The efficacy of different modes of analgesia in postoperative pain management and early mobilization in postoperative cardiac surgical patients: A systematic review

Effect of Low-dose Ketamine Infusion on Opioid Consumption in Children Undergoing Open Cardiac Surgery: A Randomized Controlled Double-Blind Study

OBJECTIVE

This study was designed to evaluate the effect of low-dose ketamine infusion on the perioperative consumption of opioids in pediatric open cardiac surgery.

DESIGN

A randomized, controlled, double-blinded single-center study was conducted.

SETTING

The study took place in a tertiary care children's hospital.

PARTICIPANTS

Patients of both sexes aged 2-12 years who underwent cardiac surgery were included.

INTERVENTIONS

Patients in the ketamine group received a bolus of 0.3 mg/kg of ketamine before skin incision followed by continuous intraoperative infusion of 0.25 mg/kg/h and postoperative infusion of 0.1 mg/kg/h for 24 h. Patients in the control groups received volumes of normal saline either bolus or continuous infusion like that of the ketamine group.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the total dose of fentanyl consumed over the first 24 hours postoperatively. Secondary outcomes were intraoperative fentanyl consumption, time to extubation, modified objective pain score, and incidence of vomiting, pruritus, diplopia, or hallucinations. A total of 80 patients were recruited but the final analysis was done on 35 patients in the ketamine group and 34 in the control group. Fentanyl consumption during surgery and in the first 24 hours postoperatively was significantly lower in the ketamine than the control group. Patients in both the ketamine and control groups had similar times to extubation. Modified objective pain scores were significantly lower in the ketamine group than the control group. None of the patients in either group had diplopia or hallucinations.

CONCLUSIONS

Low-dose ketamine infusion in children undergoing open cardiac surgery reduced intra- and postoperative opioid consumption and postoperative pain scores. Moreover, ketamine did not cause diplopia or hallucinations.

Comparison of Multiple Injection Costotransverse Block and Erector Spinae Plane Block for Post-Sternotomy Pain Relief in Pediatric Patients Undergoing Cardiac Surgery: A Prospective Randomized Comparative Study

OBJECTIVE

The aim of this study was to evaluate the efficacy of ultrasound-guided multiple injection costotransverse block (MICB) and compare it with erector spinae plane block (ESPB) for poststernotomy pain relief in pediatric cardiac surgical patients.

DESIGN

A prospective, randomized, double-blind, comparative study.

SETTING

At a single institution tertiary referral cardiac center.

PARTICIPANTS

A total of 90 children with acyanotic congenital heart disease requiring surgery via sternotomy.

INTERVENTIONS

Children were allocated randomly to 1 of the 3 following groups: ESPB (group 1), MICB (group 2), or Control (group 3). Participants in groups 1 and 2 received 4 mg/kg of 0.2% ropivacaine for bilateral ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal analgesia, and fentanyl/tramadol was used for rescue analgesia.

MEASUREMENTS AND MAIN RESULTS

The modified objective pain score (MOPS) was evaluated at 0, 1, 2, 4, 6, 8, 10, and 12 hours postextubation. After all exclusions, 84 patients were analyzed. The MOPS score was found to be significantly lower in ESPB and MICB groups compared to the control group until 10 hours postextubation (p < 0.05), with no statistically significant difference at the 12th hour (p = 0.2198). The total intraoperative fentanyl consumption (p = 0.0005), need for fentanyl supplementation on incision (p < 0.0001), and need for rescue opioid requirement in the postoperative period (p = 0.034) were significantly lower in both the ESPB and MICB groups than the control group. There were no statistically significant differences in both primary and secondary outcomes between the ESPB and MICB groups.

CONCLUSION

Ultrasound-guided MICB was effective and comparable to ESPB for post-sternotomy pain management in pediatric cardiac surgical patients.

Evaluation of Analgesic Drug Therapy for Postoperative Pain Management in Cardiovascular Surgery

Background

Cardiovascular surgery is usually associated with higher degree of postoperative pain that influences a patient's physical recovery. Multiple clinical measures have been taken to avoid overuse of opioid agents for postoperative pain management, which led to the development of clinical pathways for analgesic drug treatment using a multimodal approach.

Objective

To evaluate the effectiveness and safety of a multimodal postoperative analgesic drug pathway (ADP) for pain management following cardiovascular surgery.

Methods

This retrospective, controlled, nonrandomized study evaluated a postoperative ADP in patients undergoing cardiovascular surgery in a tertiary general hospital in Qingdao, China. Effectiveness and safety outcomes were compared before and after the implementation of the ADP. Outcome indicators included postoperative pain scores, consumption of opioids in analgesic pumps, and incidence of adverse events.

