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Rubin JE, Ng V, Chung J, Salvatierra N, Rippon B, Khatib D, Girardi NI, Pryor KO, Weinberg RY, Jiang S, Khairallah S, Mick SL, Tedore TR. Efficacy of parasternal peripheral nerve catheters versus no block for median sternotomy: a single-centre retrospective study. BJA OPEN 2024; 11:100288. [PMID: 39007154 PMCID: PMC11245929 DOI: 10.1016/j.bjao.2024.100288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 05/08/2024] [Indexed: 07/16/2024]
Abstract
Background Sternal pain after cardiac surgery results in considerable discomfort. Single-injection parasternal fascial plane blocks have been shown to reduce pain scores and opioid consumption during the first 24 h after surgery, but the efficacy of continuous infusion has not been evaluated. This retrospective cohort study examined the effect of a continuous infusion of local anaesthetic through parasternal catheters on the integrated Pain Intensity and Opioid Consumption (PIOC) score up to 72 h. Methods We performed a retrospective analysis of patients undergoing cardiac surgery with median sternotomy at a single academic centre before and after the addition of parasternal nerve catheters to a standard multimodal analgesic protocol. Outcomes included PIOC score, total opioid consumption in oral morphine equivalents, and time-weighted area under the curve pain scores up to 72 h after surgery. Results Continuous infusion of ropivacaine 0.1% through parasternal catheters resulted in a significant reduction in PIOC scores at 24 h (-62, 95% confidence interval -108 to -16; P<0.01) and 48 h (-50, 95% CI -97 to -2.2; P=0.04) compared with no block. A significant reduction in opioid consumption up to 72 h was the primary factor in reduction of PIOC. Conclusions This study suggests that continuous infusion of local anaesthetic through parasternal catheters may be a useful addition to a multimodal analgesic protocol in patients undergoing cardiac surgery with sternotomy. Further prospective study is warranted to determine the full benefits of continuous infusion compared with single injection or no block.
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Affiliation(s)
- John E. Rubin
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Vanessa Ng
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL, USA
| | - Justin Chung
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Nicolas Salvatierra
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Brady Rippon
- Division of Biostatistics and Epidemiology, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Diana Khatib
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Natalia I. Girardi
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Kane O. Pryor
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Roniel Y. Weinberg
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Silis Jiang
- Center for Perioperative Outcomes, Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Sherif Khairallah
- Department of Cardiothoracic Surgery, NewYork-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Stephanie L. Mick
- Department of Cardiothoracic Surgery, NewYork-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | - Tiffany R. Tedore
- Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medicine, New York, NY, USA
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Harloff MT, Vlassakov K, Sedghi K, Shorten A, Percy ED, Varelmann D, Kaneko T. Efficacy of opioid-sparing analgesia after median sternotomy with continuous bilateral parasternal subpectoral plane blocks. J Thorac Cardiovasc Surg 2024; 167:2157-2169.e4. [PMID: 37212769 DOI: 10.1016/j.jtcvs.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 01/09/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES Regional anesthetic techniques, traditionally underutilized in cardiac surgery, may play a role in multimodal analgesia, effectively improving pain control and reducing opioid consumption. We investigated the efficacy of continuous bilateral ultrasound-guided parasternal subpectoral plane blocks following sternotomy. METHODS We reviewed all opioid-naïve patients who underwent cardiac surgery via median sternotomy under our enhanced recovery after surgery protocol between May 2018 and March 2020. Patients were grouped based on postoperative pain management strategy-those who received standard Enhanced Recovery After Surgery (ERAS) multimodal analgesia alone (no nerve block group) versus those receiving ERAS multimodal analgesia plus continuous bilateral parasternal subpectoral plane blocks (block group). In the block group, parasternal subpectoral plane catheters were placed under ultrasound-guidance on each side of the sternum with initial 0.25% ropivacaine bolus, followed by continuous 0.125% bupivacaine infusions. Postoperative patient-reported numerical rating scale pain scores and opioid consumption in morphine milligram equivalents were compared through postoperative day 4. RESULTS Of 281 patients included in the study, the block group comprised 125 (44%) patients. Although baseline characteristics, type of surgery, and length of stay were similar between groups, average numerical rating scale pain scores and opioid consumption were significantly lower in the block group through postoperative day 4 (all P values < .05). We also observed a 44% reduction in total opioid consumption after surgery in the block group (75.1 vs 133.1 MME; P = .001) and 1 less hospital day requiring opioids (4.2 vs 3 days; P = .001). CONCLUSIONS Continuous bilateral parasternal subpectoral plane blocks may further reduce poststernotomy pain and opioid consumption within the context ERAS multimodal analgesia.
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Affiliation(s)
- Morgan T Harloff
- Division of Cardiac Surgery, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Kamen Vlassakov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Kia Sedghi
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Inova Fairfax Hospital, Falls Church, Va
| | - Andrew Shorten
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Edward D Percy
- Division of Cardiac Surgery, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Dirk Varelmann
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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Wang W, Yang W, Liu A, Liu J, Yuan C. The Analgesic Effect of Ultrasound-guided Erector Spinae Plane Block in Median Sternotomy Cardiac Surgery in Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00349-5. [PMID: 38890084 DOI: 10.1053/j.jvca.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 05/04/2024] [Accepted: 05/16/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVES To assess the analgesic effect of erector spinae plane block in adults undergoing median sternotomy cardiac surgery. DESIGN AND SETTING The Cochrane, Embase, and PubMed databases from inception to January 2024 were searched. The study has been registered in the International Prospective Register of Systematic Reviews (CRD42023470375). PARTICIPANTS Eight randomized controlled trials involving 543 patients, comparing with no block or sham block, were included, whether it was a single injection or continuous. MEASUREMENTS AND MAIN RESULTS The primary outcomes were pain scores and opioid consumption. Erector spinae plane block reduced pain scores immediately after extubation (mean difference [MD], -1.19; 95% confidence interval [CI], -1.67 to -0.71; p for heterogeneity = 0.10), at 6 hours after extubation (MD, -1.96; 95% CI, -2.85 to -1.08; p for heterogeneity < 0.0001), and at 12 hours after extubation (MD, -0.98; 95% CI, -1.55 to -0.40; p for heterogeneity < 0.00001). The decrease in pain scores reached the minimal clinically important difference within 6 hours. Opioid consumption 24 hours after surgery decreased by 35.72 mg of oral morphine equivalents (95% CI, -50.88 to -20.57; p for heterogeneity < 0.0001). Sensitivity analysis confirmed the stability of results. The quality of primary outcomes was rated as very low to moderate. CONCLUSIONS Erector spinae plane block decreased pain scores within 12 hours after extubation, reached the minimal clinically important difference within 6 hours, and decreased opioid consumption 24 hours after surgery, based on data of very low to moderate quality. However, high-quality randomized controlled trials are necessary to validate these findings.
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Affiliation(s)
- Wenzhu Wang
- Department of Anesthesiology, Jining No. 1 People's Hospital, Jining, Shandong, China
| | - Weilin Yang
- Department of Anesthesiology, Deyang People's Hospital, Deyang, Sichuan, China
| | - Ang Liu
- Department of Anesthesiology, Heze Municipal Hospital, Heze, Shandong, China
| | - Jian Liu
- Department of Emergency Surgery, Jining No. 1 People's Hospital, Jining, Shandong, China
| | - Changxiu Yuan
- Department of Anesthesiology, Jining No. 1 People's Hospital, Jining, Shandong, China.
