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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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Liang TW, Shen CH, Wu YS, Chang YT. Erector spinae plane block reduces opioid consumption and improves incentive spirometry volume after cardiac surgery: A retrospective cohort study. J Chin Med Assoc 2024; 87:550-557. [PMID: 38501787 DOI: 10.1097/jcma.0000000000001086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Effective postoperative pain management is vital in cardiac surgery to prevent opioid dependency and respiratory complications. Previous studies on the erector spinae plane (ESP) block have focused on single-shot applications or immediate postoperative outcomes. This study evaluates the efficacy of continuous ESP block vs conventional care in reducing opioid consumption and enhancing respiratory function recovery postcardiac surgery over 72 hours. METHODS A retrospective study at a tertiary hospital (January 2021-July 2022) included 262 elective cardiac surgery patients. Fifty-three received a preoperative ESP block, matched 1:1 with a control group (n = 53). The ESP group received 0.5% ropivacaine intraoperatively and 0.16% ropivacaine every 4 hours postoperatively. Outcomes measured were cumulative oral morphine equivalent (OME) dose within 72 hours postextubation, daily maximum numerical rating scale (NRS) ≥3, incentive spirometry volume, and %baseline performance, stratified by surgery type (sternotomy or thoracotomy). RESULTS Significant OME reduction was observed in the ESP group (sternotomy: median decrease of 113 mg, 95% CI: 60-157.5 mg, p < 0.001; thoracotomy: 172.5 mg, 95% CI: 45-285 mg, p = 0.010). The ESP group also had a lower risk of daily maximum NRS ≥3 (adjusted OR sternotomy: 0.22, p < 0.001; thoracotomy: 0.07, p < 0.001), a higher incentive spirometry volumes (sternotomy: mean increase of 149 mL, p = 0.019; thoracotomy: 521 mL, p = 0.017), and enhanced spirometry %baseline (sternotomy: mean increase of 11.5%, p = 0.014; thoracotomy: 26.5%, p < 0.001). CONCLUSION Continuous ESP block was associated with a reduction of postoperative opioid requirements, lower instances of pain scores ≥3, and improve incentive spirometry performance following cardiac surgery. These benefits appear particularly prominent in thoracotomy patients. Further prospective studies with larger sample size are required to validate these findings.
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Affiliation(s)
- Ting-Wei Liang
- Department of Anesthesiology, Show Chwan Memorial Hospital, Changhua, Taiwan, ROC
| | - Ching-Hui Shen
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yung-Szu Wu
- Department of Cardiac Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Yi-Ting Chang
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
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Wynne R, Fredericks S, Hyde EK, Matthews S, Bowden T, O'Keefe-McCarthy S, Martorella G, Magboo R, Gjeilo KH, Jedwab RM, Keeping-Burke L, Murfin J, Bruneau J, Lie I, Sanders J. Multimodal Analgesic Effectiveness on Acute Postoperative Pain Management After Adult Cardiac Surgery: Protocol for a Systematic Review. J Cardiovasc Nurs 2024; 39:E21-E28. [PMID: 37052583 DOI: 10.1097/jcn.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
BACKGROUND Many patients report moderate to severe pain in the acute postoperative period. Enhanced recovery protocols recommend multimodal analgesics, but the optimal combination of these is unknown. PURPOSE The aim of this study was to synthesize the best available evidence about effectiveness of multimodal analgesics on pain after adult cardiac surgery. METHODS A systematic review to determine the effect of multimodal postoperative analgesics is proposed (International Prospective Register of Systematic Reviews Registration CRD42022355834). Multiple databases including the Cochrane Library, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, American Psychological Association, the Education Resources Information Centre, the Excerpta Medica database, the Medical Literature Analysis and Retrieval System Online, Scopus, Web of Science, and clinical trials databases will be searched. Screening in Covidence and quality assessment will be conducted by 2 authors. A grading of recommendations, assessment, development, and evaluation summary of findings will be presented if meta-analysis is possible.