Results

Patients who underwent cardiovascular surgery from September to November 2021 before the implementation of the ADP (n = 193) and from September to November 2022 after the implementation of the ADP (n = 218) were enrolled. Pain scores were reduced on day 1, 3, and 5 after surgery and the reduction was most significant in mild pain (P < .001). Opioids in analgesic pumps consumption was also significantly reduced and there was decreased incidence of adverse events such as nausea and vomiting (P = .026), respiratory inhibition (P = .027), and dizziness and headache (P = .028) in cardiovascular surgery patients after implementation of the ADP.

Conclusions

Improved effectiveness and safety were observed following the implementation of the ADP. Multimodal analgesic ADP methodology can be effectively used for postoperative pain management in patients undergoing cardiovascular surgery.

Cryotherapy in Postoperative Shoulder Surgery: A Systematic Review

Cryotherapy, a therapeutic technique involving localized cooling of the body, has gained popularity for postsurgical rehabilitation. It induces a reduction in cellular metabolism, vasoconstriction, and pain relief, making it an attractive option for managing postoperative (PO) shoulder pain. This systematic review aimed to assess the effectiveness of cryotherapy in PO shoulder patients, focusing on pain, range of motion, functionality, and temperature changes. The review included six randomized clinical trials, involving a total of 233 patients who underwent various shoulder surgeries. Cryotherapy was applied using different methods, including Cryo/Cuff, Cryoton®, Polar Care 300, and ice packs. Results indicated that cryotherapy was generally effective in reducing PO shoulder pain. However, one study found no significant difference in pain outcomes between the cryotherapy group and control group. Furthermore, three studies demonstrated a decrease in intra-articular and skin temperatures with cryotherapy application. A risk of bias analysis revealed some concerns in the overall risk of bias for five studies, with one study considered to have a high risk of bias. Although publication bias assessment was not conducted due to the limited number of included studies, it was noted that the studies exhibited heterogeneity in terms of population, intervention methods, and outcome measures. In conclusion, cryotherapy appears to be a promising adjunctive treatment for PO shoulder pain, although the existing evidence has some limitations, including small sample sizes and methodological concerns. More high-quality studies are needed to establish the full extent of cryotherapy's effectiveness in PO shoulder rehabilitation, especially regarding its impact on functionality and range of motion.

Retraction speed and chronic poststernotomy pain: A randomized controlled trial

OBJECTIVES

Approximately 30% of patients develop chronic poststernotomy pain (CPSP) following cardiac surgery with sternal retraction. Risk factors have been described but no causal determinants identified. Investigators hypothesized that opening the sternum slowly would impart less force (and thereby less nerve/tissue damage) and translate to a reduced incidence of CPSP. The main objectives were to determine whether or not slower sternal retraction would reduce the incidence of CPSP and improve health-related quality of life.

METHODS

Patients undergoing coronary artery bypass graft surgery were recruited to this randomized controlled trial. Patients were randomized to slow or standard retraction (ie, sternum opened over 15 minutes vs 30 seconds, respectively). Although the anesthesiologist and surgeon were aware of the randomization, the patients, assessors, and postoperative nursing staff remained blinded. Sternotomy pain and analgesics were measured in hospital. At 3, 6, and 12 months postoperatively, all patients completed the Medical Outcomes Survey Short Form and reported on CPSP and complications requiring rehospitalization. Thirty-day rehospitalizations and mortality were recorded.

RESULTS

In total, 326 patients consented to participate and 313 were randomized to slow (n = 159) versus standard retraction (n = 154). No clinically relevant differences were detected in acute pain, analgesic consumption, or the incidence of CPSP or health-related quality of life. Although the slow group had significantly more hospitalizations at 3 and 12 months postoperatively, the reasons were unrelated to retraction speed. No differences were observed in 30-day rehospitalizations or mortality.

CONCLUSIONS

All outcomes were consistent with previous reports, but no clinically significant differences were observed with retraction speed.

Efficacy of Incisional Ropivacaine Infiltration by Presternal Multi-Orifice Catheter for Post-sternotomy Pain Relief in Pediatric Patients Undergoing Cardiac Surgery: A Prospective, Randomized, Controlled Study

OBJECTIVE

To evaluate the efficacy of incisional ropivacaine infiltration by presternal multi-orifice catheter to manage poststernotomy pain in pediatric cardiac surgery.

DESIGN

A prospective, randomized, and double-blind comparative study.

SETTING

At a single-institution tertiary referral cardiac center.

PARTICIPANTS

The study comprised 200 children undergoing cardiac surgeries through a midline sternotomy.