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Kim S, Song SW, Jeon YG, Song SA, Hong S, Park JH. Evaluating the Efficacy of the Erector Spinae Plane Block as a Supplementary Approach to Cardiac Anesthesia during Off-Pump Coronary Bypass Graft Surgery via Median Sternotomy: A Randomized Clinical Trial. J Clin Med 2024; 13:2208. [PMID: 38673480 PMCID: PMC11051109 DOI: 10.3390/jcm13082208] [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: 03/01/2024] [Revised: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Pain control after off-pump coronary artery bypass graft (OPCAB) facilitates mobilization and improves outcomes. The efficacy of the erector spinae plane block (ESPB) after cardiac surgery remains controversial. Methods: We aimed to investigate the analgesic effects of ESPB after OPCAB. Precisely 56 patients receiving OPCAB were randomly divided into ESPB and control groups. The primary outcome was visual analog scale (VAS) pain scores at 6, 12, 24, and 48 h postoperatively. Secondary outcomes were the dose of rescue analgesics in terms of oral morphine milligram equivalents, the dose of antiemetics, the length of intubation time, and the length of stay in the intensive care unit (ICU). Results: The VAS scores were similar at all time points in both groups. The incidence of severe pain (VAS score > 7) was significantly lower in the ESPB group (50% vs. 15.4%; p = 0.008). The dose of rescue analgesics was also lower in the ESPB group (19.04 ± 18.76, 9.83 ± 12.84, p = 0.044) compared with the control group. The other secondary outcomes did not differ significantly between the two groups. Conclusions: ESPB provides analgesic efficacy by reducing the incidence of severe pain and opioid use after OPCAB.
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Affiliation(s)
- Sujin Kim
- Department of Anesthesiology and Pain Medicine, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea; (S.K.); (S.W.S.); (Y.-G.J.); (S.A.S.)
| | - Seung Woo Song
- Department of Anesthesiology and Pain Medicine, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea; (S.K.); (S.W.S.); (Y.-G.J.); (S.A.S.)
| | - Yeong-Gwan Jeon
- Department of Anesthesiology and Pain Medicine, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea; (S.K.); (S.W.S.); (Y.-G.J.); (S.A.S.)
| | - Sang A. Song
- Department of Anesthesiology and Pain Medicine, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea; (S.K.); (S.W.S.); (Y.-G.J.); (S.A.S.)
| | - Soonchang Hong
- Department of Cardiovascular Surgery, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea;
| | - Ji-Hyoung Park
- Department of Anesthesiology and Pain Medicine, Wonju College of Medicine, Yonsei University, Wonju 26426, Republic of Korea; (S.K.); (S.W.S.); (Y.-G.J.); (S.A.S.)
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Greene JJ, Chao S, Tsui BCH. Clinical Outcomes of Erector Spinae Plane Block for Midline Sternotomy in Cardiac Surgery: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2024; 38:964-973. [PMID: 38341301 DOI: 10.1053/j.jvca.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/26/2023] [Accepted: 12/11/2023] [Indexed: 02/12/2024]
Abstract
OBJECTIVES To evaluate the benefit of single-shot erector spinae plane block (ESPB) on pain at postoperative hours 4 and 12, duration of mechanical ventilation, hospital length of stay, intensive care unit (ICU) length of stay, cumulative postoperative opioid usage, and incidence of postoperative nausea and vomiting (PONV) after cardiac surgery via sternotomy DESIGN: A systematic review and meta-analysis of randomized controlled trials and prospective clinical trials. SETTING Studies were identified through the search of PubMed and EMBASE on July 19, 2023. PARTICIPANTS Adults and children undergoing cardiac surgery via sternotomy. INTERVENTIONS Single-shot ESPB versus standard-of-care analgesia. MEASUREMENTS AND MAIN RESULTS A systematic review and meta-analysis of 10 studies (N = 695 patients). The single-shot ESPB arm exhibited statistically significant reductions in pain score at postoperative hour 4 (standardized mean difference [SMD] -2.95, 95% CI -5.86 to -0.04, p = 0.0466), duration of mechanical ventilation (SMD -1.23, 95% CI -2.21 to -0.24, p = 0.0145), cumulative postoperative opioid usage (SMD -1.48, 95% CI -2.46 to -0.49, p = 0.0033), and PONV incidence (risk ratio 0.4358, 95% CI 0.2105-0.9021, p = 0.0252). The single-shot ESPB arm did not exhibit a statistically significant reduction in pain score at postoperative hour 12, length of hospital stay, and length of ICU stay. CONCLUSIONS Single-shot ESPB improves near-term clinical outcomes in patients undergoing cardiac surgery via sternotomy. More randomized controlled trials are needed to validate these findings.
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Affiliation(s)
- Jacob J Greene
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA; University of California - San Francisco School of Medicine, University of California - San Francisco, San Francisco, CA
| | - Sharon Chao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Ban C H Tsui
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
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Gurz S, Dost B, Pirzirenli MG, Buyukkarabacak Y, Taslak Sengul A, Kaya C, Temel NG, Ozdemir E, Basoglu A. Awake sternal fixation; comparison of technical details and early results with sternal fixation methods performed via general anaesthesia. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae039. [PMID: 38490255 PMCID: PMC11095050 DOI: 10.1093/icvts/ivae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/29/2024] [Accepted: 03/13/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVES Isolated sternal fractures are rare pathologies that rarely require surgical fixation. Although different fixation techniques are used, it is routinely performed under general anaesthesia. In our study, we aimed to share the details of the awake sternal fixation technique performed in our clinic and to compare the early results with sternal fixation methods performed under general anaesthesia. METHODS Between January 2009 and January 2023, 129 patients who were diagnosed with sternal fracture and who underwent investigations and follow-up in our clinic were evaluated retrospectively. Thirteen patients who underwent surgical fixation for isolated sternal fracture were included in the study. Patients were categorized according to fixation and anaesthetic technique; group 1: fixation with steel wire under general anaesthesia (n = 4), group 2: fixation with titanium plate-screw under general anaesthesia (n = 4) and group 3: fixation with awake titanium plate-screw with parasternal intercostal plane block (n = 5). Demographics, surgical indication, radiological findings, surgical incision, surgical time and hospital stay were statistically compared. RESULTS The mean age of the patients included in the study was 55.15 ± 15.01 years and 84.6% (n = 11) were male. The most common reason for fixation was displaced fracture (53.8%). Fixation surgery was performed due to pain in 30.8% (n = 4) and non-union in 15.4% (n = 2) of the fractures. The mean duration of surgery were 98.75 ± 16.52, 77.5 ± 35 and 41 ± 14.74 min, respectively. Duration of surgery was significantly lower in group 3 compared to the other groups (P = 0.012). The hospital stay duration for group 1 was 6 days, group 2 was 4 days and group 3 was 1 day. A notable difference was observed among all groups (P = 0.019). CONCLUSIONS Awake sternal fixation technique with titanium plate-screw system under superficial parasternal intercostal plane block is an easy and effective method for surgical treatment of isolated sternal fractures. This technique showed a direct positive effect on the duration of surgery and hospital stay.
