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Martins A, Velez Lapão L, Nunes IL, Paula Giordano A, Semedo H, Vital C, Silva R, Coelho P, Londral A. A conversational agent for enhanced Self-Management after cardiothoracic surgery. Int J Med Inform 2024; 192:105640. [PMID: 39321492 DOI: 10.1016/j.ijmedinf.2024.105640] [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: 07/23/2024] [Revised: 09/18/2024] [Accepted: 09/22/2024] [Indexed: 09/27/2024]
Abstract
BACKGROUND Enhanced self-management is crucial for long-term survival following cardiothoracic surgery. OBJECTIVES This study aimed to develop a conversational agent to enhance patient self-management after cardiothoracic surgery. METHODOLOGY The solution was designed and implemented following the Design Science Research Methodology. A pilot study was conducted at the hospital to assess the feasibility, usability, and perceived effectiveness of the solution. Feedback was gathered to inform further interactions. Additionally, a focus group with clinicians was conducted to evaluate the acceptability of the solution, integrating insights from the pilot study. RESULTS The conversational agent, implemented using a rule-based model, was successfully tested with patients in the cardiothoracic surgery unit (n = 4). Patients received one month of text messages reinforcing clinical team recommendations on a healthy diet and regular physical activity. The system received a high usability score, and two patients suggested adding a feature to answer user prompts for future improvements. The focus group feedback indicated that while the solution met the initial requirements, further testing with a larger patient cohort is necessary to establish personalized profiles. Moreover, clinicians recommended that future iterations prioritize enhanced personalization and interoperability with other hospital platforms. Additionally, while the use of artificial generative intelligence was seen as relevant for content personalization, clinicians expressed concerns regarding content safety, highlighting the necessity for rigorous testing. CONCLUSIONS This study marks a significant step towards enhancing post-cardiothoracic surgery care through conversational agents. The integration of a diversity of stakeholder knowledge enriches the solution, grants ownership and ensures its sustainability. Future research should focus on automating message generation and delivery based on patient data and environmental factors. While the integration of artificial generative intelligence holds promise for enhancing patient interaction, ensuring the safety of its content is essential.
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Affiliation(s)
- Ana Martins
- UNIDEMI, Department of Mechanical and Industrial Engineering, Nova School of Science and Technology, Caparica 2829-516, Portugal; Value for Health CoLAB, Lisboa 1150-190, Portugal.
| | - Luís Velez Lapão
- UNIDEMI, Department of Mechanical and Industrial Engineering, Nova School of Science and Technology, Caparica 2829-516, Portugal; Laboratório Associado de Sistemas Inteligentes, Escola de Engenharia Universidade do Minho, Campus Azurém, 4800-058 Guimarães, Portugal; Comprehensive Health Research Center, Nova Medical School, Lisboa 1169-056, Portugal
| | - Isabel L Nunes
- UNIDEMI, Department of Mechanical and Industrial Engineering, Nova School of Science and Technology, Caparica 2829-516, Portugal; Laboratório Associado de Sistemas Inteligentes, Escola de Engenharia Universidade do Minho, Campus Azurém, 4800-058 Guimarães, Portugal
| | - Ana Paula Giordano
- Value for Health CoLAB, Lisboa 1150-190, Portugal; CUBE - CATÓLICA-LISBON Research Unit in Business and Economics, Portugal
| | - Helena Semedo
- Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Rua de Santa Marta, 50, 1169-023 Lisboa Portugal
| | - Clara Vital
- Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Rua de Santa Marta, 50, 1169-023 Lisboa Portugal
| | - Raquel Silva
- NOVA CLUNL - Nova University Lisbon, Colégio Almada Negreiros, 1099-032 Lisboa, Portugal
| | - Pedro Coelho
- Comprehensive Health Research Center, Nova Medical School, Lisboa 1169-056, Portugal; Hospital de Santa Marta, Centro Hospitalar Universitário Lisboa Central, Rua de Santa Marta, 50, 1169-023 Lisboa Portugal
| | - Ana Londral
- Value for Health CoLAB, Lisboa 1150-190, Portugal; Comprehensive Health Research Center, Nova Medical School, Lisboa 1169-056, Portugal; Department of Physics, Nova School of Science and Technology, Caparica 2829-516, Portugal
