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Schmedt J, Oostvogels L, Meyer-Frießem CH, Weibel S, Schnabel A. Peripheral Regional Anesthetic Techniques in Cardiac Surgery: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2024; 38:403-416. [PMID: 38044198 DOI: 10.1053/j.jvca.2023.09.043] [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: 01/30/2023] [Revised: 08/14/2023] [Accepted: 09/29/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVE The aim of this systematic review was to investigate postoperative pain outcomes and adverse events after peripheral regional anesthesia (PRA) compared to no regional anesthesia (RA), placebo, or neuraxial anesthesia in children and adults undergoing cardiac surgery. DESIGN A systematic review and meta-analysis with an assessment of the risk of bias (Cochrane RoB 1) and certainty of evidence (Grading of Recommendations, Assessment, Development, and Evaluation). SETTING Randomized controlled trials (RCTs). PARTICIPANTS Adults and children undergoing heart surgery. INTERVENTIONS Any kind of PRA compared to no RA or placebo or neuraxial anesthesia. MEASUREMENTS AND MAIN RESULTS In total, 33 RCTs (2,044 patients) were included-24 of these had a high risk of bias, and 28 were performed in adults. Compared to no RA, PRA may reduce pain intensity at rest 24 hours after surgery (mean difference [MD] -0.81 points, 95% CI -1.51 to -0.10; I2 = 92%; very low certainty evidence). Peripheral regional anesthesia, compared to placebo, may reduce pain intensity at rest (MD -1.36 points, 95% CI -1.59 to -1.13; I2 = 54%; very low certainty evidence) and during movement (MD -1.00 points, 95% CI -1.34 to -0.67; I² = 72%; very low certainty evidence) 24 hours after surgery. No data after pediatric cardiac surgery could be meta-analyzed due to the low number of included trials. CONCLUSIONS Compared to no RA or placebo, PRA may reduce pain intensity at rest and during movement. However, these results should be interpreted cautiously because the certainty of evidence is only very low.
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Affiliation(s)
- Julian Schmedt
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Lisa Oostvogels
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany
| | - Christine H Meyer-Frießem
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, BG-Universitätsklinikum Bergmannsheil gGmbH, Medical Faculty of Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, Bochum, Germany
| | - Stephanie Weibel
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Alexander Schnabel
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany.
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Maeßen T, Korir N, Van de Velde M, Kennes J, Pogatzki-Zahn E, Joshi GP. Pain management after cardiac surgery via median sternotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol 2023; 40:758-768. [PMID: 37501517 DOI: 10.1097/eja.0000000000001881] [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: 07/29/2023]
Abstract
BACKGROUND Pain after cardiac surgery via median sternotomy can be difficult to treat, and if inadequately managed can lead to respiratory complications, prolonged hospital stays and chronic pain. OBJECTIVES To evaluate available literature and develop recommendations for optimal pain management after cardiac surgery via median sternotomy. DESIGN A systematic review using PROcedure-SPECific Pain Management (PROSPECT) methodology. ELIGIBILITY CRITERIA Randomised controlled trials and systematic reviews published in the English language until November 2020 assessing postoperative pain after cardiac surgery via median sternotomy using analgesic, anaesthetic or surgical interventions. DATA SOURCES PubMed, Embase and Cochrane Databases. RESULTS Of 319 eligible studies, 209 randomised controlled trials and three systematic reviews were included in the final analysis. Pre-operative, intra-operative and postoperative interventions that reduced postoperative pain included paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), intravenous magnesium, intravenous dexmedetomidine and parasternal block/infiltration. CONCLUSIONS The analgesic regimen for cardiac surgery via sternotomy should include paracetamol and NSAIDs, unless contraindicated, administered intra-operatively and continued postoperatively. Intra-operative magnesium and dexmedetomidine infusions may be considered as adjuncts particularly when basic analgesics are not administered. It is not clear if combining dexmedetomidine and magnesium would provide superior pain relief compared with either drug alone. Parasternal block/surgical site infiltration is also recommended. However, no basic analgesics were used in the studies assessing these interventions. Opioids should be reserved for rescue analgesia. Other interventions, including cyclo-oxygenase-2 specific inhibitors, are not recommended because there was insufficient, inconsistent or no evidence to support their use and/or due to safety concerns.
