTS

We included 28 trials (4438 participants) in the updated review. We considered most participants to be at low to moderate risk of death after surgery. We assessed two studies as having low risk of bias and 11 studies high risk of bias. Investigators reported no differences in risk of mortality within the first year after surgery between low-dose versus high-dose opioid-based general anaesthesia groups (OR 0.53, 95% CI 0.25 to 1.12; eight trials, 1994 participants, low level of evidence) and between a time-directed extubation protocol versus usual care (OR 0.80, 95% CI 0.45 to 1.45; 10 trials, 1802 participants, low level of evidence).Researchers noted no significant differences between low-dose and high-dose opioid-based anaesthesia groups in the following postoperative complications: myocardial infarction (RR 0.98, 95% CI 0.48 to 1.99; eight trials, 1683 participants, low level of evidence), stroke (RR 1.17, 95% CI 0.36 to 3.78; five trials, 562 participants, low level of evidence) and tracheal reintubation (RR 1.77, 95% CI 0.38 to 8.27; five trials, 594 participants, low level of evidence).Comparisons with usual care revealed no significant differences in the risk of postoperative complications associated with a time-directed extubation protocol: myocardial infarction (RR 0.59, 95% CI 0.27 to 1.31; eight trials, 1378 participants, low level of evidence), stroke (RR 0.85, 95% CI 0.33 to 2.16; 11 trials, 1646 participants, low level of evidence) and tracheal reintubation (RR 1.34, 95% CI 0.74 to 2.41; 12 trials, 1261 participants, low level of evidence).Although levels of heterogeneity were high, low-dose opioid anaesthesia was associated with reduced time to extubation (reduction of 4.3 to 10.5 hours, 14 trials, 2486 participants, low level of evidence) and length of stay in the intensive care unit (reduction of 0.4 to 7.0 hours, 12 trials, 1394 participants, low level of evidence). Use of a time-directed extubation protocol was associated with reduced time to extubation (reduction of 3.7 to 8.8 hours, 16 trials, 2024 participants, low level of evidence) and length of stay in the intensive care unit (reduction of 3.9 to 10.5 hours, 13 trials, 1888 participants, low level of evidence). However, these two fast-track care interventions were not associated with reduced total length of stay in the hospital (low level of evidence).

AUTHORS' CONCLUSIONS

Low-dose opioid-based general anaesthesia and time-directed extubation protocols for fast-track interventions have risks of mortality and major postoperative complications similar to those of conventional (not fast-track) care, and therefore appear to be safe for use in patients considered to be at low to moderate risk. These fast-track interventions reduced time to extubation and shortened length of stay in the intensive care unit but did not reduce length of stay in the hospital.

Fast-track cardiac care for adult cardiac surgical patients

BACKGROUND

Fast-track cardiac care is a complex intervention involving several components of care during cardiac anaesthesia and in the postoperative period, all with the ultimate aim of early extubation after surgery, to reduce the length of stay in the intensive care unit and in the hospital. Safe and effective fast-track cardiac care may reduce hospital costs. This is an update of a Cochrane review published in 2003.

OBJECTIVES

To update the evidence on the safety and effectiveness of fast-track cardiac care compared to conventional (not fast-track) care in adult patients undergoing cardiac surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 3), MEDLINE (January 1966 to April 2012), EMBASE (January 1980 to April 2012), CINAHL (January 1982 to April 2012), and ISI Web of Science (January 2003 to April 2012). We searched reference lists of articles and contacted experts in the field.

SELECTION CRITERIA

All randomized controlled trials of adult cardiac surgical patients (coronary artery bypass grafts, aortic valve replacement, mitral valve replacement) that compared fast-track cardiac care and conventional (not fast-track) care groups were included. We focused on the following fast-track interventions that were designed for early extubation after surgery, administration of low-dose opioid based general anaesthesia during cardiac surgery and the use of a time-directed extubation protocol after surgery. The primary outcome was the risk of mortality. Secondary outcomes included postoperative complications, reintubation within 24 hours of surgery, time to extubation, length of stay in the intensive care unit and in the hospital, quality of life after surgery and hospital costs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data. Study authors were contacted for additional information. We used a random-effects model and reported relative risk (RR), mean difference (MD) and 95% confidence intervals (95% CI).

