Analgesia and sedation post-coronary artery bypass graft surgery: a review of the literature

A Prospective Study on Activities of Daily Living, Comfort, Body Image, and Cardiac Symptoms in Coronary Artery Bypass Patients

BACKGROUND

A coronary artery bypass graft procedure reduces mortality for cardiovascular patients, but those undergoing it often face negative body perception, loss of daily activities, and lingering symptoms, hindering full functional recovery and comfort.

AIM

To compare the comfort level, activities of daily living, and body image based on certain characteristics of patients at baseline, (ii) Evaluate changes over time in levels of discomfort, activities of daily living, body image, and cardiac symptoms before and after CABG surgery within three months.

METHOD

This descriptive prospective cohort study comprised 50 patients scheduled for coronary artery bypass surgery. The study examined cardiac symptoms, comfort levels, daily activities, and multidimensional body-self relationships as its outcomes.

RESULTS

A Friedman test revealed that patients' body image, comfort levels, activities of daily living, and each heart symptom were significantly influenced by the time of day. According to this study, patients most frequently reported experiencing exhaustion, depression, and worry as cardiac symptoms. Only the comfort level exhibited a high correlation with each heart symptom, as indicated by Spearman's rho analysis.

CONCLUSION

The body image, comfort level, activities of daily living, and cardiac symptoms of patients changed over time. Therefore, regular assessments of these symptoms during the pre- and post-operative periods could offer valuable insights into patients' needs. This information can be instrumental in developing interventions that address patients' well-being and may positively impact patient outcomes.

Evaluation of Oral Pregabalin as a Preemptive Adjuvant for Postoperative Pain in Patients Undergoing Coronary Artery Bypass Grafting With General Anesthesia and High Thoracic Epidural: A Randomized Controlled Study

Aim This study aimed to evaluate the effectiveness of oral pregabalin as a preventive supplement in managing postoperative pain in patients undergoing coronary artery bypass grafting (CABG) with a combination of general anesthesia and high thoracic epidural anesthesia. Material and methods This 18-month randomized controlled study at a tertiary hospital's anesthesiology department included 62 American Society of Anesthesiologists (ASA) II or III patients aged 35-75 with left ventricular ejection fraction >35%. Placebo (Group B, n = 31) or pregabalin (Group A, n = 31) was randomly allocated. Group A got 150 mg of pregabalin the night before surgery and 75 mg on postoperative days 0 and 1, whereas Group B received a placebo. Postoperative pain was evaluated using the Verbal Numerical Scale and Visual Analogue Scale, while sedation was assessed with the Ramsay Sedation Scale. Statistical analysis was performed using SPSS for Windows, Version 16.0 (Released 2007; SPSS Inc., Chicago). Results In this study, pregabalin significantly reduced postoperative pain on Day 0 and Day 1 (p < 0.001) compared to the placebo. The pregabalin group exhibited higher sedation scores on Day 0 (p < 0.001), but there were no significant differences on Day 1. Inotrope requirements were similar between both groups. Conclusions CABG patients' postoperative pain was greatly reduced by pregabalin without impacting sedation or inotrope needs. These data imply that pregabalin was a useful supplementary analgesic for CABG patients' multimodal pain treatment.

The impact of anxiety experienced by patients scheduled for coronary artery bypass surgery on perceived pain, self-efficacy and body esteem in the perioperative period

Introduction

Despite the large amount of researches addressed the issue of the relationship between the intensity of preoperative symptoms of depression and/ or anxiety with their postoperative intensity and any complications after surgery, there have been almost unaddressed such subjects as how the patients perceive their own capabilities or physical attractiveness, and the emotions which are evoked by various aspects of their own bodies, including postoperative scars. These aspects play a significant role in assessing the quality of patients' life and have a significant impact on the overall assessment of the surgery as an event, in both the short- and long-term perspective.

Aim

To evaluate the relationship between anxiety, pain level, self-efficacy and body esteem in the pre- and postoperative periods among patients scheduled for coronary artery bypass surgery.

Material and methods

Prospective studies were carried out in a group of 50 patients scheduled for coronary artery bypass surgery, either on a planned or urgent basis. Anxiety, both as a state and as a trait, was assessed using the Polish version of the State-Trait Anxiety Inventory (STAI). The Visual Analogue Scale (VAS) was employed to evaluate pain. The Self-Efficacy Gauge measured self-efficacy, while the Body Esteem Scale assessed body esteem.