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Affiliation(s)
- Timo Maeßen
- From the Department of Anaesthesiology, Intensive Care, and Pain Medicine, University Hospital Münster, Münster, Germany (TM, EP-Z), the Department of Cardiovascular Sciences, Section Anaesthesiology, KU Leuven and University Hospital Leuven, Leuven, Belgium (NK, MVdeV, JK), the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Centre, Dallas, Texas, USA (GPJ)
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Makkad B, Heinke TL, Sheriffdeen R, Khatib D, Brodt JL, Meng ML, Grant MC, Kachulis B, Popescu WM, Wu CL, Bollen BA. Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2. Anesth Analg 2023; 137:26-47. [PMID: 37326862 DOI: 10.1213/ane.0000000000006506] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.
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Affiliation(s)
- Benu Makkad
- From the Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Timothy Lee Heinke
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Raiyah Sheriffdeen
- Department of Anesthesiology, Medstar Washington Hospital Center, Washington, DC
| | - Diana Khatib
- Department of Anesthesiology, Weil Cornell Medical College, New York, New York
| | - Jessica Louise Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bessie Kachulis
- Department of Anesthesiology, Columbia University, New York, New York
| | - Wanda Maria Popescu
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher L Wu
- Department of Anesthesiology, Hospital of Special Surgery, Weill Cornell Medical College, New York, New York
| | - Bruce Allen Bollen
- Missoula Anesthesiology, Missoula, Montana
- The International Heart Institute of Montana, Missoula, Montana
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Zhou K, Li D, Song G. Comparison of regional anesthetic techniques for postoperative analgesia after adult cardiac surgery: bayesian network meta-analysis. Front Cardiovasc Med 2023; 10:1078756. [PMID: 37283577 PMCID: PMC10239891 DOI: 10.3389/fcvm.2023.1078756] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 05/03/2023] [Indexed: 06/08/2023] Open
Abstract
Background Patients usually suffer acute pain after cardiac surgery. Numerous regional anesthetic techniques have been used for those patients under general anesthesia. The most effective regional anesthetic technique was still unclear. Methods Five databases were searched, including PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library. The efficiency outcomes were pain scores, cumulative morphine consumption, and the need for rescue analgesia in this Bayesian analysis. Postoperative nausea, vomiting and pruritus were safety outcomes. Functional outcomes included the time to tracheal extubation, ICU stay, hospital stay, and mortality. Results This meta-analysis included 65 randomized controlled trials involving 5,013 patients. Eight regional anesthetic techniques were involved, including thoracic epidural analgesia (TEA), erector spinae plane block, and transversus thoracic muscle plane block. Compared to controls (who have not received regional anesthetic techniques), TEA reduced the pain scores at 6, 12, 24 and 48 h both at rest and cough, decreased the rate of need for rescue analgesia (OR = 0.10, 95% CI: 0.016-0.55), shortened the time to tracheal extubation (MD = -181.55, 95% CI: -243.05 to -121.33) and the duration of hospital stay (MD = -0.73, 95% CI: -1.22 to -0.24). Erector spinae plane block reduced the pain score 6 h at rest and the risk of pruritus, shortened the duration of ICU stay compared to controls. Transversus thoracic muscle plane block reduced the pain scores 6 and 12 h at rest compared to controls. The cumulative morphine consumption of each technique was similar at 24, 48 h. Other outcomes were also similar among these regional anesthetic techniques. Conclusions TEA seems the most effective regional postoperative anesthesia for patients after cardiac surgery by reducing the pain scores and decreasing the rate of need for rescue analgesia. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, ID: CRD42021276645.