MAIN RESULTS

Twenty-five trials involving 4118 patients were included in the review. There were two studies with a low risk of bias and nine studies with a high risk of bias. There were no differences in the risk of mortality within the first year after surgery between low-dose versus high-dose opioid based general anaesthesia groups (RR 0.58, 95% CI 0.28 to 1.18) and between early extubation protocol versus usual care groups (RR 0.84, 95% CI 0.40 to 1.75).There were no significant differences between low-dose versus high-dose opioid based anaesthesia groups for postoperative complications: myocardial infarction (RR 0.98, 95% CI 0.48 to 1.99), reintubation (RR 1.77, 95% CI 0.38 to 8.27), acute renal failure (RR 1.19, 95% CI 0.33 to 4.33), major bleeding (RR 0.48, 95% CI 0.16 to 1.44), and stroke (RR 1.17, 95% CI 0.36 to 3.78). Compared to the usual care, there were no significant differences in the risk of postoperative complications associated with early extubation: myocardial infarction (RR 0.94, 95% CI 0.55 to 1.60), reintubation (RR 1.91, 95% CI 0.90 to 4.07), acute renal failure (RR 0.77, 95% CI 0.19 to 3.10), major bleeding (RR 0.80, 95% CI 0.45 to 1.44), stroke (RR 0.87, 95% CI 0.31 to 2.46), major sepsis (RR 1.25, 95% CI 0.08 to 19.75) and wound infection (RR 0.67, 95% CI 0.25 to 1.83).Although there were high levels of heterogeneity, both low-dose opioid anaesthesia and the use of time-directed extubation protocols were associated with reductions in the time to extubation (3.0 to 10.5 hours) and in the length of stay in the intensive care unit (0.4 to 8.7 hours). However, these fast-track care interventions were not associated with reductions in the total length of stay in hospital. One high quality cost-effectiveness analysis included in a randomized controlled trial showed that early extubation was likely to be cost-effective.

AUTHORS' CONCLUSIONS

The use of low-dose opioid based general anaesthesia and time-directed protocols for fast-track interventions have similar risks of mortality and major postoperative complications to conventional (not fast-track) care, and therefore appear to be safe in patients considered to be at low to moderate risk. These fast-track interventions reduced the time to extubation and shortened the length of stay in the intensive care unit, but did not reduce the length of stay in the hospital.

Remifentanil in cardiac surgery: a meta-analysis of randomized controlled trials

OBJECTIVE

The authors conducted a review of randomized controlled trials to identify advantages in clinically relevant outcomes in patients undergoing cardiac surgery with remifentanil.

DESIGN

Meta-analysis.

SETTING

Hospitals.

PARTICIPANTS

A total of 1,473 patients from 16 randomized trials.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULT

PubMed, BioMedCentral, and conference proceedings were searched (updated May 2010) for randomized trials that compared remifentanil with fentanyl or sufentanil in cardiac anesthesia. Four independent reviewers performed data extraction, with divergences resolved by consensus. Overall analysis showed that the use of remifentanil was associated with a significant reduction in postoperative mechanical ventilation (WMD = -139 min [-244, -32], p for effect = 0.01, p for heterogeneity < 0.001, I(2) = 89%); length of hospital stay (WMD = -1.08 days [-1.60, -0.57], p for effect < 0.0001, p for heterogeneity = 0.004, I(2) = 71%); and cardiac troponin-I release (WMD = -2.08 ng/mL [-3.93, -0.24], p for effect = 0.03, p for heterogeneity < 0.02, I(2) = 74%). No difference was noted in mortality (3/344 [0.87%] in the remifentanil group vs [1.06%] the control group, OR 0.76 [0.17-3.38], p for effect = 0.72, p for heterogeneity = 0.35, I(2) = 5%).

