Novel approaches in pain management in cardiac surgery

Pecto-Intercostal Fascial Plane Block for Pain Management after Cardiothoracic Surgery

PURPOSE OF REVIEW

Cardiac surgery is associated with significant postoperative pain. Compared to traditional analgesics, regional nerve blocks target specific anatomical areas to improve analgesia and to reduce postoperative opioid consumption.

RECENT FINDINGS

Pecto-intercostal fascial plane block (PIFB) is a novel analgesic technique that involves ultrasound-guided injection of anesthetic between pectoralis major and external intercostal muscles. Since PIFB is a relatively underexplored method of analgesia, to date, few manuscripts have reviewed and synthesized current literature related to PIFB.

CONCLUSION

The present investigation focuses on relevant anatomy and physiology behind the PIFB, compares this novel technique with other traditional and novel methods of analgesia, and describes indications and contraindications for PIFB in cardiac surgery and other surgeries.

Pharmacokinetics of Methadone in Adult Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass

BACKGROUND

Cardiopulmonary bypass (CPB) induces profound physiological changes that may alter the pharmacokinetics of methadone. We aimed to describe the pharmacokinetics of an intravenous bolus of methadone racemate in adult patients undergoing heart surgery with CPB.

METHODS

We prospectively studied 29 patients aged 45 to 75 years scheduled for cardiac surgery with CPB who received methadone 0.2 mg/kg after anesthesia induction. Arterial blood samples (n = 10) were taken, before, during, and after CPB. Pharmacokinetic analysis was undertaken using nonlinear mixed effects models.

RESULTS

All patients completed the study. The median [interquartile range] methadone concentrations decreased from 34.8 [23.9-48.2] ng/mL (10 minutes before CPB) to 18.2 [9.9-26] ng/mL after 60 minutes of CPB (P < .001). A 3-compartment model adequately described the observed changes in methadone concentrations. The influence of CPB on methadone pharmacokinetics was best described by hemodilution in a fixed volume of 1.5 L (CPB circuit volume) and by sequestration from the CPB components (CLSEQ = 93.4 L/h, 95%CI 59-124, P < .01). The observed effect of CPB in methadone pharmacokinetics can be compensated by giving a supplementary bolus dose of 0.05 mg/kg at the end of CPB.

CONCLUSIONS

Our results confirmed a decay in methadone concentrations during CPB, which, in our modeling analysis, was attributed to hemodilution and sequestration within the CPB components.

Erector spinae plane block reduces opioid consumption and improves incentive spirometry volume after cardiac surgery: A retrospective cohort study

BACKGROUND

Effective postoperative pain management is vital in cardiac surgery to prevent opioid dependency and respiratory complications. Previous studies on the erector spinae plane (ESP) block have focused on single-shot applications or immediate postoperative outcomes. This study evaluates the efficacy of continuous ESP block vs conventional care in reducing opioid consumption and enhancing respiratory function recovery postcardiac surgery over 72 hours.

METHODS

A retrospective study at a tertiary hospital (January 2021-July 2022) included 262 elective cardiac surgery patients. Fifty-three received a preoperative ESP block, matched 1:1 with a control group (n = 53). The ESP group received 0.5% ropivacaine intraoperatively and 0.16% ropivacaine every 4 hours postoperatively. Outcomes measured were cumulative oral morphine equivalent (OME) dose within 72 hours postextubation, daily maximum numerical rating scale (NRS) ≥3, incentive spirometry volume, and %baseline performance, stratified by surgery type (sternotomy or thoracotomy).

RESULTS

Significant OME reduction was observed in the ESP group (sternotomy: median decrease of 113 mg, 95% CI: 60-157.5 mg, p < 0.001; thoracotomy: 172.5 mg, 95% CI: 45-285 mg, p = 0.010). The ESP group also had a lower risk of daily maximum NRS ≥3 (adjusted OR sternotomy: 0.22, p < 0.001; thoracotomy: 0.07, p < 0.001), a higher incentive spirometry volumes (sternotomy: mean increase of 149 mL, p = 0.019; thoracotomy: 521 mL, p = 0.017), and enhanced spirometry %baseline (sternotomy: mean increase of 11.5%, p = 0.014; thoracotomy: 26.5%, p < 0.001).

CONCLUSION

Continuous ESP block was associated with a reduction of postoperative opioid requirements, lower instances of pain scores ≥3, and improve incentive spirometry performance following cardiac surgery. These benefits appear particularly prominent in thoracotomy patients. Further prospective studies with larger sample size are required to validate these findings.

Comparison of Erector Spinae Plane Block and Pectointercostal Facial Plane Block for Enhanced Recovery After Sternotomy in Adult Cardiac Surgery

OBJECTIVES

This study aimed to investigate and compare the effects of the pectointercostal fascial plane block (PIFPB) and the erector spinae plane block (ESPB) on enhancing the recovery of patients who undergo cardiac surgery.

DESIGN

A randomized, controlled, double-blinded study.

SETTING

The operating rooms and intensive care units of university hospitals.

PARTICIPANTS

One hundred patients who were American Society of Anesthesiologists class II to III aged 18-to-70 years scheduled for elective cardiac surgery.

INTERVENTIONS

Patients were randomly assigned to undergo either ultrasound-guided bilateral PIFPB or ESPB.

MEASUREMENTS AND MAIN RESULTS

Patients shared comparable baseline characteristics. Time to extubation, the primary outcome, did not demonstrate a statistically significant difference between the groups, with median (95% confidence interval) values of 115 (90-120) minutes and 110 (100-120) minutes, respectively (p = 0.875). The ESPB group had a statistically significant reduced pain score postoperatively. The median (IQR) values of postoperative fentanyl consumption were statistically significantly lower in the ESPB group than in the PIFPB group (p < 0.001): 4 (4-5) versus 9 (9-11) µg/kg, respectively. In the ESPB group, the first analgesia request was given 4 hours later than in the PIFPB group (p < 0.001). Additionally, 12 (24%) patients in the PIFPB group reported nonsternal wound chest pain, compared with none in the ESPB group. The median intensive care unit length of stay for both groups was 3 days (p = 0.428).

CONCLUSIONS

Erector spinae plane block and PIFPB were found to equally affect recovery after cardiac surgery, with comparable extubation times and intensive care unit length of stay.

Preoperative ultrasound-guided bilateral thoracic erector spinae plane block within an enhanced recovery program is associated with decreased intraoperative lactate levels in cardiac surgery

INTRODUCTION

In the perioperative period, regional analgesia techniques may play an increasingly important role in "Enhanced Recovery After Surgery (ERAS)" programs, as they can facilitate recovery. We hypothesized that Erector Spinae Plane (ESP) block could improve regional perfusion, thereby limiting blood lactate increase. Therefore, we aimed to evaluate the effect of ESP block on intraoperative blood lactate levels in patients scheduled for elective on-pump cardiac surgery with ERAS protocol.

METHODS

A total of 68 adult patients scheduled for on-pump cardiac surgery were included. All patients were randomized to the ESP group and the non-ESP group. Blood lactate analyses were performed at intraoperative five-time points. C-Reactive protein (CRP) values were also measured.

RESULTS

Blood lactate values were significantly lower in the ESP group than in the Non-ESP group, at the end of CPB [1.78 (1.23-2.78) mmol L-1 to 2.63 (1.70-3.12) mmol L-1] and during the sternal closure period [1.78 (1.27-2.42) mmol L-1 to 2.40 (2.14-2.80) mmol L-1] (p = 0.039, p = 0.009). In addition, CRP values were significantly lower in the ESP group in the postoperative period [0.048 (0.036-0.105) g L-1 to 0.090 (0.049-0.154) g L-1] (p = 0.035).