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Zhang B, Cai C, Pan Z, Zhuang L, Qi Y. Effect of Remifentanil on Acute and Chronic Postsurgical Pain in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis. Clin J Pain 2024; 40:187-195. [PMID: 38053431 DOI: 10.1097/ajp.0000000000001183] [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: 05/06/2023] [Accepted: 11/27/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVES Our purpose was to explore the effect of remifentanil on acute and chronic postsurgical pain after cardiac surgery. MATERIALS AND METHODS Randomized controlled trials were retrieved from electronic databases, such as PubMed, Cochrane Library, China National Knowledge Internet databases, Scopus, and Web of Science. A systematic review, meta-analysis, and trial sequential analysis (TSA) were performed. Basic information and outcomes were extracted from the included studies. The primary outcome was chronic postsurgical pain. Secondary outcomes were scores of postsurgical pain and morphine consumption within 24 hours after cardiac surgery. Risk of bias (ROB) assessment was based on the Cochrane ROB tool version 2. The overall quality of the evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. RESULTS Seven studies consisting of 658 patients were enrolled in the meta-analysis. A single study had a high ROB and 2 studies had a moderate ROB. The incidence of chronic postsurgical pain (4 studies [415 patients]; risk ratio: 1.02 [95% CI: 0.53 to 1.95]; P = 0.95; I2 = 59%; TSA-adjusted CI: 0.78 to 1.20) and the postsurgical pain score (2 studies [196 patients]; mean difference: 0.09 [95% CI: -0.36 to 0.55]; P = 0.69; I2 = 0%; TSA-adjusted CI: -0.36 to 0.55) were not statistically different between the 2 groups. However, morphine consumption (6 studies [569 patients]; mean difference: 6.94 [95% CI: 3.65 to 10.22]; P < 0.01; I2 = 0%; TSA-adjusted CI: 0.00 to 0.49) was higher in the remifentanil group than in the control group. CONCLUSION There was not enough evidence to prove that remifentanil can increase the incidence of chronic postsurgical pain after cardiac surgery, but interestingly, the results tended to support a trend toward increased complications in the intervention group. However, there was moderate certainty evidence that the use of remifentanil increases the consumption of morphine for analgesia, and more direct comparison trials are needed to inform clinical decision-making with greater confidence.
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Affiliation(s)
- Bi Zhang
- Department of Anesthesia, Ningbo Medical Center, Li Huili Hospital, Ningbo, Zhejiang, China
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Heily M, Gerdtz M, Jarden RJ, Yap CY, Darvall J, Coventry AE, Rogers A, Vernon J, Bellomo R. Agitation during anaesthetic emergence: An observational study of adult cardiac surgery patients in two Australian intensive care units. Aust Crit Care 2024; 37:67-73. [PMID: 37919133 DOI: 10.1016/j.aucc.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/21/2023] [Accepted: 09/05/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Anaesthetic emergence agitation among adult patients being recovered after open cardiac and/or thoracic aorta surgery has not been described. OBJECTIVES The objective of this study was to characterise emergence agitation in terms of incidence, clinical features, and consequences in a cohort of cardiac surgery patients being recovered in the intensive care unit (ICU). METHODS A prospective, observational pilot study was implemented. Over a 5-week period, the study was conducted in two metropolitan hospitals in Victoria, Australia. The cohort comprised all patients admitted to the ICUs aged ≥18 years, who had undergone cardiac surgery via an open sternotomy with general anaesthetic, and whose emergence was directly observed. Emergence agitation was defined as a Richmond Agitation and Sedation Scale score of ≥+2. RESULTS Fifty patients were observed. Emergence agitation occurred in 24/50 (48%) of patients. Patients with emergence agitation experienced more clinical consequences than patients with calm emergence, including a significantly greater number of episodes of airway compromise (12/24, 50%, p < 0.001); ventilator dyssynchrony (23/24, 96%, p = 0.004); and hypertension (13/24, 54%, p = 0.004). Significant treatment interference (potentially dangerous patient movements such as pulling tubes) occurred with 23/24 patients (96%, p < 0.0001). Patients who underwent emergence agitation required significantly more interventions during anaesthetic emergence than patients who underwent a calm emergence. Interventions included extra nursing measures (16/24, 67%, p = 0.001) administration of sedative and/or opioid intravenous boluses (22/24, 92%, p = 0.001) and vasoactive agents (15/24, 63%, p = 0.05). CONCLUSIONS In patients recovering from cardiac surgery in the ICU, emergence agitation was clinically important. Immediate interventions were required to prevent and manage complications.