Results and Conclusions

The intensity of state anxiety significantly negatively correlated with self-efficacy following CABG surgery. There was a statistically significant negative correlation between the intensity of painand self-efficacy in the postoperative period. Among female patients, the intensity of pain, both pre- and post-operatively, negatively correlated with their assessment of body esteem concerning physical condition at the respective time points. When assessing anxiety as a trait during the perioperative period, a positive correlation with pain intensification after CABG was identified.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Impact of Chronic Kidney Disease on Clinical Outcomes during Hospitalization and Five-Year Follow-Up after Coronary Artery Bypass Grafting

Background

Chronic kidney disease (CKD) is often associated with multiple comorbidities including diabetes mellitus, and each has its own complications and impact after cardiac surgery including coronary revascularization. The objective of this work was to study the impact of CKD on clinical outcomes after coronary artery bypass grafting (CABG) and to compare outcomes in patients with different grades of renal functions. We retrospectively reviewed all patients who underwent CABG from January 2016 to August 2020 at our tertiary care hospital using electronic medical records.

Results

The study included 410 patients with a median age of 60 years, and 28.6% of them had CKD and hospital mortality of 2.7%. About 71.4% of the patients had GFR > 60 mL/min per 1.73 m2, 18.1% had early CKD (GFR 30-60), 2.7% had late CKD (GFR < 30), and 7.8% of them had end-stage renal disease (ESRD) requiring dialysis. The CKD group had significantly more frequent hospital mortality (p = 0.04), acute cerebrovascular stroke (p = 0.03), acute kidney injury (AKI) (p < 0.001), longer ICU stay (p = 0.002), post-ICU stay (p = 0.001), and sternotomy wound debridement (p = 0.03) compared to the non-CKD group. The frequencies of new need for dialysis were 2.4% vs. 14.9% vs. 45.5% (p < 0.001) in the patients with GFR > 60 mL/min per 1.73 m2, early CKD, and late CKD, respectively. Acute cerebral stroke (OR: 10.29, 95% CI: 1.82-58.08, and p = 0.008), new need for dialysis (OR: 25.617, 95% CI: 13.78-85.47, and p < 0.001), and emergency surgery (OR: 3.1, 95% CI: 1.82-12.37, and p = 0.036) were the independent predictors of hospital mortality after CABG. The patients with CKD had an increased risk of strokes (HR: 2.14, 95% CI: 1.20-3.81, and p = 0.01) but insignificant mortality increase (HR: 1.44, 95% CI: 0.42-4.92, and p = 0.56) during follow-up.

Conclusion

The patients with CKD, especially the late grade, had worse postoperative early and late outcomes compared to non-CKD patients after CABG. Patients with dialysis-independent CKD had increased risks of needing dialysis, hospital mortality, and permanent dialysis after CABG.

Sternotomy Wound Infiltration With Liposomal Versus Plain Bupivacaine for Postoperative Analgesia After Elective Cardiac Surgery

OBJECTIVES

Poor pain control after cardiac surgery can be associated with postoperative complications, longer recovery, and development of chronic pain. The authors hypothesized that adding liposomal bupivacaine (LB) to plain bupivacaine (PB) will provide better and long-lasting analgesia when used for wound infiltration in median sternotomy.

STUDY DESIGN

Prospective, randomized, and double-blinded clinical trial.

SETTING

Single institution, tertiary care university hospital.

PARTICIPANTS

Adult patients who underwent elective cardiac surgery through median sternotomy.

INTERVENTIONS

A single surgeon performed wound infiltration of LB plus PB or PB into the sternotomy wound, chest, and mediastinal tube sites.

MEASUREMENTS AND MAIN RESULTS

Patients were followed up for 72 hours for pain scores, opioid consumption, and adverse events. Sixty patients completed the study for analysis (LB group [n = 29], PB group [n = 31]). Patient characteristics, procedural variables, and pain scores measured at specific intervals from 4 hours until 72 hours postoperatively did not reveal any significant differences between the groups. Mixed-model regression showed that the trend of mean pain scores at movement in the LB group was significantly (p = 0.01) lower compared with the PB group. Opioid consumption over 72 hours was not significantly different between the 2 groups (oral morphine equivalents; median [interquartile range], 139 [73, 212] mg in LB v 105 [54, 188] mg in PB, p = 0.29). Recovery characteristics and adverse events were comparable.

CONCLUSIONS

LB added to PB for sternotomy wound infiltration during elective cardiac surgery did not significantly improve the quality of postoperative analgesia.