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Affiliation(s)
- Selcuk Gurz
- Department of Thoracic Surgery, Ondokuz Mayis University, Medical Faculty, Samsun, Turkey
| | - Burhan Dost
- Department of Anaesthesiology and Reanimation, Ondokuz Mayis University, Medical Faculty, Samsun, Turkey
| | | | - Yasemin Buyukkarabacak
- Department of Thoracic Surgery, Ondokuz Mayis University, Medical Faculty, Samsun, Turkey
| | - Aysen Taslak Sengul
- Department of Thoracic Surgery, Ondokuz Mayis University, Medical Faculty, Samsun, Turkey
| | - Cengiz Kaya
- Department of Anaesthesiology and Reanimation, Ondokuz Mayis University, Medical Faculty, Samsun, Turkey
| | - Necmiye Gul Temel
- Department of Thoracic Surgery, Educational and Research Hospital, Samsun, Turkey
| | - Emine Ozdemir
- Department of Anaesthesiology and Reanimation, Ondokuz Mayis University, Medical Faculty, Samsun, Turkey
| | - Ahmet Basoglu
- Department of Thoracic Surgery, Ondokuz Mayis University, Medical Faculty, Samsun, Turkey
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Pei D, Zeng L, Xiao T, Wu L, Wang L, Wei S, Du Z, Qu S. The optimal induction dose of ciprofol combined with low-dose rocuronium in children undergoing daytime adenotonsillectomy. Sci Rep 2023; 13:22219. [PMID: 38097763 PMCID: PMC10721598 DOI: 10.1038/s41598-023-49778-8] [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: 09/15/2023] [Accepted: 12/12/2023] [Indexed: 12/17/2023] Open
Abstract
Adenotonsillectomy is the most common daytime surgery performed on children. Anesthesiologists must select the optimal combination of drugs to ensure effective anesthesia effect and prompt recovery in children. The optimal induction dose of ciprofol in children is unclear. In this study, we aim to investigate the effect of different doses of ciprofol on anesthesia induction in children undergoing daytime adenotonsillectomy and provide a reference for clinical use. 144 children aged 3-12 years, ASA I-II, undergoing daytime adenotonsillectomy, were included in this clinical trial. The children were randomly divided into three groups and given 0.4 mg/kg (C4), 0.6 mg/kg (C6), or 0.8 mg/kg (C8) of ciprofol for anesthesia induction. The primary outcome was intubation conditions. Vital signs and injection pain were also recorded. The rates of unacceptable intubation conditions were 30.6%, 8.7%, and 8.2% in the C4, C6, and C8 groups (P value < 0.0167). The overall incidence of reported injection pain was 3.5%. The heart rate and mean arterial pressure did not differ between the groups at the same time points. We found that combining 0.6 mg/kg of ciprofol with low-dose rocuronium could provide optimal intubation conditions in pediatric daytime adenotonsillectomy patients. This combination resulted in stable circulation and BIS values. This study is registered at the Chinese Clinical Trial Registry (Registration number: ChiCTR2200063144, Date of Registration: 31/08/2022).
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Affiliation(s)
- Dongjie Pei
- Department of Anesthesiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410000, Hunan, China
| | - Li Zeng
- Department of Anesthesiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410000, Hunan, China
| | - Ting Xiao
- Department of Anesthesiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410000, Hunan, China
| | - Lei Wu
- Department of Anesthesiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410000, Hunan, China
| | - Lei Wang
- Department of Anesthesiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410000, Hunan, China
| | - Siwei Wei
- Department of Anesthesiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410000, Hunan, China
| | - Zhen Du
- Department of Anesthesiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410000, Hunan, China
| | - Shuangquan Qu
- Department of Anesthesiology, Hunan Children's Hospital, 86 Ziyuan Road, Yuhua District, Changsha, 410000, Hunan, China.
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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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Fang N, Ma B, Liu K, Hou Y, Ma Z. Feasibility and safety of ultra-fast track anesthesia for totally thoracoscopic closure of ventricular septal defect: A randomized controlled trial. Heliyon 2023; 9:e15741. [PMID: 37159704 PMCID: PMC10163645 DOI: 10.1016/j.heliyon.2023.e15741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/30/2023] [Accepted: 04/20/2023] [Indexed: 05/11/2023] Open
Abstract
Objective Ultra-fast channel anesthesia (UFTA) can reduce the dosage of opioid narcotic drugs, allow for a rapid postoperative extubation and reduce the harmful stress response during perioperative period. However, there has been limited information about the application of UFTA during thoracoscopic closure of ventricular septal defect (VSD). The aim of this study was to assess the feasibility and safety of UFTA technique in patients undergoing totally thoracoscopic closure of VSD. Methods Seventy-eight patients were randomly divided into study (UFTA) and control (standard general anesthesia) group. Totally thoracoscopic closure of VSD was performed in all patients. Extubation in the study and control group was attempted in the operating room and the intensive care unit, respectively. Results All patients in the study group were extubated in the operating room immediately after surgery, but 2 (6.1%) required reintubation. All the control group patients were extubated after a period of mechanical ventilation (3.0 ± 3.7 h vs 0 h in the study group, p = 0.001) in the intensive care unit. The intensive care and hospital stays in the study group were shorter than in the control group (4.3 ± 2.5 vs 13.4 ± 4.4 h, p = 0.003, and 5.8 ± 0.8 vs 6.5 ± 1.2 d, p = 0.047). The total costs for the treatment in the study group was lower than in the control group (5264 ± 514 vs 4662 ± 461 US dollars, p = 0.02). Conclusions UFTA and operating room extubation was feasible and safe in the majority of patients following totally thoracoscopic closure of VSD. This technique was associated with a shorter intensive care stay and lower overall costs for the surgical treatment.
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Affiliation(s)
- Ningning Fang
- Department of Anesthesia, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 Wenhua Xilu Rd, Jinan, Shandong Province, PR China
| | - Bingbing Ma
- Department of Cardiac Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 Wenhua Xilu Rd, Jinan, Shandong Province, PR China
- Institute of Thoracoscopy in Cardiac Surgery, Cheeloo College of Medicine, Shandong University, No. 107 Wenhua Xilu Rd, Jinan, Shandong Province, PR China
| | - Kai Liu
- Department of Cardiac Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 Wenhua Xilu Rd, Jinan, Shandong Province, PR China
- Institute of Thoracoscopy in Cardiac Surgery, Cheeloo College of Medicine, Shandong University, No. 107 Wenhua Xilu Rd, Jinan, Shandong Province, PR China
| | - Yuedong Hou
- Department of Anesthesia, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 Wenhua Xilu Rd, Jinan, Shandong Province, PR China
- Corresponding author. Department of Anesthesia, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 Wenhua Xilu Rd, Jinan, Shandong Province, PR China.
| | - Zengshan Ma
- Department of Cardiac Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 Wenhua Xilu Rd, Jinan, Shandong Province, PR China
- Institute of Thoracoscopy in Cardiac Surgery, Cheeloo College of Medicine, Shandong University, No. 107 Wenhua Xilu Rd, Jinan, Shandong Province, PR China
- Corresponding author. Department of Cardiac Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 Wenhua Xilu Rd, Jinan, Shandong Province, PR China.
