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Neudecker J, Andreas MN, Lask A, Strauchmann J, Elsner A, Rückert JC, Dziodzio T. [ERAS Implementation in Thoracic Surgery]. Zentralbl Chir 2024. [PMID: 38604234 DOI: 10.1055/a-2276-1694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
This manuscript provides an overview of the principles and requirements for implementing the ERAS program in thoracic surgery.The ERAS program optimises perioperative management of elective lung resection procedures and is based on the ERAS Guidelines for Thoracic Surgery of the ERAS Society. The clinical measures are described as in the current literature, with a focus on postoperative outcome. There are currently 45 enhanced recovery items covering four perioperative phases: from the prehospital admission phase (patient education, screening and treatment of potential risk factors such as anaemia, malnutrition, cessation of nicotine or alcohol abuse, prehabilitation, carbohydrate loading) to the immediate preoperative phase (shortened fasting period, non-sedating premedication, prophylaxis of PONV and thromboembolic complications), the intraoperative measures (antibiotic prophylaxis, standardised anaesthesia, normothermia, targeted fluid therapy, minimally invasive surgery, avoidance of catheters and probes) through to the postoperative measures (early mobilisation, early nutrition, removal of a urinary catheter, hyperglycaemia control). Most of these measures are based on scientific studies, with a high level of evidence and aim to reduce general postoperative complications.The ERAS program is an optimised perioperative treatment approach aiming to improve the postoperative recovery in patients after elective lung resection by reducing the overall complication rates and overall morbidity.
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Affiliation(s)
- Jens Neudecker
- Chirurgische Klinik - Exzellenzzentrum für Thoraxchirurgie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Deutschland
| | - Marco Nicolas Andreas
- Chirurgische Klinik - Exzellenzzentrum für Thoraxchirurgie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Deutschland
| | - Aina Lask
- Chirurgische Klinik - Exzellenzzentrum für Thoraxchirurgie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Deutschland
| | - Julia Strauchmann
- Chirurgische Klinik - Exzellenzzentrum für Thoraxchirurgie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Deutschland
| | - Aron Elsner
- Chirurgische Klinik - Exzellenzzentrum für Thoraxchirurgie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Deutschland
| | - Jens-Carsten Rückert
- Chirurgische Klinik - Exzellenzzentrum für Thoraxchirurgie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Deutschland
| | - Tomasz Dziodzio
- Chirurgische Klinik - Exzellenzzentrum für Thoraxchirurgie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Deutschland
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Grant MC, Chappell D, Gan TJ, Manning MW, Miller TE, Brodt JL. Pain management and opioid stewardship in adult cardiac surgery: Joint consensus report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society. J Thorac Cardiovasc Surg 2023; 166:1695-1706.e2. [PMID: 36868931 DOI: 10.1016/j.jtcvs.2023.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/07/2023] [Accepted: 01/19/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND Opioid-based anesthesia and analgesia is a traditional component of perioperative care for the cardiac surgery patient. Growing enthusiasm for Enhanced Recovery Programs (ERPs) coupled with evidence of potential harm associated with high-dose opioids suggests that we reconsider the role of opioids in cardiac surgery. METHODS An interdisciplinary North American panel of experts, using a structured appraisal of the literature and a modified Delphi method, derived consensus recommendations for optimal pain management and opioid stewardship for cardiac surgery patients. Individual recommendations are graded based on the strength and level of evidence. RESULTS The panel addressed 4 main topics: the harms associated with historical opioid use, the benefits of more targeted opioid administration, the use of nonopioid medications and techniques, and patient and provider education. A key principle that emerged is that opioid stewardship should apply to all cardiac surgery patients, entailing judicious and targeted use of opioids to achieve optimal analgesia with the fewest potential side effects. The process resulted in the promulgation of 6 recommendations regarding pain management and opioid stewardship in cardiac surgery, focused on avoiding the use of high-dose opioids, as well as encouraging more widespread application of foundational aspects of ERPs, such as the use of multimodal nonopioid medications and regional anesthesia techniques, formal patient and provider education, and structured system-level opioid prescription practices. CONCLUSIONS Based on the available literature and expert consensus, there is an opportunity to optimize anesthesia and analgesia for cardiac surgery patients. Although additional research is needed to establish specific strategies, core principles of pain management and opioid stewardship apply to the cardiac surgery population.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
| | - Michael W Manning
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Timothy E Miller
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Jessica L Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, Calif.
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Jouneau S, Ricard JD, Seguin-Givelet A, Bigé N, Contou D, Desmettre T, Hugenschmitt D, Kepka S, Le Gloan K, Maitre B, Mangiapan G, Marchand-Adam S, Mariolo A, Marx T, Messika J, Noël-Savina E, Oberlin M, Palmier L, Perruez M, Pichereau C, Roche N, Garnier M, Martinez M. SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax. Ann Intensive Care 2023; 13:88. [PMID: 37725198 PMCID: PMC10509123 DOI: 10.1186/s13613-023-01181-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 08/26/2023] [Indexed: 09/21/2023] Open
Abstract
INTRODUCTION Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management. METHODS Literature review, analysis of the literature according to the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients and organizers to reach a consensus. Only expert opinions with strong agreement were selected. RESULTS A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥ 2 cm at the hilum level on frontal chest X-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described. CONCLUSION These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.
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Affiliation(s)
- Stéphane Jouneau
- Service de Pneumologie, Centre de Compétences pour les Maladies Pulmonaires Rares, IRSET UMR 1085, Université de Rennes 1, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, Rennes Cedex 9, 35033, Rennes, France
| | - Jean-Damien Ricard
- Université Paris Cité, AP-HP, DMU ESPRIT, Service de Médecine Intensive Réanimation, Hôpital Louis Mourier, 178 Rue des Renouillers, 92700 Colombes, INSERM IAME U1137, Paris, France
| | - Agathe Seguin-Givelet
- Département de Chirurgie, Institut du Thorax Curie-Montsouris, Institut Mutualiste Montsouris, et Université Paris Sorbonne Cite, 42 Bd Jourdan, 75014, Paris, France
| | - Naïke Bigé
- Département Interdisciplinaire d'Organisation du Parcours Patient, Médecine Intensive Réanimation, Gustave Roussy, 114 Rue Edouard Vaillant, 94805, Villejuif, France
| | - Damien Contou
- Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69, rue du Lieutenant-colonel Prudhon, 95107, Argenteuil, France
| | - Thibaut Desmettre
- Emergency Department, Laboratory Chrono-environnement, UMR 6249 Centre National de La Recherche Scientifique, CHU Besançon, Université Bourgogne Franche-Comté, 3 Bd Alexandre Fleming, 25000, Besançon, France
| | - Delphine Hugenschmitt
- Samu-Smur 69, CHU Edouard-Herriot, Hospices Civils de Lyon, 5 Pl. d'Arsonval, 69003, Lyon, France
| | - Sabrina Kepka
- Emergency Department, Hôpitaux Universitaires de Strasbourg, Icube UMR 7357, 1 Place de l'hôpital, BP 426, 67091, Strasbourg, France
| | - Karinne Le Gloan
- Emergency Department, Centre Hospitalier Universitaire de Nantes, 5 All. de l'Ile Gloriette, 44000, Nantes, France
| | - Bernard Maitre
- Service de Pneumologie, Centre Hospitalier Intercommunal de Créteil, Unité de Pneumologie, GH Mondor, IMRB U 955, Equipe 8, Université Paris Est Créteil, 40 Av. de Verdun, 94000, Créteil, France
| | - Gilles Mangiapan
- Service de Pneumologie, G-ECHO: Groupe ECHOgraphie Thoracique, Unité de Pneumologie Interventionnelle, Centre Hospitalier Intercommunal de Créteil, 40 Av. de Verdun, 94000, Créteil, France
| | - Sylvain Marchand-Adam
- CHRU de Tours, Service de Pneumologie et Explorations Respiratoires Fonctionnelles, 2, boulevard tonnellé, 37000, Tours, France
| | - Alessio Mariolo
- Département de Chirurgie, Institut du Thorax Curie-Montsouris, Institut Mutualiste Montsouris, 42 Bd Jourdan, 75014, Paris, France
| | - Tania Marx
- Emergency Department, Laboratory Chrono-environnement, UMR 6249 Centre National de La Recherche Scientifique, CHU Besançon, Université Bourgogne Franche-Comté, 3 Bd Alexandre Fleming, 25000, Besançon, France
| | - Jonathan Messika
- Université Paris Cité, Inserm, Physiopathologie et Épidémiologie des Maladies Respiratoires, Service de Pneumologie B et Transplantation Pulmonaire, AP-HP, Hôpital Bichat, 46 Rue Henri Huchard, 75018, Paris, France
| | - Elise Noël-Savina
- Service de Pneumologie et soins Intensifs Respiratoires, G-ECHO: Groupe ECHOgraphie Thoracique, CHU Toulouse, 24 Chemin De Pouvourville, 31059, Toulouse, France
| | - Mathieu Oberlin
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 Place de l'hôpital, BP 426, 67091, Strasbourg, France
| | - Ludovic Palmier
- Pôle Anesthésie Réanimation Douleur Urgences, Nîmes University Hospital, 4 Rue du Professeur Robert Debré, 30900, Nîmes, France
| | - Morgan Perruez
- Emergency department, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, 75015, Paris, France
| | - Claire Pichereau
- Médecine Intensive Réanimation, Centre Hospitalier Intercommunal de Poissy Saint Germain, 10 Rue du Champ Gaillard, 78300, Poissy, France.
| | - Nicolas Roche
- Service de Pneumologie, Hôpital Cochin, APHP Centre Université Paris Cité, UMR1016, Institut Cochin, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Marc Garnier
- Sorbonne Université, AP-HP, GRC29, DMU DREAM, Service d'anesthésie-Réanimation et Médecine Périoperatoire Rive Droite, site Tenon, 4 Rue de la Chine, 75020, Paris, France
| | - Mikaël Martinez
- Pôle Urgences, Centre Hospitalier du Forez, & Groupement de Coopération Sanitaire Urgences-ARA, Av. des Monts du Soir, 42600, Montbrison, France
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Wang J, Cui X, Zhang Y, Sang X, Shen L. The effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy: a randomized, double-blinded, controlled study. BMC Surg 2023; 23:218. [PMID: 37543575 PMCID: PMC10404371 DOI: 10.1186/s12893-023-02125-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 07/25/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND We aimed to investigate the effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy. METHODS Eighty 18-70 years old, American Society of Anesthesiologists level I-III patients scheduled for hepatectomy with a J-shaped subcostal incision were enrolled and randomized to receive either intermittent bolus paravertebral ropivacaine (0.5% loading, 0.2% infusion) or 0.9% saline infusion at 1:1 ratio (25 ml loading before surgery, 0.125 ml/kg/h bolus for postoperative 48 h). The primary outcome was set as postoperative 48 h cumulative intravenous morphine consumption recorded by a patient-controlled analgesic pump. RESULTS Thirty-eight patients in each group completed the study. The cumulative morphine consumptions were lower in the paravertebral block than control group at postoperative 24 (difference -10.5 mg, 95%CI -16 mg to -6 mg, P < 0.001) and 48 (difference -12 mg, 95%CI -19.5 mg to -5 mg, P = 0.001) hours. The pain numerical rating scales at rest were lower in the paravertebral block than control group at postoperative 4 h (difference -2, 95%CI -3 to -1, P < 0.001). The active pain numerical rating scales were lower in the paravertebral block than control group at postoperative 12 h (difference -1, 95%CI -2 to 0, P = 0.005). Three months postoperatively, the paravertebral block group had lower rates of hypoesthesia (OR 0.28, 95%CI 0.11 to 0.75, P = 0.009) and numbness (OR 0.26, 95%CI 0.07 to 0.88, P = 0.024) than the control group. CONCLUSIONS Intermittent bolus paravertebral block provided an opioid-sparing effect and enhanced recovery both in hospital and after discharge in patients undergoing hepatectomy. TRIAL REGISTRATION clinicaltrials.gov (NCT04304274), date: 11/03/2020.