CONCLUSIONS

This study showed that preoperative bilateral single-shot ESP block significantly reduces intraoperative final blood lactate and postoperative CRP values. We consider that these results are related to the attenuation of intraoperative hypoperfusion and the alleviation of surgery-related postoperative inflammation. ERAS programs aim to achieve the rapid recovery of patients, a decrease in inflammation, and high-quality analgesia with less opioid consumption. Therefore, our results also prove that it is easier to reach the primary goals of ERAS programs with the application of ESP block in cardiac surgery.

To evaluate the analgesic effectiveness of bilateral erector spinae plane block versus thoracic epidural analgesia in open cardiac surgeries approached through midline sternotomy

BACKGROUND

The efficacy of the erector spinae plane (ESP) block in mitigating postoperative pain has been shown for a range of thoracic and abdominal procedures. However, there is a paucity of literature investigating its impact on postoperative analgesia as well as its influence on weaning and subsequent recovery in comparison to thoracic epidural analgesia (TEA) in median sternotomy-based approach for open-cardiac surgeries and hence the study.

METHODS

Irrespective of gender or age, 74 adult patients scheduled to undergo open cardiac surgery were enrolled and randomly allocated into two groups: the Group TEA (thoracic epidural block) and the Group ESP (bilateral Erector Spinae Plane block). The following variables were analysed prospectively and compared among the groups with regard to pain control, as determined by the VAS Scale both at rest (VASR) and during spirometry (VASS), time to extubation, quantity and frequency of rescue analgesia delivered, day of first ambulation, length of stay in the intensive care unit (ICU), and any adverse cardiac events (ACE), respiratory events (ARE), or other events, if pertinent.

RESULTS

Clinical and demographic variables were similar in both groups. Both groups had overall good pain control, as determined by the VAS scale both at rest (VASR) and with spirometry (VASS) with Group ESP demonstrating superior pain regulation compared to Group TEA during the post-extubation period at 6, 9, and 12 h, respectively (P > 0.05). Although statistically insignificant, the postoperative mean rescue analgesic doses utilised in both groups were comparable, but there was a higher frequency requirement in Group TEA. The hemodynamic and respiratory profiles were comparable, except for a few arrhythmias in Group TEA. With comparable results, early recovery, fast-track extubation, and intensive care unit (ICU) stay were achieved.

CONCLUSIONS

The ESP block has been found to have optimal analgesic effects during open cardiac surgery, resulting in a decreased need for additional analgesic doses and eliminating the possibility of a coagulation emergency. Consequently, it presents itself as a safer alternative to the potentially invasive thoracic epidural analgesia (TEA).

Comparison of the effects of transversus thoracic muscle plane block and pecto-intercostal fascial block on postoperative opioid consumption in patients undergoing open cardiac surgery: a prospective randomized study

BACKGROUND

There is an association exists between cardiac surgery, performed through median sternotomy, and a considerable postoperative pain.

OBJECTIVES

The aim of the current study is to compare the effects of transversus thoracic muscle plane block (TTMPB) and pecto-intercostal fascial plane block (PIFB) upon postoperative opioid consumption among the patients who underwent open cardiac surgery.

METHODS

The present prospective, randomized, comparative study was conducted among 80 patients who underwent elective on-pump cardiac surgery with sternotomy. The subjects were randomly assigned to two groups with each group containing 40 individuals. For the TTMPB group, bilateral ultrasound-guided TTMPB was adopted in which 20 ml of 0.25% bupivacaine was used on each side. In case of PIFB group, bilateral ultrasound-guided PIFB was adopted with the application of 20 ml of 0.25% bupivacaine on each side. The researchers recorded the first time for rescue analgesia, the overall dosage of rescue analgesia administered in the first 24 h after the operation and the postoperative complications.

RESULTS

The PIFB group took significantly longer time to raise the first request for rescue analgesia (7.8 ± 1.7 h) than the TTMPB group (6.7 ± 1.4 h). Likewise, the PIFB group subjects had a remarkably lower 'overall morphine usage' in the first 24 h after the operation (4.8 ± 1.0 mg) than TTMPB group (7.8 ± 2.0 mg).

CONCLUSION

Bilateral ultrasound-guided PIFB provided a longer time for the first analgesic demand than bilateral ultrasound-guided TTMPB in patients undergoing open cardiac surgery. In addition to this, the PIFB reported less postoperative morphine usage than the TTMPB and increases satisfaction in these patients.

TRIAL REGISTRATION

This study was registered at Clinical Trials.gov on 28/11/2022 (registration number: NCT05627869).

Hotspots and Trends in Research on Treating Pain with Electroacupuncture: A Bibliometric and Visualization Analysis from 1994 to 2022

Purpose

Electroacupuncture is widely used to pain management. A bibliometric analysis was conducted to identify the hotspots and trends in research on electroacupuncture for pain.

Methods

We retrieved studies published from 1994-2022 on the topic of pain relief by electroacupuncture from the Web of Science Core Collection database. We comprehensively analysed the data with VOSviewer, CiteSpace, and bibliometrix. Seven aspects of the data were analysed separately: annual publication outputs, countries, institutions, authors, journals, keywords and references.

Results

A total of 2030 papers were analysed, and the number of worldwide publications continuously increased over the period of interest. The most productive country and institution in this field were China and KyungHee University. Evidence-Based Complementary and Alternative Medicine was the most productive journal, and Pain was the most co-cited journal. Han Jisheng, Fang Jianqiao, and Lao Lixing were the most representative authors. Based on keywords and references, three active areas of research on EA for pain were mechanisms, randomized controlled trials, and perioperative applications. Three emerging trends were functional magnetic resonance imaging (fMRI), systematic reviews, and knee osteoarthritis.

Conclusion

This study comprehensively analysed the research published over the past 28 years on electroacupuncture for pain treatment, using bibliometrics and science mapping analysis. This work presents the current status and landscape of the field and may serve as a valuable resource for researchers. Chronic pain, fMRI-based mechanistic research, and the perioperative application of electroacupuncture are among the likely foci of future research in this area.

Regional Anesthesia With Paravertebral Blockade Is Associated With Improved Outcomes in Patients Undergoing Minithoracotomy Cardiac Surgery

OBJECTIVE

Severe postoperative pain has been shown to affect many patients following minimally invasive cardiac surgeries (MICS). Multimodal pain management with regional anesthesia, particularly by delivery of local anesthetics using a paravertebral catheter (PVC), has been shown to reduce pain in operations involving thoracotomy incisions. However, few studies have reported high-quality safety and efficacy outcomes of PVCs following MICS.

METHODS

Patients who underwent MICS at Vancouver General Hospital between 2016 and 2019 (N = 123) were reviewed for perioperative opioid-narcotic use. Primary outcomes were postoperative opioid use and hospital length of stay (LOS). Statistical analyses were performed using univariate and multivariable regression models to determine independent risk factors.

RESULTS

A total of 54 patients received routine systemic analgesia (control), 53 patients received a paravertebral catheter (PVC), and 16 patients received another mode of regional analgesia (non-PVC). The mean hospital LOS was significantly different in patients in the PVC group at 5.8 ± 2.0 days versus 8.3 ± 7.1 days in the control and 6.6 ± 2.3 days in the non-PVC group (P = 0.033). The percentage of patients who did not require postoperative oxycodone was significantly higher in the PVC group (48.1%), compared with the control (24.5%) and non-PVC (37.5%; P = 0.043) groups.

