Seven-year follow-up of persistent postsurgical pain in cardiac surgery patients: A prospective observational study of prevalence and risk factors

Association of chronic poststernotomy pain and health-related quality of life: a prospective cohort study

PURPOSE

Chronic poststernotomy pain (CPSP) after cardiac surgery is multifactorial and impacts patient recovery. We aimed to evaluate the association between CPSP severity and health-related quality of life at six months after cardiac surgery.

METHODS

This was a single-centre prospective cohort study of patients who underwent cardiac surgery with median sternotomy between September 2020 and March 2021. Telephone interviews were conducted at six and 12 months postoperatively using the Short Form McGill Pain Questionnaire and the EQ-5D-5L. Strength of correlation was described using Spearman's correlation coefficient. Multivariable regression analysis was used to account for confounding variables.

RESULTS

A total of 252 patients responded to the six-month interview (response rate, 65%). The mean (standard deviation) age of respondents was 65 (13) yr. Twenty-nine percent of respondents (72/252) reported CPSP at six months, and 14% (41/252) reported more than mild pain (score ≥ 2/5). At 12 months, of the 89% (64/72) patients who responded, 47% (30/64) still reported pain. The strength of the correlation between pain scores and EQ-5D-5L was weak (Spearman's correlation coefficient, -0.3). Risk factors for CPSP at six months included higher pain score on postoperative day 1, history of chronic pain prior to surgery, and history of depression. Intraoperative infusion of dexmedetomidine or ketamine was associated with a reduced risk of CPSP at six months.

CONCLUSION

Chronic poststernotomy pain still affects patient recovery at six and 12 months after cardiac surgery. The severity of that pain is poorly correlated with patients' quality of life.

STUDY REGISTRATION

www.osf.io ( https://osf.io/52rsw ); registered 14 May 2022.

The long-term incidence of chronic post-surgical pain after coronary artery bypass surgery - A prospective observational study

BACKGROUND

Chronic post-surgical pain (CPSP) represents a significant issue for many patients following surgery; however, the long-term incidence and impact have not been well described following cardiac surgery. Our aim was to characterize CPSP at least 5 years following coronary artery bypass grafting (CABG) surgery.

METHODS

This prospective observational study investigated a cohort of patients from a larger trial investigating cognitive outcomes following CABG surgery, with 89 of 148 eligible patients (60.1%) assessed for CPSP at a mean (standard deviation [SD]) of 6.8 [1.2] years. Questionnaires interrogated pain presence, intensity, location, neuropathic characteristics, Geriatric Depression Scale scores (GDS) and instrumental activities of daily living (IADL).

RESULTS

CPSP was described in 21/89 (23.6%), with 10 rating it as moderate to severe. Six of the CPSP patients (29%) met criteria for neuropathic pain (6.7% overall). The highest rate of CPSP was associated with the leg surgical site (chest 12/89 [13.5%], arm 8/68 [11.8%] and leg (saphenous vein graft-SVG) 11/37 [29.7%]; χ2  = 6.523, p = 0.038). IADL scores were significantly lower for patients with CPSP (mean [SD]: 36.7 [1.6] vs. no CPSP 40.6 [0.6]; p = 0.006). Patients had GDS scores consistent with moderate depression (GDS >8) in 3/21 (14.3%) with CPSP, versus 3/68 (4.4%) non-CPSP patients (χ2  = 3.20, p = 0.073).

CONCLUSIONS

This study identified a CPSP incidence of 23.6% at a mean of 6.8 years after CABG surgery, with the highest pain proportion at SVG harvest sites. CPSP was associated with neuropathic pain symptoms and had a significant impact on IADLs. This emphasizes the need for long-term follow-up of CABG patients.

SIGNIFICANCE

This study highlights the impact of CPSP 7 years following cardiac surgery and highlights the effect of surgical site, neuropathic pain and the importance of including pain assessment and management in the long-term follow-up of cardiac surgical patients. Strategies to address and prevent chronic pain following cardiac surgery should be further explored.

Effect of Remifentanil on Acute and Chronic Postsurgical Pain in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis

OBJECTIVES

Our purpose was to explore the effect of remifentanil on acute and chronic postsurgical pain after cardiac surgery.