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Affiliation(s)
- Jin Wang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xulei Cui
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
| | - Yuelun Zhang
- Center Research Lab, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinting Sang
- Department of Hepatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Le Shen
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
- State Key Laboratory of Complex Severe and Rare Disease, Beijing, China.
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Ander M, Mugve N, Crouch C, Kassel C, Fukazawa K, Izaak R, Deshpande R, McLendon C, Huang J. Regional anesthesia for transplantation surgery - A white paper part 1: Thoracic transplantation surgery. Clin Transplant 2023; 37:e15043. [PMID: 37306898 PMCID: PMC10834230 DOI: 10.1111/ctr.15043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/12/2023] [Accepted: 05/22/2023] [Indexed: 06/13/2023]
Abstract
Transplantation surgery continues to evolve and improve through advancements in transplant technique and technology. With the increased availability of ultrasound machines as well as the continued development of enhanced recovery after surgery (ERAS) protocols, regional anesthesia has become an essential component of providing analgesia and minimizing opioid use perioperatively. Many centers currently utilize peripheral and neuraxial blocks during transplantation surgery, but these techniques are far from standardized practices. The utilization of these procedures is often dependent on transplantation centers' historical methods and perioperative cultures. To date, no formal guidelines or recommendations exist which address the use of regional anesthesia in transplantation surgery. In response, the Society for the Advancement of Transplant Anesthesia (SATA) identified experts in both transplantation surgery and regional anesthesia to review available literature concerning these topics. The goal of this task force was to provide an overview of these publications to help guide transplantation anesthesiologists in utilizing regional anesthesia. The literature search encompassed most transplantation surgeries currently performed and the multitude of associated regional anesthetic techniques. Outcomes analyzed included analgesic effectiveness of the blocks, reduction in other analgesic modalities-particularly opioid use, improvement in patient hemodynamics, as well as associated complications. The findings summarized in this systemic review support the use of regional anesthesia for postoperative pain control after transplantation surgeries. Part 1 of the manuscript focuses on regional anesthesia performed in thoracic transplantation surgeries, and part 2 in abdominal transplantations.
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Affiliation(s)
- Michael Ander
- Department of Anesthesiology & Perioperative Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Neal Mugve
- Department of Anesthesiology & Perioperative Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Cara Crouch
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cale Kassel
- Department of Anesthesiology, Nebraska Medical Center, 984455 Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kyota Fukazawa
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Robert Izaak
- Department of Anesthesiology, UNC Hospitals, N2198 UNC Hospitals, North Carolina, USA
| | - Ranjit Deshpande
- Department of Anesthesiology, Yale University/Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Charles McLendon
- Department of Anesthesiology & Perioperative Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
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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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7
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Jouneau S, Ricard JD, Seguin-Givelet A, Bigé N, Contou D, Desmettre T, Hugenschmitt D, Kepka S, Gloan KL, Maitre B, Mangiapan G, Marchand-Adam S, Mariolo A, Marx T, Messika J, Noël-Savina E, Oberlin M, Palmier L, Perruez M, Pichereau C, Roche N, Garnier M, Martinez M. SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV). Respir Med Res 2023; 83:100999. [PMID: 37003203 DOI: 10.1016/j.resmer.2023.100999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management. METHODS Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected. RESULTS A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described. CONCLUSION These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.
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Affiliation(s)
- Stéphane Jouneau
- Service de Pneumologie, Centre de Compétences pour les Maladies Pulmonaires Rares, IRSET UMR 1085, Université de Rennes 1, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, 35033 Rennes Cedex 9, Rennes 35033, France.
| | - Jean-Damien Ricard
- Université Paris Cité, AP-HP, DMU ESPRIT, Service de Médecine Intensive Réanimation, Hôpital Louis Mourier, 178 Rue des Renouillers, 92700 Colombes ; INSERM IAME U1137, Paris, France
| | - Agathe Seguin-Givelet
- Département de Chirurgie, Institut du Thorax Curie-Montsouris, Institut Mutualiste Montsouris, et Université Paris Sorbonne Cité, 42 Bd Jourdan, Paris 75014, France
| | - Naïke Bigé
- Gustave Roussy, Département Interdisciplinaire d'Organisation du Parcours Patient, Médecine Intensive Réanimation, 114 Rue Edouard Vaillant, Villejuif 94805, France
| | - Damien Contou
- Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, 69, rue du Lieutenant-colonel Prudhon, Argenteuil 95107, France
| | - Thibaut Desmettre
- Emergency Department, CHU Besançon, Laboratory Chrono-environnement, UMR 6249 Centre National de La Recherche Scientifique, Université Bourgogne Franche-Comté, 3 Bd Alexandre Fleming, Besançon 25000, France
| | - Delphine Hugenschmitt
- Samu-Smur 69, CHU Édouard-Herriot, Hospices Civils de Lyon, 5 Pl. d'Arsonval, Lyon 69003, France
| | - Sabrina Kepka
- Emergency Department, Hôpitaux Universitaires de Strasbourg, Icube UMR 7357, 1 place de l'hôpital, Strasbourg BP 426 67091, France
| | - Karinne Le Gloan
- Emergency Department, centre hospitalier universitaire de Nantes, 5 All. de l'Île Gloriette, Nantes 44000, France
| | - Bernard Maitre
- Service de Pneumologie, Centre hospitalier intercommunal de Créteil, Unité de Pneumologie, GH Mondor, IMRB U 955, Equipe 8, Université Paris Est Créteil, 40 Av. de Verdun, Créteil 94000, France
| | - Gilles Mangiapan
- Unité de Pneumologie Interventionnelle, Service de Pneumologie, G-ECHO: Groupe ECHOgraphie thoracique, Centre hospitalier intercommunal de Créteil, 40 Av. de Verdun, Créteil 94000, France
| | - Sylvain Marchand-Adam
- CHRU de Tours, service de pneumologie et explorations respiratoires fonctionnelles, 2, boulevard tonnellé, Tours 37000, France
| | - Alessio Mariolo
- Département de Chirurgie, Institut du Thorax Curie-Montsouris, Institut Mutualiste Montsouris, 42 Bd Jourdan, Paris 75014, France
| | - Tania Marx
- Emergency Department, CHU Besançon, Laboratory Chrono-environnement, UMR 6249 Centre National de La Recherche Scientifique, Université Bourgogne Franche-Comté, 3 Bd Alexandre Fleming, Besançon 25000, France
| | - Jonathan Messika
- Université Paris Cité, Inserm, Physiopathologie et épidémiologie des maladies respiratoires, Service de Pneumologie B et Transplantation Pulmonaire, AP-HP, Hôpital Bichat, 46 Rue Henri Huchard, Paris 75018, France
| | - Elise Noël-Savina
- Service de pneumologie et soins intensifs respiratoires, G-ECHO: Groupe ECHOgraphie thoracique, CHU Toulouse, 24 Chemin De Pouvourville, Toulouse 31059, France
| | - Mathieu Oberlin
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, Strasbourg BP 426 67091, France
| | - Ludovic Palmier
- Pôle Anesthésie Réanimation Douleur Urgences, Nîmes University Hospital, 4 Rue du Professeur Robert Debré, Nîmes 30900, France
| | - Morgan Perruez
- Emergency department, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Paris 75015, France
| | - Claire Pichereau
- Médecine intensive réanimation, Centre Hospitalier Intercommunal de Poissy Saint Germain, 10 rue du champ Gaillard, Poissy 78300, France
| | - Nicolas Roche
- Service de Pneumologie, Hôpital Cochin, APHP Centre Université Paris Cité, UMR1016, Institut Cochin, 27 Rue du Faubourg Saint-Jacques, Paris 75014, France
| | - Marc Garnier
- Sorbonne Université, AP-HP, GRC29, DMU DREAM, service d'anesthésie-réanimation et médecine périoperatoire Rive Droite, site Tenon, 4 Rue de la Chine, Paris 75020, France
| | - Mikaël Martinez
- Pôle Urgences, centre hospitalier du Forez, & Groupement de coopération sanitaire Urgences-ARA, Av. des Monts du Soir, Montbrison 42600, France
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Zhou K, Li D, Song G. Comparison of regional anesthetic techniques for postoperative analgesia after adult cardiac surgery: bayesian network meta-analysis. Front Cardiovasc Med 2023; 10:1078756. [PMID: 37283577 PMCID: PMC10239891 DOI: 10.3389/fcvm.2023.1078756] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 05/03/2023] [Indexed: 06/08/2023] Open
Abstract
Background Patients usually suffer acute pain after cardiac surgery. Numerous regional anesthetic techniques have been used for those patients under general anesthesia. The most effective regional anesthetic technique was still unclear. Methods Five databases were searched, including PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library. The efficiency outcomes were pain scores, cumulative morphine consumption, and the need for rescue analgesia in this Bayesian analysis. Postoperative nausea, vomiting and pruritus were safety outcomes. Functional outcomes included the time to tracheal extubation, ICU stay, hospital stay, and mortality. Results This meta-analysis included 65 randomized controlled trials involving 5,013 patients. Eight regional anesthetic techniques were involved, including thoracic epidural analgesia (TEA), erector spinae plane block, and transversus thoracic muscle plane block. Compared to controls (who have not received regional anesthetic techniques), TEA reduced the pain scores at 6, 12, 24 and 48 h both at rest and cough, decreased the rate of need for rescue analgesia (OR = 0.10, 95% CI: 0.016-0.55), shortened the time to tracheal extubation (MD = -181.55, 95% CI: -243.05 to -121.33) and the duration of hospital stay (MD = -0.73, 95% CI: -1.22 to -0.24). Erector spinae plane block reduced the pain score 6 h at rest and the risk of pruritus, shortened the duration of ICU stay compared to controls. Transversus thoracic muscle plane block reduced the pain scores 6 and 12 h at rest compared to controls. The cumulative morphine consumption of each technique was similar at 24, 48 h. Other outcomes were also similar among these regional anesthetic techniques. Conclusions TEA seems the most effective regional postoperative anesthesia for patients after cardiac surgery by reducing the pain scores and decreasing the rate of need for rescue analgesia. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, ID: CRD42021276645.
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Affiliation(s)
- Ke Zhou
- Department of Cardiac Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Dongyu Li
- Department of Cardiac Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Guang Song
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
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Durey B, Djerada Z, Boujibar F, Besnier E, Montagne F, Baste JM, Dusseaux MM, Compere V, Clavier T, Selim J. Erector Spinae Plane Block versus Paravertebral Block after Thoracic Surgery for Lung Cancer: A Propensity Score Study. Cancers (Basel) 2023; 15:cancers15082306. [PMID: 37190233 DOI: 10.3390/cancers15082306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/13/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION The prevention of respiratory complications is a major issue after thoracic surgery for lung cancer, and requires adequate post-operative pain management. The erector spinae plane block (ESPB) may decrease post-operative pain. The objective of this study was to evaluate the impact of ESPB on pain after video or robot-assisted thoracic surgery (VATS or RATS). METHODS The main outcome of this retrospective study with a propensity score analysis (PSA) was to compare the post-operative pain at 24 h at rest and at cough between a group that received ESPB and a group that received paravertebral block (PVB). Post-operative morphine consumption at 24 h and complications were also assessed. RESULTS One hundred and seven patients were included: 54 in the ESPB group and 53 in the PVB group. The post-operative median pain score at rest and cough was lower in the ESPB group compared to the PVB group at 24 h (respectively, at rest 2 [1; 3.5] vs. 2 [0; 4], p = 0.0181, with PSA; ESPB -0.80 [-1.50; -0.10], p = 0.0255, and at cough (4 [3; 6] vs. 5 [4; 6], p = 0.0261, with PSA; ESPB -1.48 [-2.65; -0.31], p = 0.0135). There were no differences between groups concerning post-operative morphine consumption at 24 h and respiratory complications. CONCLUSIONS Our results suggest that ESPB is associated with less post-operative pain at 24 h than PVB after VATS or RATS for lung cancer. Furthermore, ESPB is an acceptable and safe alternative compared to PVB.