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Kummer I, Lüthi A, Klingler G, Andereggen L, Urman RD, Luedi MM, Stieger A. Adjuvant Analgesics in Acute Pain - Evaluation of Efficacy. Curr Pain Headache Rep 2024; 28:843-852. [PMID: 38865074 PMCID: PMC11416428 DOI: 10.1007/s11916-024-01276-w] [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] [Accepted: 05/15/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE OF THE REVIEW Acute postoperative pain impacts a significant number of patients and is associated with various complications, such as a higher occurrence of chronic postsurgical pain as well as increased morbidity and mortality. RECENT FINDINGS Opioids are often used to manage severe pain, but they come with serious adverse effects, such as sedation, respiratory depression, postoperative nausea and vomiting, and impaired bowel function. Therefore, most enhanced recovery after surgery protocols promote multimodal analgesia, which includes adjuvant analgesics, to provide optimal pain control. In this article, we aim to offer a comprehensive review of the contemporary literature on adjuvant analgesics in the management of acute pain, especially in the perioperative setting. Adjuvant analgesics have proven efficacy in treating postoperative pain and reducing need for opioids. While ketamine is an established option for opioid-dependent patients, magnesium and α2-agonists have, in addition to their analgetic effect, the potential to attenuate hemodynamic responses, which make them especially useful in painful laparoscopic procedures. Furthermore, α2-agonists and dexamethasone can extend the analgesic effect of regional anesthesia techniques. However, findings for lidocaine remain inconclusive.
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Affiliation(s)
- Isabelle Kummer
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland.
| | - Andreas Lüthi
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Gabriela Klingler
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Lukas Andereggen
- Department of Neurosurgery, Cantonal Hospital of Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Markus M Luedi
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrea Stieger
- Department of Anesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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Flinspach AN, Raimann FJ, Kaiser P, Pfaff M, Zacharowski K, Neef V, Adam EH. Volatile versus propofol sedation after cardiac valve surgery: a single-center prospective randomized controlled trial. Crit Care 2024; 28:111. [PMID: 38581030 PMCID: PMC10996161 DOI: 10.1186/s13054-024-04899-y] [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: 01/29/2024] [Accepted: 04/03/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Optimal intensive care of patients undergoing valve surgery is a complex balancing act between sedation for monitoring and timely postoperative awakening. It remains unclear, if these requirements can be fulfilled by volatile sedations in intensive care medicine in an efficient manner. Therefore, this study aimed to assess the time to extubation and secondary the workload required. METHODS We conducted a prospective randomized single-center trial at a tertiary university hospital to evaluate the postoperative management of open valve surgery patients. The study was randomized with regard to the use of volatile sedation compared to propofol sedation. Sedation was discontinued 60 min after admission for critical postoperative monitoring. RESULTS We observed a significantly earlier extubation (91 ± 39 min vs. 167 ± 77 min; p < 0.001), eye-opening (86 ± 28 min vs. 151 ± 71 min; p < 0.001) and command compliance (93 ± 38 min vs. 164 ± 75 min; p < 0.001) using volatile sedation, which in turn was associated with a significantly increased workload of a median of 9:56 min (± 4:16 min) set-up time. We did not observe any differences in complications. Cardiopulmonary bypass time did not differ between the groups 101 (IQR 81; 113) versus 112 (IQR 79; 136) minutes p = 0.36. CONCLUSIONS Using volatile sedation is associated with few minutes additional workload in assembling and enables a significantly accelerated evaluation of vulnerable patient groups. Volatile sedation has considerable advantages and emerges as a safe sedation technique in our vulnerable study population. TRIAL REGISTRATION Clinical trials registration (NCT04958668) was completed on 1 July 2021.
