1
|
Skojec AJ, Christensen JM, Yalamuri SM, Smith MM, Arghami A, LeMahieu AM, Schroeder DR, Mauermann WJ, Nuttall GA, Ritter MJ. Deep Parasternal Intercostal Plane Block for Postoperative Analgesia After Sternotomy for Cardiac Surgery-A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:189-196. [PMID: 37968198 DOI: 10.1053/j.jvca.2023.09.044] [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: 03/07/2023] [Revised: 07/31/2023] [Accepted: 09/29/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE To examine the analgesic efficacy of postoperative deep parasternal intercostal plane (DPIP) blocks for patients having cardiac surgery via median sternotomy. DESIGN This single-center retrospective study compared patients receiving bilateral DPIP blocks with a matched cohort of patients not receiving DPIP blocks. SETTING Large quaternary referral center. PARTICIPANTS Adult patients admitted to the authors' institution from January 1, 2016, to August 14, 2020, for elective cardiac surgery via median sternotomy. INTERVENTIONS Patients received ultrasound-guided bilateral DPIP blocks. MEASUREMENTS AND MAIN RESULTS A total of 113 patients received a DPIP block; 3,461 patients did not. The estimated multiplicative change in cumulative opioid consumption through 24 hours was 0.42 (95% CI 0.32-0.56; p < 0.001), indicating that patients receiving DPIP blocks required 60% fewer opioids than patients who did not. Proportional odds ratios for the average pain score on postoperative day (POD) 0 was 0.46 (95% CI 0.32-0.65; p < 0.001), and POD 1 was 0.67 (95% CI 0.47-0.94; p = 0.021), indicating lower pain scores for patients receiving blocks. The exploratory analysis identified an inverse correlation between DPIP blocks and atrial fibrillation incidence (2% v 15%; inverse probability of treatment weighting odds ratio 0.088, 95% CI 0.02-0.41; p = 0.002). CONCLUSIONS The use of DPIP blocks in patients undergoing cardiac surgery via median sternotomy was associated with less opioid use and improved pain scores in the early postoperative period compared with patients not receiving blocks. Prospective randomized controlled studies should further elucidate the efficacy and risks of DPIP blocks in cardiac surgery.
Collapse
Affiliation(s)
- Alexander J Skojec
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Jon M Christensen
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Suraj M Yalamuri
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Allison M LeMahieu
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - William J Mauermann
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Matthew J Ritter
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN.
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Kumar A, Ghotra GS, Dwivedi D, Bhargava DV, Joshi A, Tiwari N, Ramamurthy HR. Common Inflammatory Markers and Outcome After Pediatric Cardiac Surgery With High Thoracic Epidural Anesthesia: A Randomized Controlled Study. World J Pediatr Congenit Heart Surg 2023; 14:334-344. [PMID: 36823972 DOI: 10.1177/21501351221151053] [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: 02/25/2023]
Abstract
Background: High thoracic epidural analgesia (HTEA) plays a pivotal role in reducing stress and neuroendocrine response in cardiac surgeries. Aim: The primary objective is to assess the effect of HTEA, in pediatric cardiac surgery, on inflammatory markers (interleukin [IL]-6, IL-8, and tumor necrosis factor-α). The secondary objectives are to assess its effect on various organ systems, that is, pulmonary (PaO2, P/F ratio), renal (Creatinine clearance, somatic near infrared spectroscopy [NIRS], serum neutrophil gelatinase-associated lipocalin values), cardiac (cardiac index, serum Trop-I, and lactate levels), mechanical ventilation duration, and length of stay in hospital (LOS). Methods: The study included 188 pediatric patients, who underwent, on-pump cardiac surgery randomized into the Epidural Group (n = 92) and Non-Epidural Group (n = 96). After general anesthesia, a 23 G epidural catheter was placed at the T4-5 level with a Bupivacaine infusion while the Non-epidural Group received fentanyl infusion. Blood samples were collected at four-time points, T0(preop), T1(4 h), and on the first and second postoperative days (T2 and T3). Results: The inflammatory markers were reduced, while the outcomes variables of mechanical ventilation (MV) duration had lower values in the epidural group (19.5 h vs 47.3 h, P = .002). LOS was shorter (10.1 days vs 13.3 days, P = .016). pO2, PF ratio, and renal NIRS values were better in the Epidural Gp, while other parameters were comparable. Non-epidural Gp had more complications esp. Acute kidney injury requires RRT. Conclusion: HTEA use in pediatric, on-pump cardiac surgery offers a favorable profile in terms of reduction in the inflammatory markers and positive effect on the organ systems with lesser MV duration and the LOS.