CONCLUSIONS

The administration of regional anesthesia using PVCs was associated with reduced need for opioids and a shorter LOS. The reduction in postoperative opioids may reduce the risk of potential opioid dependency in this population. Future studies should involve randomized controlled trials with systematic evaluation of pain scores to verify current study results.

Preemptive parasternal intercostal nerve block for patients undergoing off-pump coronary artery bypass grafting: a double-blind, randomized, controlled trial

Background

Parasternal intercostal nerve block has been increasingly used for postoperative analgesia and has shown that this technique can provide effective postoperative analgesia. This study aimed to investigate the effect of preemptive parasternal intercostal nerve block on the opioid and vasoactive drug dose required for intraoperative hemodynamic stability and postoperative analgesia in patients undergoing off-pump coronary artery bypass grafting.

Methods

In this prospective, randomized controlled study, 64 participants aged 45-75 years scheduled for off-pump coronary artery bypass grafting at The Second Xiangya Hospital of Central South University. Patients were randomized into two groups and preoperatively administered ropivacaine (group R) and saline (group S), in the parasternal intercostal spaces with ultrasound-guided bilateral nerve block.

Results

The primary outcome was intraoperative sufentanil and vasopressor dosage. The secondary outcomes were intraoperative hemodynamics, postoperative pain scores, and anesthesia recovery, postoperative use of rescue dezocine, stay in intensive care unit, and length of hospital stay. The consumption of intraoperative sufentanil and vasopressor was significantly lower in group R than in group S. The visual analog score in group R was significantly lower than that in group S up to 12 h postoperatively. The time to anesthesia recovery was significantly less in group R than in group S. Most patients in group S required rescue dezocine, whereas most patients in group R did not. The hemodynamic variables were stable in all patients.

Conclusions

A preemptive parasternal intercostal nerve block effectively reduced the required intraoperative sufentanil and norepinephrine dose and provided adequate analgesia for the first 12 h after surgery. Therefore, a preemptive parasternal intercostal nerve block is a good option for patients undergoing off-pump coronary artery bypass grafting.

Clinical trial registration

chictr.org.cn, identifier ChiCTR1800017210.

Intraoperative Fascial Plane Blocks Facilitate Earlier Tracheal Extubation and Intensive Care Unit Discharge After Cardiac Surgery: A Retrospective Cohort Analysis

OBJECTIVES

Novel fascial plane blocks may allow early tracheal extubation and discharge from the intensive care unit (ICU). The present study primarily aimed to determine whether fascial plane blocks, in comparison with intravenous analgesia alone, significantly shortened tracheal extubation times in patients undergoing cardiac surgery. The secondary objectives were to compare each block's performance with that of intravenous analgesia alone in terms of the individual tracheal extubation time and length of ICU stay.

DESIGN

Retrospective observational study.

SETTING

Single-center study.

PARTICIPANTS

Patients who underwent cardiac surgery between 2018 and 2019 were identified from a prospective clinical registry. After obtaining ethics approval, the clinical and electronic records of patients undergoing cardiac surgery in 2018 were analyzed. Data of patients receiving fascial plane blocks (erector spinae plane [ESP], pectoral plane I and II [PECs], and serratus anterior plane [SAP] blocks) with intravenous analgesia were compared with those of patients receiving only intravenous analgesia. A propensity score (PS) model was used to control for differences in the baseline characteristics. Adjusted p < 0.05 was considered statistically significant.

MEASUREMENTS AND MAIN RESULTS

Of the 589 patients screened, 532 met the inclusion criteria; 404 received a fascial plane block. After PS matching, weighted linear regression revealed that by receiving a block, the predicted extubation time difference was 9.29 hours (b coefficient; 95% CI: -11.98, -6.60; p = 0.022). Similar results were obtained using PS weighting, with a reduction of 7.82 hours (b coefficient; 95% CI: -11.89, -3.75; p < 0.001) in favor of the block. In the fascial-plane-block group, ESP block achieved the best performance. The length of ICU stay decreased by 1.1 days (b coefficient; 95% CI: -1.43, -0.79; p = 0.0001) in the block group. No complications were reported.

CONCLUSIONS

Fascial plane block is associated with reduced extubation times and lengths of ICU stay. ESP block achieved the best performance, followed by PECs and SAP blocks. After PS matching, only ESP block reduced the extubation time.

The Use of Unilateral Erector Spinae Plane Block in Minimally Invasive Cardiac Surgery

OBJECTIVES

To examine the efficacy of continuous unilateral erector spinae plane (ESP) blocks in minimally invasive cardiac surgery patients.

DESIGN

A retrospective nonrandomized study.

SETTING

At a single-center, tertiary academic institution.

PARTICIPANTS

The study comprised 129 adult patients undergoing minimally invasive cardiac surgery with cardiopulmonary bypass or extracorporeal membrane oxygenation.

INTERVENTIONS

Patient data were retrospectively collected and compared. Group 1 patients received ultrasound-guided ESP blocks, and group 2 patients underwent conventional intraoperative management without ESP blocks. After intubation in the group 1 cohort, 20-to- 25 mL of 0.25% ropivacaine were deposited beneath the erector spinae plane, along with catheter placement for continuous postoperative infusion.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics (ie, age, sex, and comorbidities) were well-matched between both cohorts. The total 48-hour opioid consumption, as measured in morphine equivalents (mg), was significantly decreased in patients receiving erector spinae plane blocks compared to patients receiving conventional therapy (30.24 mg ± 23.8 v 47.82 mg ± 53.6, p = 0.04). The length of stay in the intensive care unit (ICU) also was reduced in the treatment group in comparison to the control group (1.99 days ± 1.7 v 2.65 days ± 2.4, p = 0.03). Lastly, patients receiving the blocks benefitted from a decrease in overall hospital length of stay when compared to the control group (5.93 days ± 2.4 v 7.35 days ± 5.8, p = 0.04).

CONCLUSION

Erector spinae plane catheter use may safely improve postoperative measures, including decreased opioid consumption and improved pain relief, as well as reductions in ICU and hospital lengths of stay in patients undergoing minimally invasive cardiac surgery.

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.

The influence of preoperative anxiety on postoperative pain in patients undergoing cardiac surgery

Patients undergoing cardiac surgery represent a challenge in terms of pain management due to multiple factors relating to the patients and to the procedure itself. Our aim was to identify the influence of levels of preoperative anxiety on postoperative pain in patients undergoing cardiac surgery and explore associations between preoperative anxiety, postoperative pain, analgesic requirements, and sex. We present a prospective cohort study of 116 patients undergoing cardiac surgery between January and April 2020. Preoperative anxiety was evaluated using the State-Trait Anxiety Inventory and the amount of morphine needed to keep pain intensity below 4 on the verbal numerical rating scale was recorded for 48 h post-surgery. Given the extracorporeal circulation time, type of surgery and body surface, it was observed that every percentile increase in preoperative state anxiety led to an extra 0.068 mg of morphine being administered. For each extra year of age, the amount of morphine needed decreased by 0.26 mg, no difference was observed between men and women in terms of preoperative anxiety or postoperative analgesics requirements. It may be concluded that in cardiac surgery, postoperative analgesic requirements increased with higher levels of preoperative state anxiety and decreased for every extra year of age.