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Affiliation(s)
- Benjamin Durey
- Department of Anaesthesiology and Critical Care, CHU Rouen, 76000 Rouen, France
| | - Zoubir Djerada
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne, EA3801, SFR CAP-Santé, 51000 Reims, France
| | - Fairuz Boujibar
- Univ Rouen Normandie, INSERM EnVI UMR 1096, 76000 Rouen, France
- Department of Thoracic Surgery, Rouen University Hospital, 76000 Rouen, France
| | - Emmanuel Besnier
- Department of Anaesthesiology and Critical Care, CHU Rouen, 76000 Rouen, France
- Univ Rouen Normandie, INSERM EnVI UMR 1096, 76000 Rouen, France
| | - François Montagne
- Department of Thoracic Surgery, Rouen University Hospital, 76000 Rouen, France
| | - Jean-Marc Baste
- Univ Rouen Normandie, INSERM EnVI UMR 1096, 76000 Rouen, France
- Department of Thoracic Surgery, Rouen University Hospital, 76000 Rouen, France
| | | | - Vincent Compere
- Department of Anaesthesiology and Critical Care, CHU Rouen, 76000 Rouen, France
| | - Thomas Clavier
- Department of Anaesthesiology and Critical Care, CHU Rouen, 76000 Rouen, France
- Univ Rouen Normandie, INSERM EnVI UMR 1096, 76000 Rouen, France
| | - Jean Selim
- Department of Anaesthesiology and Critical Care, CHU Rouen, 76000 Rouen, France
- Univ Rouen Normandie, INSERM EnVI UMR 1096, 76000 Rouen, France
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Cheruku SR, Fox AA, Heravi H, Doolabh N, Davis J, He J, Deonarine C, Bereuter L, Reisch J, Ahmed F, Skariah L, Machi A. Thoracic Interfascial Plane Blocks and Outcomes After Minithoracotomy for Valve Surgery. Semin Cardiothorac Vasc Anesth 2023; 27:8-15. [PMID: 36282242 DOI: 10.1177/10892532221136386] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction. Thoracic interfascial plane blocks are increasingly used for pain management after minimally invasive thoracotomy for valve repair and replacement procedures. We hypothesized that the addition of these blocks to the intercostal nerve block injected by the surgeon would further reduce pain scores and opioid utilization. Methods. In this retrospective cohort study, 400 consecutive patients who underwent minimally invasive thoracotomy for mitral or aortic valve replacement and were extubated within 2 hours of surgery were enrolled. The maximum pain score and opioid utilization on the day of surgery and other outcome variables were compared between patients who received interfascial plane blocks and those who did not. Results.193 (48%) received at least one interfascial plane block while 207 (52%) received no interfascial plane block. Patients who received a thoracic interfascial plane block had a maximum VAS score on the day of surgery (mean 7.4 ± 2.5) after the block was administered which was significantly lower than patients in the control group who did not receive the block (mean 7.9 ± 2.2) (P = .02). Opioid consumption in the interfascial plane block group on the day of surgery was not significantly different from the control group. Conclusion. Compared to intercostal blocks alone, the addition of thoracic interfascial plane blocks was associated with a modest reduction in maximum VAS score on the day of surgery. However, no difference in opioid consumption was noted. Patients who received interfascial plane blocks also had decreased blood transfusion requirements and a shorter hospital length of stay.
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Affiliation(s)
- Sreekanth R Cheruku
- Anesthesiology and Pain Management, 89063UT Southwestern Medical Center, Dallas, TX, USA
| | - Amanda A Fox
- Anesthesiology and Pain Management and McDermott Center for Human Growth and Development, 12334UT Southwestern Medical Center, Dallas, TX, USA
| | - Hooman Heravi
- Anesthesiology and Pain Management, 89063UT Southwestern Medical Center, Dallas, TX, USA
| | - Neelan Doolabh
- Cardiothoracic Surgery, 89063UT Southwestern Medical Center, Dallas, TX, USA
| | - Jennifer Davis
- Anesthesiology and Pain Management, 89063UT Southwestern Medical Center, Dallas, TX, USA
| | - Jenny He
- Anesthesiology and Pain Management, 89063UT Southwestern Medical Center, Dallas, TX, USA
| | - Christopher Deonarine
- Anesthesiology and Pain Management, 89063UT Southwestern Medical Center, Dallas, TX, USA
| | - Lauren Bereuter
- Anesthesiology and Pain Management, 89063UT Southwestern Medical Center, Dallas, TX, USA
| | - Joan Reisch
- Population and Data Sciences and Family Medicine, 89063UT Southwestern Medical Center, Dallas, TX, USA
| | - Farzin Ahmed
- Anesthesiology and Pain Management, 89063UT Southwestern Medical Center, Dallas, TX, USA
| | - Lisa Skariah
- 89063Department of Pharmacy, UT Southwestern Medical Center, Dallas, TX, USA
| | - Anthony Machi
- Anesthesiology and Pain Management, 89063UT Southwestern Medical Center, Dallas, TX, USA
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11
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Jouneau S, Ricard JD, Seguin-Givelet A, Bigé N, Contou D, Desmettre T, Hugenschmitt D, Kepka S, Le Gloan K, Maitre B, Mangiapan G, Marchand-Adam S, Mariolo A, Marx T, Messika J, Noël-Savina E, Oberlin M, Palmier L, Perruez M, Pichereau C, Roche N, Garnier M, Martinez M. [Guidelines for management of patients with primary spontaneous pneumothorax]. Rev Mal Respir 2023; 40:265-301. [PMID: 36870931 DOI: 10.1016/j.rmr.2023.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/04/2023] [Indexed: 03/06/2023]
Affiliation(s)
- S Jouneau
- Service de pneumologie, Centre de compétences pour les maladies pulmonaires rares, hôpital Pontchaillou, IRSET UMR 1085, université de Rennes 1, Rennes, France.
| | - J-D Ricard
- Université Paris Cité, AP-HP, DMU ESPRIT, service de médecine intensive réanimation, hôpital Louis-Mourier, Colombes, France; Inserm IAME U1137, Paris, France
| | - A Seguin-Givelet
- Département de chirurgie, Institut du thorax Curie-Montsouris, Institut Mutualiste Montsouris, université Paris Sorbonne Cité, Paris, France
| | - N Bigé
- Gustave-Roussy, département interdisciplinaire d'organisation du parcours patient, médecine intensive réanimation, Villejuif, France
| | - D Contou
- Réanimation polyvalente, centre hospitalier Victor-Dupouy, Argenteuil, France
| | - T Desmettre
- Emergency department, CHU Besançon, laboratory chrono-environnement, UMR 6249 Centre national de la recherche scientifique, université Bourgogne Franche-Comté, Besançon, France
| | - D Hugenschmitt
- Samu-Smur 69, CHU Édouard-Herriot, hospices civils de Lyon, Lyon, France
| | - S Kepka
- Emergency department, hôpitaux universitaires de Strasbourg, Icube UMR 7357, Strasbourg, France
| | - K Le Gloan
- Emergency department, centre hospitalier universitaire de Nantes, Nantes, France
| | - B Maitre
- Service de pneumologie, centre hospitalier intercommunal de Créteil, unité de pneumologie, GH Mondor, IMRB U 955, équipe 8, université Paris Est Créteil, Créteil, France
| | - G Mangiapan
- Unité de pneumologie interventionnelle, service de pneumologie, Groupe ECHOgraphie thoracique (G-ECHO), centre hospitalier intercommunal de Créteil, Créteil, France
| | - S Marchand-Adam
- CHRU de Tours, service de pneumologie et explorations respiratoires fonctionnelles, Tours, France
| | - A Mariolo
- Département de chirurgie, Institut du thorax Curie-Montsouris, Institut Mutualiste Montsouris, Paris, France
| | - T Marx
- Emergency department, CHU Besançon, laboratory chrono-environnement, UMR 6249 Centre national de la recherche scientifique, université Bourgogne Franche-Comté, Besançon, France
| | - J Messika
- Université Paris Cité, Inserm, physiopathologie et épidémiologie des maladies respiratoires, service de pneumologie B et transplantation pulmonaire, AP-HP, hôpital Bichat, Paris, France
| | - E Noël-Savina
- Service de pneumologie et soins intensifs respiratoires, Groupe ECHOgraphie thoracique (G-ECHO), CHU Toulouse, Toulouse, France
| | - M Oberlin
- Emergency department, hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - L Palmier
- Pôle anesthésie réanimation douleur urgences, Nîmes university hospital, Nîmes, France
| | - M Perruez
- Emergency department, hôpital européen Georges-Pompidou, Paris, France
| | - C Pichereau
- Médecine intensive réanimation, centre hospitalier intercommunal de Poissy Saint-Germain, Poissy, France
| | - N Roche
- Service de pneumologie, hôpital Cochin, AP-HP, centre université Paris Cité, UMR1016, Institut Cochin, Paris, France
| | - M Garnier
- Sorbonne université, AP-HP, GRC29, DMU DREAM, service d'anesthésie-réanimation et médecine périopératoire Rive Droite, site Tenon, Paris, France
| | - M Martinez
- Pôle urgences, centre hospitalier du Forez, Montbrison, France; Groupement de coopération sanitaire urgences-ARA, Lyon, France
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12
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Na HS, Koo CH, Koo BW, Ryu JH, Jo H, Shin HJ. Effect of the Paravertebral Block on Chronic Postsurgical Pain After Thoracic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2023; 37:252-260. [PMID: 36428202 DOI: 10.1053/j.jvca.2022.10.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to identify the benefits of thoracic paravertebral block (PVB) by focusing on its role in reducing chronic postsurgical pain (CPSP) after thoracic surgery. DESIGN A systematic review and meta-analysis of randomized controlled trials (RCTs). SETTING Electronic databases, including PubMed, EMBASE, CENTRAL, Scopus, and Web of Science, were searched to identify studies. PARTICIPANTS Patients undergoing thoracic surgeries. INTERVENTION Paravertebral block for postoperative analgesia. MEASUREMENT AND MAIN RESULTS A total of 1,028 adult patients from 10 RCTs were included in the final analysis. The incidence of CPSP at 3 months after surgery was not reduced in the PVB group compared with the no-block (odds ratio [OR] 0.59, 95% CI 0.34-1.04; p = 0.07; I2 = 6.96%) and other-block (OR 1.39, 95% CI 0.30-6.42; p = 0.67; I2 = 77.75%) groups. The PVB did not significantly reduce the incidence of CPSP after 6 months from surgery when compared with no block (OR 0.44, 95% CI 0.08-2.53; p = 0.36; I2 = 87.53%) and other blocks (OR 1.17, 95% CI 0.71-1.95; p = 0.93; I2 = 45.75%). The PVB significantly decreased postoperative pain at 24 and 48 hours at rest compared with the no- block group. The pain score was higher in the PVB group than in the other block groups 48 hours after surgery at rest. CONCLUSIONS Thoracic PVB does not prevent CPSP after thoracic surgery. Further large RCTs are required to confirm and validate the authors' results.