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Tian H, Chen YJ, Tian H, Zhang XS, Lu H, Shen S, Wang H. The anesthesia management of totally thoracoscopic cardiac surgery: A single-center retrospective study. Heliyon 2023; 9:e15737. [PMID: 37180886 PMCID: PMC10173624 DOI: 10.1016/j.heliyon.2023.e15737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 05/16/2023] Open
Abstract
Anesthesia management of Totally thoracoscopic cardiac surgery (TTCS) has been the subject of much debate and discussion. In this single center retrospective study, we summarize the experience of clinical anesthesia management for TTCS by review the medical records of our medical center and look forward to its future development. In this retrospective study, 103 patients (49 male and 54 female) were enrolled, the mean age was 56.7 ± 14.4 years old. The participants underwent Mitral Valve Replacement (MVR) + Tricuspid Valve Annuloplasty (TVA) (42, 40.8%), Mitral Valve Annuloplasty (MVA) + TVA (38, 36.9%), MVA (21, 20.4%), and MVR (2, 1.9%),respectively. Intraoperative hypoxemia, radiographic pulmonary infiltrates, and pneumonia were observed in 19 (18.4%), 84 (81.6%), and 13 (12.6%) patients, respectively. The LOS of ICU and POD were as follows: MVR + TVA (55.1 ± 25h, 9.9 ± 3.5 d), MVA + TVA (56.5 ± 28.4h, 9.4 ± 4.2d), MVA (37.9 ± 21.9h, 8.1 ± 2.3d) and MVR (48 ± 4.2h, 7.5 ± 2.1d). No reintubation, reoperations, postoperative cognitive dysfunction, 30-day mortality were observed in the present study. The present study demonstrated that applying this anesthesia management for TTCS associated with acceptable morbidity, intensive care unit and postoperative hospital lengths of stay. The finding from the present study might provide some new approach for Anesthesia management of TTCS.
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Affiliation(s)
- Hang Tian
- Department of Anesthesiology, Guangzhou Women and Children’s Medical Center, Guangdong Provincial Clinical Research Center for Child Health, Guangzhou, 510623, PR China
| | - Yan-jun Chen
- Department of Anesthesiology, The First Affiliated Hospital, Jinan University, Guangzhou 510630, PR China
| | - He Tian
- Department of Anesthesiology, The First Affiliated Hospital, Jinan University, Guangzhou 510630, PR China
| | - Xiao-shen Zhang
- Department of Cardiovascular Surgery, The First Affiliated Hospital, Jinan University, Guangzhou 510630, PR China
| | - Hua Lu
- Department of Cardiovascular Surgery, The First Affiliated Hospital, Jinan University, Guangzhou 510630, PR China
| | - Si Shen
- Department of Radiology, The First Affiliated Hospital, Jinan University, Guangzhou 510630, PR China
- Corresponding author. Department of Radiology, the First Affiliated Hospital, Jinan University, No. 613, West Huangpu Avenue, Tianhe District, Guangzhou 510630, PR China.
| | - Hao Wang
- Department of Anesthesiology, The First Affiliated Hospital, Jinan University, Guangzhou 510630, PR China
- Corresponding author. Department of Anesthesiology, the First Affiliated Hospital, Jinan University, No. 613, West Huangpu Avenue, Tianhe District, Guangzhou 510630, PR China.
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Allen BFS, McEvoy MD. Regional Anesthesia for Thoracic and Abdominal Surgery: Tips and Tricks for the Surgeon. Am Surg 2023; 89:183-191. [PMID: 35798719 DOI: 10.1177/00031348221109499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The use of ultrasound-guided regional anesthesia (UGRA) has flourished over the past two decades with the description of many novel techniques and the incorporation of UGRA into patient care pathways for many types of surgery, including thoracic and abdominal surgery. Numerous facial plane blocks have been developed for analgesia of the chest and abdomen. Though analgesic efficacy varies based on the specific technique, it is important to be aware of the regional anesthesia techniques in common usage, their analgesic distributions, side effect profiles, and efficacy. In this review, we describe fascial plane blocks developed since 2010 as well as older regional anesthesia techniques and provide context for how and why they might be incorporated into patient care pathways. We will provide salient details on block coverage and briefly discuss evidence and relevant controversies around their use.
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Affiliation(s)
- Brian F S Allen
- Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew D McEvoy
- Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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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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Réhabilitation améliorée après chirurgie cardiaque adulte sous CEC ou à cœur battant 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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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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Quintero-Cifuentes IF, Camilo Clement J, Cruz-Suárez GA, Chaparro-Mendoza K, Holguín-Noreña A, Vélez-Esquivia MA. Bilateral continuous erector spinae plane block for cardiac surgery: case series. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2022. [DOI: 10.5554/22562087.e1042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Multimodal analgesia in cardiac surgery sternotomy includes bilateral continuous erector spinae plane block (BC-ESPB). However, the effectiveness of the local anesthetic regimens is still uncertain.
The purpose of this study was to assess pain control achieved with a multimodal analgesia regimen including BC-ESPB at the level of T5 with PCA with a 0.125 % bupivacaine infusion and rescue boluses.
This is a descriptive case series study which recruited 11 adult patients undergoing cardiac surgery through sternotomy in whom multimodal analgesia including BC-ESPB was used, between February and April 2021, at a fourth level institution.
All patients reported pain according to the numeric rating scale (NRS) ≤ 3 both at rest and in motion, at extubation and then 4 and 12 hours after surgery. After 24 hours the pain was NRS ≤ 3 in 100 % of the patients at rest and in 63.6 % in motion. At 48 h 81 % of the patients reported pain NRS ≤ 3 at rest and in motion. At 72h all patients reported pain NRS ≤ 3 at rest and 82 % in motion. The average intraoperative use of fentanyl was 2.35 µg/kg and postoperative hydromorphone was 5.3, 4.1 and 3.3 mg at 24, 48 and 72 hours, respectively.
Hence, bilateral ESP block in continuous infusion plus rescue boluses allows for proper control of acute intra and post-operative pain.
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Mertes PM, Kindo M, Amour J, Baufreton C, Camilleri L, Caus T, Chatel D, Cholley B, Curtil A, Grimaud JP, Houel R, Kattou F, Fellahi JL, Guidon C, Guinot PG, Lebreton G, Marguerite S, Ouattara A, Provenchère Fruithiot S, Rozec B, Verhoye JP, Vincentelli A, Charbonneau H. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med 2022; 41:101059. [PMID: 35504126 DOI: 10.1016/j.accpm.2022.101059] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline 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 the assessment of the quality of evidence. METHODS Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions. CONCLUSIONS Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.
