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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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Pagé MG, Ganty P, Wong D, Rao V, Khan J, Ladha K, Hanlon J, Miles S, Katznelson R, Wijeysundera D, Katz J, Clarke H. A Prospective Cohort Study of Acute Pain and In-Hospital Opioid Consumption After Cardiac Surgery: Associations With Psychological and Medical Factors and Chronic Postsurgical Pain. Anesth Analg 2024; 138:1192-1204. [PMID: 38295119 DOI: 10.1213/ane.0000000000006848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND Understanding the association of acute pain intensity and opioid consumption after cardiac surgery with chronic postsurgical pain (CPSP) can facilitate implementation of personalized prevention measures to improve outcomes. The objectives were to (1) examine acute pain intensity and daily mg morphine equivalent dose (MME/day) trajectories after cardiac surgery, (2) identify factors associated with pain intensity and opioid consumption trajectories, and (3) assess whether pain intensity and opioid consumption trajectories are risk factors for CPSP. METHODS Prospective observational cohort study design conducted between August 2012 and June 2020 with 1-year follow-up. A total of 1115 adults undergoing cardiac surgery were recruited from the preoperative clinic. Of the 959 participants included in the analyses, 573 completed the 1-year follow-up. Main outcomes were pain intensity scores and MME/day consumption over the first 6 postoperative days (PODs) analyzed using latent growth mixture modeling (GMM). Secondary outcome was 12-month CPSP status. RESULTS Participants were mostly male (76%), with a mean age of 61 ± 13 years. Three distinct linear acute postoperative pain intensity trajectories were identified: "initially moderate pain intensity remaining moderate" (n = 62), "initially mild pain intensity remaining mild" (n = 221), and "initially moderate pain intensity decreasing to mild" (n = 251). Age, sex, emotional distress in response to bodily sensations, and sensitivity to pain traumatization were significantly associated with pain intensity trajectories. Three distinct opioid consumption trajectories were identified on the log MME/day: "initially high level of MME/day gradually decreasing" (n = 89), "initially low level of MME/day remaining low" (n = 108), and "initially moderate level of MME/day decreasing to low" (n = 329). Age and emotional distress in response to bodily sensations were associated with trajectory membership. Individuals in the "initially mild pain intensity remaining mild" trajectory were less likely than those in the "initially moderate pain intensity remaining moderate" trajectory to report CPSP (odds ratio [95% confidence interval, CI], 0.23 [0.06-0.88]). No significant associations were observed between opioid consumption trajectory membership and CPSP status (odds ratio [95% CI], 0.84 [0.28-2.54] and 0.95 [0.22-4.13]). CONCLUSIONS Those with moderate pain intensity right after surgery are more likely to develop CPSP suggesting that those patients should be flagged early on in their postoperative recovery to attempt to alter their trajectory and prevent CPSP. Emotional distress in response to bodily sensations is the only consistent modifiable factor associated with both pain and opioid trajectories.
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Affiliation(s)
- M Gabrielle Pagé
- From the Department of Anesthesiology and Pain Medicine, Faculty of Medicine
- Department of Psychology, Faculty of Arts and Sciences, Université de Montréal, Montreal, Quebec, Canada
- Research Center, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Praveen Ganty
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Dorothy Wong
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Vivek Rao
- Department of Cardiovascular Surgery, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - James Khan
- Department of Anesthesia, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Karim Ladha
- Department of Anaesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
| | - John Hanlon
- Department of Anaesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sarah Miles
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rita Katznelson
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Joel Katz
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology & Pain Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Psychology, York University, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anesthesiology & Pain Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Galao-Malo R, Davidson A, D'Aoust R, Baker D, Scott M, Swain J. Implementing an evidence-based guideline to decrease opioids after cardiac surgery. J Am Assoc Nurse Pract 2024; 36:241-248. [PMID: 38236128 DOI: 10.1097/jxx.0000000000000982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/21/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Deaths related to overdoses continue growing in the United States. The overprescription of opioids after surgical procedures may contribute to this problem. LOCAL PROBLEM There is inconsistency in the prescription of opioids in cardiovascular surgery patients. Recommendations regarding the reduction of opioids at discharge are not fully implemented. METHODS This is a single-center, pre-post quality improvement project in adult patients after elective cardiac surgery through sternotomy. INTERVENTIONS Changes in guidelines, modification of order sets, creation of dashboards, and education to the providers to increase the prescription of acetaminophen around the clock on the step-down unit and at discharge, decrease the number of opioid tablets to 25 or less at discharge and decrease the prescription of opioids to 25 or less morphine milligram equivalents (MME) at discharge. RESULTS The preintervention group included 67 consecutive patients who underwent cardiac surgery from November to December 2021. The postintervention group had 67 patients during the same period in 2022. Acetaminophen prescription on the step-down unit increased from 9% to 96% ( p < .001). The proportion of patients discharged with 25 or less opioid tablets increased from 18% to 90% ( p < .001) and with 25 or less MME from 30% to 55% ( p < .01). Acetaminophen prescription at discharge increased from 10% to 48% ( p < .001). CONCLUSIONS Our intervention increased the use of acetaminophen and decreased the overprescription of opioids in cardiac surgery patients at discharge. Further research is necessary to continue improving pain management to reduce the number of opioids prescribed at discharge.
