Opioid-Free Ultra-Fast-Track On-Pump Coronary Artery Bypass Grafting Using Erector Spinae Plane Catheters

A multidisciplinary opioid-reduction pathway for robotic prostatectomy: outcomes at year one

BACKGROUND

Opioid use has come under increasing scrutiny, driven in part by the opioid crisis and growing concerns that up to 6% of opioid-naïve patients may become chronic opioid users. This has resulted in a revaluation of perioperative practice. For this reason, we implemented a multidisciplinary pathway to reduce perioperative opioid usage through education and standardization of practice.

METHODS

A single-centre retrospective evaluation was performed after 1 year, comparing the outcomes to those of the 2 years prior to pathway implementation. Comparisons were made between pre- vs. post pathway change by 2:1 propensity matching between cohorts. Univariate linear regression models were created using demographic variables with those that were p < 0.15 included in the final model and using post-operative opioid use (in oral morphine equivalents, OME) as the primary outcome.

RESULTS

We found that intraoperative opioid use was significantly decreased 38.2 mg (28.3) vs. 18.0 mg (40.4) oral morphine equivalents (OME), p < .001, as was post-operative opioid use for the duration of the hospitalization, 46.3 mg (49.5) vs. 35.49 mg (43.7) OME, p = 0.002. In subgroup analysis of those that received some intraoperative opioids (n = 152) and those that received no opioids (n = 34), we found that both groups required fewer opioids in the post-operative period 47.0 mg (47.7) vs. 32.4 mg (40.6) OME, p = 0.001, + intraoperative opioids, 62.4 mg (62.9) vs. 35.8 mg (27.7) OME, p = 0.13, - intraoperative opioids. Time to discharge from the PACU was reduced in both groups 215 min (199) vs. 167 min (122), p < 0.003, + intraoperative opioids and 253 min (270) vs. 167 min (105), p = 0.028, - intraoperative opioids. The duration of time until meeting discharge criteria from PACU was 221 min (205) vs. 170 min (120), p = 0.001. Hospital length of stay (LOS) was significantly reduced 1.4 days (1.3) vs. 1.2 days (0.8), p = 0.005. Both sub-groups demonstrated reduced hospital LOS 1.5 days (1.4) vs. 1.2 days (0.8), p = 0.0047, + intraoperative opioids and 1.7 days (1.6) vs. 1.3 days (0.9), p = 0.0583, - intraoperative opioids. Average pain scores during PACU admission and post-PACU until discharge were not statistically different between cohorts.

CONCLUSIONS

These findings underscore the effectiveness of a multidisciplinary approach to reduce opioids. Furthermore, it demonstrates improved patient outcomes as measured by both shorter PACU and almost 50% reduction in perioperative opioid use whilst maintaining similar analgesia as indicated by patient-reported pain scores.

Opioid-free total intravenous anesthesia for thyroid and parathyroid surgery: Protocol for a randomized, double-blind, controlled trial

Background

Opioid-free anesthesia (OFA) may improve postoperative outcomes by reducing opioid-related adverse effects. This study aims to evaluate the effects of OFA on postoperative nausea and vomiting (PONV), postoperative pain, and 30-day outcomes after thyroid and parathyroid surgery.

Methods

This two-center, randomized, double-blind, controlled trial will include 400 adult patients scheduled for thyroid and parathyroid surgery. Patients will be randomly assigned, 1:1 and stratified by sex and site, to an OFA group (esketamine, lidocaine, and dexmedetomidine) or a control group (opioid-based anesthesia with sufentanil). All patients will receive propofol-based total intravenous anesthesia and PONV prophylaxis with dexamethasone and ondansetron. The primary outcome is the incidence of PONV (defined as experiencing any event of nausea, retching, or vomiting) during the first 48 h postoperatively. The secondary outcomes include the severity of PONV, antiemetic rescue therapy, pain scores at rest and while coughing, need for rescue analgesia, perioperative adverse effects related to anesthetics or analgesics (hypotension, bradycardia, hypertension, tachycardia, desaturation, dizziness, headache, hallucination, and nightmare), time to extubation, length of post-anesthesia care unit stay, length of postoperative hospital stay, patient satisfaction, and a composite of 30-day major adverse events (myocardial infarction, cardiac arrest, cerebrovascular accident, coma, acute renal failure, pulmonary embolism, sepsis, septic shock, deep neck space infection, reintubation, reoperation, blood transfusion, failure to wean off ventilator, and death). Analyses will be performed in the modified intention-to-treat population.