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Affiliation(s)
- Ke Zhou
- Department of Cardiac Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Dongyu Li
- Department of Cardiac Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Guang Song
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
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Lu Y, Zhou Q, Fu Y, Wen Z, Lv X. Ultrasound-Guided Bilateral Sequential Thoracic Paravertebral Block for Simultaneous Bilateral Uniportal Video-Assisted Thoracoscopic Surgery: Study Protocol for a Randomized Controlled Trial. J Pain Res 2023; 16:373-381. [PMID: 36762369 PMCID: PMC9904215 DOI: 10.2147/jpr.s398349] [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: 12/01/2022] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Purpose Simultaneous bilateral pulmonary resection via uniportal video-assisted thoracoscopic surgery (UVATS) was safe and feasible for the treatment of bilateral multiple pulmonary nodules. But, it should be noted that considerable postoperative pain at the bilateral surgical site was a crucial issue. The safety and efficacy of bilateral thoracic paravertebral block (TPVB) have been reported for postoperative analgesia. But, whether bilateral sequential TPVB can be safely and effectively used in simultaneous bilateral UVATS remains unknown. Therefore, this study aimed to determine the analgesic efficacy and safety of bilateral sequential TPVB after simultaneous bilateral UVATS. Study Design and Methods In this study, 80 participants scheduled for UVATS will be randomly allocated to the bilateral sequential TPVB group (G2) and the control group (G1). The patient of G2 will be performed bilateral TPVB at 2 time-points: before the start of the first side of pulmonary resection and before the start of the contralateral pulmonary resection. G1 will only receive standard analgesia protocol. The primary outcome is the numeric rating scale score during coughing at 24 h postoperatively. The secondary outcomes include the Prince Henry Pain Score scores, sufentanil consumption, postoperative nausea and vomiting, levels of inflammatory factors, and the Quality of Recovery-40 scores at different time points, as well as chronic pain at postoperative day (POD) 90. Discussion This is the first prospective trial to determine the safety and effectiveness of ultrasound-guided bilateral sequential TPVB for postoperative analgesia following simultaneous bilateral UVATS. This study also intended to evaluate the effect of this intervention on postoperative quality of recovery and inflammation levels. The final results will provide clinical evidence related to bilateral sequential TPVB, and promote the application of that acting as a more appropriate analgesic method for simultaneous bilateral UVATS.
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Affiliation(s)
- Yugang Lu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Qing Zhou
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Yu Fu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Zongmei Wen
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China,Correspondence: Zongmei Wen; Xin Lv, Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Road, Shanghai, 200433, People’s Republic of China, Tel/Fax +86 21 65115006, Email ;
| | - Xin Lv
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
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Geng C, Tong C, Li H, Shi S, Yu J, Huang L. Effects of Thoracic Paravertebral Block on Postoperative Anxiety and Depression for Patients Undergoing Thoracoscopic Lung Cancer Radical Surgery. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:7629012. [PMID: 36158131 PMCID: PMC9507659 DOI: 10.1155/2022/7629012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/24/2022]
Abstract
This study is aimed at investigating the effect of thoracic paravertebral block (TPVB) on the occurrence of chronic postoperative pain, postoperative anxiety, and depression in patients undergoing thoracoscopic radical lung cancer surgery. A total of 120 patients who underwent thoracoscopic radical lung cancer surgery in our hospital from June 2019 to March 2021 were included. There were 62 males and 58 females, with an age of 18-75 years old and a body mass index of 20-28 kg/m2. Patients were divided into two groups using the random number table method, TPVB group (n = 60) and normal saline group (control group, n = 60). Two-point nerve block was performed at T5-6 and T6-7 levels. Patients in the TPVB group received nerve block with 15 mL of 0.375% ropivacaine hydrochloride, while those in the control group received 5 mL of 0.9% normal saline. The numeric rating scale (NRS) scores at rest and during movement at 24 and 48 hours after surgery and the number of times the button on the patient-controlled analgesia pressed at 24 h after surgery in two groups were recorded. All patients were followed up by outpatient visits or phone visits at 1 year after surgery and assessed using Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale and Hospital Anxiety and Depression Scale (HADS). According to the inclusion, exclusion, and drop-out criteria, 108 patients were finally included, with 52 patients in the TPVB group and 56 patients in the control group. There was no statistically significant difference between the two groups in terms of age, sex, height, body weight, body mass index, ASA classification, and operation time (P > 0.05). NRS pain scores at 24 h (P = 0.0108) and 48 h (P = 0.0000) after surgery, the number of times pressing patient-controlled analgesia at 24 h after surgery (P = 0.0000), the LANSS scores (P = 0.0000), HADS anxiety score (P = 0.0000), and depression scores (P = 0.0000) at 1 year after surgery in the TPVB group were both significantly lower than those in the control group. To sum up, ultrasound-guided TPVB can effectively relieve pain at 48 hours after thoracoscopic lung cancer radical surgery and chronic postoperative pain at 6 months after V thoracoscopic lung cancer radical surgery.
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Affiliation(s)
- Congfu Geng
- Department of Anesthesiology, Jinhu People's Hospital, Huai'an, 211600 Jiangsu, China
| | - Chunting Tong
- Department of Anesthesiology, Jinhu People's Hospital, Huai'an, 211600 Jiangsu, China
| | - Houxiang Li
- Department of Anesthesiology, Jinhu People's Hospital, Huai'an, 211600 Jiangsu, China
| | - Shaojiang Shi
- Department of Anesthesiology, Jinhu People's Hospital, Huai'an, 211600 Jiangsu, China
| | - Jiancheng Yu
- Department of Anesthesiology, Jinhu People's Hospital, Huai'an, 211600 Jiangsu, China
| | - Lei Huang
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006 Jiangsu, China
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An G, Wang G, Zhao B, Zhang X, Li Z, Fu J, Zhao X. Opioid-free anesthesia compared to opioid anesthesia for laparoscopic radical colectomy with pain threshold index monitoring: a randomized controlled study. BMC Anesthesiol 2022; 22:241. [PMID: 35906554 PMCID: PMC9335965 DOI: 10.1186/s12871-022-01747-w] [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: 11/03/2021] [Accepted: 06/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Few studies have investigated the depth of intraoperative analgesia with non-opioid anesthesia. This study evaluated whether opioid-free anesthesia can provide an effective analgesia-antinociception balance monitored by the / pain threshold index in laparoscopic radical colectomy. METHODS We enrolled 102 patients undergoing laparoscopic radical colectomy with general anesthesia. Participants were randomly allocated into two groups to receive opioid-free anesthesia (group OFA) with dexmedetomidine (loading dose with 0.6 μg·kg-1 for 10 min and then 0.5 μg·kg-1·h-1 continuous infusion) and sevoflurane plus bilateral paravertebral blockade (0.2 μg·kg-1 dexmedetomidine and 0.5% ropivacaine 15 ml per side) or opioid-based anesthesia (group OA) with remifentanil, sevoflurane, and bilateral paravertebral blockade (0.5% ropivacaine 15 ml per side). The primary outcome variable was pain intensity during the operation, as assessed by the pain threshold index with the multifunction combination monitor HXD- I. Results were analyzed using repeated measures analysis of variance and Student's t-test. The secondary outcomes were wavelet index, lactic levels, and blood glucose concentration during the operation. The visual analog scale (VAS), rescue analgesic consumption, and side-effects of opioids after surgery were further assessed. RESULTS One hundred and one patients were included in the analysis. Analysis revealed that the intraoperative pain threshold index readings were not significantly different between the groups from incision to the end of the operation (P = 0.06). Furthermore, similar changes in the brain wavelet index readings were observed in the OFA and OA groups. There was no statistical difference in VAS scores between the groups (P > 0.05); however, non-opioid anesthesia did reduce the rescue analgesic consumption after operation (P < 0.05). In the OFA group, the blood glucose levels increased by 20% compared to baseline and were significantly higher than those in the OA group (P < 0.001). The incidences of postoperative nausea and vomiting, urine retention, intestinal paralysis and pruritus were not significantly different from those in the OA group (P > 0.05). CONCLUSIONS This study suggests that compared to the opioid anesthesia regimen, our opioid-free anesthesia regimen achieved an equally effective intraoperative pain threshold index in laparoscopic radical colectomy. The incidence of opioid-related adverse reactions was not different between regimens, and intraoperative blood glucose levels were higher with opioid-free anesthesia. TRIAL REGISTRATION ChiCTR1900021223, 02/02/2019, Title: " Opioid-free anesthesia in laparoscopic surgery: a randomized controlled trial ". Website: hppts:// www.chictr.ogr.cn.