Regional analgesia techniques for effective recovery from coronary artery bypass surgeries: a retrospective study involving the experience of a single center

BACKGROUND

Pain after cardiac surgery is both multifocal and multifactorial. Sternotomy, sternal retraction, internal mammary dissection, posterior rib dislocation or fracture, potential brachial plexus injury, and mediastinal and pleural drains all contribute to pain experienced in the immediate postoperative period. Ineffective pain management can result in systemic and pulmonary complications and significant cardiac consequences.

METHODS

This study compared the effectiveness of regional anesthesia techniques for perioperative pain management in cardiac surgery patients at our clinic. The effects of different analgesic methods, in terms of contributing to recovery, were examined.

RESULTS

The records of 221 patients who had undergone coronary bypass surgery were evaluated retrospectively. The extubation rate in the operating room was 91%. No patient received balloon pump support, and 20 patients were transferred to the cardiovascular intensive care unit while intubated. Regional anesthesia was performed on two of these 20 patients, but not on the remaining 18. Examination of intraoperative and postoperative opioid consumption revealed significantly lower levels among patients receiving regional anesthesia. The most effective results among the regional anesthesia techniques applied were achieved with double injection erector spinae plane block.

CONCLUSION

Regional anesthesia techniques severely limit opioid consumption during cardiac surgery. Their importance will gradually increase in terms of rapid recovery criteria. Based on our study results, double injection of the erector spinae plane block seems to be the most effective technique in cardiac surgery. We therefore favor the use of fascial plane blocks during such procedures. Trial Numbers The study is registered with ClinicalTrials (NCT05282303). Ethics committee registration and approval were Granted under Number 2021.464.IRB1.131.

Transverse thoracic muscle plane block as a routine strategy for cardiac enhanced recovery after surgery in sternotomy: A retrospective analysis

ABSTRACT

The aim of this study is to retrospectively analyze and evaluate the effect of transverse thoracic muscle plane (TTP) block as a routine analgesic strategy for cardiac enhanced recovery after surgery in sternotomy.Patients received TTP block after general anesthesia and tracheal intubation were included in this study. The baseline clinical data of the patients, intraoperative use of sufentanil, internal mammary artery separating time, the postoperative duration of invasive ventilation, visual analogue scale, the compression times of patient-controlled intravenous analgesia in the first 3 days after surgery, and postoperative nausea and vomiting were recorded.A total of 104 cases was included and divided to G group (without TTP block) and TTP group (with TTP). Sufentanil use (sufentanil dose/min, sufentanil dose/kg body weight, sufentanil dose/[min kg]) in TTP group was significantly lower than that of G group. In G group, intraoperative use of sufentanil was correlated to the duration of anesthesia (P = .035). The postoperative visual analogue scale pain scores and the compression times of patient-controlled intravenous analgesia in the TTP group were significantly decreased compared with G group (P < .01). The postoperative duration of invasive ventilation of patients with normal and mildly impaired pulmonary function was significantly correlated to the use of sufentanil (P = .027, .009).TTP block has certain analgesic effect and can reduce sufentanil use in medium-length cardiac surgery and postoperative use of opioids. It is indicated that TTP block can be used as a routine enhanced recovery after surgery strategy for sternotomy in cardiac surgery.

Evaluation of Different Pain-Control Procedures for Post-cardiac Surgery: A Systematic Review and Network Meta-Analysis

Objective

To identify superior pain-control procedures for postoperative patients who undergo cardiac surgeries.

Methods

Literature searches were conducted in globally recognized databases, including MEDLINE, EMBASE and Cochrane Central, to identify randomized controlled trials (RCTs) investigating pain-control procedures after cardiac surgeries. The parameters evaluating analgesic efficacy and postoperative recovery, namely, the pain score and ICU stay, were quantitatively pooled and estimated using Bayesian methods. The values of the surface under the cumulative ranking (SUCRA) probabilities regarding each parameter were calculated to enable the ranking of various pain-control procedures. Node-splitting analysis was performed to test the inconsistency of the main results, and the publication bias was assessed by examining the funnel-plot symmetry.

Results

After a detailed review, 13 RCTs containing 7 different procedures were included in the network meta-analysis. After pooling the results together, an erector spinae plane block (ESPB) and a local parasternal block (LPB) plus target-controlled infusion (TCI) presented the best analgesic effects for reducing pain at rest (SUCRA, .47) and during movement (SUCRA, .52), respectively, while the former also achieved the shortest ICU stay (SUCRA, .48). Moreover, the funnel-plot symmetries showed no inconsistencies or obvious publication bias in the current study.

Conclusions

The current evidence indicates that ESPB is a potential superior analgesic strategy for post-cardiac surgery patients. To verify this conclusion further, it is imperative to obtain more high-quality evidence and conduct relevant investigations in the future.

Comparative analysis of two laser wavelengths in the stimulation of acupuncture points for analgesic effects in an animal model

This study compares the effectiveness of two laser wavelengths for stimulating acupoints in an experimental model of acute postoperative pain. Forty-five Wistar rats were randomly assigned to receive treatment on their left hind paw, contralateral to a surgical procedure. Laser treatments were performed with Green Laser-GL (532 nm, 70 mW and 7 J/cm² of energy), Red Laser-RL (660 nm, 100 mW and 7 J/cm² of energy), or with Laser Off-LO. After each application, the animals were evaluated with a Von Frey analgesiometer to check for painful sensitivity on their right (with surgery) and left (without surgery) hind paws. Neuropeptides and cytokine levels in the incision site tissue of the right paw were measured by ELISA after 1, 6 and 24 hours. It was possible to observe that, in this pain model, both lasers promoted analgesia and that the GL altered the levels of TNF-α and IL-1β.

A multicenter study to evaluate the pharmacokinetics and safety of liposomal bupivacaine for postsurgical analgesia in pediatric patients aged 6 to less than 17 years (PLAY)

STUDY OBJECTIVE

To evaluate the pharmacokinetics and safety of liposomal bupivacaine in pediatric patients undergoing spine or cardiac surgery.

DESIGN

Multicenter, open-label, phase 3, randomized trial (PLAY; NCT03682302).

SETTING

Operating room.

PATIENTS

Two separate age groups were evaluated (age group 1: patients 12 to <17 years undergoing spine surgery; age group 2: patients 6 to <12 years undergoing spine or cardiac surgery).

INTERVENTION

Randomized allocation of liposomal bupivacaine 4 mg/kg or bupivacaine hydrochloride (HCl) 2 mg/kg via local infiltration at the end of spine surgery (age group 1); liposomal bupivacaine 4 mg/kg via local infiltration at the end of spine or cardiac surgery (age group 2).

MEASUREMENTS

The primary and secondary objectives were to evaluate the pharmacokinetics (eg, maximum plasma bupivacaine concentrations [C_max], time to C_max) and safety of liposomal bupivacaine, respectively.

MAIN RESULTS

Baseline characteristics were comparable across groups. Mean C_max after liposomal bupivacaine administration was lower versus bupivacaine HCl in age group 1 (357 vs 564 ng/mL); mean C_max in age group 2 was 320 and 447 ng/mL for spine and cardiac surgery, respectively. Median time to C_max of liposomal bupivacaine occurred later with cardiac surgery versus spine surgery (22.7 vs 7.4 h). In age group 1, the incidence of adverse events (AEs) was comparable between liposomal bupivacaine (61% [19/31]) and bupivacaine HCl (73% [22/30]). In age group 2, 100% (5/5) and 31% (9/29) of patients undergoing spine and cardiac surgery experienced AEs, respectively. AEs were generally mild or moderate, with no discontinuations due to AEs or deaths.

