The role of methadone in cardiac surgery for management of postoperative pain

Background

This retrospective study evaluated the efficacy and safety of intraoperative methadone compared with short-acting opioids.

Methods

Patients undergoing cardiac surgery with cardiopulmonary bypass (n=11 967) from 2018 to 2023 from a single health system were categorised into groups based on intraoperative opioid administration: no methadone (Group O), methadone plus other opioids (Group M+O), and methadone only (Group M).

Results

Patients in Groups M and M+O had lower mean pain scores until postoperative day (POD) 7 compared with Group O after adjusting for covariates (P<0.01). Both Groups M and M+O had lower total opioid administered compared with Group O for all days POD0-POD6 (all P<0.001). The median number of hours until initial postoperative opioid after surgery was 2.55 (inter-quartile range [IQR]=1.07-5.12), 6.82 (IQR=3.52-12.98), and 7.0 (IQR=3.82-12.95) for Group O, Group M+O, and Group M, respectively. The incidence of postoperative complications did not differ between groups.

Conclusions

Intraoperative administration of methadone was associated with better pain control without significant side-effects after cardiac surgery.

Urgent Spinal Surgery in a Lateral Decubitus on a Patient with a Left Ventricular Assist Device on Full Anticoagulation: A Case Report

This case report aims to demonstrate the feasibility of performing spinal surgery in patients with a left ventricular assist device (LVAD), who are traditionally considered unsuitable candidates due to the need for anticoagulation and the challenges associated with the prone position. A case of a patient with an LVAD undergoing microdiscectomy in the left lateral decubitus position is presented. The procedure was carried out by a specialized interdisciplinary team with appropriate monitoring. The patient underwent the procedure safely, demonstrating that spinal surgery can be performed in patients with LVAD without reversing anticoagulation or resorting to the prone position. This approach mitigates the risk of thrombotic events and hemodynamic instability. This case study suggests that spinal surgery, specifically microdiscectomy, can be safely performed in patients with LVAD using the left lateral decubitus position. This finding has significant implications for patients who are unable to ambulate and therefore struggle to qualify for a heart transplant.

A novel visual facial anxiety scale for assessing preoperative anxiety

Background

There is currently no widely accepted instrument for measuring preoperative anxiety. The objective of this study was to develop a simple visual facial anxiety scale (VFAS) for assessing acute preoperative anxiety.

Methods

The initial VFAS was comprised of 11 similarly styled stick-figure reflecting different types of facial expressions (Fig 1). After obtaining IRB approval, a total of 265 participant-healthcare providers (e.g., anesthesiologists, anesthesiology residents, and perioperative nurses) were recruited to participate in this study. The participants were asked to: (1) rank the 11 faces from 0–10 (0 = no anxiety, while 10 = highest anxiety) and then to (2) match one of the 11 facial expression with a numeric verbal rating scale (NVRS) (0 = no anxiety and 10 = highest level of anxiety) and a specific categorical level of anxiety, namely no anxiety, mild, mild-moderate, moderate, moderate-high or highest anxiety. Based on these data, the Spearman correlation and frequencies of the 11 faces in relation to the 11-point numerical anxiety scale and 6 categorical anxiety levels were calculated. The highest frequency of a face assigned to a level of the numerical anxiety scale resulted in a finalized order of faces corresponding to the 11-point numeric rating scale.

Results

The highest frequency for each of the NVRS anxiety scores were as follow: A0, A1, A2, A3, A4, A5, A7, A6, A8, A9 and A10 (Fig 2). For the six categorical anxiety levels, a total of 260 (98.1%) participants chose the face A0 as representing ‘no’ anxiety, 250 (94.3%) participants chose the face A10 as representing ‘highest’ anxiety and 147 (55.5%) participants chose the face A8 as representing ‘moderate-high’ anxiety. Spearman analysis showed a significant correlation between the faces A3 and A5 assigned to the mild-moderate anxiety category (r = 0.58), but A5 was ultimately chosen due to its higher frequency compared to the frequency of A3 (30.6% vs 24.9%)(Fig 3). Similarly, the correlation of the faces A7 and A6 was significantly correlated with moderate anxiety (r = 0.87), but A7 remained because of its higher frequency (35.9% vs 22.6%). Using frequency and Spearman correlations, the final order of the faces assigned to the categories none, mild, mild-moderate, moderate, moderate-high and highest anxiety levels was A0, A1, A5, A7, A8 and A10, respectively (Fig 4).

Conclusion

The proposed VFAS was a valid tool for assessing the severity of acute [state] anxiety, and could be easy to administer in routine clinical practice.

Anesthetic considerations for an adult heart transplant recipient undergoing noncardiac surgery: a case report

Approximately 3,500 Americans undergo heart transplantation each year. A portion of this patient population will possibly present later for an elective noncardiac surgery. Anesthesia professionals can be tasked to assess and provide the anesthesia management for heart transplant recipients undergoing a noncardiac surgical procedure. A 57-year-old man with a complicated cardiac history before undergoing heart transplantation was scheduled to undergo a right inguinal hernia repair. The patient underwent general anesthesia and had an uneventful course of surgery and recovery. Management of the patient with a heart transplant includes consideration of the altered physiology of a denervated heart; the perioperative anesthetic considerations specific to this patient population; and the risks of rejection, infection, and pharmacologic interactions brought about by immunosuppression. The purposes of this case report were to discuss the indications for the perioperative care of heart transplant recipients undergoing noncardiac procedures, and to discuss the evidence-based literature to provide delivery of safe and effective patient care.