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Affiliation(s)
- Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chang-Hoon Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Bon-Wook Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jung-Hee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hayoung Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Republic of Korea
| | - Hyun-Jung Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Republic of Korea; Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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13
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Jouneau S, Ricard JD, Seguin-Givelet A, Bigé N, Contou D, Desmettre T, Hugenschmitt D, Kepka S, Le Gloan K, Maître B, Mangiapan G, Marchand-Adam S, Mariolo A, Marx T, Messika J, Noël-Savina E, Oberlin M, Palmier L, Perruez M, Pichereau C, Roche N, Garnier M, Martinez† M. Recommandations formalisées d’experts pour la prise en charge des pneumothorax spontanés primaires. ANNALES FRANCAISES DE MEDECINE D URGENCE 2023. [DOI: 10.3166/afmu-2022-0472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Introduction : Le pneumothorax spontané primaire (PSP) est un épanchement gazeux dans la cavité pleurale, survenant hors traumatisme et pathologie respiratoire connue. Des recommandations formalisées d'experts sur le sujet sont justifiées par les pluralités de moyens diagnostiques, stratégies thérapeutiques et disciplines médicochirurgicales intervenant dans leur prise en charge.
Méthodes : Revue bibliographique, analyse de la littérature selon méthodologie GRADE (Grading of Recommendation Assessment, Development and Evaluation) ; propositions de recommandations cotées par experts, patients et organisateurs pour obtenir un consensus. Seuls les avis d'experts avec accord fort ont été retenus.
Résultats : Un décollement sur toute la hauteur de la ligne axillaire et supérieur ou égal à 2 cm au niveau du hile à la radiographie thoracique de face définit la grande abondance. La stratégie thérapeutique dépend de la présentation clinique : exsufflation en urgence pour PSP suffocant ; en l'absence de signe de gravité : prise en charge conservatrice (faible abondance), exsufflation ou drainage (grande abondance). Le traitement ambulatoire est possible si organisation en amont de la filière. Les indications, procédures chirurgicales et l'analgésie périopératoire sont détaillées. Les mesures associées, notamment le sevrage tabagique, sont décrites.
Conclusion : Ces recommandations sont une étape de l'optimisation des stratégies de traitement et de suivi des PSP en France.
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Thalji NK, Patel SJ, Augoustides JG, Schiller RJ, Dalia AA, Low Y, Hamzi RI, Fernando RJ. Opioid-Free Cardiac Surgery: A Multimodal Pain Management Strategy With a Focus on Bilateral Erector Spinae Plane Block Catheters. J Cardiothorac Vasc Anesth 2022; 36:4523-4533. [PMID: 36184473 PMCID: PMC9745636 DOI: 10.1053/j.jvca.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Nabil K Thalji
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Jayant Patel
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robin J Schiller
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Yinghui Low
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Rawad I Hamzi
- Department of Anesthesiology, Regional Anesthesia and Acute Pain Management, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC.
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15
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King M, Stambulic T, Hassan SMA, Norman PA, Derry K, Payne DM, El Diasty M. Median sternotomy pain after cardiac surgery: To block, or not? A systematic review and meta-analysis. J Card Surg 2022; 37:3729-3742. [PMID: 36098374 DOI: 10.1111/jocs.16882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/25/2022] [Accepted: 08/08/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Inadequate pain control after median sternotomy leads to reduced mobilization, increased respiratory complications, and longer hospital stays. Typically, postoperative pain is controlled by opioid analgesics that may have several adverse effects. Parasternal intercostal block (PSB) has emerged as part of a multimodal strategy to control pain after median sternotomy. However, the effectiveness of this intervention on postoperative pain control and analgesic use has not been fully established. METHODS AND RESULTS We conducted a meta-analysis to assess the effect of PSB on postoperative pain and analgesic use in adult cardiac surgery patients undergoing median sternotomy. PubMed, Embase, Google Scholar, and the Cochrane database were searched with the following search strategy: ([postoperative pain] or [pain relief] OR [analgesics] or [analgesia] or [nerve block] or [regional block] or [local block] or [regional anesthesia] or [local anesthetic] or [parasternal block] and [sternotomy]) and (humans [filter]). Inclusion criteria were: patients who underwent cardiac surgery via median sternotomy, age >18 and parasternal block (continuous and single dose). Exclusion criteria were: noncardiac surgery, nonparasternal nerve blocks, and the use of NSAIDS in parasternal block. Quality assessment was performed by three independent reviewers via the Cochrane risk of bias assessment tool. Of 1165 total citations, 18 were found to be relevant. Of these 18 citations, 7 citations (N = 2223 patients) reported postoperative pain scores in an extractable format and 11 citations (N = 2155 patients) reported postoperative opioid use in an extractable format. For postoperative opioid use, morphine equivalent doses were calculated for all studies and postoperative pain scores were standardized to a 10-point visual analog scale for comparison between studies; both these were reported as total opioid use or cumulative score ranging from 24 to 72 h postoperative. All data analyses were run using a random effects model, using a restricted maximum likelihood estimator, to obtain summary standardized mean differences with 95% confidence interval (CI's). For studies which only reported median and interquatile range (IQR), the median was standard deviation was estimated by IQR/1.35. Following median sternotomy both postoperative pain (SMD [95% CI] -0.49 [-0.92 to -0.06]) and postoperative morphine equivalent use (SMD [95% CI] -1.68 [-3.11 to -0.25]) were significantly less in the PSB group. CONCLUSION Our meta-analysis suggests that parasternal nerve block significantly reduces postoperative pain and opioid use.
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Affiliation(s)
- Morgan King
- Queen's School of Medicine, Kingston, Ontario, Canada
| | | | | | - Patrick A Norman
- Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Kendra Derry
- Department of Anesthesiology, Queen's University, Kingston, Ontario, Canada
| | - Darrin M Payne
- Division of Cardiac Surgery, Queen's University, Kingston, Ontario, Canada
| | - Mohammad El Diasty
- Division of Cardiac Surgery, Queen's University, Kingston, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Regional anesthesia is gaining attention as a valuable component of multimodal, opioid-sparing analgesia in cardiac surgery, where improving the patient's quality of recovery while minimizing the harms of opioid administration are key points of emphasis in perioperative care. This review serves as an outline of recent advancements in a variety of applications of regional analgesia for cardiac surgery. RECENT FINDINGS Growing interest in regional analgesia, particularly the use of newer "chest wall blocks", has led to accumulating evidence for the efficacy of multiple regional techniques in cardiac surgery. These include a variety of technical approaches, with results consistently demonstrating optimized pain control and reduced opioid requirements. Regional and pain management experts have worked to derive consensus around nerve block nomenclature, which will be foundational to establish best practice, design and report future research consistently, improve medical education, and generally advance our knowledge in this vital area of perioperative patient care. SUMMARY The field of regional analgesia for cardiac surgery has matured over the last several years. A variety of regional techniques have been described and shown to be efficacious as part of the multimodal, opioid-sparing approach to pain management in the cardiac surgical setting.
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Zhao Y, Kan Y, Huang X, Wu M, Luo W, Nie J. The efficacy and safety of paravertebral block for postoperative analgesia in renal surgery: A systematic review and meta-analysis of randomized controlled trials. Front Surg 2022; 9:865362. [PMID: 35923436 PMCID: PMC9339658 DOI: 10.3389/fsurg.2022.865362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 06/29/2022] [Indexed: 11/29/2022] Open
Abstract
Background Paravertebral block (PVB) has been widely used in postoperative analgesia, especially in thoracic and breast surgery. However, the efficacy and safety of PVB for analgesia after renal surgery remains uncertain. Therefore, this study aimed to determine the postoperative analgesic efficacy and safety of PVB in renal surgery. Methods PubMed, Web of Science, Embase, and the Cochrane Library databases were systematically searched up to December 20, 2021. All randomized controlled trials (RCTs) evaluating the postoperative analgesic efficacy of PVB in renal surgery were collected. The meta-analysis was performed using RevMan 5.4 and Stata/MP 14.0 software. Results A total of 16 RCTs involving 907 patients were included in the meta-analysis. Ten studies investigated patients under percutaneous nephrolithotomy (PCNL), and six studies were done for patients under other renal surgery (nephrectomy or pyeloplasty). Compared with control groups (no block, sham block, or other nerve blocks), meta-analysis showed that PVB reduced 24-hour postoperative opioid consumption significantly (SMD = −0.99, 95%CI: −1.60–0.38, p = 0.001, I2 = 92%) and reduced pain scores at various time points within 24 h at rest and 1 h, 4 h, and 24 h at movement after renal surgery, furthermore, PVB prolonged the time to first postoperative analgesic requirement (SMD = 2.16, 95%CI: 0.94–3.39, p = 0.005, I2 = 96%) and reduced the incidence of postoperative additional analgesia (OR = 0.14, 95%CI: 0.06∼0.33, p < 0.00001, I2 = 50%). Subgroup analysis revealed that the postoperative analgesia effect of PVB was more significant in PCNL, and the use of bupivacaine for PVB seemed to have a better performance. Besides, there was no difference in the incidence of postoperative nausea, vomiting, and itching between PVB and control groups. Conclusion This study indicates that PVB may provide effective postoperative analgesia in patients under renal surgery, especially PCNL patients. Moreover, PVB is a safe analgesic method without significant analgesia-related complications.
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Affiliation(s)
- You Zhao
- Department of Urology, People’s Hospital of Liyang City, Liyang, China
| | - Yanan Kan
- Department of Orthopedic, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xin Huang
- Department of Urology, People’s Hospital of Liyang City, Liyang, China
| | - Ming Wu
- Department of Urology, People’s Hospital of Liyang City, Liyang, China
| | - Weiping Luo
- Department of Urology, People’s Hospital of Liyang City, Liyang, China
- Correspondence: Weiping Luo Jun Nie
| | - Jun Nie
- Department of Urology, People’s Hospital of Liyang City, Liyang, China
- Correspondence: Weiping Luo Jun Nie
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18
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Sharma R, Louie A, Thai CP, Dizdarevic A. Chest Wall Nerve Blocks for Cardiothoracic, Breast Surgery, and Rib-Related Pain. Curr Pain Headache Rep 2022; 26:43-56. [PMID: 35089532 DOI: 10.1007/s11916-022-01001-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Perioperative analgesia in patients undergoing chest wall procedures such as cardiothoracic and breast surgeries or analgesia for rib fracture trauma can be challenging due to several factors: the procedures are more invasive, the chest wall innervation is complex, and the patient population may have multiple comorbidities increasing their susceptibility to the well-defined pain and opioid-related side effects. These procedures also carry a higher risk of persistent pain after surgery and chronic opioid use making the analgesia goals even more important. RECENT FINDINGS With advances in ultrasonography and clinical research, regional anesthesia techniques have been improving and newer ones with more applications have emerged over the last decade. Currently in cardiothoracic procedures, para-neuraxial and chest wall blocks have been utilized with success to supplement or substitute systemic analgesia, traditionally relying on opioids or thoracic epidural analgesia. In breast surgeries, paravertebral blocks, serratus anterior plane blocks, and pectoral nerve blocks have been shown to be effective in providing pain control, while minimizing opioid use and related side effects. Rib fracture regional analgesia options have also expanded and continue to improve. Advances in regional anesthesia have tremendously improved multimodal analgesia and contributed to enhanced recovery after surgery protocols. This review provides the latest summary on the use and efficacy of chest wall blocks in cardiothoracic and breast surgery, as well as rib fracture-related pain and persistent postsurgical pain.
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Affiliation(s)
- Richa Sharma
- Division of Regional Anesthesiology, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Aaron Louie
- Division of Regional Anesthesiology, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Carolyn P Thai
- Division of Regional Anesthesiology, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Anis Dizdarevic
- Division of Regional Anesthesiology, Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, 10032, USA.