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Affiliation(s)
- Roberto Galao-Malo
- Department of Cardiovascular Surgery, Mount Sinai Hospital, New York, New York
| | - Alison Davidson
- Department of Cardiovascular Surgery, Mount Sinai Hospital, New York, New York
| | - Rita D'Aoust
- Johns Hopkins School of Nursing, Baltimore, Maryland
| | - Deborah Baker
- Johns Hopkins School of Nursing, Baltimore, Maryland
| | - Mackenzy Scott
- Cardiac Services, Mount Sinai Hospital, New York, New York
| | - Julie Swain
- Department of Cardiovascular Surgery, Mount Sinai Hospital, New York, New York
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Singh A, Indumati, Kapoor D, Dhillon S, Narula JK, Garg S. Continuous Bilateral Transversus Thoracicmuscle Plane Block: An Analgesia Boon for Scoliotic Patients Undergoing Cardiac Surgery. Ann Card Anaesth 2024; 27:61-64. [PMID: 38722124 PMCID: PMC10876124 DOI: 10.4103/aca.aca_47_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/10/2023] [Accepted: 05/21/2023] [Indexed: 05/12/2024] Open
Abstract
ABSTRACT A person with thoracolumbar scoliosis for cardiac surgery presents with problems of restrictive lung disease with the additional risk of reduced lung compliance and respiratory complications compared to the other patients. Post-operative analgesia in the form of continuous bilateral transversus thoracic muscle plane block (TTMPB) may help such patients in early respiratory rehabilitation by decreasing the time to extubation, reducing the opioid requirement, and early initiation of physiotherapy decreasing the risk of complications.
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Affiliation(s)
- Avneet Singh
- Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Indumati
- Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Dheeraj Kapoor
- Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Suman Dhillon
- Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Jasmine K. Narula
- Department of Anesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Sidharth Garg
- Department of General Surgery, Government Medical College and Hospital, Chandigarh, India
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Pain Trajectory after Short-Stay Anorectal Surgery: A Prospective Observational Study. J Pers Med 2023; 13:jpm13030528. [PMID: 36983710 PMCID: PMC10052694 DOI: 10.3390/jpm13030528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/05/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023] Open
Abstract
The evolution of pain after anorectal surgery has not been well characterized. The main objective of this study is to evaluate patterns in acute postoperative pain in patients undergoing short-stay anorectal surgery. A total of 217 patients were included in the study, which used group-based trajectory modeling to estimate postoperative pain and then examined the relationships between sociodemographic or surgical factors and pain trajectories. Three distinct postoperative pain trajectories were determined: hemorrhoidectomy (OR, 0.15), higher anxiety (OR, 3.26), and a higher preoperative pain behavior score (OR, 3.15). In multivariate analysis, they were associated with an increased likelihood of being on the high pain trajectory. The pain trajectory group was related to postoperative analgesic use (p < 0.001), with the high-low group needing more nonsteroidal analgesics. The study showed that there were three obvious pain trajectories after anorectal surgery, including an unreported low-moderate-low type. More than 60% of patients maintained moderate to severe pain within 7 days after the operation. These postoperative pain trajectories were predominantly defined by surgery factors and patient factors.
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Mori M, Dhruva SS, Geirsson A, Krumholz HM. Characterization of multi-domain postoperative recovery trajectories after cardiac surgery using a digital platform. NPJ Digit Med 2022; 5:192. [PMID: 36564550 PMCID: PMC9789027 DOI: 10.1038/s41746-022-00736-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/29/2022] [Indexed: 12/25/2022] Open
Abstract
Understanding postoperative recovery is critical for guiding efforts to improve post-acute phase care. How recovery evolves during the first 30 days after cardiac surgery is not well-understood. A digital platform may enable granular quantification of recovery by frequently capturing patient-reported outcome measures (PROM) that can be clinically implemented to support recovery. We conduct a prospective cohort study using a digital platform to measure recovery after cardiac surgery using a PROM sent every 3 days for 30 days after surgery to characterize recovery in multiple domains (e.g., pain, sleep, activities of daily living, anxiety) and to identify factors related to the patient's perception of overall recovery. We enroll patients who underwent cardiac surgery at a tertiary center between January 2019 and March 2020 and automatically deliver PROMs and reminders electronically. Of the 10 surveys delivered per patient, 8 (IQR 6-10) are completed. Patients who experienced postoperative complications more commonly belong to the worst overall recovery trajectory. Of the 12 domains modeled, only the worst anxiety trajectory is associated with the worse overall recovery trajectory membership, suggesting that even when patients struggle in the recovery of other domains, the patient may still feel progress in their recovery. We demonstrate that using a digital platform, automated PROM data collection, and characterization of multi-domain recovery trajectories is feasible and likely implementable in clinical practice. Overall recovery may be impacted by complications, while slow progress in constituent domains may still allow for the perception of overall recovery progression.
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Affiliation(s)
- Makoto Mori
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Sanket S Dhruva
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA, USA
- Section of Cardiology, San Francisco VA Medical Center, San Francisco, CA, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA.
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine and the Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA.
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