CONCLUSIONS

Remifentanil reduces cardiac troponin release, time of mechanical ventilation, and length of hospital stay in patients undergoing cardiac surgery.

[Leipzig fast-track protocol for cardio-anesthesia. Effective, safe and economical]

BACKGROUND

In November 2005 a complex, multimodal anesthesia fast-track protocol (FTP) was introduced for elective cardiac surgery patients in the Cardiac Center of the University of Leipzig which included changing from an opioid regime to remifentanil and postoperative treatment in a special post-anesthesia recovery and care unit. The goal was to speed up recovery times while maintaining safety and improving costs.

METHOD

A total of 421 patients who underwent the FTP and were treated in the special recovery room were analyzed retrospectively. These patients were compared with patients who had been treated by a standard protocol (SP) prior to instituting the FTP. Primary outcomes were time to extubation, length of stay in the intensive care unit (ICU) and treatment costs.

RESULTS

The times to extubation were significantly shorter in the FTP group with 75 min (range 45-110 min) compared to 900 min (range 600-1140 min) in the SP group. Intensive care unit stay and hospital length of stay were also significantly shorter in the FTP group (p<0.01). The reduction of treatment costs of intensive care for FTP patients was 53.5% corresponding to savings of EUR 738 per patient in the FTP group compared with the SP group.

CONCLUSIONS

The Leipzig fast-track protocol for cardio-anesthesia including the central elements of switching opiate therapy to remifentanil and switching patient recovery to a special post-anesthesia recovery and care unit, shortened therapy times, is safe and economically effective.

The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care

BACKGROUND

Improving perioperative efficiency and throughput has become increasingly important in the modern practice of anesthesiology. Fast-track surgery represents a multidisciplinary approach to improving perioperative efficiency by facilitating recovery after both minor (i.e., outpatient) and major (inpatient) surgery procedures. In this article we focus on the expanding role of the anesthesiologist in fast-track surgery.

METHODS

A multidisciplinary group of clinical investigators met at McGill University in the Fall of 2005 to discuss current anesthetic and surgical practices directed at improving the postoperative recovery process. A subgroup of the attendees at this conference was assigned the task of reviewing the peer-reviewed literature on this topic as it related to the role of the anesthesiologist as a perioperative physician.

RESULTS

Anesthesiologists as perioperative physicians play a key role in fast-track surgery through their choice of preoperative medication, anesthetics and techniques, use of prophylactic drugs to minimize side effects (e.g., pain, nausea and vomiting, dizziness), as well as the administration of adjunctive drugs to maintain major organ system function during and after surgery.

CONCLUSION

The decisions of the anesthesiologist as a key perioperative physician are of critical importance to the surgical care team in developing a successful fast-track surgery program.

Determinants of Early Discharge From the Intensive Care Unit After Cardiac Operations

BACKGROUND

The length of stay in the intensive care unit is one of the factors limiting operating room utilization in cardiac surgery. We investigated the impact of a goal-oriented program aimed at discharging the patients from the intensive care unit the morning after the operation within a comprehensive model including other explanatory variables.

METHODS

A multivariable predictive model for early discharge from the intensive care unit was established using a stepwise forward logistic regression. The analysis was retrospectively conducted on 9120 consecutive patients undergoing cardiac surgical procedures at our institution.

RESULTS

A total of 1874 patients were discharged early from the intensive care unit. Factors associated with early discharge were ejection fraction, lowest hematocrit on cardiopulmonary bypass, lowest temperature on cardiopulmonary bypass, and the presence of the goal-oriented strategy (odds ratio, 5.5; 95% confidence interval, 4.8 to 6.3). Factors associated with late discharge were age, preoperative serum creatinine value, unstable angina, congestive heart failure, redo operation, combined operation, and cardiopulmonary bypass duration. An extubation time of 4 hours after the arrival in the intensive care unit was associated with the peak rate of early discharge. Patients being early discharged according to the goal-oriented strategy did not demonstrate a different complication rate compared with patients treated with a standard strategy.