Collapse
Affiliation(s)
- Alok Kumar
- Department of Anaesthesia & Critical Care, 521937Army Hospital (Research & Referral), New Delhi, India
| | - Gurpinder Singh Ghotra
- Department of Anaesthesia & Critical Care, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Deepak Dwivedi
- Department of Anaesthesia & Critical Care, Department of Anaesthesia & Critical Care, 30154Command Hospital (Eastern command), Kolkata, India
| | - D V Bhargava
- Department of Anaesthesia & Critical Care, Army Institute of Cardiothoracic Sciences, Pune, India
| | - Ankur Joshi
- Department of Anaesthesia & Critical Care, 521937Army Hospital (Research & Referral), New Delhi, India
| | - Nikhil Tiwari
- Department of Cardiothoracic Surgery, 521937Army Hospital (Research & Referral), New Delhi, India
| | - H R Ramamurthy
- Department of Paediatrics, 521937Army Hospital (Research & Referral), New Delhi, India
| |
Collapse
|
4
|
Vinzant NJ, Christensen JM, Yalamuri SM, Smith MM, Nuttall GA, Arghami A, LeMahieu AM, Schroeder DR, Mauermann WJ, Ritter MJ. Pectoral Fascial Plane Versus Paravertebral Blocks for Minimally Invasive Mitral Valve Surgery Analgesia. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00099-X. [PMID: 36948910 DOI: 10.1053/j.jvca.2023.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 01/24/2023] [Accepted: 02/06/2023] [Indexed: 02/13/2023]
Abstract
OBJECTIVES This study examined the postoperative analgesic efficacy of single-injection pectoral fascial plane (PECS) II blocks compared to paravertebral blocks for elective robotic mitral valve surgery. DESIGN A single-center retrospective study that reported patient and procedural characteristics, postoperative pain scores, and postoperative opioid use for patients undergoing robotic mitral valve surgery. SETTING This investigation was performed at a large quaternary referral center. PARTICIPANTS Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2016, to August 14, 2020, for elective robotic mitral valve repair who received either a paravertebral or PECS II block for postoperative analgesia. INTERVENTIONS Patients received an ultrasound-guided, unilateral paravertebral or PECS II nerve block. MEASUREMENTS AND MAIN RESULTS One hundred twenty-three patients received a PECS II block, and 190 patients received a paravertebral block during the study period. The primary outcome measures were average postoperative pain scores and cumulative opioid use. Secondary outcomes included hospital and intensive care unit lengths of stay, need for reoperation, need for antiemetics, surgical wound infection, and atrial fibrillation incidence. Patients receiving the PECS II block required significantly fewer opioids in the immediate postoperative period than the paravertebral block group, and had comparable postoperative pain scores. No increase in adverse outcomes was noted for either group. CONCLUSIONS The PECS II block is a safe and highly effective option for regional analgesia for robotic mitral valve surgery, with demonstrated efficacy comparable to the paravertebral block.
Collapse
Affiliation(s)
- Nathan J Vinzant
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Jon M Christensen
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Suraj M Yalamuri
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Gregory A Nuttall
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Allison M LeMahieu
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Darrell R Schroeder
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - William J Mauermann
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Matthew J Ritter
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
| |
Collapse
|
5
|
Devarajan J, Balasubramanian S, Nazarnia S, Lin C, Subramaniam K. Current Status of Neuraxial and Paravertebral Blocks for Adult Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2021; 25:252-264. [PMID: 34162252 DOI: 10.1177/10892532211023337] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cardiac surgeries are known to produce moderate to severe pain. Pain management has traditionally been based on intravenous opioids. Poorly controlled pain can result in increased incidence of respiratory complications such as atelectasis and pneumonia leading to prolonged intubation and intensive care unit length of stay and subsequent prolonged hospital stay. Adequate perioperative analgesia improves hemodynamics and immunologic responses, which would result in better outcomes after cardiac surgery. Opioid sparing "Enhanced Recovery After Surgery" protocols are increasingly being incorporated into cardiac surgeries. This will reduce opioid requirements and opioid-related side effects and facilitate fast-tracking of patients. Regional analgesia can be provided by neuraxial blocks, fascial plane blocks, peripheral nerve blocks, or simply by the infiltration of the wound with local anesthetics for cardiac surgery. Neuraxial analgesia is provided through epidural, spinal, and paravertebral routes. Though they are being replaced by peripheral fascial plane blocks, epidural and spinal analgesia are still being used in some centers. In this article, neuraxial forms of analgesia are focused. We sought to review epidural analgesia and its impact in suppressing hemodynamic stress response, reducing pulmonary complications, and development of chronic pain. The relationship between intraoperative heparinization and potential neuraxial hematoma is discussed. Other neuraxial options such as spinal and paravertebral analgesia and their usefulness, benefits, and limitations are also reviewed.