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19
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Hu M, Wang Y, Hao B, Gong C, Li Z. Evaluation of Different Pain-Control Procedures for Post-cardiac Surgery: A Systematic Review and Network Meta-Analysis. Surg Innov 2022; 29:269-277. [PMID: 35061568 DOI: 10.1177/15533506211068930] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective To identify superior pain-control procedures for postoperative patients who undergo cardiac surgeries. Methods Literature searches were conducted in globally recognized databases, including MEDLINE, EMBASE and Cochrane Central, to identify randomized controlled trials (RCTs) investigating pain-control procedures after cardiac surgeries. The parameters evaluating analgesic efficacy and postoperative recovery, namely, the pain score and ICU stay, were quantitatively pooled and estimated using Bayesian methods. The values of the surface under the cumulative ranking (SUCRA) probabilities regarding each parameter were calculated to enable the ranking of various pain-control procedures. Node-splitting analysis was performed to test the inconsistency of the main results, and the publication bias was assessed by examining the funnel-plot symmetry. Results After a detailed review, 13 RCTs containing 7 different procedures were included in the network meta-analysis. After pooling the results together, an erector spinae plane block (ESPB) and a local parasternal block (LPB) plus target-controlled infusion (TCI) presented the best analgesic effects for reducing pain at rest (SUCRA, .47) and during movement (SUCRA, .52), respectively, while the former also achieved the shortest ICU stay (SUCRA, .48). Moreover, the funnel-plot symmetries showed no inconsistencies or obvious publication bias in the current study. Conclusions The current evidence indicates that ESPB is a potential superior analgesic strategy for post-cardiac surgery patients. To verify this conclusion further, it is imperative to obtain more high-quality evidence and conduct relevant investigations in the future.
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Affiliation(s)
- Mengjie Hu
- Department of Hepatobiliary and Pancreatic Surgery, Zhongnan Hospital of Wuhan University, Wuhan , China
| | - Yuqi Wang
- Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin , China
| | - Bihai Hao
- School of Nursing, Huanggang Polytechnic College, Huanggang , China
| | - Cheng Gong
- Department of Hepatobiliary and Pancreatic Surgery, Zhongnan Hospital of Wuhan University, Wuhan , China
| | - Zhen Li
- Department of Hepatobiliary and Pancreatic Surgery, Zhongnan Hospital of Wuhan University, Wuhan , China
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20
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Jiang T, Ting A, Leclerc M, Calkins K, Huang J. Regional Anesthesia in Cardiac Surgery: A Review of the Literature. Cureus 2021; 13:e18808. [PMID: 34804666 PMCID: PMC8590887 DOI: 10.7759/cureus.18808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 11/30/2022] Open
Abstract
With our population getting older and sicker, we are witnessing a steady increase in the volume of cardiothoracic procedures performed. As the role of anesthesiologists continues to shift towards being perioperative physicians, it is crucial to tailor the anesthetic to manage the surgical pain in both intraoperative and postoperative periods. In cardiac surgery, poorly controlled surgical pain can lead to opioid-induced hyperalgesia as well as chronic pain syndrome. As current practice encourages early extubation and decreased length of stay, clinicians have increasingly steered away from heavy intraop narcotic therapy over the past two decades. To blunt the sympathetic response and postoperative pain control, some have been using various fascial plane nerve blocks to reduce opioid use during surgery. These blocks are considered very safe to perform and do not lead to hemodynamic changes seen in neuraxial blockades. In this review article, we provide a brief overview of each of the commonly used blocks and summarize and discuss the latest clinical data for each of the common blocks and their efficacy in the setting of cardiothoracic surgery.
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Affiliation(s)
- Tianyu Jiang
- Anesthesiology, Oak Hill Hospital, Brooksville, USA
| | | | | | - Kerry Calkins
- College of Medicine, University of South Florida, Tampa, USA
| | - Jeffrey Huang
- Anesthesiology, Oak Hill Hospital, Brooksville, USA.,Anesthesiology, HCA Healthcare, Orlando, USA
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21
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Sun Y, Luo X, Yang X, Zhu X, Yang C, Pan T, Du Y, Zhang R, Wang D. Benefits and risks of intermittent bolus erector spinae plane block through a catheter for patients after cardiac surgery through a lateral mini-thoracotomy: A propensity score matched retrospective cohort study. J Clin Anesth 2021; 75:110489. [PMID: 34481363 DOI: 10.1016/j.jclinane.2021.110489] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/11/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE A lateral mini-thoracotomy approach to cardiac surgery causes severe and complicated postoperative pain compared to the sternotomy approach. In this study we assessed the benefits and risks of intermittent bolus erector spinae plane block (ESPB) via a catheter for patients who underwent cardiac surgery through a lateral mini-thoracotomy. DESIGN A propensity score-matched retrospective cohort study. SETTING University hospital. PATIENTS 452 consecutive patients that underwent cardiac surgery through a lateral mini-thoracotomy from 2018 to 2020. INTERVENTIONS Patients who received intermittent bolus ESPB through a catheter for 3 days (ESPB group, n = 93) were compared with patients who did not receive any regional anesthesia (Control group, n = 174) after propensity score matching. MEASUREMENTS The primary endpoint was postoperative in-hospital cumulative opioid consumption (calculated as oral morphine milligram equivalents, MME). The secondary outcomes were intraoperative sufentanil doses, therapeutic use of antiemetic, pulmonary infection (assessed using a modified clinical pulmonary infection score, CPIS), durations of ICU and hospital stays, and ESPB related/unrelated complications. MAIN RESULTS There is a lower oral MME in the ESPB group, 266 ± 126 mg in the ESPB group vs. 346 ± 105 mg in the control group (95% CI -113 to -46; P < 0.01). Fewer patients received therapeutic antiemetic agents in the ESPB group (30% vs. 42%, odds ratio 0.58; 95% CI 0.34 to 0.99; P = 0.04). The modified CPIS in the ESPB group is lower: 1.4 ± 0.9 vs. 2.0 ± 1.0 (95% CI -0.9 to -0.3; P < 0.01) on postoperative day 1; 1.6 ± 0.9 vs. 2.0 ± 0.9 (95% CI -0.7 to -0.2; P < 0.01) on postoperative day 2. The observed complications associated with ESPB include pneumothorax (1%), staxis around stomas (5%), hypotension (1%), catheter displacement (3%), and catheter obstruction (2%). None of the patients had any adverse outcomes. CONCLUSION Intermittent bolus ESPB is relatively safe and correlated with a reduction in the use of opioids and antiemetics for cardiac surgery through a lateral mini-thoracotomy.
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Affiliation(s)
- Yanhua Sun
- Department of Anesthesiology, the Affiliated Drum Tower Hospital of Nanjing, University Medical School, 321 Zhongshan Road, Nanjing 210008, China
| | - Xuan Luo
- Department of Thoracic and Cardiovascular Surgery, the Affiliated Drum Tower Hospital of Nanjing, University Medical School, 321 Zhongshan Road, Nanjing 210008, China
| | - Xuelin Yang
- Department of Anesthesiology, the Affiliated Drum Tower Hospital of Nanjing, University Medical School, 321 Zhongshan Road, Nanjing 210008, China
| | - Xuewen Zhu
- Department of Anesthesiology, the Affiliated Drum Tower Hospital of Nanjing, University Medical School, 321 Zhongshan Road, Nanjing 210008, China
| | - Can Yang
- Department of Anesthesiology, the Affiliated Drum Tower Hospital of Nanjing, University Medical School, 321 Zhongshan Road, Nanjing 210008, China
| | - Tuo Pan
- Department of Thoracic and Cardiovascular Surgery, the Affiliated Drum Tower Hospital of Nanjing, University Medical School, 321 Zhongshan Road, Nanjing 210008, China
| | - Yingjie Du
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, No.1 Dongjiaominxiang Road, Dongchen District, Beijing, 100730, China
| | - Rui Zhang
- Department of Anesthesiology, the Affiliated Drum Tower Hospital of Nanjing, University Medical School, 321 Zhongshan Road, Nanjing 210008, China
| | - Dongjin Wang
- Department of Thoracic and Cardiovascular Surgery, the Affiliated Drum Tower Hospital of Nanjing, University Medical School, 321 Zhongshan Road, Nanjing 210008, China.
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22
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Acute pain after serratus anterior plane or thoracic paravertebral blocks for video-assisted thoracoscopic surgery: A noninferiority randomised trial. Eur J Anaesthesiol 2021; 38:S97-S105. [PMID: 34170884 DOI: 10.1097/eja.0000000000001450] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Serratus anterior plane blocks (SAPBs) and thoracic paravertebral blocks (TPVBs) can both be used for video-assisted thoracic surgery. However, it remains unknown whether the analgesic efficacy of a SAPB is comparable to that of a TPVB. OBJECTIVE We tested the primary hypothesis that SAPBs provide noninferior analgesia compared with TPVBs for video-assisted thoracic surgery. DESIGN A noninferiority randomised trial. SETTING Shanghai Chest Hospital, between August 2018 and November 2018. PATIENTS Ninety patients scheduled for video-assisted thoracic lobectomy or segmentectomy were randomised. Patients were excluded if they were unable to perform the visual analogue pain scale, or surgery was converted to thoracotomy. INTERVENTIONS Blocks were performed after induction of general anaesthesia. The three groups were paravertebral blocks (n = 30); serratus anterior plane blocks (n = 29); and general anaesthesia alone (n = 30). PRIMARY OUTCOME MEASURES Visual analogue pain scores (0 to 10 cm) at rest and while coughing, and Prince-Henry pain scores (0 to 4 points) were used to assess postoperative analgesia at 2, 24 and 48 h after surgery. We assessed the noninferiority of SAPBs with TPVBs on all three primary pain outcomes using a delta of 1 cm or one point as appropriate. RESULTS The mean difference (95% confidence intervals) in visual analogue scores between the SAPBs and TPVBs was -0.04 (-0.10 to 0.03) cm at rest, -0.22 (-0.43 to -0.01) cm during coughing and -0.10 (-0.25 to 0.05) for Prince-Henry pain scores. As the upper limit of the confidence intervals were less than 1 (all P < 0.001), noninferiority was claimed for all three primary outcomes. Compared with general anaesthesia alone, the VAS scores at rest and while coughing, and the Prince-Henry pain scores for the two blocks were significantly lower during the initial 2 h after surgery. CONCLUSIONS Serratus anterior plane blocks are quicker and easier to perform than paravertebral blocks and provide comparable analgesia in patients having video-assisted thoracic surgery. Both blocks provided analgesia that was superior to general anaesthesia alone during the initial 2 h after surgery. TRIAL REGISTRATION Chinese Clinical Trial Registry, identifier: ChiCTR1800017671.
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23
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Devarajan J, Balasubramanian S, Nazarnia S, Lin C, Subramaniam K. Current Status of Neuraxial and Paravertebral Blocks for Adult Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2021; 25:252-264. [PMID: 34162252 DOI: 10.1177/10892532211023337] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Charles Lin
- University of Pittsburgh, Pittsburgh, PA, USA
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24
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Clendenen N, Ahlgren B, Robitaille MJ, Christensen E, Morabito J, Grae L, Lyman M, Weitzel N. Year in Review 2020: Noteworthy Literature in Cardiothoracic Anesthesiology. Semin Cardiothorac Vasc Anesth 2021; 25:94-106. [PMID: 33938302 PMCID: PMC10088871 DOI: 10.1177/10892532211013614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The year 2020 was marred by the emergence of a deadly pandemic that disrupted every aspect of life. Despite the disruption, notable research accomplishments in the practice of cardiothoracic anesthesiology occurred in 2020 with an emphasis on optimizing care, improving outcomes, and expanding what is possible for patients undergoing cardiac surgery. This year's edition of Noteworthy Literature Review will focus on specific themes in cardiac anesthesiology that include preoperative anemia, predictors of acute kidney injury following cardiac surgery, pain management modalities, anticoagulation strategies after transcatheter aortic valve replacement, mechanical circulatory support, and future directions in research.