CONCLUSIONS

Early discharge from the intensive care unit depends on a combination of preoperative and intraoperative factors, but most of all on the presence of a goal-oriented strategy. A very early extubation is not required for an early discharge from the intensive care unit.

Fast-Track Cardiac Anesthesia: Efficacy and Safety of Remifentanil Versus Sufentanil

OBJECTIVE

The purpose of this study was to compare the safety and efficacy of fast-track cardiac anesthesia with remifentanil (group R) versus sufentanil (group S).

DESIGN

Prospective, single-blinded, randomized study.

SETTING

University hospital.

PARTICIPANTS

One hundred twenty patients undergoing coronary artery bypass graft surgery and/or cardiac valve surgery.

INTERVENTIONS

After routine standardized anesthesia induction, anesthesia was maintained with isoflurane (0.4-0.8 vol%) together with either remifentanil (group R) (1 microg/kg/min) or sufentanil (group S) (1 microg/kg for induction, 0.5 microg/kg for skin incision, and then 0.02 microg/kg/min). After surgery, which included cardiopulmonary bypass in all cases, postoperative sedation was achieved in both groups with propofol until the patient was deemed ready for extubation. Additionally, patients in group R received remifentanil, 0.25 microg/kg/min.

MEASUREMENTS AND MAIN RESULTS

Recovery profile in group R patients was faster (p < 0.05), with a median time interval between end of surgery and eligibility for extubation of 295 minutes versus 375 minutes. Time from end of surgery to being eligible for discharge from intensive care unit was similar in both groups, with 22.9 hours in group R versus 26.3 hour in group S. Remifentanil provided a better protection against intraoperative stimuli at skin incision and maximal sternal spread (p < 0.05). The incidence of adverse events was comparable in both groups. Postoperative pain scores during the first hour of weaning were higher in group R (p < 0.05).

CONCLUSIONS

Remifentanil for fast-track cardiac anesthesia provided safe and stable operating conditions and facilitated earlier tracheal extubation. However, postoperative pain management should be planned carefully.

Endogenous opiates and behavior: 2005

This paper is the 28th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over a quarter-century of research. It summarizes papers published during 2005 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity, neurophysiology and transmitter release (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); immunological responses (Section 17).

Gender Differences for Rapid After Bypass Back Into Telemetry Tract Following Cardiac Surgery

The Rapid After Bypass Back Into Telemetry program is based on a simple clinical algorithm to predict same-day transfer of patients to the cardiac telemetry unit following cardiac surgery. This program proved to be an excellent predictor for decreased postoperative complications, shorter intensive care unit and hospital stay, and lower costs. We believe that any candidate for cardiac surgery should be screened for eligibility to participate in the program with special focus on female patients to further improve their outcomes.

Perioperative use of α2-adrenoceptor agonists and the cardiac patient

The centrally acting alpha2-adrenoceptor agonists clonidine and dexmedetomidine have been used with success to provide haemodynamic stability for patients undergoing surgery. Particularly in the case of patients with overt or underlying cardiac disease the actions of alpha2-adrenoceptor agonists, which include maintenance of stable systemic blood pressure and low heart rate and a reduction in overall oxygen consumption, can be expected to reduce the risk of procedure-related cardiac events. This expectation has been corroborated in clinical trials with clonidine, dexmedetomidine and mivazerol and meta-analyses; additional large controlled trials would be instructive in establishing a robust estimate of the scale of the benefit. In addition, alpha2-adrenoceptor agonists used as premedication have been shown to substantially reduce anaesthetic requirements among surgical patients, and the use of these agents has been associated with a reduced risk of postoperative delirium, which may be expected to improve considerably the postoperative course for at-risk patients. Dexmedetomidine is the only alpha2-adrenoceptor agonist currently approved for use in the intensive care unit. A distinctive feature of dexmedetomidine in that setting is that in addition to haemodynamic stability it confers a distinctive and advantageous quality of sedation: patients are tranquil but responsive to requests from attending staff. This review examines the pharmacological principles underlying the use of alpha2-adrenoceptor agonists as adjuncts to surgery and clinical experience in that indication.