CONCLUSIONS

Plasma bupivacaine levels following local infiltration with liposomal bupivacaine remained below the toxic threshold in adults (~2000-4000 ng/mL) across age groups and procedures. AEs were mild to moderate, supporting the safety of liposomal bupivacaine in pediatric patients undergoing spine or cardiac surgery. Clinical trial number and registry URL: ClinicalTrials.gov identifier: NCT03682302.

Bilateral transversus thoracis muscle plane block provides effective analgesia and enhances recovery after open cardiac surgery

BACKGROUND

The mid-sternum is the main source of pain after open cardiac surgery. The aim of this study was to investigate the effect of bilateral transversus thoracis muscle plane (TTMP) blocks on open cardiac surgery.

METHODS

Sixty patients were randomly divided into two groups: bilateral TTMP blocks (TP group) or no nerve block (CO group). The primary endpoint was perioperative sufentanil consumption. The secondary outcome measures included postoperative pain, flurbiprofen axetil administration, quality of sleep after extubation, time to extubation, time to the return of gastrointestinal function, time to drain removal, the Intensive Care Unit (ICU) stay time, and hospital stay.

RESULTS

The TP group reported significantly less sufentanil and flurbiprofen axetil consumption than the CO group. The CO group had higher Numerical Rating Scale (NRS) pain scores at 1, 2, 6, 12, and 24 h after extubation both at rest and during movement than the TP groups. Compared with the CO group，time to extubation, time to the first bowel movement, ICU stay time, and hospital stay were significantly decreased in the TP group. The TP group was rated as better in the quality of the two nights of sleep after extubation.

CONCLUSION

Bilateral TTMP blocks can provide good perioperative analgesia for patients undergoing open cardiac surgery and promote postoperative recovery.

Ultrasound-Guided Continuous Parasternal Intercostal Block Relieves Postoperative Pain After Open Cardiac Surgery: A Case Series

Pain after open cardiac surgery can be severe and may persist for several days, potentially developing into chronic postsurgical pain. Herein the authors describe three patients who underwent open cardiac surgery via traditional median sternotomy approach. Postoperative pain was relieved in these patients via a novel, straightforward, ultrasound-guided parasternal intercostal block, peripheral regional anesthetic technique. This plane block, thus, may represent an effective regional anesthetic strategy and a valuable component of a multimodal analgesic approach for patients who have undergone open cardiac surgery with median sternotomy.

Efficacy of parasternal block to decrease intraoperative opioid use in coronary artery bypass surgery via sternotomy: a randomized controlled trial

OBJECTIVE

This study aims to assess the effect of a preoperative parasternal plane block (PSB) on opioid consumption required to maintain hemodynamic stability during sternotomy for coronary artery bypass graft surgery.

METHODS

This double-blind, randomized, placebo-controlled trial prospectively enrolled 35 patients scheduled for coronary artery bypass graft surgery under general anesthesia with propofol and remifentanil. Patients were randomized to receive preoperative PSB using either ropivacaine (PSB group) or saline solution (placebo group) (1:1 ratio). The primary endpoint was the maximal effect-site concentration of remifentanil required to maintain heart rate and blood pressure within the recommended ranges during sternotomy.

RESULTS

Median maximum concentration of remifentanil necessary to maintain adequate hemodynamic status during sternotomy was significantly reduced in PSB group (4.2 (2.5-6.0) ng/mL) compared with placebo group (7.0 (5.2-8.0) ng/mL) (p=0.02). Mean maximum concentration of propofol used to control depth of anesthesia was also reduced (3.9±1.1 µg/mL vs 5.0±1.5 µg/mL, PSB vs placebo, respectively; p=0.02). This reduction in propofol consumption during sternotomy enabled a more adequate level of sedation to be maintained in patients (minimum patient state index was 11.7±8.7 in placebo group and 18.3±6.8 in PSB group; p=0.02). PSB reduced postoperative inflammatory response by limiting concentrations of proinflammatory cytokines IL-8, IL-18, IL-23, IL-33 and MCP-1 measured in the first 7-day after surgery (p<0.05).

CONCLUSIONS

Preoperative PSB reduced the maximum concentrations of remifentanil and propofol required to maintain hemodynamic stability and depth of anesthesia during sternotomy.

TRIAL REGISTRATION NUMBER

NCT03734159.Sébastien Bloc, M.D.^1,2; Brieuc P. Pérot, Ph.D.³; Hadrien Gibert, M.D.¹; Jean-Dominique Law Koune, M.D.¹; Yannick Burg, M.D.¹; Didier Leclerc, M.D.¹; Anne-Sophie Vuitton, M.D.¹; Christophe De La Jonquière, M.D.¹; Marine Luka, L.S.³; Thierry Waldmann, M.D.⁴; Nicolas Vistarini, M.D.⁴; Stéphane Aubert, M.D.⁴; Mickaël M. Ménager, Ph.D.³; Messaouda Merzoug, Ph.D.²; Cécile Naudin, Ph.D.²; Pierre Squara, M.D.^2,5.

Analgesic Effect of Dual Injection Technique for the Erector Spinae Plane Block in Beating Heart Coronary By-Pass Surgeries

Introduction

Various regional anesthesia techniques such as thoracic epidural, thoracic paravertebral block, erector spinae plane block (ESPB), parasternal intercostal blocks are used in cardiac surgery for postoperative analgesia. In our study, we investigated the analgesic efficacy of the dual injection technique of ESPB in beating heart coronary bypass surgeries.

Methods

The records of patients with coronary artery bypass (CABG) surgery in the beating heart at the VKV American Hospital between January and December 2019 were retrospectively analyzed. The data of 30 patients who met the criteria to be included in the study were analyzed. Whether any opioid use is required for maintenance of anesthesia it is recorded. The pain scores of the patients are recorded by the intensive care team and cardiovascular service nurses for the first 48 hours.

Results

The absence of secondary responses to pain in all surgical periods, including skin incision and sternotomy, and low number of rating scale (NRS) scores in the postoperative 0- to 24-hour period show that the technique we developed can produce effective analgesia. After the 24th postoperative hour, the patients were followed up in the cardiovascular service and there was no opioid use between 24- to 48-hour period.

Conclusion

Our approach, in which the local anesthetic is applied by approaching the superior costa-transverse ligament (SCTL) in the ESPB, provides an effective analgesia in coronary artery bypass surgeries in the beating heart. The main purpose of our new approach is to increase the amount of local anesthetic in the paravertebral area. We recommend using our modified technique for effective analgesia after CABG surgeries.

Effectiveness of music on anxiety and pain among cardiac surgery patients: A quantitative systematic review and meta-analysis of randomized controlled trials

AIM

The aim of this study is to evaluate the effectiveness of music on anxiety and pain among patients following cardiac surgery.

BACKGROUND

Cardiac surgery affects patients physically, psychologically and socially. Anxiety and pain are the usual problems among patients following cardiac surgery.

DESIGN

The study design is a systematic review and meta-analysis.

DATA SOURCES

The Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), Excerpta Medica database (EMBASE) and Web of Science databases were searched for randomized controlled trials from January 2000 to December 2017.

REVIEW METHODS

The Cochrane collaboration guidelines were followed and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to summarize the quality of evidence.