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Affiliation(s)
- Meredith Heily
- Intensive Care Unit, The Royal Melbourne Hospital, Grattan St, Parkville 3050, Australia; Department of Nursing, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry St, Carlton, 3010, Australia.
| | - Marie Gerdtz
- Department of Nursing, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry St, Carlton, 3010, Australia.
| | - Rebecca J Jarden
- Department of Nursing, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry St, Carlton, 3010, Australia; Austin Health, Melbourne, Australia.
| | - Celene Yl Yap
- Department of Nursing, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Level 6, Alan Gilbert Building, 161 Barry St, Carlton, 3010, Australia.
| | - Jai Darvall
- Intensive Care Unit & Department of Anaesthetics, The Royal Melbourne Hospital, Grattan St, Parkville, 3050, Australia; Department of Critical Care, Faculty of Medicine, Dentistry & Health Sciences, The University of Melbourne, Grattan St, Parkville, 3010, Australia.
| | - Andrew Ej Coventry
- Intensive Care Unit, The Royal Melbourne Hospital, Grattan St, Parkville 3050, Australia.
| | - Amy Rogers
- Intensive Care Unit, The Royal Melbourne Hospital, Grattan St, Parkville 3050, Australia.
| | - Julie Vernon
- Intensive Care Unit, The Royal Melbourne Hospital, Grattan St, Parkville 3050, Australia.
| | - Rinaldo Bellomo
- Intensive Care Unit, The Royal Melbourne Hospital, Grattan St, Parkville 3050, Australia; Department of Critical Care, Faculty of Medicine, Dentistry & Health Sciences, The University of Melbourne, Grattan St, Parkville, 3010, Australia; Intensive Care Unit, Austin Health, Australia.
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Eid Aburuz M, Al-Dweik G, Ahmed FR. The Effect of Listening to Holy Quran Recital on Pain and Length of Stay Post-CABG: A Randomized Control Trial. Crit Care Res Pract 2023; 2023:9430510. [PMID: 37965250 PMCID: PMC10643035 DOI: 10.1155/2023/9430510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/02/2023] [Accepted: 10/21/2023] [Indexed: 11/16/2023] Open
Abstract
Background Nearly, 75% of patients post-CABG complain of moderate to severe pain during their hospital stay. Nonpharmacological interventions have been investigated; however, the effect of Holy Quran recital post-CABG is still not well studied, especially in developing Islamic countries. Objective To investigate the effect of listening to the Holy Quran recital on pain and length of stay post-CABG. Methods This was a randomized control trial on 132 patients recruited from four hospitals in Amman, Jordan. The intervention group listened to the Holy Quran recited for 10 minutes twice daily while the control group received the usual care. Data were analyzed using paired and independent samples t-tests. Results Paired t-test testing showed that there was a significant reduction in the pain level, (M [SD], 6.82 [2.27] vs. 4.65 [2.18], t = 23.65, p < 0.001) for the intervention group. In addition, the intervention group had shorter LoS in the ICU and in the hospital compared to the control group, (M [SD], 5.0 [4.02] vs. 6.58 [4.18], t = -2.1, p < 0.05), (M [SD], 10.15 [9.21] vs. 15.01 [13.14], t = -2.6, p < 0.05), respectively. Conclusions Listening to the Quran was significantly effective in improving pain intensity among post-CABG patients and shortening their hospital/ICU stay. This trial is registered with NCT05419554.