MATERIALS AND METHODS

Randomized controlled trials were retrieved from electronic databases, such as PubMed, Cochrane Library, China National Knowledge Internet databases, Scopus, and Web of Science. A systematic review, meta-analysis, and trial sequential analysis (TSA) were performed. Basic information and outcomes were extracted from the included studies. The primary outcome was chronic postsurgical pain. Secondary outcomes were scores of postsurgical pain and morphine consumption within 24 hours after cardiac surgery. Risk of bias (ROB) assessment was based on the Cochrane ROB tool version 2. The overall quality of the evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Seven studies consisting of 658 patients were enrolled in the meta-analysis. A single study had a high ROB and 2 studies had a moderate ROB. The incidence of chronic postsurgical pain (4 studies [415 patients]; risk ratio: 1.02 [95% CI: 0.53 to 1.95]; P = 0.95; I2 = 59%; TSA-adjusted CI: 0.78 to 1.20) and the postsurgical pain score (2 studies [196 patients]; mean difference: 0.09 [95% CI: -0.36 to 0.55]; P = 0.69; I2 = 0%; TSA-adjusted CI: -0.36 to 0.55) were not statistically different between the 2 groups. However, morphine consumption (6 studies [569 patients]; mean difference: 6.94 [95% CI: 3.65 to 10.22]; P < 0.01; I2 = 0%; TSA-adjusted CI: 0.00 to 0.49) was higher in the remifentanil group than in the control group.

CONCLUSION

There was not enough evidence to prove that remifentanil can increase the incidence of chronic postsurgical pain after cardiac surgery, but interestingly, the results tended to support a trend toward increased complications in the intervention group. However, there was moderate certainty evidence that the use of remifentanil increases the consumption of morphine for analgesia, and more direct comparison trials are needed to inform clinical decision-making with greater confidence.

Deep Parasternal Intercostal Plane Block for Intraoperative Pain Control in Cardiac Surgical Patients for Sternotomy: A Prospective Randomized Controlled Trial

OBJECTIVES

Sternotomy pain is common after cardiac surgery. The deep parasternal intercostal plane (DPIP) block is a novel technique that provides analgesia to the anterior chest wall. The aim of this study was to investigate the analgesic effect of bilateral DPIP blocks on intraoperative pain control in cardiac surgery.

DESIGN

This is a double-blinded, prospective randomized controlled trial (Oct 2020-Dec 2022).

SETTINGS

This study was conducted in a single institution, which is an academic university hospital.

PARTICIPANTS

Eighty-six elective cardiac surgical patients with median sternotomy were recruited.

INTERVENTIONS

Patients were randomly divided into DPIP or control group. Either 20ml 0.25% levobupivacaine or 0.9% normal saline was injected for the DPIP under ultrasound guidance after induction of general anaesthesia.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was intraoperative opioids consumption and hemodynamic changes at sternotomy. Secondary outcomes included postoperative morphine consumption, postoperative pain and time to tracheal extubation. Intraoperative opioids requirement was reduced from a median (IQR) intravenous morphine equivalence of 21.4mg (13.8-24.3mg) in control group to 9.5mg (7.3-11.2mg) in the DPIP group (P<0.001). Hemodynamic parameters were more stable in DPIP group at sternotomy, as evidenced by lower percentage increase in systolic, diastolic and mean arterial blood pressure from baseline. No difference was observed in time to tracheal extubation, postoperative morphine consumption, postoperative pain score and spirometry.

CONCLUSIONS

Bilateral DPIP block provides effective intraoperative analgesia and opioid-sparing. It may be included as part of the multimodal analgesia for enhanced recovery in cardiac surgery.

The Effect of Listening to Holy Quran Recital on Pain and Length of Stay Post-CABG: A Randomized Control Trial

Background

Nearly, 75% of patients post-CABG complain of moderate to severe pain during their hospital stay. Nonpharmacological interventions have been investigated; however, the effect of Holy Quran recital post-CABG is still not well studied, especially in developing Islamic countries.