RESULTS

Fourteen studies were included in systematic review and 13 in meta-analysis. The meta-analysis revealed that there was a significant reduction in anxiety and pain among patients who received musical intervention compared with those who did not.

CONCLUSION

Music has positive benefits on anxiety and pain. However, well-designed and high-quality trials are needed to generate higher quality evidence.

A Randomized Double-Blind Controlled Trial to Assess the Efficacy of Ultrasound-Guided Erector Spinae Plane Block in Cardiac Surgery

OBJECTIVE

Cardiac surgical pain is of moderate-to-severe intensity. Ineffective pain control may lead to increased cardiopulmonary complications and poor surgical outcomes. This study aimed to assess the efficacy of ultrasound-guided erector spinae plane block in providing analgesia in adult cardiac surgeries.

DESIGN

Prospective, randomized, double-blinded clinical trial.

SETTINGS

Single-center, tertiary care hospital with university affiliation.

PARTICIPANTS

Thirty patients of either sex, aged 18-to-60 years, body mass index 19-to-30 kg/m², undergoing elective on-pump single-vessel coronary artery bypass grafting or valve replacement under general anesthesia.

INTERVENTIONS

Patients were randomly categorized into two groups of 15 patients each to receive bilateral erector spinae plane block with 20 mL per side of 0.25% levobupivacaine (group E) or sham block with 20 mL of normal saline (group C).

MAIN RESULTS

Mean analgesic requirement in terms of fentanyl equivalents (µg) in the first 24 hours postoperatively was 225 ± 112 in group E and 635 ± 145 in group C (95% confidence interval, 313.10-506.90; p < 0.05). Mean time to first rescue analgesia was 356.9 ± 34.5 in group E and 123.9 ± 13.1 minutes in group C (p < 0.05). Cox proportional hazard ratio for rescue analgesic requirement in group E-to-group C was 5.0. Duration of mechanical ventilation was 88.4 ± 17 and 103.5 ± 18 minutes in groups E and C, respectively (p < 0.05). Ramsay sedation score at six hours postextubation was 1.45 ± 0.53 in group E and 3.19 ± 0.62 in group C (p < 0.05). Mean numerical rating score was 3.67 ± 1.41 in group E and 4.50 ± 1.00 in group C (p = 0.17). No significant differences were observed in the incidences of postoperative nausea vomiting, pruritus, and erector spinae plane block-related infection and pneumothorax.

CONCLUSION

Single-shot erector spinae plane block provides superior analgesia as compared with sham block. It decreased the first 24-hour postoperative analgesic consumption by 64.5% and risk of pain by five times in the authors' population. It also reduced the sedation and duration of mechanical ventilation in postcardiac surgery patients.

Fast-track cardiac anaesthesia protocols: Is quality pushed to the edge?

Background

The quest for methods expediting rapid postoperative patient turnover has triggered implementation of various fast-track cardiac anaesthesia protocols. Using three different fast-track protocols in randomized controlled studies (RCT) conducted 2010-2016 we found minimal achievements in ventilation time together with actual and eligible length of stay in cardiac recovery unit. The comparable control group patients were evaluated in this retrospective post hoc analysis, for an association between above mentioned parameters and quality parameters, to assess whether the marginal gains have been at the expense of quality of recovery and patient comfort.

Method

90 control patients from three RCT with comparable demographic parameters and receiving standard department treatment were evaluated using time parameters and an objective/semi-objective Intensive Care Unit (ICU) score system (IDS score).

Results

Ventilation time was statistical significant lower in latest study (C) than the early (A) and intermedium (B) studies (A=293, B=261, C=205 minutes; P=0.04). The IDS was lower at extubation and all time points in the early study compared to other studies (P < 0.001;). The average IDS in latest study were the double of previous studies at the end of observations, and marginally above the acceptable score for discharge. The postoperative morphine requirement A=15.0, B=10.0 and C=26.5 mg; P=0.002) was statistical significant higher in the latest study compared to previous studies.

Conclusion

The implementation of strict fast-track protocols resulting in shorter ventilation time did not convert to earlier eligibility to discharge from the ICU. However, the quality of recovery appears challenged.

Predictors of new persistent opioid use after coronary artery bypass grafting

OBJECTIVE

Deaths from prescription opioid overdose have quadrupled in the past 15 years, and no studies have evaluated appropriate opioid prescribing after cardiac surgery. The aim of this study is to quantify the amount of outpatient opioids prescribed to patients after coronary artery bypass grafting and determine the incidence and risk factors for new persistent opioid use after coronary artery bypass grafting.

METHODS

Insurance claim data from privately insured opioid-naïve patients who underwent coronary artery bypass grafting from 2014 to 2016 were evaluated. New persistent opioid use was defined as patients who filled an opioid prescription in the perioperative period and filled opioid prescriptions between 90 and 180 days after surgery. Multivariable logistic regression was used to determine the preoperative and operative factors associated with new persistent opioid use.

RESULTS

Among 7292 opioid-naïve patients undergoing coronary artery bypass grafting, 5628 (77.2%) filled opioid prescriptions in the perioperative period, and 590 (8.1%) had new persistent opioid use. Female gender (odds ratio [OR], 1.30; confidence interval [CI], 1.05-1.61; P = .018), anxiety (OR, 1.40; CI, 1.09-1.81; P = .009), tobacco use (OR, 1.34; CI, 1.08-1.65; P = .007), prior substance abuse (OR, 1.99; CI, 1.16-3.41; P = .013), chronic obstructive pulmonary disease (OR, 1.29; CI, 1.02-1.63; P = .037), living in the Southern United States (OR, 1.46; CI, 1.21-1.77; P < .001), and increased amount of opioids prescribed in the perioperative period (OR, 1.016; CI, 1.014-1.018; P < .001) were independently associated with new persistent opioid use.

CONCLUSIONS

New persistent opioid use after coronary artery bypass grafting is surprisingly common. Prospective studies are needed to determine the opioid requirements of patients after coronary artery bypass grafting to prevent opioid dependence.

Effects of Massage in Reducing the Pain and Anxiety of the Cardiac Surgery Critically Ill-a Randomized Controlled Trial

Objective

To evaluate the effectiveness of hand massage on the pain and anxiety of the cardiac surgery critically ill.

Design

A three-arm randomized controlled trial.

Setting

This study was conducted in a medical-surgical intensive care unit in Canada.

Subjects

Adult patients who underwent elective cardiac surgery, who were able to speak French/English and to self-report symptoms, without a high risk of postoperative complications were eligible.

Methods

Patients were randomly allocated to standard care plus either two 20-minute hand massages (experimental), two 20-minute hand holdings (active control), or two 20-minute rest periods (passive control/standard care). Pain intensity, pain unpleasantness, anxiety, muscle tension, and vital signs were evaluated before, after, and 30 minutes later for each intervention.

Results

From the 83 patients recruited, 60 were randomized (20 massage, 19 hand holding, 21 standard care). After controlling for baseline scores, the massage group reported significantly lower pain intensity, pain unpleasantness, and anxiety for the first data collection set compared with both hand holding and standard care (analysis of covariance, P < 0.02), with an average decrease of two points on a 0-10 scale. No statistically significant differences were noted between hand holding and standard care for any of the symptoms. Similar results were observed for the second data collection set (N = 43). Patients had decreased muscle tension post massage. Vital signs did not differ significantly between groups.

Conclusions

Findings suggest that a 20-minute hand massage in addition to routine postoperative pain management can concomitantly reduce pain intensity, pain unpleasantness, and anxiety by two points on average on a 0-10 scale.

Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting: a feasibility study

BACKGROUND

Whether thoracic paravertebral block (PVB) is useful in patients undergoing off-pump coronary artery bypass grafting (OPCABG) remains unknown. This study aimed to investigate the feasibility of bilateral PVB combined with general anesthesia (GA) in patients undergoing OPCABG.

METHODS

This feasibility study assessed 60 patients scheduled for OPCABG at the Qingdao Municipal Hospital in 2016-2017. Patients were randomly assigned to receive nerve stimulator-guided bilateral PVB combined with GA (PVB + GA) or GA alone (n = 30/group). Patients were asked to rate rest and cough pain hourly after the surgery. The primary endpoint was the visual analogue scale (VAS) pain score within 48 h postoperatively. Secondary endpoints were rescue analgesia and morphine consumption, fentanyl dose within 48 h postoperatively, as well as operative time, time to extubation, intensive care unit (ICU) stay, hospital stay and other postoperative adverse events.

RESULTS

Both rest and cough pains were lower in the PVB + GA group at 12, 24, 36, and 48 h after surgery compared with the GA group. There were fewer patients who needed rescue analgesia in the PVB + GA group at 12 and 24 h than in the GA group. Morphine consumptions at 24 and 48 h were lower in the PVB + GA group compared with the GA group. Time to extubation (P = 0.035) and ICU stay (P = 0.028) were shorter in the PVB + GA group compared with the GA group. AEs showed no differences between the two groups.

CONCLUSIONS

Nerve stimulator-guided bilateral thoracic PVB combined with GA in OPCABG is associated with a reduced rescue analgesia and morphine consumption, compared to GA.

Comparisons and correlations of pain intensity and respiratory and peripheral muscle strength in the pre- and postoperative periods of cardiac surgery

OBJECTIVE

To evaluate respiratory and peripheral muscle strength after cardiac surgery. Additionally, we compared the changes in these variables on the third and sixth postoperative days.

METHODS

Forty-six patients were recruited, including 17 women and 29 men, with a mean age of 60.50 years (SD = 9.20). Myocardial revascularization surgery was performed in 36 patients, replacement of the aortic valve in 5 patients, and replacement of the mitral valve in 5 patients.

RESULTS

A significant reduction in respiratory and peripheral muscle strength and a significant increase in pain intensity were observed on the third and sixth postoperative days (p < 0.05), except for the variable maximal inspiratory pressure; on the sixth postoperative day, maximal inspiratory pressure values were already similar to the preoperative and predicted values (p > 0.05). There was an association between peripheral muscle strength, specifically between maximal expiratory pressure preoperatively (rs = 0.383; p = 0.009), on the third postoperative day (rs = 0.468; p = 0.001) and on the sixth postoperative day (rs = 0.311; p = 0.037). The effect sizes were consistently moderate-to-large for respiratory muscle strength, the Medical Research Council scale and the visual analog scale, in particular between preoperative assessment and the sixth postoperative day.

CONCLUSION

There is a decrease in respiratory and peripheral muscle strength after cardiac surgery. In addition, maximal expiratory pressure is the variable that is most associated with peripheral muscle strength. These variables, especially respiratory and peripheral muscle strength, should be considered by professionals working in the intensive care setting.

Optimising pain management protocols following cardiac surgery: A protocol for a national quality improvement study

•

Severe pain is associated with tachyarrhythmias, shallow breathing and poor recovery.

•

Our protocol was effective at reducing post-cardiac surgery pain in a single centre.

•

It consists of pre-operative gabapentin and dividing patients based on risk of pain.

•

High-risk group receive PCA along with paracetamol and codeine given to all patients.

•

Centres will undertake a baseline audit, then implement a protocol and re-audit pain.

Pain following cardiac surgery is a multifaceted phenomenon resulting from a number of mechanisms. High-levels of post-operative pain are associated with cardiovascular and respiratory complications and adequate pain management is crucial for enabling fast recovery. However, adequate pain control is complex, a challenge that stems from a combination of poor reporting of pain, significant variation amongst patients and the side-effects of strong, particularly opioid, analgesics. An initial audit at our hospital demonstrated high-levels of post-operative pain following cardiac surgery and a protocol was therefore devised by the anaesthetic department for cardiac surgical pain management. The protocol stratified patients into high- or low-risk of pain based on the presence of risk factors for pain and utilised a combination of pre-operative one-off dose of gabapentin, intra-operative opioid infusion and post-operative multimodal analgesia with paracetamol, weak and strong opioids. Additionally, patients at high-risk of pain also received patient controlled analgesia. Use of this protocol was associated with improved pain scores on the first three post-operative days. We have devised this study to test for reproducibility of the benefit experienced at our hospital at a larger multicentre level. After acquiring pre-existing post-operative pain management strategies through an initial survey, local study leads will undertake a baseline audit. Local study leads will then lead a 4-week period of protocol implementation. Trusts with official pain management protocols will be given the option to re-circulate their pre-existing protocols. Subsequently, pain scores during post-operative days 1–3 will be re-audited.

The effect of local anesthetic continuous wound infusion for the prevention of postoperative pneumonia after on-pump cardiac surgery with sternotomy: the STERNOCAT randomized clinical trial

PURPOSE

Postoperative pain after cardiac surgery, exacerbated by cough and sternal mobilization, limits clearance of bronchopulmonary secretions and may predispose to postoperative pneumonia. In this study, we tested the ability of local anesthetic continuous wound infusion to prevent pneumonia after cardiac surgery with sternotomy and cardiopulmonary bypass (CPB) owing to better analgesia and bronchopulmonary drainage.

METHODS

In this randomized, double-blind, placebo-controlled trial conducted in five academic centers, patients undergoing cardiac surgery with sternotomy and CPB were enrolled from February 2012 until November 2014, and were followed over 30 days. Patients were assigned to a 48-h infusion (10 ml h-1) of L-bupivacaine (12.5 mg h-1) or placebo (saline) via a pre-sternal multiperforated catheter. Anesthesia and analgesia protocols were standardized. The primary end point was the incidence of pneumonia during the study period, i.e., until hospital discharge or 30 days. We hypothesized a 30% reduction in the incidence of pneumonia.

RESULTS

Among 1493 randomized patients, 1439 completed the trial. Pneumonia occurred in 36/746 patients (4.9%) in the L-bupivacaine group and in 42/739 patients (5.7%) in the placebo group (absolute risk difference taking into account center and baseline risk of postoperative pneumonia, - 1.3% [95% CI - 3.4; 0.8] P = 0.22). In the predefined subgroup of patients at high risk, L-bupivacaine decreased the incidence of pneumonia (absolute risk difference, - 5.6% [95% CI - 10.0; - 1.1], P = 0.01).

CONCLUSIONS

After cardiac surgery with sternotomy, continuous wound infusion of L-bupivacaine failed to decrease the incidence of pneumonia. These findings do not support the use of local anesthetic continuous wound infusion in this indication. Further study should investigate its effect in high-risk patients.

TRIAL REGISTRATION

EudraCT Number: 2011-003292-10; Clinicaltrials.gov Identifier: NCT01648777.

Effect of Acupressure on Pain Severity in Patients Undergoing Coronary Artery Graft: A Randomized Controlled Trial

Background

Considering the contradictory results on the role of complementary therapies in correcting post-operative side effects, the aim of this study was to evaluate the effect of acupressure on pain severity in patients undergoing coronary artery graft admitted to a coronary care unit.