INTERVENTIONS

Children were allocated randomly to 1 of 3 groups. Group A (n = 65) and group B (n = 64) received 0.375% ropivacaine infusion and intermittent bolus, respectively, by presternal multi-orifice catheter, whereas Group C (n = 64) did not receive any local anesthetic (LA) drug. Postoperatively, intravenous paracetamol was used for multimodal analgesia, and fentanyl was given as rescue analgesia, respectively.

MEASUREMENTS AND MAIN RESULTS

Pain was assessed by a Modified Objective Pain Score (MOPS) for 48 hours postextubation. Group B had significantly lower early MOPS at the first hour, but in the later period, the mean MOPS was lower in group A. The requirement of the first rescue analgesia was 3 ± 1.51, 6.1 ± 2.26, and 2.6 ± 0.87 hours for groups A (n = 60), B (n = 60), and C (n = 60), respectively. The 48-hour fentanyl consumption was significantly lower (p < 0.001) in group A (0.5 ± 0.68 µg/kg) and group B (0.7 ± 0.86 µg/kg) than the control group (3.4 ± 0.68 µg/kg). The length of intensive care unit stay was lower (p < 0.001) in groups A and B than in group C; however, the length of hospital stay was comparable (p = 0.07).

CONCLUSION

LA bolus and infusion through presternal multi-orifice catheter provided effective analgesia postoperatively. However, the bolus was more efficacious in the early phase but equivalent in later periods. Therefore, bolus and LA infusion can be used for steady poststernotomy pain relief in children undergoing cardiac surgeries.

Parasternal intercostal plane block catheters for cardiac surgery: a retrospective, propensity weighted, cohort study

Aim: Anesthesia for cardiac surgery has evolved toward fast-track recovery strategies incorporating non opioid analgesics and regional anesthesia. Materials & methods: This retrospective cohort study compared opioid consumption, pain scores and length of stay in patients who underwent cardiac surgery via median sternotomy and did or did not receive preoperative parasternal intercostal plane block catheters with postoperative ropivacaine infusions. Results: Postoperative opioid consumption and postoperative pain scores did not differ. Blocks were associated with decreased intraoperative opioids and reduced length of stay in the intensive care unit and hospital. Conclusion: Parasternal intercostal plane block catheters were not associated with decreased postoperative opioid consumption or pain scores, but were associated with reduced intraoperative opioids and length of stay.

The anesthesia management of totally thoracoscopic cardiac surgery: A single-center retrospective study

Anesthesia management of Totally thoracoscopic cardiac surgery (TTCS) has been the subject of much debate and discussion. In this single center retrospective study, we summarize the experience of clinical anesthesia management for TTCS by review the medical records of our medical center and look forward to its future development. In this retrospective study, 103 patients (49 male and 54 female) were enrolled, the mean age was 56.7 ± 14.4 years old. The participants underwent Mitral Valve Replacement (MVR) + Tricuspid Valve Annuloplasty (TVA) (42, 40.8%), Mitral Valve Annuloplasty (MVA) + TVA (38, 36.9%), MVA (21, 20.4%), and MVR (2, 1.9%)，respectively. Intraoperative hypoxemia, radiographic pulmonary infiltrates, and pneumonia were observed in 19 (18.4%), 84 (81.6%), and 13 (12.6%) patients, respectively. The LOS of ICU and POD were as follows: MVR + TVA (55.1 ± 25h, 9.9 ± 3.5 d), MVA + TVA (56.5 ± 28.4h, 9.4 ± 4.2d), MVA (37.9 ± 21.9h, 8.1 ± 2.3d) and MVR (48 ± 4.2h, 7.5 ± 2.1d). No reintubation, reoperations, postoperative cognitive dysfunction, 30-day mortality were observed in the present study. The present study demonstrated that applying this anesthesia management for TTCS associated with acceptable morbidity, intensive care unit and postoperative hospital lengths of stay. The finding from the present study might provide some new approach for Anesthesia management of TTCS.