Collapse
Affiliation(s)
| | | | | | - Charles Lin
- University of Pittsburgh, Pittsburgh, PA, USA
| | | |
Collapse
|
6
|
Greco KJ, Brovman EY, Nguyen LL, Urman RD. The Impact of Epidural Analgesia on Perioperative Morbidity or Mortality after Open Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2019; 66:44-53. [PMID: 31672606 DOI: 10.1016/j.avsg.2019.10.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/08/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Epidural analgesia (EA) is frequently used as an adjuvant to general anesthesia (GA) for improved postoperative analgesia and reduced rates of cardiac, pulmonary, and renal complications. However, only a few studies have examined EA-GA specifically during open abdominal aortic aneurysm (AAA) repair. The effects of EA-GA specifically during open AAA repair regarding postoperative outcomes are unknown. This study was performed to evaluate postoperative outcomes in patients undergoing open AAA repair with EA-GA versus GA alone. METHODS We performed a retrospective analysis for patients undergoing surgery between January 1, 2014 and December 31, 2016 using the National Surgical Quality Improvement Program (NSQIP) database. Propensity score matching was used to establish cohorts for analysis. Multivariable logistic regression was performed to determine significant perioperative outcomes for each anesthesia type. A total of 2,171 patients underwent open AAA repair in our date range; we excluded emergent and ruptured AAA. A total of 2,145 patients were included in our analysis, of whom 653 patients received EA-GA and 1,492 patients received GA only. RESULTS Major postoperative outcomes included mortality, pulmonary cardiac and renal complications, infections, thrombosis, and blood transfusion requirement (including Cell-Saver usage). Additional overall outcomes included hospital length of stay, return to the operating room, and readmission. Patients in EA + GA and GA alone groups were comparable regarding demographics, functional status, and comorbidities. Decreased odds of readmission was observed in EA + GA compared with GA (0.49, 95% CI [0.28-0.86]; P = 0.014); and increased odds of receiving a blood transfusion was observed in those who underwent EA + GA (1.63, 95% CI [1.23-2.14]; P = 0.001). No difference was observed between patients who had an AAA repair with EA + GA versus GA alone with regard to mortality, return to operating room, major pulmonary, cardiac, renal, or infectious complications. CONCLUSIONS EA + GA was not associated with decreased mortality or decreased rates of major postoperative pulmonary, cardiac, or renal complications. EA + GA was associated with increased transfusion requirements and decreased rates of hospital readmission.
Collapse
Affiliation(s)
- Katherine J Greco
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Ethan Y Brovman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Louis L Nguyen
- Division Vascular and Endovascular Surgery, Department Surgery, Brigham and Women's Hospital, Boston, MA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
7
|
Obersztyn M, Trejnowska E, Nadziakiewicz P, Knapik P. Evaluation of thoracic epidural analgesia in patients undergoing coronary artery bypass surgery - a prospective randomized trial. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2018; 15:72-78. [PMID: 30069186 PMCID: PMC6066681 DOI: 10.5114/kitp.2018.76471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/12/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Most recent studies tend to confirm the beneficial effect of thoracic epidural analgesia (TEA) in cardiac surgery. AIM To assess whether intensive care unit TEA has an influence on the perioperative course following low-risk coronary artery surgery. MATERIAL AND METHODS This prospective, randomized trial was performed in patients scheduled for low-risk coronary artery surgery. Eighty patients undergoing off-pump or on-pump coronary artery bypass surgery were prospectively randomized to receive either combined general and epidural anesthesia or general anesthesia only. Time of postoperative ventilations and intensive care unit stay was compared between the groups. For all comparisons (p < 0.05) was considered statistically significant. RESULTS The addition of TEA to general anesthesia significantly attenuated the stress response expressed by intraoperative heart rate, systolic blood pressure and cumulative doses of opioids. Time to the return of spontaneous respiration, time to extubation and time of stay in the postoperative care unit were all shorter in the study group, with no difference in hospital stay. Patients with TEA required midazolam less frequently (12.8% vs. 53.8%, p < 0.001). The percentage of patients given morphine in the study group was lower (46.2% vs. 89.7%, p < 0.001) and the mean dose given in patients receiving morphine was also lower (9.3 ±5.3 mg vs. 18.2 ±9.1 mg, p < 0.001). CONCLUSIONS Addition of TEA to general anesthesia shortens the return of respiratory function, duration of mechanical ventilation and ICU stay in the postoperative period after coronary artery surgery, providing comparable hemodynamic stability to general anesthesia alone.
Collapse
Affiliation(s)
- Maciej Obersztyn
- Department of Anesthesia, University Clinical Centre, Medical University of Silesia, Katowice, Poland
| | - Ewa Trejnowska
- Department of Cardiac Anesthesia and Intensive Therapy, Silesian Centre for Heart Diseases in Zabrze, Medical University of Silesia in Katowice, Poland
| | - Paweł Nadziakiewicz
- Department of Cardiac Anesthesia and Intensive Therapy, Silesian Centre for Heart Diseases in Zabrze, Medical University of Silesia in Katowice, Poland
| | - Piotr Knapik
- Department of Cardiac Anesthesia and Intensive Therapy, Silesian Centre for Heart Diseases in Zabrze, Medical University of Silesia in Katowice, Poland
| |
Collapse
|
8
|
Oon Z, Woo A. Should thoracic epidurals be routinely sited in patients having cardiac surgery? Br J Hosp Med (Lond) 2017; 78:730. [PMID: 29240502 DOI: 10.12968/hmed.2017.78.12.730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Zhihao Oon
- Specialist Registrar (ST7), Department of Anaesthesia & Pain Management, King's College Hospital NHS Foundation Trust, London SE5 9RS
| | - Adam Woo
- Consultant in Pain Management, Department of Anaesthesia & Pain Management, King's College Hospital NHS Foundation Trust, London
| |
Collapse
|