Discussion

We hypothesize that our OFA regimen reduces PONV after thyroid and parathyroid surgery. We will also investigate whether OFA leads to improvements in postoperative pain and major adverse events. Our results will offer evidence for optimizing anesthesia regimens in patients who undergo thyroid and parathyroid surgical procedures.

Clinical trial registration

http://www.chictr.org.cn, identifier: ChiCTR2200059656.

Implementation of Bilateral Rectus Sheath Blocks in Conjunction With Transversus Thoracis Plane and Pectointercostal Fascial Blocks for Immediate Postoperative Analgesia After Cardiac Surgery

Pain continues to be a well-known complication of cardiac surgery in the postoperative period and intravenous opioid analgesia has traditionally been employed to manage cardiac surgical pain. However, both components have contributed to a multitude of undesirable adverse effects which can further exacerbate delays in recovery. Often overlooked in the analgesic plan, chest tube pain contributes significantly to the overall postoperative pain from cardiac surgery. Novel regional anesthetic blocks have shown great promise as analgesic adjuncts for cardiothoracic anesthesia but preliminary investigations focus primarily on management of sternotomy pain. Reduction of chest tube pain should be considered while implementing regional blocks to control surgical pain. This study presents a case where the rectus sheath block minimized chest tube pain after aortic valve replacement in conjunction with intercostal nerve blocks and a multimodal analgesic plan.

Successful Management of a Patient With a History of Postoperative Delirium Undergoing Cardiac Surgery With an Erector Spinae Plane Block and Multimodal Analgesia: A Case Report

Perioperative delirium is an acute confusional state with fluctuating levels of consciousness, which can be precipitated by opioid-based anesthetics and inadequate pain control, especially in patients undergoing cardiac surgery. We seek to minimize opioid usage to avoid postoperative delirium in a patient with multiple risk factors undergoing aortic valve replacement. We used cardiac enhanced recovery after surgery protocols (ERAS-C), which include multimodal analgesia and regional anesthesia via bilateral erector spinae plane (ESP) blocks. Our observations suggest that bilateral ESP blocks and cardiac ERAS protocols offer a potential option to manage pain and control risk factors in patients at high risk of postoperative delirium undergoing cardiac surgery.

Anesthesia for minimally invasive cardiac surgery

Due to its potential benefits and increased patient satisfaction minimal invasive cardiac surgery (MICS) is rapidly gaining in popularity. These procedures are not without challenges and require careful planning, pre-operative patient assessment and excellent intraoperative communication. Assessment of patient suitability for MICS by a multi-disciplinary team during pre-operative workup is desirable. MICS requires additional skills that many might not consider to be part of the standard cardiac anesthetic toolkit. Anesthetists involved in MICS need not only be highly skilled in performing transesophageal echocardiography (TEE) but need to be proficient in multimodal analgesia, including locoregional or neuroaxial techniques. MICS procedures tend to cause more postoperative pain than standard median sternotomies do, and patients need analgesic management more in keeping with thoracic operations. Ultrasound guided peripheral regional anesthesia techniques like serratus anterior block can offer an advantage over neuroaxial techniques in patients on anti-platelet therapy or anticoagulation with low molecular weight or unfractionated heparin The article reviews the salient points pertaining to pre-operative assessment and suitability, intraoperative process and postoperative management of minimally invasive cardiac procedures in the operating theatre as well as the catheterization lab. Special emphasis is given to anesthetic management and analgesia techniques.