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Affiliation(s)
- Paul-Michel Mertes
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Michel Kindo
- Department of Cardiac Surgery, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Julien Amour
- Institut de Perfusion, de Réanimation, d'Anesthésie de Chirurgie Cardiaque Paris Sud, IPRA, Hôpital Privé Jacques Cartier, Massy, France
| | - Christophe Baufreton
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France; MITOVASC Institute CNRS UMR 6214, INSERM U1083, University, Angers, France
| | - Lionel Camilleri
- Department of Cardiovascular Surgery, CHU Clermont-Ferrand, T.G.I, I.P., CNRS, SIGMA, UCA, UMR 6602, Clermont-Ferrand, France
| | - Thierry Caus
- Department of Cardiac Surgery, UPJV, Amiens University Hospital, Amiens Picardy University Hospital, Amiens, France
| | - Didier Chatel
- Department of Cardiac Surgery (D.C.), Institut du Coeur Saint-Gatien, Nouvelle Clinique Tours Plus, Tours, France
| | - Bernard Cholley
- Anaesthesiology and Intensive Care Medicine, Hôpital Européen Georges-Pompidou, AP-HP, Université de Paris, INSERM, IThEM, Paris, France
| | - Alain Curtil
- Department of Cardiac Surgery, Clinique de la Sauvegarde, Lyon, France
| | | | - Rémi Houel
- Department of Cardiac Surgery, Saint Joseph Hospital, Marseille, France
| | - Fehmi Kattou
- Department of Anaesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France; Faculté de Médecine Lyon Est, Université Claude-Bernard Lyon 1, Lyon, France
| | - Catherine Guidon
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Intensive Care, Dijon University Hospital, Dijon, France; University of Bourgogne and Franche-Comté, LNC UMR1231, Dijon, France; INSERM, LNC UMR1231, Dijon, France; FCS Bourgogne-Franche Comté, LipSTIC LabEx, Dijon, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM, Unité mixte de recherche CardioMetabolisme et Nutrition, ICAN, AP-HP, Hôpital Pitié-Salpétrière, Paris, France
| | - Sandrine Marguerite
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Alexandre Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, UMR 1034, Biology of Cardiovascular Diseases, F-33600 Pessac, France
| | - Sophie Provenchère Fruithiot
- Department of Anaesthesia, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France; Centre d'Investigation Clinique 1425, INSERM, Université de Paris, Paris, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laennec, CHU Nantes, Nantes, France; Université de Nantes, CHU Nantes, CNRS, INSERM, Institut duDu Thorax, Nantes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - André Vincentelli
- Department of Cardiac Surgery, University of Lille, CHU Lille, Lille, France
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Ali Gado A, Alsadek WM, Ali H, Ismail AA. Erector Spinae Plane Block for Children Undergoing Cardiac Surgeries via Sternotomy: A Randomized Controlled Trial. Anesth Pain Med 2022; 12:e123723. [PMID: 35991776 PMCID: PMC9383540 DOI: 10.5812/aapm-123723] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/25/2022] [Accepted: 03/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background Ineffective management of postoperative pain following pediatric cardiac surgeries adversely affects a patient’s postoperative course. The erector spinae plane (ESP) block has been described in the literature regarding perioperative pain management. We hypothesized that bilateral ESP blocks in pediatric patients would decrease intraoperative fentanyl consumption, reduce the need for postoperative morphine consumption, and improve pain scores. Objectives The aim of this double-blinded randomized controlled trial was to assess the efficacy and safety of bilateral ESP blocks in pediatric patients undergoing cardiac surgeries through a median sternotomy. Methods The study involved 98 children aged 6 months to 7 years who were American Society of Anesthesiologists (ASA) II and III and scheduled for cardiac surgery through a median sternotomy. Patients were divided randomly into 2 groups: the ES group (n = 50) who received bilateral ultrasound-guided ESP blocks, and the N group (n = 48) who received no block. The primary outcome was the total dose of administered fentanyl intraoperatively. Secondary outcomes included morphine consumption in the first 24 hours postoperatively; the length of time before the first need for postoperative analgesia; and FLACC (face, legs, activity, consolability, and cry) scores at the first and second hours postoperatively and every 4 hours, with readings taken for a period of 24 hours. Results There were statistically significantly higher levels of administered fentanyl intraoperatively (6.7 ± 3 vs 4.3 ± 1.9 µg.kg-1) and postoperative morphine consumption (0.5 ± 0.2 vs 0.4 ± 0.2 mg.kg-1) in the N group compared with the ES group (P < 0.001). Moreover, the timing of the first rescue analgesia was significantly delayed in the ES group compared with the N group (231.6 ± 104.5 vs 108.8 ± 47.8 minutes). Conclusions Bilateral ultrasound-guided ESP blocks can be used to reduce perioperative opioid consumption in pediatric patients undergoing cardiac surgery through a sternotomy. It also can be used to decrease postoperative pain scores.
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Affiliation(s)
- Ahmed Ali Gado
- Anesthesia Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | | | - Hassan Ali
- Anesthesia Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Ahmed Abdelaziz Ismail
- Anesthesia Department, Faculty of Medicine, Cairo University, Giza, Egypt
- Corresponding Author: Anesthesia Department, Faculty of Medicine, Cairo University, Giza, Egypt.
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Hamed MA, Boules ML, Sobhy MM, Abdelhady MA. The Analgesic Efficacy of Ultrasound-Guided Bilateral Transversus Thoracic Muscle Plane Block After Open-Heart Surgeries: A Randomized Controlled Study. J Pain Res 2022; 15:675-682. [PMID: 35281480 PMCID: PMC8906859 DOI: 10.2147/jpr.s355231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/24/2022] [Indexed: 11/24/2022] Open
Abstract
Background We aimed to evaluate the analgesic efficacy of ultrasound-guided bilateral transversus thoracic muscle plane block after open-heart surgeries. Methods Seventy patients aged above 18 years and scheduled for valve replacement or adult congenital via median sternotomy were enrolled in this study. Patients were divided into two groups, randomized by computer-generated random numbers: the block group, which had the ultrasound-guided bilateral transversus thoracic muscle plane block, and the control group, which had a sham block. The primary outcome was total fentanyl consumption in the first 24-hours. The secondary outcomes were pain score, time to the first analgesic request, time to extubation, ICU stays, and hospital stay. Results The total fentanyl consumption in the first 24 hours was significantly lower in the block group, with a mean difference of −158.286 (95% CI = (−179.271 to −137.300; p =<0.0001)). The time to the first analgesic request was statistically significantly shorter in the non-block group (median 3 hours) than the block group (median 14 hours). During the postoperative period (0.5–24 hours), at-rest pain scores were 1.86 units lower in the block group (the estimate was −1.80, 95% CI = −2.14 to −1.45, t = −10.323 with p < 0.0001). Likewise, pain scores with cough were 3.29 units lower in the block group (the estimate was −3.29, 95% CI = −3.80 to −2.77, t = −12.703, p < 0.0001). Conclusion Bilateral transversus thoracic muscle plane block is a promising and effective technique in reducing opioid consumption and controlling post-sternotomy pain after open-heart surgery via median sternotomy.
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Affiliation(s)
- Mohamed Ahmed Hamed
- Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
- Correspondence: Mohamed Ahmed Hamed, Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum, 63511, Egypt, Tel +20 111-856-0065, Email
| | - Maged Labib Boules
- Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Mina Mahrous Sobhy
- Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
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Abstract
The aims of "Fast track" cardiac anesthesia including shortening time to tracheal extubation and to hospital discharge in selected patients. The evidence is weak and recommendations are mostly based on observational, nonrandomized data and expert opinion. The majority of outcomes studied include: time to tracheal extubation, hospital/ICU length of stay, procedure-related financial costs, and the type/amount of opioids used in the peri-operative period. There should be a shift in focus to generating higher quality evidence supporting the use of enhanced recovery protocols in cardiac surgical patients and finding ways to tailor enhanced recovery principles to all cardiac surgical patients. Research should focus on the quality of care for individual patients and the delivery of health care to the public.