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Affiliation(s)
- Mohannad Eid Aburuz
- Clinical Nursing Department, Faculty of Nursing, Applied Science Private University, Amman, Jordan
| | - Ghadeer Al-Dweik
- Nursing Administration, Faculty of Nursing, Applied Science Private University, Amman, Jordan
| | - Fatma Refaat Ahmed
- Department of Nursing, College of Health Sciences, University of Sharjah, Sharjah, UAE
- Critical Care and Emergency Nursing, Alexandria University, Alexandria, Egypt
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Xiao MZX, Khan JS, Dana E, Rao V, Djaiani G, Richebé P, Katz J, Wong D, Clarke H. Prevalence and Risk Factors for Chronic Postsurgical Pain after Cardiac Surgery: A Single-center Prospective Cohort Study. Anesthesiology 2023; 139:309-320. [PMID: 37192204 DOI: 10.1097/aln.0000000000004621] [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: 05/18/2023]
Abstract
BACKGROUND Chronic postsurgical pain is a common complication of surgery. The role of psychologic risk factors like depression and anxiety is substantially understudied in cardiac surgery. This study sought to identify perioperative factors associated with chronic pain at 3, 6, and 12 months after cardiac surgery. The authors hypothesize that baseline psychologic vulnerabilities have a negative influence on chronic postsurgical pain. METHODS The authors prospectively collected demographic, psychologic, and perioperative factors in a cohort of 1,059 patients undergoing cardiac surgery at the Toronto General Hospital between 2012 and 2020. Patients were followed and completed chronic pain questionnaires at 3, 6, and 12 months after surgery. RESULTS The study included 767 patients who completed at least one follow-up questionnaire. The incidence of postsurgical pain (more than 0 out of 10) at 3, 6, and 12 months after surgery was 191 of 663 (29%), 118 of 625 (19%), and 89 of 605 (15%), respectively. Notably, among patients reporting any pain, the incidence of pain compatible with a neuropathic phenotype increased from 56 of 166 (34%) at 3 months to 38 of 97 (39%) at 6 months and 43 of 67 (64%) at 12 months. Factors associated with postsurgical pain scores at 3 months include female sex, pre-existing chronic pain, previous cardiac surgery, preoperative depression, baseline pain catastrophizing scores, and moderate-to-severe acute pain (4 or more out of 10) within 5 postoperative days. CONCLUSIONS Nearly one in three patients undergoing cardiac surgery reported pain at 3 months of follow-up, with approximately 15% reporting persistent pain at 1 yr. Female sex, pre-existing chronic pain, and baseline depression were associated with postsurgical pain scores across all three time periods. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Maggie Z X Xiao
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - James S Khan
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Elad Dana
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; Department of Anesthesia, Intensive Care and Pain Medicine, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vivek Rao
- Division of Cardiovascular Surgery, University of Toronto, Toronto, Canada
| | - George Djaiani
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Research Center of the Integrated University Health and Social Services Center of the East-Island of Montreal, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Canada
| | - Joel Katz
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; Department of Psychology, York University, Toronto, Canada; Transitional Pain Service, Toronto General Hospital, Toronto, Canada
| | - Dorothy Wong
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; Transitional Pain Service, Toronto General Hospital, Toronto, Canada
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Madjarov JM, Katz MG, Hadas Y, Kim SJ, Freage-Kahn L, Madzharov S, Vincek A, Madjarova SJ, Seidman P, Shtraizent N, Robicsek SA, Eliyahu E. Chronic thoracic pain after cardiac surgery: role of inflammation and biomechanical sternal stability. FRONTIERS IN PAIN RESEARCH 2023; 4:1180969. [PMID: 37637509 PMCID: PMC10450746 DOI: 10.3389/fpain.2023.1180969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/28/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction The pathogenesis of chronic chest pain after cardiac surgery has not been determinate. If left untreated, postoperative sternal pain reduces the quality of life and patient satisfaction with cardiac surgery. The purpose of the study was to examine the effect of chest inflammation on postoperative pain, risk factors for chronic pain after cardiac surgery and to explore how chest reconstruction was associated with the intensity of pain. Methods The authors performed a study of acute and chronic thoracic pain after cardiac surgery in patients with and without sternal infection and compared different techniques for chest reconstruction. 42 high-risk patients for the development of mediastinitis were included. Patients with mediastinitis received chest reconstruction (group 1). Their demographics and risk factors were matched with no-infection patients with chest reconstruction (group 2) and subjects who underwent conventional sternal closure (group 3). Chronic pain was assessed by the numeric rating scale after surgery. Results The assessment of the incidence and intensity of chest pain at 3 months post-surgery demonstrated that 14 out of 42 patients across all groups still experienced chronic pain. Specifically, in group 1 with sternal infection five patients had mild pain, while one patient experienced mild pain in group 2, and eight patients in group 3. Also, follow-up results indicated that the highest pain score was in group 3. While baseline levels of cytokines were increased among patients with sternal infection, at discharge only the level of interleukin 6 remained high compared to no infection groups. Compared to conventional closure, after chest reconstruction, we found better healing scores at 3-month follow-up and a higher percentage of patients with the complete sternal union. Conclusions Overall, 14 out of 42 patients have chronic pain after cardiac surgery. The intensity of the pain in mediastinitis patients significantly decreased at 3 months follow-up after chest reconstruction. Thus, post-surgery mediastinitis is not a determining factor for development the chronic chest pain. There is no correlation between cytokines levels and pain score except interleukin 6 which remains elevated for a long time after treatment. Correlation between sternal healing score and chronic chest pain was demonstrated.
