Early extubation after cardiac surgery: emotional status in the early postoperative period

The analgesic efficacy of continuous presternal bupivacaine infusion through a single catheter after cardiac surgery

Background:

Median sternotomy, sternal spreading, and sternal wiring are the main causes of pain during the early recovery phase following cardiac surgery.

Aim:

This study was designed to evaluate the analgesic efficacy of continuous presternal bupivacaine infusion through a single catheter after parasternal block following cardiac surgery.

Materials and Methods:

The total of 40 patients (American Society of Anesthesiologist status II, III), 45–60 years old, undergoing coronary – artery bypass grafting were enrolled in this prospective, randomized, double-blind study. A presternal catheter was inserted with continuous infusion of 5 mL/h bupivacaine 0.25% (Group B) or normal saline (Group C) during the first 48 postoperative hrs. Primary outcomes were postoperative morphine requirements and pain scores, secondary outcomes were extubation time, postoperative respiratory parameters, incidence of wound infection, Intensive Care Unit (ICU) and hospital stay duration, and bupivacaine level in blood.

Statistical Methods:

Student's t-test was used to analyze the parametric data and Chi-square test for categorical variables.

Results:

During the postoperative 48 h, there was marked reduction in morphine requirements in Group B compared to Group C, (8.6 ± 0.94 mg vs. 18.83 ± 3.4 mg respectively, P = 0.2), lower postoperative pain scores, shorter extubation time (117 ± 10 min vs. 195 ± 19 min, respectively, P = 0.03), better respiratory parameters (PaO₂/FiO_2, PaCO₂ and pH), with no incidence of wound infection, no differences in ICU or hospital stay duration. The plasma concentration of bupivacaine remained below the toxic threshold (at T24, 1.2 ug/ml ± 0.3 and T48 h 1.7 ± 0.3 ug/ml).

Conclusion:

Continuous presternal bupivacaine infusion has resulted in better postoperative analgesia, reduction in morphine requirements, shorter time to extubation, and better postoperative respiratory parameters than the control group.

Preoperative patient education for open-heart patients: a source of anxiety?

OBJECTIVE

The purpose of this study was to assess the impact of preoperative patient education on anxiety and recovery of the Lebanese patients undergoing open-heart surgery.

METHODS

This quasi-experimental study was conducted at a large hospital in Beirut, which is a university hospital. All patients who were admitted to the cardiac surgery unit and who met the inclusion criteria were randomly assigned to as experimental or a control group. The patients in the experimental group (n = 57) received a special educational session on their admission day and had a tour of the cardiac surgery unit. The control group (n = 53) followed the routine hospital protocol, which encompassed almost no preoperative education or a tour. Anxiety was assessed using the Beck Anxiety Inventory while recovery was measured by physiological outcomes, days of hospital stay, and presence of complications. A Multivariate Analysis of Covariance (MANCOVA) was performed with adjustment for potential confounding variables.

RESULTS

Borderline statistical significance was noted for the experimental group in terms of preoperative and postoperative anxiety. The experimental group had a shorter time from awakening to extubation.

CONCLUSION

Unlike most studies published previously, which noted the benefits of preoperative patient education, this study with the Lebanese clients, failed to support earlier findings.

PRACTICE IMPLICATIONS

The results suggest that patient education should not be initiated before assessing the patient's cultural and social background.

Depression, Healing, and Recovery From Coronary Artery Bypass Surgery

• Background Effects of postoperative depression on recovery from coronary artery bypass grafting have not been widely studied.

• Objectives To evaluate emotional and physical recovery after bypass surgery and investigate associations between depressive symptoms and infections and impaired wound healing in patients with high and low levels of depressive symptoms.

• Methods A nonrandomized, comparative, longitudinal design was used to study 72 bypass surgery patients without serious noncardiac comorbidities who were available for follow-up after discharge. Patients completed questionnaires to assess depressive symptoms, emotional recovery, and physical recovery within 48 hours after extubation, at discharge from the hospital, and 6 weeks later and performed 6-minute walk tests at the last 2 times. Infections and impaired wound healing (as indicated by positive cultures, antibiotic treatment, or extra treatments, such as debridements or incisions and drainage) were identified by chart audit.

• Results At discharge, patients with higher depressive symptom scores (indicating more symptoms) reported poorer emotional recovery (P < .001) and poorer physical recovery (P = .007) and achieved shorter walking distances (P<.001) than did patients with lower scores (indicating fewer symptoms). Six weeks after discharge, emotional and physical recovery remained lower in patients with more depressive symptoms (P < .001). Infections and impaired wound healing were more common among patients with higher depressive symptom scores (46%) than among patients with lower scores (19%, P=.03).

• Conclusions After bypass surgery, depressive symptoms are associated with infections, impaired wound healing, and poor emotional and physical recovery.

Routine Immediate Extubation After Off-Pump Coronary Artery Bypass Surgery: 514 Consecutive Patients

OBJECTIVE

The purpose of this study was to evaluate the feasibility of routine immediate extubation in patients undergoing off-pump coronary artery bypass surgery.

DESIGN

Case series.

SETTING

Private hospital.