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Affiliation(s)
- Armin Niklas Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany.
| | - Florian Jürgen Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Philipp Kaiser
- Department of Cardiothoracic Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Michaela Pfaff
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Elisabeth Hannah Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590, Frankfurt am Main, Germany
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Delijani D, Race A, Cassiere H, Pena J, Shore-Lesserson LJ, Demekhin V, Manetta F, Huang X, Karman DA, Hartman A, Yu PJ. Impact of Limited Enhanced Recovery Pathway for Cardiac Surgery: A Single-Institution Experience. J Cardiothorac Vasc Anesth 2024; 38:175-182. [PMID: 37980194 DOI: 10.1053/j.jvca.2023.10.021] [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: 07/30/2023] [Revised: 10/09/2023] [Accepted: 10/16/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVES Enhanced recovery pathway (ERP) refers to extensive multidisciplinary, evidence-based pathways used to facilitate recovery after surgery. The authors assessed the impact that limited ERP protocols had on outcomes in patients undergoing cardiac surgery at their institution. DESIGN A retrospective cohort study. SETTING This study was a single-institution study conducted at a university hospital. PARTICIPANTS Patients undergoing open adult cardiac surgery. INTERVENTIONS Enhanced recovery pathways limited to preoperative, intraoperative, and postoperative management of pain, atrial fibrillation prevention, and nutrition optimization were implemented. MEASUREMENTS AND MAIN RESULTS A total of 1,058 patients were included in this study. There were 374 patients in each pre- and post-ERP cohort after propensity matching, with no significant baseline differences between the 2 cohorts. Compared to the matched patients in the pre-ERP group, patients in the post-ERP group had decreased total ventilation hours (6.8 v 7.8, p = 0.006), less use of postoperative opioid analgesics as determined by total morphine milligram equivalent (32.5 v 47.5, p < 0.001), and a decreased rate of postoperative atrial fibrillation (23.3% v 30.5%, p = 0.032). Post-ERP patients also experienced less subjective pain and postoperative nausea and drowsiness as compared to their matched pre-ERP cohorts. CONCLUSIONS Limited ERP implementation resulted in significantly improved perioperative outcomes. Patients additionally experienced less postoperative pain despite decreased opioid use. Implementation of ERP, even in a limited format, is a promising approach to improving outcomes in patients undergoing cardiac surgery.
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Affiliation(s)
- David Delijani
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Abigail Race
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Hugh Cassiere
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Joseph Pena
- Department of Anesthesia, North Shore University Hospital, Northwell Health, Manhasset, NY
| | | | - Valerie Demekhin
- Department of Pharmacy, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Frank Manetta
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Xueqi Huang
- Department of Biostatistics, Feinstein Institutes for Medical Research, Manhasset, NY
| | - Douglas A Karman
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Alan Hartman
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY
| | - Pey-Jen Yu
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Manhasset, NY.
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Pollock KM, Ambroziak R, Mullen C, King L, Barsa A. Outcomes Related to Cardiac Enhanced Recovery After Surgery Protocol. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00234-3. [PMID: 37127522 DOI: 10.1053/j.jvca.2023.03.043] [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: 12/08/2022] [Revised: 03/17/2023] [Accepted: 03/30/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES The objective of this study was to assess the quality of pain control and outcomes in patients who underwent coronary artery bypass graft (CABG) over a period of 96 hours preimplementation of a cardiac enhanced recovery after surgery (C-ERAS) protocol compared with postimplementation. DESIGN Single-center, retrospective cohort study. SETTING Cleveland Clinic Akron General Hospital. PARTICIPANTS Patients ≥18 years of age who underwent CABG surgery and received perioperative pain management pre- and post-C-ERAS protocol implementation at admission to Cleveland Clinic Akron General Hospital. INTERVENTIONS A hospital C-ERAS protocol that included a multimodal analgesia approach to postoperative pain management. MEASUREMENTS AND MAIN RESULTS The primary outcome was the amount of opioid used measured in morphine milligram equivalents (MME) within 96 hours postoperatively. A total of 146 charts were reviewed, with 133 included (66 pre-C-ERAS and 67 post-C-ERAS). There was a significant reduction in median MMEs 96 hours postoperatively post-C-ERAS (98 [52-135] v 211 [130-290], p < 0.001). Additionally, a significant reduction in median MMEs was observed post-C-ERAS before (65 [43-100] v 129 [95-165], p < 0.001) and after (10 [0-40] v 68 [21-141], p < 0.001) chest tube removal and for the entire prescription at discharge (0 [0-109] v 90 [0-210], p = 0.005). CONCLUSIONS Implementing a C-ERAS protocol within a CABG surgery patient population reduced the amount of MME.