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Affiliation(s)
- Mike Charlesworth
- Department of Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK.
| | - Andrew Klein
- Department of Cardiothoracic Anaesthesia and Critical Care, Royal Papworth Hospital NHS Foundation Trust, Papworth Road, Trumpington, Cambridge CB2 0AY, UK
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Intrathecal Morphine for Analgesia in Minimally Invasive Cardiac Surgery: A Randomized, Placebo-controlled, Double-blinded Clinical Trial. Anesthesiology 2021; 135:864-876. [PMID: 34520520 DOI: 10.1097/aln.0000000000003963] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intrathecal morphine decreases postoperative pain in standard cardiac surgery. Its safety and effectiveness have not been adequately evaluated in minimally invasive cardiac surgery. The authors hypothesized that intrathecal morphine would decrease postoperative morphine consumption after minimally invasive cardiac surgery. METHODS In this randomized, placebo-controlled, double-blinded clinical trial, patients undergoing robotic totally endoscopic coronary artery bypass received either intrathecal morphine (5 mcg/kg) or intrathecal saline before surgery. The primary outcome was postoperative morphine equivalent consumption in the first 24 h after surgery; secondary outcomes included pain scores, side effects, and patient satisfaction. Pain was assessed via visual analog scale at 1, 2, 6, 12, 24, and 48 h after intensive care unit arrival. Opioid-related side effects (nausea/vomiting, pruritus, urinary retention, respiratory depression) were assessed daily. Patient satisfaction was evaluated with the Revised American Pain Society Outcome Questionnaire. RESULTS Seventy-nine patients were randomized to receive intrathecal morphine (n = 37) or intrathecal placebo (n = 42), with 70 analyzed (morphine 33, placebo 37). Intrathecal morphine patients required significantly less median (25th to 75th percentile) morphine equivalents compared to placebo during first postoperative 24 h (28 [16 to 46] mg vs. 59 [41 to 79] mg; difference, -28 [95% CI, -40 to -18]; P < 0.001) and second postoperative 24 h (0 [0 to 2] mg vs. 5 [0 to 6] mg; difference, -3.3 [95% CI, -5 to 0]; P < 0.001), exhibited significantly lower visual analog scale pain scores at rest and cough at all postoperative timepoints (overall treatment effect, -4.1 [95% CI, -4.9 to -3.3] and -4.7 [95% CI, -5.5 to -3.9], respectively; P < 0.001), and percent time in severe pain (10 [0 to 40] vs. 40 [20 to 70]; P = 0.003) during the postoperative period. Mild nausea was more common in the intrathecal morphine group (36% vs. 8%; P = 0.004). CONCLUSIONS When given before induction of anesthesia for totally endoscopic coronary artery bypass, intrathecal morphine decreases use of postoperative opioids and produces significant postoperative analgesia for 48 h. EDITOR’S PERSPECTIVE
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21
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Regional Anesthesia for Cardiac Surgery: A Review of Fascial Plane Blocks and Their Uses. Adv Anesth 2021; 39:215-240. [PMID: 34715976 DOI: 10.1016/j.aan.2021.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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22
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Vaughan BN, Bartone CL, McCarthy CM, Answini GA, Hurford WE. Ultrasound-Guided Continuous Bilateral Erector Spinae Plane Blocks Are Associated with Reduced Opioid Consumption and Length of Stay for Open Cardiac Surgery: A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10215022. [PMID: 34768541 PMCID: PMC8584924 DOI: 10.3390/jcm10215022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/21/2021] [Accepted: 10/25/2021] [Indexed: 11/16/2022] Open
Abstract
This study tested the hypothesis that continuous bilateral erector spinae plane blocks placed preoperatively would reduce opioid consumption and improve outcomes compared with standard practice in open cardiac surgery patients. Patients who received bilateral continuous erector spinae plane blocks for primary open coronary bypass, aortic valve, or ascending aortic surgery were compared to a historical control group. Patients in the block group received a 0.5% ropivacaine bolus preoperatively followed by a 0.2% ropivacaine infusion begun postoperatively. No other changes were made to the perioperative care protocol. The primary outcome was opioid consumption. Secondary outcomes were time to extubation and length of stay. Twenty-eight patients received continuous erector spinae plane blocks and fifty patients served as historic controls. Patients who received blocks consumed less opioids, expressed as oral morphine equivalents, both intraoperatively (34 ± 17 vs. 224 ± 125 mg) and during their hospitalization (224 ± 108 vs. 461 ± 185 mg). Patients who received blocks had shorter times to extubation (126 ± 87 vs. 257 ± 188 min) and lengths of stay in the intensive care unit (35 ± 17 vs. 58 ± 42 h) and hospital (5.6 ± 1.6 vs. 7.7 ± 4.6 days). Continuous erector spinae plane blocks placed prior to open cardiac surgical procedures reduced opioid consumption, time to extubation, and length of stay compared to a standard perioperative pathway.
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Affiliation(s)
- Brian N. Vaughan
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH 45267, USA;
- Correspondence: ; Tel.: +1-513-258-6313
| | - Cheryl L. Bartone
- The Christ Hospital Health Network, Heart and Vascular Services, Cincinnati, OH 45219, USA; (C.L.B.); (C.M.M.); (G.A.A.)
| | - Catherine M. McCarthy
- The Christ Hospital Health Network, Heart and Vascular Services, Cincinnati, OH 45219, USA; (C.L.B.); (C.M.M.); (G.A.A.)
| | - Geoffrey A. Answini
- The Christ Hospital Health Network, Heart and Vascular Services, Cincinnati, OH 45219, USA; (C.L.B.); (C.M.M.); (G.A.A.)
| | - William E. Hurford
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH 45267, USA;
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Kaya C, Dost B, Dokmeci O, Yucel SM, Karakaya D. Comparison of Ultrasound-Guided Pectointercostal Fascial Block and Transversus Thoracic Muscle Plane Block for Acute Poststernotomy Pain Management After Cardiac Surgery: A Prospective, Randomized, Double-Blind Pilot Study. J Cardiothorac Vasc Anesth 2021; 36:2313-2321. [PMID: 34696966 DOI: 10.1053/j.jvca.2021.09.041] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The objective of the present study was to evaluate morphine consumption and pain scores 24 hours postoperatively to compare the effects of a bilateral pectointercostal fascial block (PIFB) with those of a transversus thoracic muscle plane block (TTMPB) on acute poststernotomy pain in cardiac surgery patients who have undergone median sternotomy. DESIGN Prospective, randomized, double-blinded. SETTING The operating room, intensive care unit, and patient ward at a university hospital. PARTICIPANTS Thirty-nine American Society of Anesthesiologists II-to-III patients aged 18- to-80 years, scheduled for elective cardiac surgery via median sternotomy. INTERVENTIONS Patients randomly were allocated to groups scheduled to receive bilateral ultrasound-guided PIFB or TTMPB. MEASUREMENTS AND MAIN RESULTS The primary outcome was postoperative morphine use within the first 24 hours. Secondary outcomes were the numerical pain rating scale (NRS) scores at rest and during coughing, time of first analgesic demand from the patient-controlled analgesia (PCA) device, and rescue analgesia use. The nausea/vomiting scores, time to extubation, length of stays in intensive care and the hospital, patient satisfaction scores, and complications were also recorded. The first 24-hour morphine use did not significantly differ between the PIFB and TTMPB groups (mean ± standard deviation [95% CI], 13.89 ± 6.80 [10.83-16.95] mg/24 h and 15.08 ± 7.42 [11.83-18.33] mg/24 h, respectively, p = 0.608). No significant difference between the two groups in the NRS scores at rest and during coughing was observed; the groups had similar requirements for rescue analgesia in the first 24 hours (n [%], three [15.8] and seven [35], p = 0.273, respectively). The time from PCA to the first analgesia request was longer in the PIFB than in the TTMPB group (median [interquartile range], 660 [540-900] minutes, and 240 [161-525] minutes, respectively, p = 0.002). CONCLUSIONS PIFB and TTMPB showed similar effectiveness for morphine consumption within 24 hours postoperatively and in pain scores in cardiac surgery patients.