Immersive Virtual Reality to Distract From Pain in Children Treated With L-asparaginase by Intramuscular Injection

Background Treatment-related pain and discomfort are two of the most common manifestations in children with acute lymphoblastic leukemia (ALL). Patients with ALL are usually treated with L-asparaginase (L-ASP) by intramuscular injection. Children receiving L-ASP chemotherapy must bear adverse reactions such as pain caused by intramuscular injections. The use of virtual reality (VR) distraction technology could be a non-pharmacological intervention to bolster patients' comfort and decrease anxiety and procedure-related pain within hospital settings. Methodology The study explored the potential benefits of VR as a psychological intervention to induce positive emotions and reduce pain levels in participants receiving L-ASP injections. Participants in the study had the opportunity to select a nature theme of their choosing during their treatment session. The study provided a noninvasive solution that promoted relaxation to reduce anxiety by shifting an individual's mood positively during treatment. The objective was met by measuring participants' mood and pain levels before and after the VR experience and participant satisfaction with the use of the technology. This mixed-methods study of children aged six to 18 received L-ASP between April 2021 and March 2022, using a Numerical Rating Scale (NRS) with sheer numbers ranging from 0 (no pain) to 10 (extreme or most pain possible). Semi-structured interviews were conducted to collect new data and explore participants' thoughts and beliefs about a particular topic. A total of 14 patients participated. Descriptive statistics and content analysis are used to describe the data analyzed. VR is an enjoyable distraction intervention for managing treatment-related pain in ALL with intramuscular chemotherapy. Results Eight of 14 patients found a reduction in perceived pain after wearing VR. During the intervention implementation, the primary caregivers felt that the patient's pain perception was more positive when using the virtual reality device, and there was less resistance and less crying. Conclusions This study describes changes and experiences associated with pain and physical discomfort in children with ALL receiving intramuscular chemotherapy. This teaching model is applied to developing medical personnel, providing information about the disease and daily care, and educating the participants' family members. This study may expand the usage of VR applications so that more patients can benefit from them.

Comparing the effect of two methods of using ear protective device on pain intensity in patients undergoing coronary artery bypass grafting: A randomized clinical trial

Background

Severe pain is the most prevalent complication after Coronary Artery Bypass Grafting (CABG). The aim of this study is to compare the impact of two methods using ear protective devices on pain intensity in patients undergoing CABG.

Materials and Methods

The present randomized clinical trial was conducted between October 2019 and February 2020. The participants included 84 patients undergoing CABG, who were randomly divided into two intervention groups (A, B) and a control group. On the first night after the heart surgery, ear protective devices were used for the patients in group A during the evening and night sleep, while they were used in group B only during the night sleep. A demographic questionnaire and Visual Analog Scale (VAS) were the data collection tools used in this study. Data were analyzed using Chi-square test, paired t-test, and one-way Analysis of Variance (ANOVA) in Statistical Package for the Social Sciences (SPSS) software.

Results

Before the intervention, the mean (SD) of pain intensity in the two intervention groups (A, B) and the control group was 6.46 (1.71), 6.32 (1.36), and 6.54 (1.45), respectively, and there was no significant difference between the groups (F_2,81 = 0.14; p = 0.86). However, after the intervention, the mean (SD) of pain intensity in the two intervention groups (A, B) and the control group was 3.39 (1.87), 4.46 (1.55), and 6.39 (1.54), respectively, which showed a significant difference (F_2,81 = 23.37; p < 0.001).

Conclusions

The use of ear protective device is recommended as a non-invasive and accessible way of reducing pain intensity in patients after CABG.

Different modalities of analgesia in open heart surgeries in Mansoura University

Background: Opioid usage in cardiac surgery is considered to be the corner stone in management. Inadequate pain control after cardiac surgery complicates patient recovery and increases the load on healthcare services. Multimodal analgesia can be used to achieve better analgesic effect and improves patient outcome.  Material and methods: A total of 90 patients undergoing cardiac surgery with median sternotomy were randomly allocated equally into three groups intraoperatively where first group received continuous infusion of high dose opioids, second group received boluses of low dose opioids and third group received multimodal non opioid analgesics including dexmedetomidine, ketamine and magnesium sulphate. All patients received the same post-operative analgesic regimen consists of morphine patient controlled analgesia (PCA). Results: Patients in multimodal non opioid group had more stable hemodynamics intra and postoperatively. Also, patients in multimodal group had lower pain scores extubation, earlier extubation, shorter ICU stay, earlier mobilization and earlier return of bowel movements compared to patients of both groups received intraoperative higher opioid doses.