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Affiliation(s)
- Kailee M Pollock
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, OH
| | - Ronda Ambroziak
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, OH
| | - Chanda Mullen
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, OH
| | - Liz King
- Department of Surgery, Cleveland Clinic Akron General, Akron, OH
| | - Angela Barsa
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, OH.
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Jiang S, Wang L, Teng H, Lou X, Wei H, Yan M. The Clinical Application of Ultra-Fast-Track Cardiac Anesthesia in Right-Thoracoscopic Minimally Invasive Cardiac Surgery: A Retrospective Observational Study. J Cardiothorac Vasc Anesth 2023; 37:700-706. [PMID: 36804223 DOI: 10.1053/j.jvca.2023.01.010] [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: 04/05/2022] [Revised: 12/15/2022] [Accepted: 01/08/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the effect of ultra-fast-track cardiac anesthesia (UFTCA) on rapid postoperative recovery in patients undergoing right-thoracoscopic minimally invasive cardiac surgery. DESIGN A retrospective observational study. SETTING A single large teaching hospital. PARTICIPANTS A total of 153 patients who underwent right-thoracoscopic minimally invasive cardiac surgery between January 2021 and August 2021 were enrolled. The inclusion criteria were American Society of Anesthesiologists grade I to III, New York Heart Association (NYHA) cardiac function class I to III, and age ≥18 years. The exclusion criteria were NYHA class IV, local anesthetic allergy, severe pulmonary hypertension (pulmonary arterial systolic pressure, PASP >70 mmHg), age ≤18 years or ≥80 years old, emergency surgery, and patients with incomplete or missing data. INTERVENTIONS Finally, a total of 122 patients were included and grouped by different anesthesia strategies. Sixty patients received serratus anterior plane block-assisted ultra-fast- track cardiac anesthesia (UFTCA group), and 62 patients received conventional general anesthesia (CGA group). The primary outcomes were lengths of hospital stay and postoperative intensive care unit (ICU) stay. The secondary outcomes were postoperative pain scores, opioids use, postoperative chest tube drainage, and complications. MEASUREMENTS AND MAIN RESULTS The intraoperative dosages of sufentanil and remifentanil in the UFTCA group were significantly lower than those in the CGA group (66.25 ± 1.03 µg v 283.31 ± 11.36 µg, p < 0.001; and 1.94 ± 0.38 mg v 2.14 ± 0.99 mg, p < 0.001, respectively). The incidence of postoperative rescue analgesia in the UFTCA group was significantly lower than that in the CGA group (10 patients [16.67%] v 30 patients [48.38%], p < 0.001). In the postoperative ICU, there were fewer patients with pain score Numeric Rating Scale ≥3 in the UFTCA group than that in the CGA group (10 patients [16.67%] v 29 patients [46.78%], p < 0.001). The postoperative extubation time in the UFTCA group was shorter than that in the CGA group (0.3 hours [range, 0.25-0.4 hours] v 13.84 hours [range, 10.25-18.36 hours], p < 0.001). Lengths of ICU stay and hospital stay in the UFTCA group were shorter than those in the CGA group (27.73 ± 16.54 hours v 61.69 ± 32.48 hours, p < 0.001; and 8 days [range, 7-9] v 9 days [range, 8-12], p < 0.001, respectively). Compared with the CGA group, the patients in the UFTCA group had less chest tube drainage within 24 hours after surgery (197.67 ± 13.05 mL v 318.23 ± 160.10 mL, p < 0.001). There were no significant differences in in-hospital mortality, postoperative bleeding, or secondary surgery between the 2 groups. The incidences of postoperative nausea, vomiting, or atelectasis were comparable between the 2 groups. CONCLUSIONS Serratus anterior plane block-assisted ultra-fast-track cardiac anesthesia can promote rapid postoperative recovery in patients with right-thoracoscopic minimally invasive cardiac surgery. This anesthesia regimen is clinically safe and feasible.