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Affiliation(s)
| | - Bryan Ahlgren
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mark J Robitaille
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Joseph Morabito
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lyndsey Grae
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew Lyman
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nathaen Weitzel
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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25
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Naganuma M, Tokita T, Sato Y, Kasai T, Kudo Y, Suzuki N, Masuda S, Nagaya K. Efficacy of Preoperative Bilateral Thoracic Paravertebral Block in Cardiac Surgery Requiring Full Heparinization: A Propensity-Matched Study. J Cardiothorac Vasc Anesth 2021; 36:477-482. [PMID: 34099376 DOI: 10.1053/j.jvca.2021.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess the efficacy of preoperative bilateral paravertebral block (PVB) with general anesthesia (GA) in contributing to early extubation and decreasing opioid consumption in cardiac surgery. DESIGN A propensity score-matched retrospective study. SETTING A single tertiary medical center between January 2018 and December 2020. PARTICIPANTS Adult patients undergoing isolated first-time aortic valve replacement and coronary artery bypass grafting with full sternotomy. INTERVENTIONS A cohort of 44 patients who received PVB with GA (PVB group) was matched with 44 patients who underwent similar surgery with GA only (GA only group). MEASUREMENTS AND MAIN RESULTS The completion rate of extubation in the operating room was significantly greater in the PVB group (65.9%) than in the GA only group (43.2%; p = 0.032). The completion rate of extubation within eight hours after surgery also was significantly greater in the PVB group (86.4%) than in the GA only group (68.2%; p = 0.042). The median amount of intraoperative fentanyl administered was significantly less in the PVB group (4.8 µg/kg; interquartile range [IQR], 3.3-7.2) than in the GA only group (8.4 µg/kg; IQR, 5.4-12.7; p < 0.001). The median amount of postoperative fentanyl administered was significantly less in the PVB group (6.8 µg/kg; IQR, 3.9-10.6) than in the GA only group (8.1 µg/kg; IQR, 6.2-15.9; p = 0.012). CONCLUSIONS This study demonstrated that preoperative bilateral PVB combined with GA contributed to early extubation in isolated first-time aortic valve replacement and coronary artery bypass grafting and in the reduction of intraoperative and postoperative fentanyl consumption.
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Affiliation(s)
- Masaaki Naganuma
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan.
| | - Takaharu Tokita
- Department of Anesthesiology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Yuri Sato
- Department of Anesthesiology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Toshinori Kasai
- Department of Anesthesiology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Yasushi Kudo
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Nobuaki Suzuki
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Shinya Masuda
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Koichi Nagaya
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
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26
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Nobukuni K, Hatta M, Nakagaki T, Yoshino J, Obuchi T, Fujimura N. Retrolaminar versus epidural block for postoperative analgesia after minor video-assisted thoracic surgery: a retrospective, matched, non-inferiority study. J Thorac Dis 2021; 13:2758-2767. [PMID: 34164168 PMCID: PMC8182553 DOI: 10.21037/jtd-21-238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background The role of thoracic epidural analgesia (TEA) for postoperative analgesia after video-assisted thoracic surgery (VATS) is still controversial. Some studies have reported the efficacy of ultrasound-guided retrolaminar block (RLB) for the postoperative management of pain after chest wall surgery. The purpose of this study was to compare the postoperative analgesic efficacy and adverse effects of ultrasound-guided RLB with those of TEA in patients undergoing minor VATS procedures. Methods A total of 192 relevant records of patients were enrolled in this study. We reviewed electronic medical records of patients undergoing minor VATS procedures under general anesthesia. The primary outcome was the median differences in the numerical rating scale (NRS) scores during rest between the groups at the morning of postoperative day 1 (POD 1m). A propensity-matched analysis incorporating preoperative variables was used to compare the efficacy of postoperative analgesia in two groups. Results Overall, 94 patients were identified for analysis. Propensity score matching resulted in 47 patients in each group. There were no significant differences in the NRS scores between the two groups. The median differences in NRS scores during rest between the two groups at POD 1m were under 1, which indicates non-inferiority of RLB. There were no significant differences in the incidence of adverse effects and rescue dose of analgesic consumption between the two groups. Conclusions The analgesic effects of continuous ultrasound-guided RLB were non inferior to those of TEA for minor VATS procedures.
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Affiliation(s)
- Keiko Nobukuni
- Department of Anesthesiology, St. Mary's Hospital, Our Lady of the Snow Social Medical Corporation, Kurume, Japan
| | - Mariko Hatta
- Department of Anesthesiology, St. Mary's Hospital, Our Lady of the Snow Social Medical Corporation, Kurume, Japan
| | - Toshiaki Nakagaki
- Department of Anesthesiology, St. Mary's Hospital, Our Lady of the Snow Social Medical Corporation, Kurume, Japan
| | - Jun Yoshino
- Department of Anesthesiology, St. Mary's Hospital, Our Lady of the Snow Social Medical Corporation, Kurume, Japan
| | - Toshiro Obuchi
- Department of Thoracic Surgery, St. Mary's Hospital, Our Lady of the Snow Social Medical Corporation, Kurume, Japan
| | - Naoyuki Fujimura
- Department of Anesthesiology, St. Mary's Hospital, Our Lady of the Snow Social Medical Corporation, Kurume, Japan
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27
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Ng Cheong Chung J, Kamarajah SK, Mohammed AA, Sinclair RCF, Saunders D, Navidi M, Immanuel A, Phillips AW. Comparison of multimodal analgesia with thoracic epidural after transthoracic oesophagectomy. Br J Surg 2021; 108:58-65. [PMID: 33640920 DOI: 10.1093/bjs/znaa013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/07/2020] [Accepted: 08/18/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Thoracic epidural analgesia (TEA) has been regarded as the standard of care after oesophagectomy for pain control, but has several side-effects. Multimodal (intrathecal diamorphine, paravertebral and rectus sheath catheters) analgesia (MA) may facilitate postoperative mobilization by reducing hypotensive episodes and the need for vasopressors, but uncertainty exists about whether it provides comparable analgesia. This study aimed to determine whether MA provides comparable analgesia to TEA following transthoracic oesophagectomy. METHODS Consecutive patients undergoing oesophagectomy for cancer between January 2015 and December 2018 were grouped according to postoperative analgesia regimen. Propensity score matching (PSM) was used to account for treatment selection bias. Pain scores at rest and on movement, graded from 0 to 10, were used. The incidence of hypotensive episodes and the requirement for vasopressors were evaluated. RESULTS The study included 293 patients; 142 (48.5 per cent) received TEA and 151 (51.5 per cent) MA. After PSM, 100 patients remained in each group. Mean pain scores were significantly higher at rest in the MA group (day 1: 1.5 versus 0.8 in the TEA group, P = 0.017; day 2: 1.7 versus 0.9 respectively, P = 0.014; day 3: 1.2 versus 0.6, P = 0.047). Fewer patients receiving MA had a hypotensive episode (25 per cent versus 45 per cent in the TEA group; P = 0.003) and fewer required vasopressors (36 versus 53 per cent respectively; P = 0.016). There was no significant difference in the overall complication rate (71.0 versus 61.0 per cent; P = 0.136). CONCLUSION MA is less effective than TEA at controlling pain, but this difference may not be clinically significant. However, fewer patients experienced hypotension or required vasopressor support with MA; this may be beneficial within an enhanced recovery programme.
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Affiliation(s)
- J Ng Cheong Chung
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S K Kamarajah
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - A A Mohammed
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - R C F Sinclair
- Department of Anaesthesia and Critical Care Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - D Saunders
- Department of Anaesthesia and Critical Care Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - M Navidi
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - A Immanuel
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - A W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK.,School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
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28
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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Balan C, Bubenek-Turconi SI, Tomescu DR, Valeanu L. Ultrasound-Guided Regional Anesthesia-Current Strategies for Enhanced Recovery after Cardiac Surgery. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:312. [PMID: 33806175 PMCID: PMC8065933 DOI: 10.3390/medicina57040312] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/09/2021] [Accepted: 03/22/2021] [Indexed: 11/25/2022]
Abstract
With the advent of fast-track pathways after cardiac surgery, there has been a renewed interest in regional anesthesia due to its opioid-sparing effect. This paradigm shift, looking to improve resource allocation efficiency and hasten postoperative extubation and mobilization, has been pursued by nearly every specialty area in surgery. Safety concerns regarding the use of classical neuraxial techniques in anticoagulated patients have tempered the application of regional anesthesia in cardiac surgery. Recently described ultrasound-guided thoracic wall blocks have emerged as valuable alternatives to epidurals and landmark-driven paravertebral and intercostal blocks. These novel procedures enable safe, effective, opioid-free pain control. Although experience within this field is still at an early stage, available evidence indicates that their use is poised to grow and may become integral to enhanced recovery pathways for cardiac surgery patients.
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Affiliation(s)
- Cosmin Balan
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (S.-I.B.-T.); (L.V.)
| | - Serban-Ion Bubenek-Turconi
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (S.-I.B.-T.); (L.V.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Dana Rodica Tomescu
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
- 3rd Department of Anesthesiology and Intensive Care, Fundeni Clinical Institute, 258 Fundeni Road, 022328 Bucharest, Romania;
| | - Liana Valeanu
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (S.-I.B.-T.); (L.V.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Berna P, Quesnel C, Assouad J, Bagan P, Etienne H, Fourdrain A, Le Guen M, Leone M, Lorne E, Nguyen YNL, Pages PB, Roz H, Garnier M. Guidelines on enhanced recovery after pulmonary lobectomy. Anaesth Crit Care Pain Med 2021; 40:100791. [PMID: 33451912 DOI: 10.1016/j.accpm.2020.100791] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS). DESIGN A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions. CONCLUSIONS A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.
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Affiliation(s)
- Pascal Berna
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Christophe Quesnel
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France
| | - Jalal Assouad
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Patrick Bagan
- Department of Thoracic and Vascular Surgery, Victor Dupouy Hospital, 95100 Argenteuil, France
| | - Harry Etienne
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Alex Fourdrain
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Morgan Le Guen
- D,partement d'Anesth,sie, H"pital Foch, Universit, Versailles Saint Quentin, 92150 Suresnes, France; INRA UMR 892 VIM, 78350 Jouy-en-Josas, France
| | - Marc Leone
- Aix Marseille Universit, - Assistance Publique H"pitaux de Marseille - Service d'Anesth,sie et de R,animation - H"pital Nord - 13005 Marseille, France
| | - Emmanuel Lorne
- Departement d'Anesth,sie-R,animation, Clinique du Mill,naire, 34000 Montpellier, France
| | - Y N-Lan Nguyen
- Anaesthesiology and Critical Care Department, APHP Centre, Paris University, 75000 Paris, France
| | - Pierre-Benoit Pages
- Department of Thoracic Surgery, Dijon Burgundy University Hospital, 21000 Dijon, France; INSERM UMR 1231, Dijon Burgundy University Hospital, University of Burgundy, 21000 Dijon, France
| | - Hadrien Roz
- Unit, d'Anesth,sie R,animation Thoracique, H"pital Haut Leveque, CHU de Bordeaux, 33000 Bordeaux, France
| | - Marc Garnier
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France.
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Misra S, Parida S, Chakravarthy M, Mehta Y, Puri GD. A career in cardiac anaesthesia in India: The heart of the matter. Indian J Anaesth 2021; 65:12-16. [PMID: 33767497 PMCID: PMC7980240 DOI: 10.4103/ija.ija_1488_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/17/2020] [Accepted: 12/25/2020] [Indexed: 11/04/2022] Open
Abstract
Cardiac anaesthesia is a demanding, but fulfilling speciality which challenges the skills, knowledge, professional and personal competence of cardiac anaesthesiologists on a daily basis. This article outlines the brief history of the subspecialty of cardiac anaesthesia in India, its growth and progress over the decades, reasons for choosing it as a career option, variations in practice standards and how the speciality has been affected by the coronavirus 2019 pan?demic.