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Affiliation(s)
- Guangquan An
- Department of Second Surgery, the Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Guiying Wang
- Department of Second Surgery, the Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.,Present Address: Department of Anesthesia, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Bingsha Zhao
- Department of Anesthesia, the Fourth Hospital of Hebei Medical University, 12 Jiankang Road, Shijiazhuang, 050011, People's Republic of China.,Present Address: Department of Anesthesia, Tianjin Chest Hospital, Tianjin, People's Republic of China
| | - Xiaoying Zhang
- Department of Anesthesia, the Fourth Hospital of Hebei Medical University, 12 Jiankang Road, Shijiazhuang, 050011, People's Republic of China
| | - Zhihan Li
- Department of Second Surgery, the Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Jianfeng Fu
- Department of Anesthesia, the Fourth Hospital of Hebei Medical University, 12 Jiankang Road, Shijiazhuang, 050011, People's Republic of China
| | - Xuelian Zhao
- Department of Anesthesia, the Fourth Hospital of Hebei Medical University, 12 Jiankang Road, Shijiazhuang, 050011, People's Republic of China.
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Yao Y, Xu M. The effect of continuous intercostal nerve block vs. single shot on analgesic outcomes and hospital stays in minimally invasive direct coronary artery bypass surgery: a retrospective cohort study. BMC Anesthesiol 2022; 22:64. [PMID: 35260084 PMCID: PMC8903669 DOI: 10.1186/s12871-022-01607-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 03/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Minimally invasive direct coronary artery bypass (MIDCAB) grafting surgery is accompanied by severe pain. Although continuous intercostal nerve block (CINB) has become one of the multimodal analgesic techniques in single port thoracoscopic surgery, its effects on MIDCAB are unclear. The purpose of this study was to compare the effects of CINB and single shot on analgesic outcomes and hospital stays in patients undergoing MIDCAB in a real-world setting. METHODS A retrospective cohort study was carried out at Peking University Third Hospital, China. Two hundred and sixteen patients undergoing MIDCAB were divided into two groups: a CINB group and a single block (SI) group. The primary outcome was postoperative maximal visual analog scale (VAS); secondary outcomes included the number of patients with maximal VAS ≤ 3, the demand for and consumed doses of pethidine and tramadol, and the length of intensive care unit (ICU) and hospital stays. The above data and the area under the VAS curve in the 70 h after extubation for the two subgroups (No. of grafts = 1) were also compared. RESULTS The maximum VAS was lower in the CINB group, and there were more cases with maximum VAS ≤ 3 in the CINB group: CINB 52 (40%) vs. SI 17 (20%), P = 0.002. The percentage of cases requiring tramadol and pethidine was less in CINB, P = 0.001. Among all patients, drug doses were significantly lower in the CINB group [tramadol: CINB 0 (0-100) mg vs. SI 100 (0-225) mg, P = 0.0001; pethidine: CINB 0 (0-25) mg vs. SI 25 (0-50) mg, P = 0.0004]. Further subgroup analysis showed that the area under the VAS curve in CINB was smaller: 28.05 in CINB vs. 30.41 in SI, P = 0.002. Finally, the length of ICU stay was shorter in CINB than in SI: 20.5 (11.3-26.0) h vs. 22.0 (19.0-45.0) h, P = 0.011. CONCLUSIONS CINB is associated with decreased demand for rescue analgesics and shorter length of ICU stay when compared to single shot intercostal nerve block. Additional randomized controlled trial (RCT) is needed to support these findings.