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Affiliation(s)
- Shenjie Jiang
- Rehabilitation Medicine Center, Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Lixin Wang
- Jinzhou Medical University NO 40, Jinzhou City, Liaoning Province, China
| | - Haokang Teng
- Jinzhou Medical University NO 40, Jinzhou City, Liaoning Province, China
| | - Xiaokan Lou
- Rehabilitation Medicine Center, Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Hanwei Wei
- Rehabilitation Medicine Center, Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Meijuan Yan
- Rehabilitation Medicine Center, Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China.
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Bello C, Luedi MM. High time for a holistic approach to perioperative care in urological surgery. World J Urol 2022; 40:1061-1062. [PMID: 33837449 DOI: 10.1007/s00345-021-03677-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
- Corina Bello
- Department of Anesthesiology, Spitalregion Rheintal, Werdenberg, Sarganserland, Spitalstrasse 44, 9472, Grabs, Switzerland.
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Abstract
Purpose of Review Postcraniotomy headache (PCH) is a highly underappreciated and very common adverse event following craniotomy. Recent Findings Analgetic medication with opioids often interferes with neurologic evaluation in the acute phase of recovery and should be kept to a minimal, in general, in the treatment of chronic pain as well. We provide an update on the latest evidence for the management of acute and chronic PCH. Summary Especially in the neurosurgical setting, enhanced recovery after surgery protocols need to include a special focus on pain control. Patients at risk of developing chronic pain must be identified and treated as early as possible.
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Fuchs A, Heinisch PP, Luedi MM, Reid CS. Pain after cardiac surgery: Time to include multimodal pain management concepts in ERAS protocols. J Clin Anesth 2021; 76:110583. [PMID: 34768206 DOI: 10.1016/j.jclinane.2021.110583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Paul Philipp Heinisch
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Catherine S Reid
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Hartmann ES, Heinisch PP, Luedi MM, Mihalj M. Many steps can be taken to enhance recovery after thoracic surgery. J Cardiothorac Surg 2021; 16:278. [PMID: 34583731 PMCID: PMC8480051 DOI: 10.1186/s13019-021-01655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
Our letter to the editor comments on issues raised in the May 14, 2020, article by Budacan et al. addressing the development of enhanced recovery after thoracic surgery. In the United Kingdom and Ireland, a nationwide survey identified issues. Here, we expand on the authors’ findings.
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Affiliation(s)
| | - Paul Philipp Heinisch
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maks Mihalj
- Department of Cardiovascular Surgery, Bern University Hospital, University of Bern, Bern, Switzerland.
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Damstra J, Geerts BF, Rex S, Vlaar APJ, Driessen AHG, Engelman DT, Klautz RJM, Eberl S. Perioperative Care Standards in Cardiac Surgery Patients Aiming at Enhancing Recovery: A Nationwide Survey in the Netherlands and Belgium. J Cardiothorac Vasc Anesth 2021; 36:109-117. [PMID: 34602324 DOI: 10.1053/j.jvca.2021.08.106] [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: 12/19/2020] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this survey was to describe existing perioperative care standards and best practices in the Netherlands and Belgium. DESIGN An online survey was followed up by an in-depth personal interview. The main outcomes were the existing standards of perioperative care for patients undergoing cardiac surgery. SETTING The online survey and subsequent interviews were targeted to one representative in the intensive care unit (ICU), cardiac surgery, and anesthesiology department from each cardiac surgical center in the Netherlands and Belgium. PARTICIPANTS A representative intensive care physician, cardiac surgeon, and cardiac anesthesiologist. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The response rate was 60% (71% for the Netherlands, and 44% in Belgium). Agreement across centers was found for discontinuation of proton-pump inhibitors (80%) and avoiding intra- and postoperative (92%) nonsteroidal antiinflammatory drugs. Additionally, 98% of respondents stated that physiotherapy should be started immediately in the ICU. Major divergence was found for elements such as the discontinuation of angiotensin-converting enzyme inhibitors (55%) or the postoperative use of chest support vests (44%). CONCLUSIONS The authors demonstrated a wide range of different local protocols. Strategies differed among disciplines, hospitals, and countries. This emphasized the need for the implementation of a more universal protocol to further reduce variance and improve recovery practices. This nationwide survey was the first of its kind simultaneously studying best practices for cardiac surgery through the entire care pathway at the advent of Enhanced Recovery After Surgery (ERAS) Cardiac implementation. A multinational randomized controlled trial to test the implementation of an evidence-based ERAS Cardiac protocol is the next step to pave the way for further outcome improvements in this high-risk population.