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Affiliation(s)
- Jeko M. Madjarov
- Department of Cardiovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, United States
- Department of Cardiovascular Surgery, Atrium Health Sanger Heart and Vascular Institute, Charlotte, NC, United States
| | - Michael G. Katz
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Yoav Hadas
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sofia Jisoo Kim
- Department of Biology and Environmental Studies, New York University, New York, NY, United States
| | | | - Svetozar Madzharov
- Department of Cardiovascular Surgery, Atrium Health Sanger Heart and Vascular Institute, Charlotte, NC, United States
| | - Adam Vincek
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Piers Seidman
- Baruch College, City University of New York, New York, NY, United States
| | - Nataly Shtraizent
- Frezent Biological Solutions, New York, NY, United States
- Senex, New York, NY, United States
| | - Steven A. Robicsek
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Efrat Eliyahu
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Icahn School of Medicine at Mount Sinai, Icahn Genomics Institute, New York, NY, United States
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Jin L, Liang Y, Yu Y, Miao P, Huang Y, Xu L, Wang H, Wang C, Huang J, Guo K. Evaluation of the Effect of New Multimodal Analgesia Regimen for Cardiac Surgery: A Prospective, Randomized Controlled, Single-Center Clinical Study. Drug Des Devel Ther 2023; 17:1665-1677. [PMID: 37309414 PMCID: PMC10257907 DOI: 10.2147/dddt.s406929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/23/2023] [Indexed: 06/14/2023] Open
Abstract
Objective To investigate the feasibility of multimodal regimen by paracetamol, gabapentin, ketamine, lidocaine, dexmedetomidine and sufentanil among cardiac surgery patients, and compare the analgesia efficacy with conventional sufentanil-based regimen. Design A single-center, prospective, randomized, controlled clinical trial. Setting One participating center, the cardiovascular center of the major integrated teaching hospital. Participants A total of 115 patients were assessed for eligibility: 108 patients were randomized, 7 cases were excluded. Interventions The control group (group T) received conventional anesthesia management. Interventions in the multimodal group (group M) were as follows in addition to the standard of care: gabapentin and acetaminophen 1 hour before surgery; ketamine for induction and to maintain anesthesia with lidocaine and dexmedetomide. Ketamine, lidocaine, and dexmedetomidine were added to routine sedatives postoperatively in group M. Measurements and Main Results The incidence of moderate-to-severe pain on coughing made no significant difference (68.5% vs 64.8%, P=0.683). Group M had significantly less sufentanil use (135.72µg vs 94.85µg, P=0.000) and lower rescue analgesia rate (31.5% vs 57.4%, P=0.007). There was no significant difference in the incidence of chronic pain, PONV, dizziness, inflammation index, mechanical ventilation time, length of stay, and complications between the two groups. Conclusion Our multimodal regimen in cardiac surgery is feasible, but was not superior to traditional sufentanil-based regimen in the aspects of analgesia effects; however, it did reduce perioperative opioid consumption along with rescue analgesia rate. Moreover, it showed the same length of stay and the incidences of postoperative complications.
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Affiliation(s)
- Lin Jin
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Yafen Liang
- Department of Anesthesiology, University of Texas Health Center at Houston, Houston, TX, USA
| | - Ying Yu
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Peng Miao
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Yihao Huang
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Liying Xu
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Huilin Wang
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Chunsheng Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine University of Louisville, Louisville, KY, USA
| | - Kefang Guo
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of 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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11
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Harvey RE, Fischer MA, Williams TM, Neelankavil J. Growing Pains: Opportunity Knocks in the 2022 Center for Disease Control Clinical Practice Guidelines for Prescribing Opioids for Pain. J Cardiothorac Vasc Anesth 2023; 37:857-859. [PMID: 36868905 DOI: 10.1053/j.jvca.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Affiliation(s)
- Reed E Harvey
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA.