Elements not Graded in the Cardiac Enhanced Recovery After Surgery Guidelines Might Improve Postoperative Outcome: A Comprehensive Narrative Review

Enhanced Recovery Programs (ERPs) are protocols involving the whole patient surgical journey. These protocols are based on multimodal, multidisciplinary, evidence-based, and patient-centered approaches aimed at improving patient recovery after a surgical intervention. Such programs have shown striking positive results in different surgical specialties. However, only a few research groups have incorporated preoperative, intraoperative, and postoperative evidence-based interventions in bundles used to standardize care and build cardiac surgery ERPs. The Enhanced Recovery After Surgery Society recently published evidence-based recommendations for perioperative care in cardiac surgery. Their recommendations included 22 perioperative interventions that may be part of any cardiac ERP. However, various components integrated in already-published cardiac ERPs were neither graded nor reported in these recommendations. The goals of the current review are to present published cardiac ERPs and their effects on patient outcomes and reported components incorporated into these ERPs and to discuss the objectives and scope of cardiac ERPs.

Opioid Avoidance in Liver Transplant Recipients: Reduction in Postoperative Opioid Use Through a Multidisciplinary Multimodal Approach

The prevalence of substance use disorder in the liver transplantation (LT) population makes postoperative pain management challenging. We report our initial experience with a novel, comprehensive, multidisciplinary opioid avoidance pathway in 13 LT recipients between January 2018 and September 2019. Patients received comprehensive pre-LT education on postoperative opioid avoidance by the surgeon, pharmacist, and psychologist at the time of listing. Immediately after LT, patients received a continuous incisional ropivacaine infusion, ketamine, acetaminophen, and gabapentin as standard nonopioid medications; rescue opioids were used as needed. We compared outcomes with a historical cohort of 27 LT recipients transplanted between August 2016 and January 2018 managed primarily with opioids. On average, opioid avoidance patients used 92% fewer median (interquartile range [IQR]) morphine milligram equivalents (MMEs) versus the historical cohort (7 [1-11] versus 87 [60-130] MME; P < 0.001) per postoperative day over a similar length of stay (8 [7-10] versus 6 [6-10] days; P = 0.14). Fewer outpatient MMEs were prescribed within the first 60 days after LT in the opioid avoidance group versus the historical cohort: 125 (25-150) versus 270 (0-463) MME (P = 0.05). This proof-of-concept study outlines the potential to profoundly reduce opioid utilization in the LT population using a comprehensive multidisciplinary approach.

Erector Spinae Regional Anesthesia for Robotic Coronary Artery Bypass Surgery Is Not Associated With Reduced Postoperative Opioid Use: A Retrospective Observational Study

OBJECTIVE

Regional anesthesia techniques are gaining traction in cardiac surgery. The aim of this study was to compare the analgesic efficacy of erector spinae plane block catheters (ESPBC), serratus anterior plane block catheters (SAPBC), and paravertebral single-shot block (PVB) versus no block after robotic minimally invasive direct coronary artery bypass (MIDCAB).

DESIGN

This was a retrospective observational study of routinely recorded data.

SETTING

The study was performed at a single healthcare system.

PARTICIPANTS

All patients underwent robotic MIDCAB.

INTERVENTION

Data were analyzed from 346 patients during a 53-month period. The clinical data warehouse was queried for all robotic MIDCAB surgeries. Variables abstracted included type of nerve block, age, sex, use of adjuncts, Society of Thoracic Surgeons predicted short length of stay (PSLOS), total opioid consumption during the 72 hours after surgery, and postoperative hospital length of stay (LOS). The primary outcome was total oral morphine milligram equivalents (MME) consumed during the first 72 hours after surgery. The secondary outcome was hospital LOS.

MEASUREMENTS AND MAIN RESULTS

In a model adjusting for PSLOS, the authors did not observe an association between ESPBC and the reduction of total administered oral MME within 72 hours after surgery. There was no significant difference in MME when comparing patients who received PVB to patients with ESPBC. Older age and female sex were associated with significantly lower MME. Patients who received ESPBC had a significantly shorter hospital LOS than patients with SAPBC.

CONCLUSIONS

These findings suggested that postoperative pain after MIDCAB surgery might not be completely covered by ESPBC. Prospective studies are needed to further elucidate the value of this technique for robotic MIDCAB.