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Affiliation(s)
- Youxiu Yao
- Department of Anesthesiology, Peking University Third Hospital, Beijing, People's Republic of China
| | - Mao Xu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, People's Republic of China.
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GÜVEN BB, ERTÜRK T, ERSOY A. Postoperative analgesic effectiveness of bilateral erector spinae plane block for adult cardiac surgery: a randomized controlled trial. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1013908] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Jiang T, Ting A, Leclerc M, Calkins K, Huang J. Regional Anesthesia in Cardiac Surgery: A Review of the Literature. Cureus 2021; 13:e18808. [PMID: 34804666 PMCID: PMC8590887 DOI: 10.7759/cureus.18808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2021] [Indexed: 11/30/2022] Open
Abstract
With our population getting older and sicker, we are witnessing a steady increase in the volume of cardiothoracic procedures performed. As the role of anesthesiologists continues to shift towards being perioperative physicians, it is crucial to tailor the anesthetic to manage the surgical pain in both intraoperative and postoperative periods. In cardiac surgery, poorly controlled surgical pain can lead to opioid-induced hyperalgesia as well as chronic pain syndrome. As current practice encourages early extubation and decreased length of stay, clinicians have increasingly steered away from heavy intraop narcotic therapy over the past two decades. To blunt the sympathetic response and postoperative pain control, some have been using various fascial plane nerve blocks to reduce opioid use during surgery. These blocks are considered very safe to perform and do not lead to hemodynamic changes seen in neuraxial blockades. In this review article, we provide a brief overview of each of the commonly used blocks and summarize and discuss the latest clinical data for each of the common blocks and their efficacy in the setting of cardiothoracic surgery.
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Affiliation(s)
- Tianyu Jiang
- Anesthesiology, Oak Hill Hospital, Brooksville, USA
| | | | | | - Kerry Calkins
- College of Medicine, University of South Florida, Tampa, USA
| | - Jeffrey Huang
- Anesthesiology, Oak Hill Hospital, Brooksville, USA.,Anesthesiology, HCA Healthcare, Orlando, USA
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Naganuma M, Tokita T, Sato Y, Kasai T, Kudo Y, Suzuki N, Masuda S, Nagaya K. Efficacy of Preoperative Bilateral Thoracic Paravertebral Block in Cardiac Surgery Requiring Full Heparinization: A Propensity-Matched Study. J Cardiothorac Vasc Anesth 2021; 36:477-482. [PMID: 34099376 DOI: 10.1053/j.jvca.2021.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To assess the efficacy of preoperative bilateral paravertebral block (PVB) with general anesthesia (GA) in contributing to early extubation and decreasing opioid consumption in cardiac surgery. DESIGN A propensity score-matched retrospective study. SETTING A single tertiary medical center between January 2018 and December 2020. PARTICIPANTS Adult patients undergoing isolated first-time aortic valve replacement and coronary artery bypass grafting with full sternotomy. INTERVENTIONS A cohort of 44 patients who received PVB with GA (PVB group) was matched with 44 patients who underwent similar surgery with GA only (GA only group). MEASUREMENTS AND MAIN RESULTS The completion rate of extubation in the operating room was significantly greater in the PVB group (65.9%) than in the GA only group (43.2%; p = 0.032). The completion rate of extubation within eight hours after surgery also was significantly greater in the PVB group (86.4%) than in the GA only group (68.2%; p = 0.042). The median amount of intraoperative fentanyl administered was significantly less in the PVB group (4.8 µg/kg; interquartile range [IQR], 3.3-7.2) than in the GA only group (8.4 µg/kg; IQR, 5.4-12.7; p < 0.001). The median amount of postoperative fentanyl administered was significantly less in the PVB group (6.8 µg/kg; IQR, 3.9-10.6) than in the GA only group (8.1 µg/kg; IQR, 6.2-15.9; p = 0.012). CONCLUSIONS This study demonstrated that preoperative bilateral PVB combined with GA contributed to early extubation in isolated first-time aortic valve replacement and coronary artery bypass grafting and in the reduction of intraoperative and postoperative fentanyl consumption.