Parasternal Intercostal Nerve Blocks in Patients Undergoing Cardiac Surgery: Evidence Update and Technical Considerations

In the Enhanced Recovery After Surgery era, parasternal intercostal nerve block has been proposed to improve pain control and reduce opioid use in patients undergoing cardiac surgery. However current literature has reported conflicting evidence about the effect of this multimodal pain management, as procedural variations might pose a significant bias on outcomes evaluation. In this setting, the infiltration of the parasternal plane into 2 intercostal spaces, second and fifth, with a local anesthetic spread under or above the costal plane with ultrasound guidance, seem to be standardized in theory, but significant differences might be observed in clinical practice. This narrative review summarizes and defines the optimal techniques for parasternal plane blocks in patients undergoing cardiac surgery with full median sternotomy, considering both pectointercostal fascial block and transversus thoracic plane block. A total of 10 randomized trials have been published, in adjunct to observational studies, which are heterogeneous in terms of techniques, methods, and outcomes. Parasternal block has been shown to reduce perioperative opioid consumption and provide a more favorable analgesic profile, with reduced postoperative opioid-related side effects. A trend toward reduced intensive care unit stay or duration of mechanical ventilation should be confirmed by adequately powered randomized trials or registry studies. Differences in operative technique might impact outcomes and, therefore, standardization of the procedure plays a pivotal role before reporting specific outcomes. Parasternal plane blocks might significantly improve outcomes of cardiac surgery with full median sternotomy, and should be introduced comprehensively in Enhanced Recovery After Surgery protocols.

Evaluation of the effect of different block techniques on open-heart surgery in the postoperative period: a prospective observational study

BACKGROUND

Open-heart surgery is associated with severe postoperative pain. Adequate analgesia after open-heart surgery improves patients' early postoperative recovery, extubation, ambulation and early discharge from hospital. Regional anaesthesia techniques are the new hope for adequate postoperative analgesia after cardiac surgery and are widely used for early pain management in the first six hours.

METHODS

A total of 100 patients with the American Society of Anesthesiologists physical status classification I-III, aged 18 years and over, undergoing open-heart surgery with sternotomy for coronary artery bypass grafting or valve replacement under general anaesthesia, were included in this study. For postoperative analgesia, 50 patients with pectoral nerve (PECS II) block and 50 with parasternal (PS) block were consecutively enrolled in one of the groups at the end of the surgery and compared in terms of sedation scores, ventilation duration, pain scores at rest after extubation, block duration, total morphine consumption and complications.

RESULTS

The block duration in the PS group was statistically significantly higher than in the PECS II group (p = 0.001, p < 0.05, respectively). The visual analogue scale scores at rest in the fourth and sixth hours were statistically significantly higher in the PECS II group than in the PS group ( p = 0.001, p = 0.001, p < 0.01). Cumulative morphine consumption in the PECS II group was statistically significantly higher than in the PS group in the fourth, sixth, 12th and 24th hours ( p = 0.001, p = 0.001, p = 0.001, p = 0.001, p = 0.001, p < 0.01, respectively).

CONCLUSIONS

PS block provided longer block duration with lower postoperative pain and sedation scores than the PECS II block, with lower cumulative morphine consumption.

Ultrasound-guided erector spinae plane block improve opioid-sparing perioperative analgesia in pediatric patients undergoing thoracoscopic lung lesion resection: a prospective randomized controlled trial

BACKGROUND

Pediatric patients often experience severe pain after thoracic surgery, especially in the early postoperative period. Recently, the focus has been on regional analgesia with the introduction of ultrasound-guided erector spinae plane blocks. We assumed that preoperative erector spinae plane block (ESPB) in children undergoing video-assisted thoracoscopic surgery (VATS) would reduce the consumption of perioperative opioids.

METHODS

This randomized, double-blind study enrolled 60 children aged 1-3 years who underwent thoracoscopic lung lesion resection. The patients were enrolled in the study and randomly divided into two groups. The general anesthesia (GA) group received GA alone, and the GA + ESPB group received ESPB. The consumptions of remifentanil and sufentanil were recorded, and the children's face, legs, activity, cry, consolability (FLACC) scores were assessed after awakening. The time to first rescue analgesia, length of hospital stay, parental satisfaction and adverse events were also recorded.

RESULTS

The consumptions of remifentanil and sufentanil in the GA + ESPB group were significantly lower than those in the GA group, mean difference [95% confidence interval (CI)]: -26.57 (-31.98 to -21.17) and -0.21 (-0.27 to -0.17), respectively, (both P<0.001); while the time to first rescue analgesia and parental satisfaction scores were significantly longer and higher, respectively, in the GA + ESPB group than those in the GA group, mean difference (95% CI): 2.37 (1.77 to 2.97) and 2.47 (1.79 to 3.15), respectively, (both P<0.001). The FLACC scores in the GA + ESPB group were significantly lower than those in the GA group 1 to 24 hours postoperatively (P=0.023 at 1 h, and P<0.001 at 3 h, 6 h, 12 h, 18 h, 24 h), but not at immediate admission to the post-anesthesia care unit (PACU) (P=0.189 at 0 h). The GA + ESPB group had significantly lower incidence rates of postoperative nausea and vomiting (P=0.037 and P=0.020).