Opioids: Understanding How Acute Actions Impact Chronic Consequences

In the last decade, critical-care nurses have seen a surge in acute opioid overdose admissions to intensive care units; there have also been significant increases in intensive care unit admissions due to opioid-related illness such as dependence, tolerance, and hyperalgesia. Despite these issues, opioids continue to be the criterion standard of pain management, and the search for opioid alternatives has not produced a clear replacement. A contributor to this problem has been the prevailing opinion that once bound to a receptor, all opioids engaged in the same types of intracellular signaling, which resulted in the same types of responses, only differing in the magnitude of those responses. Contemporary research with G-protein-coupled receptor models (eg, opioids) has demonstrated that this oversimplification is incorrect or incomplete. Understanding the complexity of opioid pharmacodynamics and pharmacokinetics helps us to grasp the intricacies of opioid-related adverse effects. Although there are many potential adverse effects related to opioids, this review focuses on the major adverse effects commonly seen in critical care, namely, respiratory depression, tolerance, hyperalgesia, and central sensitization. In addition, a case study has been incorporated to aid in understanding of strategies nurses can incorporate into their practices: that help mitigate the development of these effects.

Malewicz N, Ebel M, K. Zahn P, H. Meyer-Frießem C. Pupillometric Monitoring of Nociception in Cardiac Anesthesia

BACKGROUND

High-dose opioids are conventionally used for cardiac anesthesia, but without monitoring of nociception. In non-cardiac surgical procedures the intra - operative dose of opioids can be individualized and reduced with pupillometric monitoring of the pupillary pain index (PPI; scale 1-9). A randomized controlled trial was carried out to explore whether pupillometry can be used for nociception monitoring in cardiac anesthesia and whether it leads to opioid reduction.

METHODS

A sample of 57 cardiac surgery patients receiving continuously administered sufentanil (initial dosage 0.7 μg*kg-¹*h-¹) was divided into a PPI group (sufentanil reduction if PPI<3 up to a minimum of 0.15 μg*kg-¹*h-¹, n=32) and a control group (standard anesthesia; n = 25). The primary outcome was the time from the end of anesthesia to extubation. The secondary outcomes were total intraoperative dose of sufentanil/noradrenaline, postoperative pain intensity (numeric rating scale [NRS] 0-10) and intraoperative awareness. German Clinical Trials Registry no. DRKS 00012329.

RESULTS

The primary outcome, extubation time, did not differ between the two groups (1.14 h, 95% confidence interval [-0.99; 3.27], p = 0.592). Compared with the control patients (68% male, age 70 ± 10.4 years, PPI 1.1 ± 0.2), the mean sufentanil infusion rate in the PPI patients (81% male, age 68 ± 10.3 years, PPI 1.1 ± 0.2) decreased by 81.8% (-0.68 μg*kg-¹*h-¹ [-0,7; -0.67], p<0.001) to the predetermined minimum level, without intraoperative awareness. Moreover, the noradrenaline dose was reduced by 56% (1235.51 μg [321.91; 2149.12], p = 0.005) and the postoperative pain intensity by 45% (2.11 NRS [0.93; 3.3] after 24 h, p = 0.003).

CONCLUSION

Pupillometry is appropriate for nociception monitoring in cardiac anesthesia. Thereby a considerable reduction of intraoperative opioids as well as increased intraoperative hemodynamic stability was achieved and postoperative opioid-induced hyperalgesia was prevented. The consistently low PPI scores, indicating adequate analgesia, suggest that further reduction of opioid doses is feasible.

Can hypnosis and virtual reality reduce anxiety, pain and fatigue among patients who undergo cardiac surgery: a randomised controlled trial

Background

Different non-pharmacological techniques, including hypnosis and virtual reality (VR) are currently used as complementary tools in the treatment of anxiety, acute and chronic pain. A new technique called virtual reality hypnosis (VRH), which encompasses a combination of both tools, is regularly used although its benefits and underlying mechanisms remain unknown to date. With the goal to improve our understanding of VRH combination effects, it is necessary to conduct randomised and controlled research trials in order to understand their clinical interest and potential benefits.

Methods

Patients (n = 100) undergoing cardiac surgery at the Liège University Hospital will be randomly assigned to one of four conditions (control, hypnosis, VR or VRH). Each patient will receive two sessions of one of the techniques: one the day before the surgery and one the day after. Physiological assessments will be made on the monitor and patients will rate their levels of anxiety, fatigue, pain, absorption and dissociation.

Discussion

This study will help to expand knowledge on the application of virtual reality, hypnosis and VRH in the specific context of cardiac and intensive care procedures, and the influence of these non-pharmacological techniques on patient’s anxiety, fatigue, pain and phenomenological experience.

Trial registration

ClinicalTrials.gov: NCT03820700. Date registered on 29 January 2019.

Study recruitment date: October 6, 2018. Study anticipated completion date: December 28, 2020.