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Affiliation(s)
- Masaaki Naganuma
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan.
| | - Takaharu Tokita
- Department of Anesthesiology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Yuri Sato
- Department of Anesthesiology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Toshinori Kasai
- Department of Anesthesiology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Yasushi Kudo
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Nobuaki Suzuki
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Shinya Masuda
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Koichi Nagaya
- Department of Cardiovascular Surgery, Aomori Prefectural Central Hospital, Aomori, Japan
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The Incidence of New Persistent Opioid Use Following Cardiac Surgery via Sternotomy. Ann Thorac Surg 2021; 113:33-40. [PMID: 33930358 DOI: 10.1016/j.athoracsur.2021.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 03/30/2021] [Accepted: 04/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND In recent years, increased attention has turned toward the risk of chronic opioid use after surgery. In this nationwide cohort study, we examined the rate of new persistent opioid use after cardiac surgery by sternotomy. METHODS All opioid-naive patients undergoing heart surgery by sternotomy from 2005 to 2018 in Iceland were included in the study. Naivety was defined as not filling an opioid prescription within 6 months before surgery. Persistent opioid use was defined as filling at least 1 opioid prescription during the first 90 days after surgery and another 90 to 180 days after the operation. In addition to estimating the incidence of new persistent opioid use, differences in patient characteristics, survival, and readmission rates were compared between the group with and without new persistent opioid use. RESULTS Of 1227 patients who underwent cardiac surgery by sternotomy during the study period, 925 were included in the study. Of those, 4.6% developed new persistent opioid use. When only patients who filled an opioid prescription after surgery were included, 10.1% developed new persistent opioid use. Chronic obstructive pulmonary disease, preoperative use of nonsteroidal anti-inflammatory drugs, gabapentinoids, and nitrates were associated with increased risk for new persistent opioid use. Patients with new persistent opioid use did not have higher rates of readmission nor all-cause mortality. CONCLUSIONS The rate of new persistent opioid use after cardiac surgery was 4.6%. Future steps should identify strategies to minimize the development of new persistent opioid use.
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Kang K, Meng X, Li B, Yuan J, Tian E, Zhang J, Zhang W. Effect of thoracic paravertebral nerve block on the early postoperative rehabilitation in patients undergoing thoracoscopic radical lung cancer surgery. World J Surg Oncol 2020; 18:298. [PMID: 33183325 PMCID: PMC7664097 DOI: 10.1186/s12957-020-02071-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 10/27/2020] [Indexed: 12/31/2022] Open
Abstract
Objective To evaluate the effect of thoracic paravertebral nerve block on early postoperative rehabilitation in patients undergoing radical thoracoscopic surgery for lung cancer. Methods Ninety patients scheduled for elective video-assisted thoracoscopic lobectomy of lung cancer were divided into 2 groups: the general anesthesia group (GA group, n = 45) and the TPVB group (TP group, n = 45). The primary outcome was the decline rate of the 6-min walking test (6MWT); the second outcomes were as follows: absolute value and the completion rate of 6MWT, postoperative analgesia deficiency and pain scores, oxycodone consumption, sleep quality, the incidence of postoperative pulmonary complications, and the hospital stay. Results Compared with the GA group, the TP group had a lower decline rate of the 6MWT on POD1 and POD2. The walking distance on POD1 and POD2 in the TP group was significantly longer than that in the GA group; the completion rate at POD1 in the TP group was higher than that in the GA group. The pain scores and oxycodone consumption at POD1 in the TP group were lower than the GA group. The sleep quality in the TP group was higher than the GA group. Conclusions TPVB can significantly improve postoperative rehabilitation in patients undergoing thoracoscopic radical lung cancer surgery, which is helpful for promoting the early recovery of patients. Trial registration Chinese Clinical Trial Registry, ChiCTR1900026213. Registered 26 Sept. 2019, http://www.chictr.org.cn/showproj.aspx?proj=43733.