CONCLUSIONS

In pediatric Thoracoscopic surgery, the results of this study confirm our hypothesis that ESPB decreases the consumptions of intraoperative remifentanil and postoperative sufentanil in 24 hours and demonstrates better postoperative analgesia compared with a control group.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200056166.

Comparison of Intra- and postoperative effectiveness of erector spinae plane block and patient controlled analgesia in patients undergoing coronary artery bypass grafting surgery

The aim of our study was to compare bilateral erector spinae plane block (ESPB) efficacy on pain management with patient controlled analgesia (PCA) during the perioperative period in patients scheduled for coronary artery bypass grafting (CABG). After ethics committee approval (2019-7/31 dated 09.04.2019) from the Bursa Uludağ University Medical Trials Ethics Committee, (https://uludag.edu.tr/buuetikkurulu) ASA II-III, 50 patients aged between 18-80 years were included. They were randomly divided into two groups, ESPB (n=25) and control (n=25). In the preoperative period, bilateral ESPB with ultrasonography was applied to both groups with 0.25% bupivacaine (0.5 ml/kg) + dexamethasone (8 mg) or saline, respectively. PCA prepared with morphine was given to all patients postoperatively. Perioperative opioid use, extubation times, coughing/resting Visual Analog Scale (VAS) scores, duration for first PCA bolus dose requirement, rescue analgesia needs, mobilization times, and opioid side effects were evaluated. In the ESPB group, compared to the control group, intraoperative fentanyl consumption was lower (P=0.001). During the postoperative period; extubation time was shorter, the need for initial PCA was much later, morphine consumption and need for rescue analgesia was less (P=0.001; P<0.001; P<0.001; P=0.009, respectively). The postoperative VAS scores were lower for each measurement period (P<0.05). Opioid-related side effects were more common in the control group (P=0.040). First mobilization time in ESPB group was earlier (P<0.001). As a result, ESPB has a significant analgesic effect in CABG patients. It was concluded that bilateral ESPB reduces opioid requirement compared to intravenous morphine PCA alone and provides better pain management and more comfortable recovery.

Ketamine Use in the Surgical Patient: a Literature Review

PURPOSE OF REVIEW

While ketamine is an established anesthetic, its role in the management of acute surgical pain is less certain. Therefore, a literature review is warranted to examine the role of ketamine in acute pain management.

RECENT FINDINGS

The use of ketamine appears to be most efficacious in larger procedures that lead to increased systemic inflammation or extensive tissue damage. In addition, ketamine seems to be most successful when administered consistently throughout a procedure, such as by an infusion instead of a single bolus, in order to have adequate dosing for an analgesic effect. Therefore, the focus of research should be on procedures that lead to moderate to severe pain using frequent dosing to determine the most effective role of ketamine. Most importantly, the current literature shows that ketamine can be used as a successful part of multimodal anesthesia with few side effects in patients undergoing major procedures associated with moderate to severe pain.

Pre-clinical evaluation of new dibucaine formulations for preventive analgesia

We have previously developed ammonium sulphate gradient loaded liposomes to encapsulate dibucaine. Thus, the purpose of this study was to evaluate the pre-clinical safety and effectiveness of this novel ionic liposomal formulation of dibucaine (DBC), as described in previous work. Effectiveness was evaluated in vivo on Wistar rats (n = 8) that received plain DBC or liposomal DBC (DBC_LUV). Control empty liposomes (without DBC) or saline were also used as control. Sciatic nerve block was performed using the formulations or controls (0.4 mL). A hindpaw incision-based postoperative pain model was used to evaluate mechanical hypersensitivity with von Frey filaments. To verify antiinflamatory activity protein levels of TNF-α, IL-1β, substance P and CGRP were measured by ELISA in the hindpaw tissue after 1 and 6 hours of the incision. To corroborate drug safety, sciatic nerve Schwann cell cultures were treated with the aforementioned formulations and assessed for cell viability (MTT assay) and death (flow cytometry assay). Histopathology of the tissues surrounding the sciatic nerve region was also assessed 2 and 7 days after treatment. All animals presented post incisional hypersensitivity and DBC_LUV showed longer analgesic effect (p < 0.001). DBC_LUV reduced TNF-α and CGRP levels (p < 0.05). Histopathological evaluation showed greater inflammatory reaction after the administration of control liposomes when compared to DBC (p < 0.05). There was no difference in Schwann cell viability and death between plain and encapsulated DBC. DBC_LUV was safe and enhanced anaesthesia duration due to slow release of dibucaine from ammonium sulphate gradient loaded liposomes.