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Vanneman MW, Kiwakyou LM, Harrison TK, Mariano ER. Heartfelt Healing: Charting New Trajectories in Postsurgical Pain. Anesth Analg 2024; 138:1187-1191. [PMID: 38771601 DOI: 10.1213/ane.0000000000006871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Affiliation(s)
- Matthew W Vanneman
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Larissa M Kiwakyou
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - T Kyle Harrison
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
- Department of Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Edward R Mariano
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
- Department of Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
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Singh K, Tsang S, Zvara J, Roach J, Walters S, McNeil J, Jossart S, Abdel-Malek A, Yount K, Mazzeffi M. Intraoperative Methadone Use Is Associated With Reduced Postoperative Pain and More Rapid Opioid Weaning After Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00322-7. [PMID: 38876810 DOI: 10.1053/j.jvca.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE To explore the association between intraoperative methadone use, postoperative pain, and opioid consumption after coronary artery bypass grafting (CABG) surgery. DESIGN Retrospective cohort study. SETTING Single academic medical center. PARTICIPANTS Patients undergoing isolated CABG over a 5-year period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic data, comorbidities, and intraoperative anesthetic medications were recorded. Primary study outcomes were average and maximum pain scores and morphine milligram equivalent consumption on the first 2 postoperative days (PODs). Linear mixed-effects regression models were used to examine the effect of intraoperative methadone use on study outcomes. Among 1,338 patients, 78.6% received intraoperative methadone (0.2 mg/kg). Patients who did not receive methadone had higher average (estimated [Est], 0.48; 95% confidence interval [CI], 0.22-0.73; p < 0.001) and maximum postoperative (Est, 0.49; 95% CI, 0.23-0.75; p < 0.001) pain scores over PODs 0 to 2. For postoperative opioid consumption, there was a significant intraoperative methadone use-time interaction effect on postoperative opioid use (odds ratio [OR], 2.21; 95% CI, 1.74-2.80; p < 0.001). Across PODs 0 to 2, patients who received intraoperative methadone had a faster decline in postoperative opioid use than those who did not receive intraoperative methadone. Patients who did not receive intraoperative methadone were extubated slightly faster (OR, 0.82; 95% CI, 0.72-0.93; p < 0.01). CONCLUSIONS Our data suggest that the use of intraoperative methadone is safe, reduces postoperative pain, and expedites weaning from postoperative opioids after CABG surgery.
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Affiliation(s)
- Karen Singh
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Siny Tsang
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Jessica Zvara
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Joshua Roach
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Susan Walters
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - John McNeil
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Scott Jossart
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Amir Abdel-Malek
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Kenan Yount
- Department of Cardiothoracic Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA.
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Xin L, Feng Y. In reply: Efficacy of erector spinae plane block for postoperative analgesia after minimally invasive cardiac surgery. Can J Anaesth 2024:10.1007/s12630-024-02733-1. [PMID: 38509435 DOI: 10.1007/s12630-024-02733-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 03/22/2024] Open
Affiliation(s)
- Ling Xin
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Yi Feng
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China.
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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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Cameron MJ, Long J, Kardash K, Yang SS. Superficial parasternal intercostal plane blocks in cardiac surgery: a systematic review and meta-analysis. Can J Anaesth 2024:10.1007/s12630-024-02726-0. [PMID: 38443735 DOI: 10.1007/s12630-024-02726-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/11/2024] [Accepted: 01/20/2024] [Indexed: 03/07/2024] Open
Abstract
PURPOSE Traditional multimodal analgesic strategies have several contraindications in cardiac surgery patients, forcing clinicians to use alternative options. Superficial parasternal intercostal plane blocks, anesthetizing the anterior cutaneous branches of the thoracic intercostal nerves, are being explored as a straightforward method to treat pain after sternotomy. We sought to evaluate the literature on the effects of superficial parasternal blocks on pain control after cardiac surgery. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). We searched MEDLINE, Embase, CENTRAL, and Web of Science databases for RCTs evaluating superficial parasternal intercostal plane blocks in adult patients undergoing cardiac surgery via midline sternotomy published from inception to 11 March 2022. The prespecified primary outcome was opioid consumption at 12 hr. The risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool, and the quality of evidence was evaluated using the grading of recommendations, assessments, development, and evaluations. Outcomes were analyzed with a random-effects model. All subgroups were prespecified. RESULTS We reviewed 1,275 citations. Eleven RCTs, comprising 756 patients, fulfilled the inclusion criteria. Only one study reported the prespecified primary outcome, precluding the possibility of meta-analysis. This study reported a reduction in opioid consumption (-11.2 mg iv morphine equivalents; 95% confidence interval [CI], -8.2 to -14.1) There was a reduction in opioid consumption at 24 hr (-7.2 mg iv morphine equivalents; 95% CI, -5.6 to -8.7; five trials; 436 participants; moderate certainty evidence). All five studies measuring complications reported that none were detected, which included a sample of 196 blocks. CONCLUSION The literature suggests a potential benefit of using superficial parasternal blocks to improve acute postoperative pain control after cardiac surgery via midline sternotomy. Future studies specifying dosing regimens and adjuncts are required. STUDY REGISTRATION PROSPERO (CRD42022306914); first submitted 22 March 2022.
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Affiliation(s)
- Matthew J Cameron
- Faculty of Medicine, McGill University, Montreal, QC, Canada.
- Department of Anesthesia, Jewish General Hospital, K1401-3755 Cote Sainte Catherine, Montreal, QC, H3T 1E2, Canada.
- Lady Davis Research Institute, Montreal, QC, Canada.
| | - Justin Long
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Kenneth Kardash
- Faculty of Medicine, McGill University, Montreal, QC, Canada
- Department of Anesthesia, Jewish General Hospital, Montreal, QC, Canada
| | - Stephen S Yang
- Faculty of Medicine, McGill University, Montreal, QC, Canada
- Department of Anesthesia, Jewish General Hospital, Montreal, QC, Canada
- Lady Davis Research Institute, Montreal, QC, Canada
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Hoogma DF, Coppens S, Rex S. Efficacy of erector spinae plane block for minimally invasive mitral valve surgery: Results of a double-blind, prospective randomized placebo-controlled trial: Response to Xue et al. J Clin Anesth 2024; 92:111311. [PMID: 37913696 DOI: 10.1016/j.jclinane.2023.111311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 11/03/2023]
Affiliation(s)
- Danny Feike Hoogma
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium.
| | - Steve Coppens
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium.
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium.
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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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Magoon R, Jose J. Perioperative Pain Management in Cardiac Surgery: Learning More From the Experts. Anesth Analg 2023; 137:e51-e52. [PMID: 37973138 DOI: 10.1213/ane.0000000000006707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Rohan Magoon
- Department of Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India,
| | - Jes Jose
- Department of Cardiac Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
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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. In Response. Anesth Analg 2023; 137:e52-e53. [PMID: 37973139 DOI: 10.1213/ane.0000000000006708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Benu Makkad
- Department of Anesthesiology, University of Cincinnati College of Medicine, 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 Health Care 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
- Department of Anesthesiology, Missoula Anesthesiology and The International Heart Institute of Montana, Missoula, Montana
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Magoon R. Analgesia research in cardiac surgery: Same, same but different? Anaesth Crit Care Pain Med 2023; 42:101303. [PMID: 37709199 DOI: 10.1016/j.accpm.2023.101303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Rohan Magoon
- Department of Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi 110001, India.
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Nathan N. Persistent Pain After Thoracic Surgery-What Works, What Doesn't. Anesth Analg 2023; 137:1. [PMID: 37326861 DOI: 10.1213/ane.0000000000006550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
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