Methods

In this double-blind, randomized, clinical trial, 70 patients were selected randomly after coronary artery bypass grafting (CABG) surgery based on inclusion criteria and then assigned to two groups (35 in acupressure and 35 in control) randomly by the minimization method. The intervention group received acupressure at the LI4 point for 20 minutes in 10-second pressure and 2-second resting periods. In the control group, only touching was applied without any pressure in the same pattern as the intervention group. Pain severity was measured before, immediately, and 20 minutes after applying pressure and touch in both groups using the visual analogue scale.

Results

The results of repeated measures analysis of variance (ANOVA) showed a decrease in the pain score in the intervention group (group effect) during multiple measurements (time effect) and a reduction in the mean pain score in the various measurements taking into account the groups (the interaction between time and group; P = 0.001).

Conclusions

Acupressure can be used as a complementary and alternative therapeutic approach to relieve post-operative pain in CABG patients.

Post-Operative Pain and Comfort in Children After Heart Surgery: A Comparison of Nurses and Families Pre-operative Expectations

PURPOSE

Parents' and nurses' expectations about pain control and comfort in children after heart surgery were explored to contribute to evidence-based family-centered interventions.

DESIGN AND METHODS

20 nurses and 23 parents from a tertiary pediatric center in the Pacific Northwest, were interviewed about their expectations of children's pain control and comfort experience in the hospital after heart surgery. In this descriptive study, data were collected from semi-structured recall interviews and analyzed using content analysis.

RESULTS

Most parents expected their child be medicated at a level of not feeling any pain. Many expected their child to remain in a heavily sedated state after the surgery. A few parents did not know what to expect. In contrast, nurses expected children to have controlled pain with intermittent discomfort, yet, tolerating recovery activities.

CONCLUSIONS

Although both parents and nurses expect to partner in the comfort care of the child, there is variation on the expectations around the nurse-parent relationship and the operational definition of pain management and comfort.

PRACTICE IMPLICATIONS

Awareness of parents' expectations about pediatric post-operative comfort present an opportunity for the development of interventions aimed to enhance alignment of nurse and family strategies for children after heart surgery. Pre-operative preparation for families specific to post-operative recovery and pain management of children hospitalized for heart surgery is needed.

Bilateral sternal infusion of ropivacaine and length of stay in ICU after cardiac surgery with increased respiratory risk: A randomised controlled trial

BACKGROUND

The continuous bilateral infusion of a local anaesthetic solution around the sternotomy wound (bilateral sternal) is an innovative technique for reducing pain after sternotomy.

OBJECTIVE

To assess the effects of the technique on the need for intensive care in cardiac patients at increased risk of respiratory complications.

DESIGN

Randomised, observer-blind controlled trial.

SETTING

Single centre, French University Hospital.

PATIENTS

In total, 120 adults scheduled for open-heart surgery, with one of the following conditions: age more than 75 years, BMI >30 kg m, chronic obstructive pulmonary disease, active smoking habit.

INTERVENTION

Either a bilateral sternal infusion of 0.2% ropivacaine (3 ml h through each catheter; 'intervention' group), or standardised care only ('control' group). Analgesia was provided with paracetamol and self-administered intravenous morphine.

MAIN OUTCOME MEASURES

The length of time to readiness for discharge from ICU, blindly assessed by a committee of experts.

RESULTS

No effect was found between groups for the primary outcome (P = 0.680, intention to treat); the median values were 42.4 and 37.7 h, respectively for the control and intervention groups (P = 0.873). Similar nonsignificant trends were noted for other postoperative delays. Significant effects favouring the intervention were noted for dynamic pain, patient satisfaction, occurrence of nausea and vomiting, occurrence of delirium or mental confusion and occurrence of pulmonary complications. In 12 patients, although no symptoms actually occurred, the total ropivacaine plasma level exceeded the lowest value for which neurological symptoms have been observed in healthy volunteers.

CONCLUSION

Because of a small size effect, and despite significant analgesic effects, this strategy failed to reduce the time spent in ICU.

TRIAL REGISTRATION

EudraCT (N°: 2012-005225-69); ClinicalTrials.gov (NCT01828788).

Acupuncture for chronic pain: an update and critical overview

PURPOSE OF REVIEW

Acupuncture is now recommended for several chronic pain conditions. Despite supportive evidence of its effectiveness, this ancient approach is often misunderstood, and may still be underused in mainstream practice. A critical review on its effectiveness and practice integration, and mechanisms of action is essential to the medical community that is continuing to seek nonopioid therapies for chronic pain.

RECENT FINDINGS

Mounting evidence supports the effectiveness of acupuncture to treat chronic low back, neck, shoulder, and knee pain, as well as headaches. Additional data are emerging that support the use of acupuncture as an adjunct or alternative to opioids, and in perioperative settings. Findings related to its mechanisms of action include transient receptor potential cation channel vanilloid 1 activation in the periphery, microglial suppression in the cerebral cortex and spinal cord, and regulation of cytokines and other key inflammatory factors in the spinal cord. Incremental integration of acupuncture into pain medicine practices and training programmes continues to grow.

SUMMARY

Acupuncture is effective, safe, and cost-effective for treating several chronic pain conditions when performed by well-trained healthcare professionals. Further studies on its use as an adjunct or alternative to opioids, and in perioperative settings are needed.

Continuous PECS II block for postoperative analgesia in patients undergoing transapical transcatheter aortic valve implantation

It has been reported that PECS II block can alleviate postoperative pain following transapical transcatheter aortic valve implantation (TA-TAVI). However, the effectiveness of continuous PECS II block with catheterization has not yet been reported on the postoperative pain in patients undergoing TA-TAVI. We experienced two cases of TA-TAVI who received PECS II block with catheterization to manage postoperative pain. In the first case, a bolus injection for intraoperative pain and subsequent catheterization were performed before the implantation. However, the patient developed severe pain postoperatively in spite of the continuous block due to displacement of the catheter. In the second case, a bolus injection and the catheterization for the continuous block were performed before and after the implantation, respectively, which provided high-quality pain control. Continuous PECS II block may be useful to control perioperative pain associated with TA-TAVI. The insertion of the catheter after the implantation could be useful to avoid its displacement during the surgery.

Chronic stress moderates the impact of social exclusion on pain tolerance: an experimental investigation

BACKGROUND

Experiences of social pain due to social exclusion may be processed in similar neural systems that process experiences of physical pain. The present study aimed to extend the findings on social exclusion and pain by examining the impact of social exclusion on an affective (ie, heat pain tolerance) and a sensory component of pain (ie, heat pain intensity). Whether a potential effect may be moderated by chronic life stress, social status, or social sup-port was further examined.

MATERIALS AND METHODS

A community-based sample of 59 women was studied. Social exclusion and inclusion were experimentally manipulated by using a virtual ball-tossing game called Cyberball in which participants were randomly assigned to either being excluded or being included by two other virtual players. Heat pain tolerance and intensity were assessed before and after the game. Potential psychosocial moderators were assessed via a questionnaire.

RESULTS

The main finding of this study is that chronic stress moderates the impact of social exclusion on pain tolerance (p<0.05). When chronic stress was high, socially excluded participants showed a lower heat pain tolerance than participants who were socially included. Contrary to the authors' hypothesis, pain sensitivity was increased in socially included participants compared with socially excluded participants after the game (p<0.05).

CONCLUSION

Higher levels of chronic stress may enhance the vulnerability of affective pain processing to acute social exclusion.