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Affiliation(s)
- Cengiz Kaya
- Department of Anaesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Burhan Dost
- Department of Anaesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey.
| | - Ozgur Dokmeci
- Department of Anaesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Semih Murat Yucel
- Department of Cardiovascular Surgery, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Deniz Karakaya
- Department of Anaesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
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Mancel L, Van Loon K, Lopez AM. Role of regional anesthesia in Enhanced Recovery After Surgery (ERAS) protocols. Curr Opin Anaesthesiol 2021; 34:616-625. [PMID: 34325463 DOI: 10.1097/aco.0000000000001048] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Enhanced Recovery After Surgery (ERAS) protocols and interventional locoregional anesthesia (LRA) techniques continuously evolve. This review outlines the latest recommendations for the use of regional anesthesia in ERAS protocols and emerging interventional analgesia techniques. RECENT FINDINGS Research in ultrasound-guided regional anesthesia has led to a refinement of the traditional techniques and the introduction of a number of new approaches to complement ERAS strategies. The efficacy and versatility of LRA enable its use in an increasing number of ERAS indications. SUMMARY The implementation of ERAS protocols in different surgical procedures reduces overall complications and recovery time. Multimodal analgesia strategies with regional anesthesia techniques are some of the key interventions contributing to the improvement in postoperative outcomes.
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Affiliation(s)
- Leander Mancel
- Department of Anesthesiology, UZ Leuven, Leuven, Belgium
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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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26
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Krakowski JC, Hallman MJ, Smeltz AM. Persistent Pain After Cardiac Surgery: Prevention and Management. Semin Cardiothorac Vasc Anesth 2021; 25:289-300. [PMID: 34416847 PMCID: PMC8669213 DOI: 10.1177/10892532211041320] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Persistent postoperative pain (PPP) after cardiac surgery is a significant complication that negatively affects patient quality of life and increases health care system burden. However, there are no standards or guidelines to inform how to mitigate these effects. Therefore, in this review, we will discuss strategies to prevent and manage PPP after cardiac surgery. Adequate perioperative analgesia may prove instrumental in the prevention of PPP. Although opioids have historically been the primary analgesic approach to cardiac surgery, an opioid-sparing strategy may prove advantageous in reducing side effects, avoiding secondary hyperalgesia, and decreasing risk of PPP. Implementing a multimodal analgesic plan using alternative medications and regional anesthetic techniques may offer superior efficacy while reducing adverse effects.
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Affiliation(s)
| | | | - Alan M Smeltz
- University of North Carolina at Chapel Hill, NC, USA
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27
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Bloc S, Perot BP, Gibert H, Law Koune JD, Burg Y, Leclerc D, Vuitton AS, De La Jonquière C, Luka M, Waldmann T, Vistarini N, Aubert S, Ménager MM, Merzoug M, Naudin C, Squara P. Efficacy of parasternal block to decrease intraoperative opioid use in coronary artery bypass surgery via sternotomy: a randomized controlled trial. Reg Anesth Pain Med 2021; 46:671-678. [PMID: 33990437 DOI: 10.1136/rapm-2020-102207] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 04/19/2021] [Accepted: 05/01/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE This study aims to assess the effect of a preoperative parasternal plane block (PSB) on opioid consumption required to maintain hemodynamic stability during sternotomy for coronary artery bypass graft surgery. METHODS This double-blind, randomized, placebo-controlled trial prospectively enrolled 35 patients scheduled for coronary artery bypass graft surgery under general anesthesia with propofol and remifentanil. Patients were randomized to receive preoperative PSB using either ropivacaine (PSB group) or saline solution (placebo group) (1:1 ratio). The primary endpoint was the maximal effect-site concentration of remifentanil required to maintain heart rate and blood pressure within the recommended ranges during sternotomy. RESULTS Median maximum concentration of remifentanil necessary to maintain adequate hemodynamic status during sternotomy was significantly reduced in PSB group (4.2 (2.5-6.0) ng/mL) compared with placebo group (7.0 (5.2-8.0) ng/mL) (p=0.02). Mean maximum concentration of propofol used to control depth of anesthesia was also reduced (3.9±1.1 µg/mL vs 5.0±1.5 µg/mL, PSB vs placebo, respectively; p=0.02). This reduction in propofol consumption during sternotomy enabled a more adequate level of sedation to be maintained in patients (minimum patient state index was 11.7±8.7 in placebo group and 18.3±6.8 in PSB group; p=0.02). PSB reduced postoperative inflammatory response by limiting concentrations of proinflammatory cytokines IL-8, IL-18, IL-23, IL-33 and MCP-1 measured in the first 7-day after surgery (p<0.05). CONCLUSIONS Preoperative PSB reduced the maximum concentrations of remifentanil and propofol required to maintain hemodynamic stability and depth of anesthesia during sternotomy. TRIAL REGISTRATION NUMBER NCT03734159.Sébastien Bloc, M.D.1,2; Brieuc P. Pérot, Ph.D.3; Hadrien Gibert, M.D.1; Jean-Dominique Law Koune, M.D.1; Yannick Burg, M.D.1; Didier Leclerc, M.D.1; Anne-Sophie Vuitton, M.D.1; Christophe De La Jonquière, M.D.1; Marine Luka, L.S.3; Thierry Waldmann, M.D.4; Nicolas Vistarini, M.D.4; Stéphane Aubert, M.D.4; Mickaël M. Ménager, Ph.D.3; Messaouda Merzoug, Ph.D.2; Cécile Naudin, Ph.D.2; Pierre Squara, M.D.2,5.
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Affiliation(s)
- Sébastien Bloc
- Anesthesiology Department, CMC Ambroise Paré, Neuilly-sur-Seine, France .,Clinical Research Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Brieuc P Perot
- Laboratory of Inflammatory Responses and Transcriptomic Networks in Diseases, Imagine Institute, INSERM UMR 1163, ATIP-Avenir Team, Université de Paris, Paris, France
| | - Hadrien Gibert
- Anesthesiology Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | | | - Yannick Burg
- Anesthesiology Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Didier Leclerc
- Anesthesiology Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | | | | | - Marine Luka
- Laboratory of Inflammatory Responses and Transcriptomic Networks in Diseases, Imagine Institute, INSERM UMR 1163, ATIP-Avenir Team, Université de Paris, Paris, France
| | - Thierry Waldmann
- Cardiac Surgery Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Nicolas Vistarini
- Cardiac Surgery Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Stéphane Aubert
- Cardiac Surgery Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Mickaël M Ménager
- Laboratory of Inflammatory Responses and Transcriptomic Networks in Diseases, Imagine Institute, INSERM UMR 1163, ATIP-Avenir Team, Université de Paris, Paris, France
| | - Messaouda Merzoug
- Clinical Research Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Cécile Naudin
- Clinical Research Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Pierre Squara
- Clinical Research Department, CMC Ambroise Paré, Neuilly-sur-Seine, France.,Critical Care Medicine Department, CMC Ambroise Paré, Neuilly-sur-Seine, France
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Fuller S, Kumar SR, Roy N, Mahle WT, Romano JC, Nelson JS, Hammel JM, Imamura M, Zhang H, Fremes SE, McHugh-Grant S, Nicolson SC. The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recovery after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2021; 162:931-954. [PMID: 34059337 DOI: 10.1016/j.jtcvs.2021.04.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif.