Objective

To investigate the effect of listening to the Holy Quran recital on pain and length of stay post-CABG.

Methods

This was a randomized control trial on 132 patients recruited from four hospitals in Amman, Jordan. The intervention group listened to the Holy Quran recited for 10 minutes twice daily while the control group received the usual care. Data were analyzed using paired and independent samples t-tests.

Results

Paired t-test testing showed that there was a significant reduction in the pain level, (M [SD], 6.82 [2.27] vs. 4.65 [2.18], t = 23.65, p < 0.001) for the intervention group. In addition, the intervention group had shorter LoS in the ICU and in the hospital compared to the control group, (M [SD], 5.0 [4.02] vs. 6.58 [4.18], t = -2.1, p < 0.05), (M [SD], 10.15 [9.21] vs. 15.01 [13.14], t = -2.6, p < 0.05), respectively.

Conclusions

Listening to the Quran was significantly effective in improving pain intensity among post-CABG patients and shortening their hospital/ICU stay. This trial is registered with NCT05419554.

The mechanisms and management of persistent postsurgical pain

An estimated 10%-50% of patients undergoing a surgical intervention will develop persistent postsurgical pain (PPP) lasting more than 3 months despite adequate acute pain management and the availability of minimally invasive procedures. The link between early and late pain outcomes for surgical procedures remains unclear-some patients improve while others develop persistent pain. The elective nature of a surgical procedure offers a unique opportunity for prophylactic or early intervention to prevent the development of PPP and improve our understanding of its associated risk factors, such as pre-operative anxiety and the duration of severe acute postoperative pain. Current perioperative pain management strategies often include opioids, but long-term consumption can lead to tolerance, addiction, opioid-induced hyperalgesia, and death. Pre-clinical models provide the opportunity to dissect mechanisms underpinning the transition from acute to chronic, or persistent, postsurgical pain. This review highlights putative mechanisms of PPP, including sensitisation of peripheral sensory neurons, neuroplasticity in the central nervous system and nociceptive signalling along the neuro-immune axis.

Sex-Specific Associations Between Preoperative Chronic Pain and Moderate to Severe Chronic Postoperative Pain in Patients 2 Years After Cardiac Surgery

Background and Purpose

Chronic postoperative pain (CPSP) after cardiac surgery can cause severe health problems. As demonstrated in noncardiac surgeries, preoperative chronic pain can potentially lead to CPSP. However, the association between preoperative chronic pain and CPSP over follow-up in cardiac surgical settings in the context of sex differences is still lacking. This observational study aims to explore the role and sex differences of preoperative chronic pain in the occurrence and development of long-term CPSP and CPSP-related complications after cardiac surgery.

Patients and Methods

This observational study enrolled 495 patients (35.3% women) who underwent cardiac surgery via median sternotomy in March 2019. Validated questionnaires were delivered to assess preoperative chronic pain and moderate to severe CPSP at 3 and 24 months following surgical procedures. The secondary outcomes included the occurrence of moderate to severe chronic pruritus, sleep disturbance, and daily activities interference at follow-up. Multivariable logistic regression was employed.

Results

Of 495 patients analyzed, the incidences of preoperative chronic pain (29.7% versus 20.6%) and moderate to severe CPSP (14.8% versus 8.1%) were both higher in females than males. Female sex (P = 0.048) and preoperative chronic pain (P = 0.008) were identified as significant risk factors for CPSP occurrence. However, preoperative chronic pain contributed significantly to CPSP (P = 0.008), sleep disturbance (P =0.047), and daily activities interference (P =0.019) in females, but not in males.

Conclusion

The 2-year prevalence of moderate to severe CPSP after cardiac surgery was 10.5%. Compared to males, females are more susceptible to CPSP and pain-related outcomes in the long term. In addition, preoperative chronic pain was associated with a higher risk of CPSP in females but not in males.

Analgesic efficacy and risk of low-to-medium dose intrathecal morphine in patients undergoing cardiac surgery: An updated meta-analysis

Background

To evaluate the analgesic efficacy and risk of low-to-medium dose intrathecal morphine (ITM) (i.e., ≤0.5 mg) following cardiac surgery.