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Affiliation(s)
- Kang Kang
- Department of Perioperative Medicine and Anesthesiology, Henan University People's Hospital; Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, Henan Province, China
| | - Xing Meng
- Department of Perioperative Medicine and Anesthesiology, Henan University People's Hospital; Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, Henan Province, China
| | - Bing Li
- Department of Perioperative Medicine and Anesthesiology, Henan University People's Hospital; Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, Henan Province, China
| | - Jingli Yuan
- Department of Perioperative Medicine and Anesthesiology, Henan University People's Hospital; Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, Henan Province, China
| | - Erhu Tian
- Department of Cardiology, Henan University People's Hospital, No. 7, Weiwu Road, Zhengzhou City, Henan Province, China
| | - Jiaqiang Zhang
- Department of Perioperative Medicine and Anesthesiology, Henan University People's Hospital; Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, Henan Province, China
| | - Wei Zhang
- Department of Perioperative Medicine and Anesthesiology, Henan University People's Hospital; Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, Henan Province, China.
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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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Tan X, Fu D, Feng W, Zheng X. The analgesic efficacy of paravertebral block for percutaneous nephrolithotomy: A meta-analysis of randomized controlled studies. Medicine (Baltimore) 2019; 98:e17967. [PMID: 31770205 PMCID: PMC6890373 DOI: 10.1097/md.0000000000017967] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The analgesic efficacy of paravertebral block for percutaneous nephrolithotomy remains controversial. We conduct a systematic review and meta-analysis to explore the analgesic efficacy of paravertebral block for patients with percutaneous nephrolithotomy. METHODS We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases, and randomized controlled trials (RCTs) assessing analgesic efficacy of paravertebral block for percutaneous nephrolithotomy are included in this meta-analysis. RESULTS Five RCTs are included in the meta-analysis. Overall, compared with control group after percutaneous nephrolithotomy, paravertebral block is associated with the decrease in analgesic consumption (standard mean difference (Std. MD) = -1.55; 95% confidence interval (CI) = -2.18 to -0.92; P < .00001) and additional analgesics (risk ratio (RR) = 0.17; 95% CI = 0.07 to 0.44; P = .0003), prolonged time to first analgesic requirement (Std. MD = 1.51; 95% CI = 0.26 to 2.76; P = .02). There is no statistical difference of adverse events including nausea or vomiting (RR = 0.51; 95% CI = 0.11 to 2.35; P = .38), or itching (RR = 0.69; 95% CI = 0.26 to 1.81; P = .45) between 2 groups. CONCLUSIONS Paravertebral block is effective for pain control after percutaneous nephrolithotomy.
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Affiliation(s)
- Xiaoyu Tan
- Department of Urology, The Fourth People's Hospital of Chongqing
| | - Donglin Fu
- Department of Critical Care Medicine, Chongqing General Hospital, China
| | - Wubing Feng
- Department of Urology, The Fourth People's Hospital of Chongqing
| | - Xiangqi Zheng
- Department of Urology, The Fourth People's Hospital of Chongqing
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