PARTICIPANTS

Five hundred forty-eight consecutive patients undergoing off-pump coronary bypass surgery, representing 5 years of a single anesthesiologist's practice, were evaluated for routine immediate extubation. Thirty-four patients were excluded because they were already intubated, in preoperative cardiogenic shock, or converted to on-pump during the procedure.

INTERVENTION

Patients received general anesthesia or general anesthesia plus thoracic epidural analgesia (25%) and underwent off-pump coronary bypass surgery.

MEASUREMENTS AND MAIN RESULTS

All 514 patients who were intended to be immediately extubated were expeditiously extubated in the operating room. The numbers of reintubations, morbidity, and mortality were low.

CONCLUSIONS

Routine immediate extubation of most off-pump coronary artery bypass patients appears feasible and most probably safe.

Parasternal Block and Local Anesthetic Infiltration with Levobupivacaine After Cardiac Surgery with Desflurane: The Effect on Postoperative Pain, Pulmonary Function, and Tracheal Extubation Times

Early tracheal extubation has become common after cardiac surgery. Anesthetic techniques designed to achieve this goal can make immediate postoperative analgesia challenging. We conducted this randomized, placebo-controlled, double-blind study to investigate the effect of a parasternal block on postoperative analgesia, respiratory function, and extubation times. We enrolled 20 patients having cardiac surgery via median sternotomy; 17 patients completed the study. A de-sflurane-based, small-dose opioid anesthetic was used. Before sternal wire placement, the surgeons performed the parasternal block and local anesthetic infiltration of sternotomy and tube sites with either 54 mL of saline placebo or 54 mL of 0.25% levobupivacaine with 1:400,000 epinephrine. Effects on pain and respiratory function were studied over 24 h. Patients in the levobupivacaine group used significantly less morphine in the first 4 h after surgery (20.8 +/- 6.2 mg versus 33.2 +/- 10.9 mg in the placebo group; P=0.013); they also had better oxygenation at the time of extubation. Four of nine in the placebo group needed rescue pain medication, versus none of eight in the levobupivacaine group (P=0.08). Peak serum levobupivacaine concentrations were below potentially toxic levels in all patients (0.64 +/- 0.43 microg/mL; range, 0.24-1.64 microg/mL). Parasternal block and local anesthetic infiltration of the sternotomy wound and mediastinal tube sites with levobupivacaine can be a useful analgesic adjunct for patients who are expected to undergo early tracheal extubation after cardiac surgery.

Implications of the use of neuromuscular transmission monitoring on immediate postoperative extubation in off-pump coronary artery bypass surgery

BACKGROUND AND OBJECTIVE

When continuous infusions of neuromuscular blocking drugs are administered during lengthy interventions and no routine antagonism of their effects is applied, there is a dramatic incidence of residual curarization. We have examined whether the use of neuromuscular transmission monitoring results in differences in the incidence of postoperative residual curarization, the use of antagonist agents, and the endotracheal extubation rate and outcome after continuous infusion of rocuronium in patients undergoing off-pump coronary artery bypass surgery.

METHODS

Twenty patients were assigned to group 1 (n = 10, non-blinded neuromuscular transmission monitoring) or group 2 (n = 10, blinded neuromuscular transmission monitoring). In group 1, patients were given rocuronium at an infusion rate of 6 microg kg(-1) min(-1). The rate was manually adjusted in order to maintain T1/T0 at 10%. In group 2, a rocuronium infusion was started 30 min after induction of anaesthesia, at a rate of 6 microg kg(-1) min(-1); this rate was left unchanged during surgery. The rocuronium infusion was discontinued on completion of all vascular anastomoses; propofol was stopped at the beginning of closure of the subcutis and pirinitramide (piritramide) 15 mg was administered intravenously. Remifentanil was discontinued at the beginning of skin closure and neostigmine (50 microg kg(-1)) administered at the end of surgery when the train-of-four ratio was < 0.9 in group 1, and routinely in group 2. A 20 min test period for spontaneous ventilation was allowed once surgery had been accomplished. When the train-of-four ratio was > or = 0.9 (group 1), patients were extubated if also breathing spontaneously, fully awake and able to follow commands. When they met the clinical criteria for normal neuromuscular function after induced blockade, patients in group 2 were extubated when fully awake and able to follow commands.

RESULTS

In group 1, the rate of rocuronium infusion required to keep T1/T0 at 10% was 5 +/- 1.9 microg kg(-1) min(-1); this was not significantly different from the fixed rate in group 2 (P = 0.15). One patient in group 2 was excluded. Eight out of 10 and eight out of nine patients in groups 1 and 2, respectively, reached the extubation criteria. Three out of eight, and five out of eight, patients from groups 1 and 2, respectively, were extubated in the operating room. At that time of endotracheal extubation, all three patients from group 1, but only four of the five patients from group 2 had a train-of-four ratio > or = 0.9. In group 2, one patient was reintubated in the intensive care unit. The incidence of pharmacological reversal was high in group 1.

CONCLUSIONS

Although we found no additional benefit of using neuromuscular transmission monitoring, it seems an absolute necessity for safety reasons. Pharmacological antagonism was mandatory. However, in our opinion, it is not wise routinely to perform immediate postoperative extubation in off-pump coronary artery bypass surgery.