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Affiliation(s)
- Satyajeet Misra
- Department of Anaesthesiology and Critical Care, AIIMS, Bhubaneswar, Odisha, India
| | - Satyen Parida
- Department of Anaesthesiology and Critical Care, JIPMER, Puducherry, India
| | | | - Yatin Mehta
- Institute of Critical Care and Anaesthesiology, Medanta Heart Institute, Delhi, India
| | - Goverdhan Dutt Puri
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Nair S, Gallagher H, Conlon N. Paravertebral blocks and novel alternatives. BJA Educ 2021; 20:158-165. [PMID: 33456945 DOI: 10.1016/j.bjae.2020.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2020] [Indexed: 12/28/2022] Open
Affiliation(s)
- S Nair
- St Vincent's University Hospital, Dublin, Ireland
| | - H Gallagher
- St Vincent's University Hospital, Dublin, Ireland
| | - N Conlon
- St Vincent's University Hospital, Dublin, Ireland
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Sahajanandan R, Varsha AV, Kumar DS, Kuppusamy B, Karuppiah S, Shukla V, Thankachen R. Efficacy of paravertebral block in "Fast-tracking" pediatric cardiac surgery - Experiences from a tertiary care center. Ann Card Anaesth 2021; 24:24-29. [PMID: 33938827 PMCID: PMC8081147 DOI: 10.4103/aca.aca_83_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Fast tracking plays a crucial role in reducing perioperative morbidity and financial burden by facilitating early extubation and discharge from hospital. Paravertebral block (PVB) is becoming more popular in paediatric surgeries as an alternative to epidural and caudal analgesia. There is scarcity of data regarding the efficacy and safety of PVB in paediatric cardiac surgery. Methods: We performed a review of records of paediatric cardiac patients who underwent cardiac surgery under general anaesthesia with single shot PVB and compared the analgesia and postoperative outcomes with matched historical controls who underwent cardiac surgery with same anaesthesia protocol without PVB. Results: The data from 200 children were analysed. 100 children who received paravertebral block were compared with a matched historical controls. The median time to extubation was shorter in the PVB group (0 hr, IQR 0-3 hrs) compared to the control group (16 hrs, IQR 4-20 hrs) (P value 0.017*). Intraoperative and postoperative fentanyl requirement was much lower in the PVB group (3.49 (0.91)) compared to the control group (9.86 (1.37)) P value <0.01*. Time to first rescue dose of analgesic was longer (7 hrs vs 5 hrs, P 0.01*), while time to extubation and duration of ICU stay were significantly less in PVB group . Mean postoperative pain scores were significantly lower in the PVB group at the time of ICU admission (0.85 vs 3.12, P 0.001*) till 4 hours (2.11 vs 3.32, P 0.001*). Conclusion: PVB provides an effective and safe anaesthetic approach which can form an important component of “fast-track” care in paediatric cardiac surgery.
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Affiliation(s)
- Raj Sahajanandan
- Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - A V Varsha
- Department of Cardiothoracic Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - D Sathish Kumar
- Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Balaji Kuppusamy
- Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sathappan Karuppiah
- Department of Cardiothoracic Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Vinayak Shukla
- Department of Cardiothoracic Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Roy Thankachen
- Department of Cardiothoracic Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Epidural analgesia for postoperative pain: Improving outcomes or adding risks? Best Pract Res Clin Anaesthesiol 2020; 35:53-65. [PMID: 33742578 DOI: 10.1016/j.bpa.2020.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 02/02/2023]
Abstract
Current evidence shows that the benefits of epidural analgesia (EA) are not as impressive as believed in the past, while the risks of adverse effects and serious complications are greater than previously estimated. There are many reasons for the decreasing role of epidural technique in clinical practice (table). Indeed, EA can cause harm and hinder early mobilization in enhanced recovery after surgery (ERAS) programmes. Some ERAS interventions are complex, confusing, sometimes contradictory and apparently unimplementable. In spite of much hype and after almost 25 years, the originator of the concept has described the current status of ERAS as 'far from good'. Outpatient surgery setup has been a remarkable success for many major surgical procedures, and it predates ERAS and appears to be a simpler and better model for reducing postoperative morbidity and hospitalization times. Systematic reviews of comparative studies have shown that less invasive and safer but equally effective alternatives to EA are available for almost all major surgical procedures. These include: paravertebral block, peripheral nerve blocks, catheter wound infusion, periarticular local infiltration analgesia, preperitoneal catheters and transversus abdominis plane block. Increasingly, these non-EA methods are being used as surgeon-delivered regional analgesia (RA) techniques. This encouraging trend of active surgeon participation, with anaesthesiologist collaboration, will undoubtedly improve the decades-old twin problems of underused RA techniques and undertreated postoperative pain. The continued use of EA at any institution can only be justified by results from its own audits; however, regrettably only very few institutions perform such regular audits.
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Misra S, Behera BK, Preetam C, Mohanty S, Mahapatra RP, Tapuria P, Elayat A, Nayak A, Kotkar K, McNeil JS, Blank RS. Peripheral Cardiopulmonary Bypass in Two Patients With Symptomatic Tracheal Masses: Perioperative Challenges. J Cardiothorac Vasc Anesth 2020; 35:1524-1533. [PMID: 33339662 DOI: 10.1053/j.jvca.2020.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/18/2020] [Indexed: 11/11/2022]
Abstract
Tracheal tumors or masses causing critical airway obstruction require resection for symptom relief. However, the location and extent of these tumors or masses often preclude conventional general anesthesia and tracheal intubation. Peripheral cardiopulmonary bypass often is required before anesthetizing these patients. Herein, two cases of patients with tracheal masses, in whom awake peripheral cardiopulmonary bypass was instituted, are reported. The first case was that of an obese male child weighing 102 kg, with tracheal rhinoscleroma, who developed Harlequin, or north-south, syndrome after institution of femorofemoral venoarterial partial cardiopulmonary bypass. The second case was that of a female patient with adenoid cystic carcinoma of the trachea causing near-total central airway occlusion. She had severe pulmonary artery hypertension, which prevented the use of venovenous bypass. Instead, femoral vein-axillary artery venoarterial bypass was established to avoid Harlequin syndrome. Some of the challenges encountered were the development of Harlequin syndrome with risk of myocardial and cerebral ischemia, type and conduct of extracorporeal bypass, choice of monitoring sites, and provision of regional anesthesia for peripheral extracorporeal cannulations. Management of such patients needs frequent troubleshooting and multidisciplinary coordination for a successful surgical outcome.
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Affiliation(s)
- Satyajeet Misra
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India.
| | - Bikram Kishore Behera
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Chappity Preetam
- Department of ENT, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Satyapriya Mohanty
- Department of Cardiac Surgery, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Rudra Pratap Mahapatra
- Department of Cardiac Surgery, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Priyank Tapuria
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Anirudh Elayat
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Anindya Nayak
- Department of ENT, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Kunal Kotkar
- Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - John S McNeil
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Randal S Blank
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
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Piccioni F, Droghetti A, Bertani A, Coccia C, Corcione A, Corsico AG, Crisci R, Curcio C, Del Naja C, Feltracco P, Fontana D, Gonfiotti A, Lopez C, Massullo D, Nosotti M, Ragazzi R, Rispoli M, Romagnoli S, Scala R, Scudeller L, Taurchini M, Tognella S, Umari M, Valenza F, Petrini F. Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care. Perioper Med (Lond) 2020; 9:31. [PMID: 33106758 PMCID: PMC7582032 DOI: 10.1186/s13741-020-00159-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria. Results Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis. Conclusions These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.
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Affiliation(s)
- Federico Piccioni
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Cecilia Coccia
- Department of Anesthesia and Critical Care Medicine, National Cancer Institute "Regina Elena"-IRCCS, Rome, Italy
| | - Antonio Corcione
- Department of Critical Care Area Monaldi Hospital, Ospedali dei Colli, Naples, Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Roberto Crisci
- Department of Thoracic Surgery, University of L'Aquila, L'Aquila, Italy
| | - Carlo Curcio
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Carlo Del Naja
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Paolo Feltracco
- Department of Medicine, Anaesthesia and Intensive Care, University Hospital of Padova, Padova, Italy
| | - Diego Fontana
- Thoracic Surgery Unit - San Giovanni Bosco Hospital, Turin, Italy
| | | | - Camillo Lopez
- Thoracic Surgery Unit, 'V Fazzi' Hospital, Lecce, Italy
| | - Domenico Massullo
- Anesthesiology and Intensive Care Unit, Azienda Ospedaliero Universitaria S. Andrea, Rome, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria Sant'Anna, Ferrara, Italy
| | - Marco Rispoli
- Anesthesia and Intensive Care, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, University of Florence, Florence, Italy.,Department of Anesthesia and Critical Care, Careggi University Hospital, Florence, Italy
| | - Raffaele Scala
- Pneumology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Luigia Scudeller
- Clinical Epidemiology Unit, Scientific Direction, Fondazione IRCCS San Matteo, Pavia, Italy
| | - Marco Taurchini
- Department of Thoracic Surgery, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, FG Italy
| | - Silvia Tognella
- Respiratory Unit, Orlandi General Hospital, Bussolengo, Verona, Italy
| | - Marzia Umari
- Combined Department of Emergency, Urgency and Admission, Cattinara University Hospital, Trieste, Italy
| | - Franco Valenza
- Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Flavia Petrini
- Department of Anaesthesia, Perioperative Medicine, Pain Therapy, RRS and Critical Care Area - DEA ASL2 Abruzzo, Chieti University Hospital, Chieti, Italy
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Deebis A, Elattar H, Saber O, Elfakharany K, Elnahal N. Continuous paravertebral block by intraoperative direct access versus systemic analgesia for postthoracotomy pain relief. THE CARDIOTHORACIC SURGEON 2020. [DOI: 10.1186/s43057-020-00027-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Systemic analgesia with paracetamol and nonsteroidal anti-inflammatory drugs plus opioids as a rescue medication had reported to be better than that depend mainly on opioids for postoperative pain relief. Thoracic paravertebral block reported to provide a comparable postthoracotomy pain relief to epidural analgesia, with fewer side effects due to its unilateral effect. Thoracic paravertebral catheter can be inserted intraoperatively under direct vision during thoracic surgery (Sabanathan’s technique). This prospective randomized study was designed to evaluate the safety and efficacy of this technique with continuous infusion of lidocaine compared to systemic analgesia for postthoracotomy pain relief.
Results
Sixty-three patients were randomized to receive a continuous infusion of lidocaine in the paravertebral catheter for 3 postoperative days (thoracic paravertebral group, n = 32) or systemic analgesia (systemic analgesia group, n = 31). All patients underwent standard posterolateral thoracotomy. There were no significant differences between both groups in age, sex, side, type, and duration of operation. Pain scores measured on visual analogue scale and morphine consumption were significantly lower in thoracic paravertebral group in all postoperative days. Spirometric pulmonary functions were not reaching the preoperative values in the third postoperative day in both groups, but restorations of pulmonary functions were superior in paravertebral group. No complications could be attributed to the paravertebral catheter. Side effects, mainly nausea and vomiting followed by urinary retention, were significantly more in systemic analgesia group (P = 0.03). Also, pulmonary complications were more in systemic analgesia group but not reaching statistical significance (P = 0.14).
Conclusion
Continuous paravertebral block by direct access to the paravertebral space using a catheter inserted by the surgeon is a simple technique, with low risk of complications, provides effective pain relief with fewer side effects, and reduces the early loss of postoperative pulmonary functions when compared to systemic analgesia.