| | - Matthew A Fischer
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Tiffany M Williams
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jacques Neelankavil
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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12
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Torres CM, Geneslaw AS, Svoboda L, Smerling AJ, Schlosser Metitiri KR. Effect of Standing Intravenous Acetaminophen on Postoperative Opioid Exposure in a Pediatric Cardiac Intensive Care Unit. J Pediatr 2022; 255:236-239.e2. [PMID: 36572175 DOI: 10.1016/j.jpeds.2022.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/21/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
This study assessed the association between standing intravenous acetaminophen and opioid exposure after cardiac surgery. Before vs after implementation of a standardized pain pathway, we report decreased opioid exposure, 0.38 milligram per kilogram of morphine equivalents [IQR 0.10-0.81] vs 0.26 milligram per kilogram of morphine equivalents [0.09-0.56] (P = .01) and increased acetaminophen exposure, 3 [2-4] vs 4 [4-5] doses (P < .001).
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Affiliation(s)
- Chelsea M Torres
- Department of Pediatrics, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY; Division of General Academic Pediatrics, Department of Pediatrics, University of South Florida, Tampa, FL.
| | - Andrew S Geneslaw
- Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Leanne Svoboda
- Department of Pharmacy, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Arthur J Smerling
- Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Katherine R Schlosser Metitiri
- Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY
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13
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Chen IW, Sun CK, Ko CC, Fu PH, Teng IC, Liu WC, Lin CM, Hung KC. Analgesic efficacy and risk of low-to-medium dose intrathecal morphine in patients undergoing cardiac surgery: An updated meta-analysis. Front Med (Lausanne) 2022; 9:1017676. [PMID: 36275818 PMCID: PMC9581243 DOI: 10.3389/fmed.2022.1017676] [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: 08/12/2022] [Accepted: 09/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background To evaluate the analgesic efficacy and risk of low-to-medium dose intrathecal morphine (ITM) (i.e., ≤0.5 mg) following cardiac surgery. Methods Medline, Cochrane Library, Google scholar and EMBASE databases were searched from inception to February 2022. The primary outcome was pain intensity at postoperative 24 h, while the secondary outcomes included intravenous morphine consumption (IMC), extubation time, hospital/intensive care unit (ICU) length of stay (LOS), and ITM-associated side effects (e.g., respiratory depression). Subgroup analysis was performed on ITM dosage (low: <0.3 mg vs. medium: 0.3–0.5 mg). Results Fifteen RCTs involving 683 patients published from 1988 to 2021 were included. Pooled results showed significantly lower postoperative 24-h pain scores [mean difference (MD) = −1.61, 95% confidence interval: −1.98 to −1.24, p < 0.00001; trial sequential analysis: sufficient evidence; certainty of evidence: moderate] in the ITM group compared to the controls. Similar positive findings were noted at 12 (MD = −2.1) and 48 h (MD = −1.88). Use of ITM was also associated with lower IMC at 24 and 48 h (MD: −13.69 and −14.57 mg, respectively; all p < 0.05) and early tracheal extubation (i.e., 48.08 min). No difference was noted in hospital/ICU LOS, and nausea/vomiting in both groups, but patients receiving ITM had higher risk of pruritus (relative risk = 2.88, p = 0.008). There was no subgroup difference in IMC except a lower pain score with 0.3–0.5 mg than <0.3 mg at postoperative 24 h. Respiratory depression events were not noted in the ITM group. Conclusion Our results validated the analgesic efficacy of low-to-medium dose ITM for patients receiving cardiac surgery without increasing the risk of respiratory depression.
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Affiliation(s)
- I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung City, Taiwan,College of Medicine, I-Shou University, Kaohsiung City, Taiwan
| | - Ching-Chung Ko
- Department of Medical Imaging, Chi Mei Medical Center, Tainan City, Taiwan,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan,Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung City, Taiwan
| | - Pei-Han Fu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - I-Chia Teng
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Wei-Cheng Liu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chien-Ming Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan,*Correspondence: Kuo-Chuan Hung,
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Morsy AG, Atallah MM, El-Motleb EAA, Tawfik MM. Different modalities of analgesia in open heart surgeries in Mansoura University. Int J Health Sci (Qassim) 2022:1846-1869. [DOI: 10.53730/ijhs.v6ns4.6375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Abstract
Background: Opioid usage in cardiac surgery is considered to be the corner stone in management. Inadequate pain control after cardiac surgery complicates patient recovery and increases the load on healthcare services. Multimodal analgesia can be used to achieve better analgesic effect and improves patient outcome. Material and methods: A total of 90 patients undergoing cardiac surgery with median sternotomy were randomly allocated equally into three groups intraoperatively where first group received continuous infusion of high dose opioids, second group received boluses of low dose opioids and third group received multimodal non opioid analgesics including dexmedetomidine, ketamine and magnesium sulphate. All patients received the same post-operative analgesic regimen consists of morphine patient controlled analgesia (PCA). Results: Patients in multimodal non opioid group had more stable hemodynamics intra and postoperatively. Also, patients in multimodal group had lower pain scores extubation, earlier extubation, shorter ICU stay, earlier mobilization and earlier return of bowel movements compared to patients of both groups received intraoperative higher opioid doses.
