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Tong L, Solla C, Staack JB, May K, Tran B. Perioperative Pain Management for Thoracic Surgery: A Multi-Layered Approach. Semin Cardiothorac Vasc Anesth 2024:10892532241235750. [PMID: 38506340 DOI: 10.1177/10892532241235750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Cardiothoracic surgeries frequently pose unique challenges in the management of perioperative acute pain that require a multifaceted and personalized approach in order to optimize patient outcomes. This article discusses various analgesic strategies including regional anesthesia techniques such as thoracic epidurals, erector spinae plane blocks, and serratus anterior plane blocks and underscores the significance of perioperative multimodal medications, while providing nuanced recommendations for their use. This article further attempts to provide evidence for the efficacy of the different modalities and compares the effectiveness of the choice of analgesia. The roles of Acute Pain Services (APS) and Transitional Pain Services (TPS) in mitigating opioid dependence and chronic postsurgical pain are also discussed. Precision medicine is also presented as a potential way to offer a patient tailored analgesic strategy. Supported by various randomized controlled trials and meta-analyses, the article concludes that an integrated, patient-specific approach encompassing regional anesthesia and multimodal medications, while also utilizing the services of the Acute Pain Service can help to enhance pain management outcomes in cardiothoracic surgery.
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Affiliation(s)
- Larry Tong
- Virginia Commonwealth University, Richmond, VA, USA
| | - Che Solla
- University of Tennessee, Knoxville, TN, USA
| | | | - Keith May
- University of Tennessee, Knoxville, TN, USA
| | - Bryant Tran
- Virginia Commonwealth University, Richmond, VA, USA
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Said ET, Drueding RE, Martin EI, Furnish TJ, Meineke MN, Sztain JF, Abramson WB, Swisher MW, Jacobsen GR, Gosman AA, Gabriel RA. The Implementation of an Acute Pain Service for Patients Undergoing Open Ventral Hernia Repair with Mesh and Abdominal Wall Reconstruction. World J Surg 2021; 45:1102-1108. [PMID: 33454790 DOI: 10.1007/s00268-020-05915-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In this retrospective cohort single-institutional study, we report the outcomes of implementing a standardized protocol of multimodal pain management with thoracic epidural analgesia via the acute pain service (APS) for patients undergoing ventral hernia repair with mesh placement and abdominal wall reconstruction. METHODS The primary outcome evaluated was postoperative 72-h opioid consumption, measured in intravenous morphine equivalents (MEQ). Secondary outcomes included hospital length of stay (LOS) among other outcomes. The two cohorts were the APS versus non-APS group, in which the former cohort had an APS providing epidural and multimodal analgesia and the latter utilized pain management per surgical team, which mostly consisted of opioid therapy. Using1:1 propensity-score-matched cohorts, Wilcoxon signed-rank test was used to calculate the differences in outcomes. A p < 0.05 was considered statistically significant. RESULTS There were 83 patients, wherein 51 (61.4%) were in the APS group. Between matched cohorts, the non-APS cohort's median [quartiles] total opioid consumption during the first three days was 85.6 mg MEQs [58.9, 112.8 mg MEQs]. The APS cohort was 31.7 mg MEQs [16.0, 55.3 mg MEQs] (p < 0.0001). The non-APS hospital LOS median [quartiles] was 5 days [4, 7 days] versus 4 days [4, 5 days] in the APS group (p = 0.01). DISCUSSION A dedicated APS was associated with decreased opioid consumption by 75%, as well as a decreased hospital LOS. We report no differences in ICU length of stay, time to oral intake, time to ambulation or time to urinary catheter removal.
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Affiliation(s)
- Engy T Said
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Ross E Drueding
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Erin I Martin
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Timothy J Furnish
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Minhthy N Meineke
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Wendy B Abramson
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Matthew W Swisher
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA
| | - Garth R Jacobsen
- Department of Surgery, Division of Minimally Invasive Surgery, University of California, La Jolla, San Diego, CA, USA
| | - Amanda A Gosman
- Department of Surgery, Division of Plastic Surgery, University of California, La Jolla, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain Medicine, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA.
- Department of Medicine, Division of Biomedical Informatics, University of California, 9400 Campus Point Dr, MC 7770, La Jolla, San Diego, CA, 92037, USA.
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