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Smeltz AM, Bhatia M, Arora H, Long J, Kumar PA. Anesthesia for Resection and Reconstruction of the Trachea and Carina. J Cardiothorac Vasc Anesth 2020; 34:1902-1913. [DOI: 10.1053/j.jvca.2019.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/11/2019] [Accepted: 10/02/2019] [Indexed: 12/17/2022]
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Pisano A, Torella M, Yavorovskiy A, Landoni G. The Impact of Anesthetic Regimen on Outcomes in Adult Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:711-729. [PMID: 32434720 DOI: 10.1053/j.jvca.2020.03.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/18/2020] [Accepted: 03/29/2020] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Antonio Pisano
- Department of Critical Care, Cardiac Anesthesia and Intensive Care Unit, AORN Dei Colli, Monaldi Hospital, Naples, Italy
| | - Michele Torella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, First Moscow State Medical University, Moscow, Russia
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy; Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Gawęda B, Borys M, Belina B, Bąk J, Czuczwar M, Wołoszczuk-Gębicka B, Kolowca M, Widenka K. Postoperative pain treatment with erector spinae plane block and pectoralis nerve blocks in patients undergoing mitral/tricuspid valve repair - a randomized controlled trial. BMC Anesthesiol 2020; 20:51. [PMID: 32106812 PMCID: PMC7047405 DOI: 10.1186/s12871-020-00961-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 02/17/2020] [Indexed: 01/08/2023] Open
Abstract
Background Effective postoperative pain control remains a challenge for patients undergoing cardiac surgery. Novel regional blocks may improve pain management for such patients and can shorten their length of stay in the hospital. To compare postoperative pain intensity in patients undergoing cardiac surgery with either erector spinae plane (ESP) block or combined ESP and pectoralis nerve (PECS) blocks. Methods This was a prospective, randomized, controlled, double-blinded study done in a tertiary hospital. Thirty patients undergoing mitral/tricuspid valve repair via mini-thoracotomy were included. Patients were randomly allocated to one of two groups: ESP or PECS + ESP group (1:1 randomization). Patients in both groups received a single-shot, ultrasound-guided ESP block. Participants in PECS + ESP group received additional PECS blocks. Each patient had to be extubated within 2 h from the end of the surgery. Pain was treated via a patient-controlled analgesia (PCA) pump. The primary outcome was the total oxycodone consumption via PCA during the first postoperative day. The secondary outcomes included pain intensity measured on the visual analog scale (VAS), patient satisfaction, Prince Henry Hospital Pain Score (PHHPS), and spirometry. Results Patients in the PECS + ESP group used significantly less oxycodone than those in the ESP group: median 12 [interquartile range (IQR): 6–16] mg vs. 20 [IQR: 18–29] mg (p = 0.0004). Moreover, pain intensity was significantly lower in the PECS + ESP group at each of the five measurements during the first postoperative day. Patients in the PECS + ESP group were more satisfied with pain management. No difference was noticed between both groups in PHHPS and spirometry. Conclusions The addition of PECS blocks to ESP reduced consumption of oxycodone via PCA, reduced pain intensity on the VAS, and increased patient satisfaction with pain management in patients undergoing mitral/tricuspid valve repair via mini-thoracotomy. Trial registration The study was registered on the 19th July 2018 (first posted) on the ClinicalTrials.gov identifier: NCT03592485.
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Affiliation(s)
- Bogusław Gawęda
- Division of Cardiovascular Surgery, St. Jadwiga Provincial Clinical Hospital, ul. Lwowska 60, 35-301, Rzeszów, Poland
| | - Michał Borys
- Second Department of Anesthesia and Intensive Care, Medical University of Lublin, ul. Staszica 16, 20-081, Lublin, Poland.
| | - Bartłomiej Belina
- Anesthesiology and Intensive Care Department with the Center for Acute Poisoning, St. Jadwiga Provincial Clinical Hospital, ul. Lwowska 60, 35-301, Rzeszów, Poland
| | - Janusz Bąk
- Division of Cardiovascular Surgery, St. Jadwiga Provincial Clinical Hospital, ul. Lwowska 60, 35-301, Rzeszów, Poland
| | - Miroslaw Czuczwar
- Second Department of Anesthesia and Intensive Care, Medical University of Lublin, ul. Staszica 16, 20-081, Lublin, Poland
| | - Bogumiła Wołoszczuk-Gębicka
- Anesthesiology and Intensive Care Department with the Center for Acute Poisoning, St. Jadwiga Provincial Clinical Hospital, ul. Lwowska 60, 35-301, Rzeszów, Poland
| | - Maciej Kolowca
- Division of Cardiovascular Surgery, St. Jadwiga Provincial Clinical Hospital, ul. Lwowska 60, 35-301, Rzeszów, Poland
| | - Kazimierz Widenka
- Division of Cardiovascular Surgery, St. Jadwiga Provincial Clinical Hospital, ul. Lwowska 60, 35-301, Rzeszów, Poland
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Alalade E, Bilinovic J, Walch AG, Burrier C, Mckee C, Tobias J. Perioperative Pain Management for Median Sternotomy in a Patient on Chronic Buprenorphine/Naloxone Maintenance Therapy: Avoiding Opioids in Patients at Risk for Relapse. J Pain Res 2020; 13:295-299. [PMID: 32104051 PMCID: PMC7008173 DOI: 10.2147/jpr.s222885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 01/17/2020] [Indexed: 12/14/2022] Open
Abstract
The opioid crisis in the United States has been pandemic. As such, anesthesia providers are frequently faced with patients who have a history of opioid abuse or are currently receiving chronic therapy for such disorders. The chronic administration of medications such as buprenorphine-naloxone can impact the choice of perioperative anesthesia and pain control. Furthermore, the postoperative administration of opioids may lead to relapse in patients with a history of opioid abuse. We present a 26-year-old male with a history of opioid abuse on maintenance therapy with buprenorphine-naloxone, who presented for median sternotomy, cardiopulmonary bypass, and pulmonary valve replacement. The perioperative implications of buprenorphine-naloxone and implementation of multimodal analgesia are discussed, along with options to decrease or eliminate the perioperative use of opioids.
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Affiliation(s)
- Emmanuel Alalade
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jena Bilinovic
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ana Gabriela Walch
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Candice Burrier
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Christopher Mckee
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Ultrasound-guided blocks for cardiovascular surgery: which block for which patient? Curr Opin Anaesthesiol 2020; 33:64-70. [DOI: 10.1097/aco.0000000000000818] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Rai R, Notaras A, Corke P, Falk GL. Regional pain management for oesophagectomy: Cohort study suggests a viable alternative to a thoracic epidural to enhance recovery after surgery. Eur Surg 2020. [DOI: 10.1007/s10353-019-00620-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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45
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Regional anesthesia considerations for cardiac surgery. Best Pract Res Clin Anaesthesiol 2019; 33:387-406. [DOI: 10.1016/j.bpa.2019.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/09/2019] [Indexed: 01/22/2023]
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Pregernig A, Beck-Schimmer B. Which Anesthesia Regimen Should Be Used for Lung
Surgery? CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00356-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Reyad RM, Shaker EH, Ghobrial HZ, Abbas DN, Reyad EM, Abd Alrahman AAM, AL‐Demery A, Issak ERH. The impact of ultrasound‐guided continuous serratus anterior plane block versus intravenous patient‐controlled analgesia on the incidence and severity of post‐thoracotomy pain syndrome: A randomized, controlled study. Eur J Pain 2019; 24:159-170. [DOI: 10.1002/ejp.1473] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 08/26/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Raafat M. Reyad
- Department of Anesthesia and Pain Medicine National Cancer Institute Cairo University Cairo Egypt
| | - Ehab H. Shaker
- Department of Anesthesia and Pain Medicine National Cancer Institute Cairo University Cairo Egypt
| | - Hossam Z. Ghobrial
- Department of Anesthesia and Pain Medicine National Cancer Institute Cairo University Cairo Egypt
| | - Dina N. Abbas
- Department of Anesthesia and Pain Medicine National Cancer Institute Cairo University Cairo Egypt
| | - Ehab M. Reyad
- Department of Clinical Pathology National Hepatology and Tropical Medicine Research Institute Cairo Egypt
| | | | - Amr AL‐Demery
- Department of Surgical Oncology National Cancer Institute Cairo University Cairo Egypt
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A cadaver pilot study to evaluate the impact of the needle bevel orientation on the ease of paravertebral catheter insertion. Can J Anaesth 2019; 66:1421-1422. [PMID: 31452011 DOI: 10.1007/s12630-019-01468-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/08/2019] [Accepted: 08/08/2019] [Indexed: 10/26/2022] Open
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Erector spinae-plane block as an analgesic alternative in patients undergoing mitral and/or tricuspid valve repair through a right mini-thoracotomy - an observational cohort study. Wideochir Inne Tech Maloinwazyjne 2019; 15:208-214. [PMID: 32117506 PMCID: PMC7020722 DOI: 10.5114/wiitm.2019.85396] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/25/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction One of the main challenges in cardiac surgery is effective postoperative analgesia. Erector spinae-plane block (ESP block) is a novel regional technique, introduced by Forero in 2016 for neuropathic chest pain, then used successfully for mastectomy. Aim To establish the efficacy of the ESP block in patients undergoing mitral and/or tricuspid valve repair through a right mini-thoracotomy. Material and methods It is a prospective observational cohort study performed in a tertiary health center. In the treatment group, a single-shot ESP block was performed before anesthetic induction. General anesthesia was induced with etomidate, remifentanil, and rocuronium, and continued with sevoflurane and remifentanil. Remifentanil infusion was continued for 2 h post-operatively, then stopped, and the patient’s trachea was extubated. Patient-controlled analgesia was started with oxycodone immediately. Total oxycodone consumption and pain severity on the visual analog scale during the first 24 h were analyzed. In the control group, no regional block was performed. Instead of remifentanil, fentanyl was used. Patients were extubated on the second day. Pain was treated with morphine, administered according to nurses’ discretion. Pain intensity was evaluated on the numerical rating scale. Results Nineteen patients were evaluated in the ESP and 25 in the control group. Mechanical ventilation time was shorter in the ESP group (0.6 (0.4–1.1) h) than in the control one (10 (8–17) h, p = 0.00001). Moreover, patients in the ESP group spent fewer days in the intensive care unit (1 (1–1) vs. (2 (2–2), p = 0.0001). Conclusions The ESP block seems to be safe and efficient for pain control in patients undergoing right mini-thoracotomy for mitral and/or tricuspid valve repair.
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Stokes SM, Wakeam E, Antonoff MB, Backhus LM, Meguid RA, Odell D, Varghese TK. Optimizing health before elective thoracic surgery: systematic review of modifiable risk factors and opportunities for health services research. J Thorac Dis 2019; 11:S537-S554. [PMID: 31032072 PMCID: PMC6465421 DOI: 10.21037/jtd.2019.01.06] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 12/31/2018] [Indexed: 12/20/2022]
Abstract
Despite progress in many different domains of surgical care, we are still striving toward practices which will consistently lead to the best care for an increasingly complex surgical population. Thoracic surgical patients, as a group, have multiple medical co-morbidities and are at increased risk for developing complications after surgical intervention. Our healthcare systems have been focused on treating complications as they occur in the hopes of minimizing their impact, as well as aiding in recovery. In recent years there has emerged a body of evidence outlining opportunities to optimize patients and likely prevent or decrease the impact of many complications. The purpose of this review article is to summarize four major domains-optimal pain control, nutritional status, functional fitness, and smoking cessation-all of which can have a substantial impact on the thoracic surgical patient's course in the hospital-as well as to describe opportunities for improvement, and areas for future research efforts.
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Affiliation(s)
- Sean M. Stokes
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Elliot Wakeam
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Mara B. Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson, Cancer Center, Houston, TX, USA
| | - Leah M. Backhus
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Robert A. Meguid
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - David Odell
- Division of Thoracic Surgery, Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Thomas K. Varghese
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA
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