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Affiliation(s)
- Jill Damstra
- Department of Anesthesiology, Amsterdam University Medical Center (UMC), Location AMC, the Netherlands.
| | - Bart F Geerts
- Department for Intensive Care, Spaarne Gasthuis, Haarlem, the Netherlands
| | - Steffen Rex
- Department of Anesthesiology, University Hospital Leuven, Belgium; and Department of Cardiovascular Sciences, Katholieke Universiteit (KU) Leuven, Belgium
| | | | - Antoine H G Driessen
- Department of Cardiothoracic Surgery, Amsterdam UMC, location AMC, the Netherlands
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, Springfield and University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Amsterdam UMC, location AMC, the Netherlands
| | - Susanne Eberl
- Department of Anesthesiology, Amsterdam University Medical Center (UMC), Location AMC, the Netherlands
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12
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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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Ahuja S, Luedi MM. Too little or too much anesthesia: Age paradox of electroencephalogram indices. J Clin Anesth 2021; 73:110358. [PMID: 34082269 DOI: 10.1016/j.jclinane.2021.110358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Sanchit Ahuja
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Health System, Detroit, MI, United States; Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, United States
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Heinisch PP, Reid CS, Meineri M, Luedi MM. Understanding perioperative patient blood management practices in Europe: Are we following the guidelines? J Clin Anesth 2021; 73:110349. [PMID: 34062475 DOI: 10.1016/j.jclinane.2021.110349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/13/2021] [Accepted: 05/13/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Catherine S Reid
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Massimiliano Meineri
- Department of Anaesthesiology and Intensive Care Medicine, Heart Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Kotfis K, Jamioł-Milc D, Skonieczna-Żydecka K, Folwarski M, Stachowska E. The Effect of Preoperative Carbohydrate Loading on Clinical and Biochemical Outcomes after Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Trials. Nutrients 2020; 12:nu12103105. [PMID: 33053694 PMCID: PMC7600335 DOI: 10.3390/nu12103105] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 12/11/2022] Open
Abstract
Background and aim: Preoperative fasting leads to metabolic stress and causes insulin resistance in patients undergoing cardiac surgery. The aim of this study was to assess the effect of preoperative oral carbohydrate loading (OCH) on outcome in patients undergoing planned cardiac surgery by systematically reviewing the literature and synthesizing evidence from randomized controlled trials (RCTs). Methods: Systematic search of PubMed/MEDLINE/Embase/Cinahl/Web of Science/ClinicalTrials databases was performed to identify relevant RCTs from databased inception until 05/03/2020. We included studies that compared outcome measures between OCH with control (placebo or standard starvation). We conducted a random-effect meta-analysis of clinical and biochemical parameters. Results: Nine studies (N = 9) were included with a total of 507 patients. OCH significantly decreased aortic clamping duration (n = 151, standardized mean difference (SMD) = −0.28, 95% confidence interval (CI) = −0.521 to −0.038, p = 0.023 and differences in means (DM) = −6.388, 95%CI = −11.246 to −1.529, p = 0.010). Patients from treatment groups had shorter intensive care unit (ICU) stay (n = 202, SMD = −0.542, 95%CI = −0.789 to −0.295, p < 0.001 and DM = −25.925, 95%CI = −44.568 to −7.283, p = 0.006) and required fewer units of insulin postoperatively (n = 85, SMD = −0.349, 95%CI = −0.653 to −0.044, p = 0.025 and DM = −4.523, 95%CI = −8.417 to −0.630, p = 0.023). The necessity to use inotropic drugs was significantly lower in the OCH group (risk ratio (RR) = 0.795, 95%CI = 0.689 to 0.919, p = 0.002). All other primary outcomes did not reveal a significant effect. Conclusions: Preoperative OCH in patients undergoing cardiac surgery demonstrated a 20% reduction in the use of inotropic drugs, a 50% reduction of the length of ICU stay, a 28% decrease in aortic clamping duration and a 35% decrease of postoperative insulin requirement.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, 70-111 Szczecin, Poland;
| | - Dominika Jamioł-Milc
- Department of Human Nutrition and Metabolomics, Pomeranian Medical University in Szczecin, 71-460 Szczecin, Poland; (K.S.-Ż.); (E.S.)