The Impact of Anesthetic Regimen on Outcomes in Adult Cardiac Surgery: A Narrative Review

Despite improvements in surgical techniques and perioperative care, cardiac surgery still is burdened by relatively high mortality and frequent major postoperative complications, including myocardial dysfunction, pulmonary complications, neurologic injury, and acute kidney injury. Although the surgeon's skills and volume and patient- and procedure-related risk factors play a major role in the success of cardiac surgery, there is growing evidence that also optimizing perioperative care may improve outcomes significantly. The present review focuses on the aspects of perioperative care that are strictly related to the anesthesia regimen, with special reference to volatile anesthetics and neuraxial anesthesia, whose effect on outcome in adult cardiac surgery has been investigated extensively.

Regional anesthesia for cardiac surgery

PURPOSE OF REVIEW

Anesthesia for cardiac surgery has traditionally utilized high-dose opioids to blunt the sympathetic response to surgery. However, recent data suggest that opioids prolong postoperative intubation, leading to increased morbidity. Given the increased risk of opioid dependency after in-hospital exposure to opioids, coupled with an increase in morbidity, regional techniques offer an adjunct for perioperative analgesia. The aim of this review is to describe conventional and emerging regional techniques for cardiac surgery.

RECENT FINDINGS

Well-studied techniques such as thoracic epidurals and paravertebral blocks are relatively low risk despite lack of widespread adoption. Benefits include reduced opioid exposure after paravertebral blocks and reduced risk of perioperative myocardial infarction after epidurals. To further lower the risk of epidural hematoma and pneumothorax, new regional techniques have been studied, including parasternal, pectoral, and erector spinae plane blocks. Because these are superficial compared with paravertebral and epidural blocks, they may have even lower risks of hematoma formation, whereas patients are anticoagulated on cardiopulmonary bypass. Efficacy data have been promising, although large and generalizable studies are lacking.

SUMMARY

New regional techniques for cardiac surgery may be potent perioperative analgesic adjuncts, but well-designed studies are needed to quantify the effectiveness and safety of these blocks.

Effect of opioid-free anaesthesia on post-operative period in cardiac surgery: a retrospective matched case-control study

BACKGROUND

No study has been conducted to demonstrate the feasibility of an opioid-free anesthesia (OFA) protocol in cardiac surgery to improve patient care. The aim of the present study was to evaluate the effect of OFA on post-operative morphine consumption and the post-operative course.

METHODS

After retrospectively registering to clinicaltrial.gov (NCT03816592), we performed a retrospective matched cohort study (1:1) on cardiac surgery patients with cardiopulmonary bypass between 2018 and 2019. Patients were divided into two groups: OFA (lidocaine, dexamethasone and ketamine) or opioid anaesthesia (OA) (sufentanil). The main outcome was the total postoperative morphine consumption in the 48 h after surgery. Secondary outcomes were rescue analgesic use, a major adverse event composite endpoint, and ICU and hospital length of stay (LOS).

RESULTS

One hundred ten patients were matched (OFA: n = 55; OA: n = 55). On inclusion, demographic and surgical data for the OFA and OA groups were comparable. The total morphine consumption was higher in the OA group than in the OFA group (15 (6-34) vs 5 mg (2-18), p = 0.001). The pain score during the first 48 post-operative hours did not differ between the two groups. Creatinine values did not differ on the first post-operative day (80 (IQR: 66-115) vs 77 mmol/l (IQR: 69-95), p = 0.284). Incidence of the composite endpoint was lower in the OFA group (25 patients (43%) vs 38 patients (68%), p = 0.021). The time to extubation and the ICU stays were shorter in the OFA group (3 (1-5) vs 5 (3-6) hours, p = 0.001 and 2 (1-3) vs 3 (2-5) days, p = 0.037).

CONCLUSION

The use of OFA was associated with lower morphine consumption. OFA might be associated with shorter intubation time and ICU stays. Further randomized studies are needed to confirm these results.

TRIAL REGISTRATION

This study was retrospectively registered to ct2 (identifier: NCT03816592 ) on January 25, 2019.