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Li J, Lin L, Peng J, He S, Wen Y, Zhang M. Efficacy of ultrasound-guided parasternal block in adult cardiac surgery: a meta-analysis of randomized controlled trials. Minerva Anestesiol 2022; 88:719-728. [PMID: 35381838 DOI: 10.23736/s0375-9393.22.16272-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Pain after cardiac surgery is a common and severe postoperative complication. As a new regional nerve block method, ultrasound-guided parasternal block (PSB) has been increasingly used to supplement the analgesic effects of opioids in order to eliminate opioid-related adverse drug events, but its efficacy still remains controversial. In the present meta-analysis, we aim to screen all eligible randomized controlled trials (RCTs) and give a comprehensive summary of the clinical value of PSB after adult cardiac surgery. EVIDENCE ACQUISITION We searched all RCTs about PSB after cardiac surgery in the database of Pubmed, Embase, Cochrane, CNKI and Wanfang with no limitation of language from inception to September 2021. Two reviewers were independently involved in the process of data extraction. Meta-analysis was performed by using Review Manager software. The quality of included RCTs were assessed by using Cochrane's risk of bias assessment tool, and funnel plots were drawn to assess publication bias. EVIDENCE SYNTHESIS A total of 12 RCTs with 366 patients in PSB group and 364 patients in control group were included in the present meta-analysis. Pooled analysis revealed that intraoperative and postoperative consumption of sufentanil were significantly decreased with the addition of PSB (P<0.05). Numerical rating scale (NRS) scores in PSB group were found to be significantly lower than that of control group at extubation, postoperative 4h and 8h (P<0.05) instead of postoperative 24h or longer. PSB could reduce the incidence of postoperative nausea and vomiting (PONV) (P<0.05). In addition, we demonstrated that PSB was significantly related to decreased mechanical ventilation time, total length of ICU stay and hospital days (P<0.05). CONCLUSIONS Through decreasing the consumption of opioids, ultrasound-guided PSB could relieve pain and limit opioid-related complications. Clinical outcomes, such as mechanical ventilation time, total length of ICU stay and hospital days, will also be improved. Our findings prove that ultrasound-guided PSB is an effective regional analgesic method after adult cardiac surgery.
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Affiliation(s)
- Jing Li
- Department of Anesthesiology, People's Hospital of Yilong County, Nanchong, China
| | - Lu Lin
- Department of Anesthesiology, The General Hospital of Western Theater Command Hospital, Chengdu, China
| | - Jian Peng
- Department of Anesthesiology, People's Hospital of Yilong County, Nanchong, China
| | - Shushao He
- Department of Anesthesiology, People's Hospital of Yilong County, Nanchong, China
| | - Yan Wen
- Department of Anesthesiology, Traditional Chinese Medicine Hospital of Nanchong, Nanchong, China
| | - Ming Zhang
- Department of Neurology, People's Hospital of Yilong County, Nanchong, China -
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Subramaniam K, Sultan I, Weitzel N, Kertai MD. Is It Time for Paradigm Shift in Pain Management for Cardiac Surgery Patients? Semin Cardiothorac Vasc Anesth 2021; 25:249-251. [PMID: 34789035 DOI: 10.1177/10892532211058494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kathirvel Subramaniam
- Professor, Department of Anesthesiology and Perioperative Medicine, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Associate Professor, Department of Cardiothoracic Surgery, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nathaen Weitzel
- Professor, Department of Anesthesiology, University of Colorado Medical Center, Denver, CO, USA
| | - Miklos D Kertai
- Professor, Department of Anesthesiology, Vanderbilt University Medical Center, Vanderbilt, Nashville, TN, USA
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