- Correspondence: ; Tel.: +48-91-441-48-06; Fax: +48-91-441-48-07
| | - Karolina Skonieczna-Żydecka
- Department of Human Nutrition and Metabolomics, Pomeranian Medical University in Szczecin, 71-460 Szczecin, Poland; (K.S.-Ż.); (E.S.)
| | - Marcin Folwarski
- Department of Clinical Nutrition and Dietetics, Medical University of Gdansk, 80-210 Gdansk, Poland;
- Home Enteral and Parenteral Nutrition Unit, General Surgery, Nicolaus Copernicus Hospital, 80-210 Gdansk, Poland
| | - Ewa Stachowska
- Department of Human Nutrition and Metabolomics, Pomeranian Medical University in Szczecin, 71-460 Szczecin, Poland; (K.S.-Ż.); (E.S.)
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Cardinale JP, Latimer R, Curtis C, Bukovskaya Y, Kosarek L, Falterman J, Tatum DM, Trusheim J. Incorporation of the Transverse Thoracic Plane Block Into a Multimodal Early Extubation Protocol for Cardiac Surgical Patients. Semin Cardiothorac Vasc Anesth 2020; 25:301-309. [DOI: 10.1177/1089253220957484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background The aim for early extubation remains an important goal in cardiac surgical patients. Therefore, employment of a multimodal approach to pain management that includes a transverse thoracic plane block was retrospectively examined at a single-center tertiary care hospital on the effects of time to extubation, opioid consumption, and length of stay in patients undergoing cardiac surgery via median sternotomy. Methods Blocks were performed on all cardiac surgical patients except for those undergoing left ventricular assist device placement, thoracic transplant, emergent surgery, or redo sternotomy. Following additional exclusions for intra- and postoperative complications unrelated to anesthesia, final analysis was conducted on 75 patients per group. Multimodal pain management included intravenous analgesics and transverse thoracic plane block where patients received 15 mL 0.5% bupivacaine + epinephrine bilaterally under ultrasound guidance prior to incision. Results Following transverse thoracic plane block and multimodal analgesics, 50.6% of patients were extubated in the operation room versus 8.6% in the control group. Intraoperative opioids were decreased, and intensive care unit and total length of stay were reduced by 5 hours and 1 day, respectively, in block patients as compared with controls. Postoperative opioids were not significantly different. There were no reported complications directly attributed to the block. Conclusions The transverse thoracic plane block and multimodal regimen for patients undergoing median sternotomy resulted in a significant number of patients extubated in the operation room without an increase in postoperative re-intubations. Moreover, the block appears to be a quick and safe procedure to utilize on cardiac surgery patients.