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, Mass
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer C Romano
- Departments of Cardiac Surgery and Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, Mich
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, and Department of Surgery, University of Central Florida College of Medicine, Orlando, Fla
| | - James M Hammel
- Department of Cardiothoracic Surgery, Children's Hospital and Medical Center of Omaha, Omaha, Neb
| | - Michiaki Imamura
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sara McHugh-Grant
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Penn
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Mechanisms of action of the erector spinae plane (ESP) block: a narrative review. Can J Anaesth 2021; 68:387-408. [DOI: 10.1007/s12630-020-01875-2] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/06/2020] [Accepted: 09/06/2020] [Indexed: 12/27/2022] Open
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30
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Abdelbaser II, Mageed NA. Analgesic efficacy of ultrasound guided bilateral transversus thoracis muscle plane block in pediatric cardiac surgery: a randomized, double-blind, controlled study. J Clin Anesth 2020; 67:110002. [DOI: 10.1016/j.jclinane.2020.110002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/01/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
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Ochroch J, Usman A, Kiefer J, Pulton D, Shah R, Grosh T, Patel S, Vernick W, Gutsche JT, Raiten J. Reducing Opioid Use in Patients Undergoing Cardiac Surgery - Preoperative, Intraoperative, and Critical Care Strategies. J Cardiothorac Vasc Anesth 2020; 35:2155-2165. [PMID: 33069556 DOI: 10.1053/j.jvca.2020.09.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/01/2020] [Accepted: 09/09/2020] [Indexed: 02/08/2023]
Abstract
Patients undergoing cardiothoracic surgery are exposed to opioids in the operating room and intensive care unit and after hospital discharge. Opportunities exist to reduce perioperative opioid use at all stages of care and include alternative oral and intravenous medications, novel intraoperative regional anesthetic techniques, and postoperative opioid-sparing sedative and analgesic strategies. In this review, currently used and investigational strategies to reduce the opioid burden for cardiothoracic surgical patients are explored.
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Affiliation(s)
- Jason Ochroch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Asad Usman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse Kiefer
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Danielle Pulton
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ro Shah
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Taras Grosh
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William Vernick
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse Raiten
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Best practice in cardiac anesthesia during the COVID-19 pandemic: Practical recommendations. Best Pract Res Clin Anaesthesiol 2020; 34:569-582. [PMID: 33004168 PMCID: PMC7333625 DOI: 10.1016/j.bpa.2020.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 12/17/2022]
Abstract
The COVID-19 outbreak has influenced the entire health care system, including cardiac surgery. In this review, the authors reveal practical aspects that are important during the COVID-19 pandemic with regards to the safe delivery of cardiac anesthesia. Timing for operations of the cardio-vascular system may be well programmed in most cases. Hence, the level of priorities must be defined for any single patient. The postponement of surgery may be convenient for most cases, if it is made in the best interest of the patient. The preanesthetic evaluation should be attentive of the respiratory history of the patient. Cardiac anesthesia always implies some respiratory monitoring; hence the existing clinical situation of the patient's respiratory system should be clear. In case of emergency surgery, the patient should be treated as if they potentially have or are at risk for the virus. In the case of a COVID-19 confirmed or suspected patient, attention must be made to preserve operating room and team integrity. The machineries are to be draped with plastic to simplify the disinfection after the operation. Perioperative management of suspected or confirmed COVID-19 patients must strictly follow the most relevant international guidelines. This review article has synthesized the common aspects present in the most important of these.
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Ha B, Usman AA, Augoustides JG. Minimally Invasive Cardiac Surgery-Identifying Opportunities for Further Improvement in the Quality of Postoperative Patient Recovery. J Cardiothorac Vasc Anesth 2020; 34:3231-3233. [PMID: 32950344 DOI: 10.1053/j.jvca.2020.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Bao Ha
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Asad Ali Usman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Yoon U, Topper J, Goldhammer J. Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 36:1429-1448. [PMID: 32891522 DOI: 10.1053/j.jvca.2020.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/30/2020] [Accepted: 08/09/2020] [Indexed: 12/13/2022]
Abstract
Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.
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Affiliation(s)
- Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA.
| | - James Topper
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jordan Goldhammer
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
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Abstract
Multimodal pain management of cardiac surgical patients is a paradigm shift in postoperative care. This promising approach features complementary medications and techniques that spare opioids and improves symptomatic and functional recovery. Although the specific elements remain to be defined, the collaboration of the health care team and patient and continuous iterative programmatic improvements are important pillars of this approach.
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Karuppiah N, Pehora C, Haller C, Taylor K. Surgical Closure of Atrial Septal Defects in Young Children-A Review of Anesthesia Care in Sternotomy and Thoracotomy Approaches. J Cardiothorac Vasc Anesth 2020; 35:123-127. [PMID: 32758407 DOI: 10.1053/j.jvca.2020.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/03/2020] [Accepted: 07/04/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To review and compare the anesthetic management of atrial septal defect (ASD) closures via mini lateral thoracotomy and sternotomy approaches. DESIGN Retrospective analysis. SETTING Single- center pediatric quaternary care hospital. PARTICIPANTS Patients aged <8 years of age undergoing ASD closure. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Outcome measures included anesthetic technique, total amount and type of analgesics, pain scores, procedure duration, complications, blood transfusion requirements, and duration of stay. Each group had 15 patients. All patients in the sternotomy group received 0.25% bupivacaine subcutaneous infiltration. Eleven of the 15 thoracotomy patients received a fascial plane block, including serratus anterior and erector spinae blocks, and 3 received subcutaneous infiltration. There was no difference in opioid consumption intraoperatively or in the first 24 hours after surgery (0.28 ± 0.24 mg/kg morphine equivalents in thoracotomy group and 0.21 ± 0.12 mg/kg in sternotomy group). Duration of procedure and cardiopulmonary bypass duration were longer in the thoracotomy group. There was no difference in cross-clamp duration between groups. There was no difference in intensive care unit or hospital stay. CONCLUSIONS The authors reviewed perioperative pain management strategies used in surgical ASD closures. Different fascial plane blocks were used. This study has paved way to design a randomized control trial to compare various regional techniques for cardiac surgeries and identified opportunities for improved pain assessment scoring in children after cardiac surgery.
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Affiliation(s)
- Niveditha Karuppiah
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Carolyne Pehora
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Christoph Haller
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada
| | - Katherine Taylor
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada; University of Toronto, Toronto, Canada.
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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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