Methods

Medline, Cochrane Library, Google scholar and EMBASE databases were searched from inception to February 2022. The primary outcome was pain intensity at postoperative 24 h, while the secondary outcomes included intravenous morphine consumption (IMC), extubation time, hospital/intensive care unit (ICU) length of stay (LOS), and ITM-associated side effects (e.g., respiratory depression). Subgroup analysis was performed on ITM dosage (low: <0.3 mg vs. medium: 0.3–0.5 mg).

Results

Fifteen RCTs involving 683 patients published from 1988 to 2021 were included. Pooled results showed significantly lower postoperative 24-h pain scores [mean difference (MD) = −1.61, 95% confidence interval: −1.98 to −1.24, p < 0.00001; trial sequential analysis: sufficient evidence; certainty of evidence: moderate] in the ITM group compared to the controls. Similar positive findings were noted at 12 (MD = −2.1) and 48 h (MD = −1.88). Use of ITM was also associated with lower IMC at 24 and 48 h (MD: −13.69 and −14.57 mg, respectively; all p < 0.05) and early tracheal extubation (i.e., 48.08 min). No difference was noted in hospital/ICU LOS, and nausea/vomiting in both groups, but patients receiving ITM had higher risk of pruritus (relative risk = 2.88, p = 0.008). There was no subgroup difference in IMC except a lower pain score with 0.3–0.5 mg than <0.3 mg at postoperative 24 h. Respiratory depression events were not noted in the ITM group.

Conclusion

Our results validated the analgesic efficacy of low-to-medium dose ITM for patients receiving cardiac surgery without increasing the risk of respiratory depression.

Nosocomial Extracardiac Infections After Cardiac Surgery

Purpose of Review

Nosocomial extracardiac infections after cardiac surgery are a major public health issue affecting 3–8.2% of patients within 30–60 days following the intervention.

Recent Findings

Here, we have considered the most important postoperative infective complications that, in order of frequency, are pneumonia, surgical site infection, urinary tract infection, and bloodstream infection. The overall picture that emerges shows that they cause a greater perioperative morbidity and mortality with a longer hospitalization time and excess costs. Preventive interventions and corrective measures, diminishing the burden of nosocomial extracardiac infections, may reduce the global costs. A multidisciplinary team may assure a more appropriate management of nosocomial extracardiac infections leading to a reduction of hospitalization time and mortality rate.

Summary

The main and most current data on epidemiology, prevention, microbiology, diagnosis, and management for each one of the most important postoperative infective complications are reported. The establishment of an antimicrobial stewardship in each hospital seems to be, at the moment, the more valid strategy to counteract the challenging problems.

Impact of Opioid-Free Anesthesia on Analgesia and Recovery Following Bariatric Surgery: a Meta-Analysis of Randomized Controlled Studies

This meta-analysis aimed at exploring the impact of opioid-free anesthesia (OFA) on pain score and opioid consumption in patients undergoing bariatric surgery (BS). Literature search identified eight eligible trials. Forest plot revealed a significantly lower pain score (mean difference (MD) =  - 0.96, p = 0.0002; 318 patients), but not morphine consumption (MD =  - 5.85 mg, p = 0.1; 318 patients) at postoperative 24 h in patients with OFA than in those without. Pooled analysis also showed a lower pain score (p = 0.002), morphine consumption (p = 0.0003) in the postanesthetic care unit, and risk of postoperative nausea/vomiting (p = 0.0003) in the OFA group compared to the controls. In conclusion, this meta-analysis demonstrated that opioid-free anesthesia improved pain outcomes immediately and at 24 h after surgery without a beneficial impact on opioid consumption at postoperative 24 h. KEY POINTS: • Roles of opioid-free anesthesia (OFA) in bariatric surgery (BS) were investigated. • Outcomes included postoperative pain score, opioid use, and nausea/vomiting risk. • OFA was associated with lower 24-h pain score but not opioid consumption. • Lower pain score and opioid consumption were noted in the postanesthetic care unit. • OFA correlated with a lower risk of postoperative nausea/vomiting.