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17
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Baxter R, Squiers J, Conner W, Kent M, Fann J, Lobdell K, DiMaio JM. Enhanced Recovery After Surgery: A Narrative Review of its Application in Cardiac Surgery. Ann Thorac Surg 2020; 109:1937-1944. [DOI: 10.1016/j.athoracsur.2019.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 10/30/2019] [Accepted: 11/01/2019] [Indexed: 01/23/2023]
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18
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Grant MC, Isada T, Ruzankin P, Whitman G, Lawton JS, Dodd-o J, Barodka V, Grant MC, Isada T, Ibekwe S, Mihocsa AB, Ruzankin P, Gottschalk A, Liu C, Whitman G, Lawton JS, Mandal K, Dodd-o J, Barodka V. Results from an enhanced recovery program for cardiac surgery. J Thorac Cardiovasc Surg 2020; 159:1393-1402.e7. [DOI: 10.1016/j.jtcvs.2019.05.035] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/19/2019] [Accepted: 05/10/2019] [Indexed: 11/29/2022]
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Coleman SR, Chen M, Patel S, Yan H, Kaye AD, Zebrower M, Gayle JA, Liu H, Urman RD. Enhanced Recovery Pathways for Cardiac Surgery. Curr Pain Headache Rep 2019; 23:28. [DOI: 10.1007/s11916-019-0764-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Noss C, Prusinkiewicz C, Nelson G, Patel PA, Augoustides JG, Gregory AJ. Enhanced Recovery for Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 32:2760-2770. [DOI: 10.1053/j.jvca.2018.01.045] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Indexed: 12/13/2022]
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Affiliation(s)
- Junichi Sugita
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Katsuhito Fujiu
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo.,Department of Advanced Cardiology, Graduate School of Medicine, The University of Tokyo
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Jing X, Zhang B, Xing S, Tian L, Wang X, Zhou M, Li J. Cost-benefit analysis of enhanced recovery after hepatectomy in Chinese Han population. Medicine (Baltimore) 2018; 97:e11957. [PMID: 30142819 PMCID: PMC6113004 DOI: 10.1097/md.0000000000011957] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs have been proved effective for enhancing the clinical healing rate and reducing hospitalization cost in most countries of the world. It's a multi-model approach that designed to optimize perioperative pathway, attenuate the surgical stress response, and decrease postoperative complications. OBJECTIVE The economic benefit from the application of ERAS to colorectal surgery has been demonstrated in China. However, such economic benefit of ERAS programs for hepatectomy hasn't been clarified yet. This study was carried out to explore the clinical efficacy and cost effectiveness of ERAS in Chinese Han population after hepatectomy. METHODS ERAS program was implemented in our department for hepatectomy in December 2016. In total, 79 consecutive patients after hepatectomy were chosen as ERAS group (ERAS protocol) in coming half year while 121 consecutive patients after hepatectomy were chosen as Pre-ERAS group (traditional protocol) in past half year. The operation time, intraoperative blood loss, length of hospital stay (LOS), complication, readmission, and hospitalization cost of 2 groups were compared. RESULTS The LOS of ERAS group was 5.81 ± 1.79 days, significantly shorter than that of Pre-ERAS group (8.06 ± 3.40 d) (P = .000). The operation time was 168.03 ± 46.20 minutes for ERAS group and 175.41 ± 64.64 minutes for Pre-ERAS group respectively (P = .417). The intraoperative blood loss was 166.58 ± 194.13 mL (ERAS group) and 205.45 ± 279.63 mL (Pre-ERAS group) (P = .293). It should be noted that the hospitalization cost of ERAS group was 51556.18 ± 8926.05 Yuan (7835.05 ± 1355.45 US dollars), significantly less than that of Pre-ERAS group 60554.66 ± 15615.31 Yuan (9202.56 ± 2371.24 US dollars) (P = .000). The application of ERAS effectively saved 8998.48 Yuan (1367.51 US dollars) for each patient. CONCLUSIONS ERAS implementation for hepatectomy surgery is safe and feasible for Chinese Han population. It eventually enhanced the clinical healing rate. The benefits from such programs include a reduction of the LOS, complication, and readmission rates. So each patient has access to better medical service. It effectively relieved the financial burden of patients. The benefits from such programs include a reduction of the hospitalization cost, especially in medication cost. So each patient can afford the diseases.
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