Efficacy of non-pharmacological interventions in pain relief and opioid consumption after cardiac surgery: A systematic review and Bayesian network meta-analysis

Enhanced Recovery After Surgery (ERAS) cardiac turnkey order set for perioperative pain management in cardiac surgery: Proceedings from the American Association for Thoracic Surgery (AATS) ERAS Conclave 2023

Objective

Optimal perioperative pain management is an essential component of perioperative care for the cardiac surgical patient. This turnkey order set is part of a series created by the Enhanced Recovery After Surgery Cardiac Society, first presented at the Annual Meeting of The American Association for Thoracic Surgery in 2023. Several guidelines and expert consensus documents have been published to provide guidance on pain management and opioid reduction in cardiac surgery. Our objective is to consolidate that guidance into an evidence-based order set that will assist in the implementation of a comprehensive multimodal approach to pain management.

Methods

Subject matter experts were consulted to translate existing guidelines and peer-reviewed literature into a sample turnkey order set for pain management. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the order set in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type.

Results

Opioid-based analgesia is associated with delayed recovery and opioid-related adverse events. Several multimodal medications have been shown to reduce reliance upon opioids. These include the scheduled use of acetaminophen, gabapentinoids, and nonsteroidal anti-inflammatory drugs. In addition, intravenous analgesics such as dexmedetomidine, ketamine, magnesium, and lidocaine have been shown to both complement the maintenance of anesthesia as well as optimize pain control postoperatively. Long-acting opioids remain a key component of pain management when provided to reduce the overall use of short-acting synthetic opioids or in direct response to break though pain after exhausting other alternatives. When applied in a bundled fashion, several studies have demonstrated a reduction in overall opioid administration and improved rates of postoperative recovery.

Conclusions

There has been increased awareness regarding the potential short- and long-term adverse effects of both inadequate analgesia and excessive opioid administration after cardiac surgery. This turnkey order set aims to facilitate implementation of a comprehensive approach toward provision of multimodal, opioid-sparing medications to optimize pain management in cardiac surgery.

Effects of Footbath on Pain, Anxiety, Sleep, and Comfort Levels in Patients With Postlaparoscopic Cholecystectomy: A Randomized Controlled Study

PURPOSE

The aim of the study is to determine the effect of of hot footbaths on the pain, anxiety, sleep, and comfort levels of patients who underwent laparoscopic cholecystectomy.

DESIGN

The study is a randomized controlled designed.

METHODS

This study was conducted in surgery clinic of a university hospital between January 2022 and November 2022. The research was completed with 54 patients in the experimental group and 54 patients in the control group.

FINDINGS

The mean state anxiety score and VAS-Sleep score of the patients in the experimental group 120 minutes after the application was 31.07±4.70 and 612.62±82.37, respectively, which was statistically significantly lower than that of the patients in the control group ( P <0.05). On the other hand, at the 120th minutes after the application, the mean VAS-Comfort scores of the patients in the experimental group were statistically significantly higher than those of the patients in the control group ( P <0.05). A positive relationship was found between the mean VAS-Pain and VAS-Sleep scores of the patients in the experimental group, and a significant negative relationship was found between the mean VAS-Comfort and state anxiety scores.

CONCLUSIONS

Foot bath is effective in reducing the pain and anxiety levels of patients undergoing laparoscopic cholecystectomy surgery.

Efficacy of perioperative pain management in paediatric cardiac surgery: a protocol for a network meta-analysis

INTRODUCTION

Congenital heart disease is a common birth defect, but advancements in diagnosis and treatment have improved survival rates. Enhanced recovery after surgery (ERAS) programmes have emerged in paediatric cardiac surgery. Multimodal pain management, as a vital part of ERAS programmes, has been found to be effective in reducing pain and improving outcomes in cardiac surgery patients. Traditional methods of pain control using high-dose opioids can lead to complications, so nonopioid analgesics and regional anaesthesia techniques are being used to reduce the consumption. However, there is a significant variability in pain management practices in paediatric cardiac surgery. A network meta-analysis (NMA) is needed to comprehensively compare the effects of different analgesic interventions in this population.

METHODS AND ANALYSIS

A comprehensive electronic literature database search will be performed using electronic databases, mainly including PubMed, EMBASE, Web of Science and Cochrane Central Register of Controlled Trials. All randomised controlled trials associated with perioperative pain management for paediatric cardiac surgery will be included. The primary outcome will be visual analogue score or numeric rating scale of pain and total opioid consumption (or equivalent) 24 hours after postoperative tracheal extubation. The Revised Cochrane Risk of Bias Tool will be employed to assess the quality of included articles. A random-effects pairwise meta-analysis will be performed to report the head-to-head comparison. Following the assessment of individual articles, an NMA will be conducted using a Bayesian framework with random-effects' models.

ETHICS AND DISSEMINATION

Ethics approval is not necessary because this study will be based on publications. The results of this study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023477520.

Evidence-based interventions to improve sleep quality after thoracic surgery:A retrospective analysis of clinical studies

OBJECTIVE

To investigate and rank the evidence for the efficacy of interventions in improving sleep quality after cardiac surgery using comprehensive comparisons.

BACKGROUND

Clinical evidence suggests that over 80 % of adult cardiac surgery patients experience sleep disturbances during the first week postoperatively. While certain interventions have been shown to improve post-thoracic surgery sleep quality, a systematic description of the effects of these varied interventions is lacking.

METHODS

This systematic search was conducted across PubMed, Web of Science, Cochrane, Embase, and CINAHL databases to collate all published randomized clinical trials as evidence. Two researchers independently extracted pertinent information from eligible trials and assessed the quality of included studies. Based on statistical heterogeneity, traditional meta-analysis using fixed or random-effects models was employed to assess the efficacy of interventions, and a Frequentist network meta-analysis using a consistency model was conducted to rank the effectiveness of intervention protocols.

RESULTS

Our review incorporated 37 articles (n = 3569), encompassing 46 interventions, including 9 reports on pharmacological interventions (24.3 %), 28 on non-pharmacological interventions (75.7 %), and 5 on anesthetic management interventions (13.5 %). The analysis indicated the efficacy of Benson's relaxation technique, Progressive muscle relaxation, Education, Aromatherapy, Acupressure, Massage, and Eye masks in enhancing postoperative sleep quality. Specifically, Benson's relaxation technique (cumulative ranking curve area: 0.80; probability: 98.3 %) and Acupressure (cumulative ranking curve area: 0.96; probability: 58.3 %) were associated with the highest probability of successfully improving postoperative sleep quality, while Progressive muscle relaxation (cumulative ranking curve area: 0.70; probability: 35.2 %) and Eye masks (cumulative ranking curve area: 0.81; probability: 78.8 %) were considered secondary options. Eye masks and Massage significantly reduced postoperative sleep latency, with Eye masks (cumulative ranking curve area: 0.82; probability: 51.0 %) being most likely to enhance sleep quality postoperatively, followed by Massage (cumulative ranking curve area: 0.60; probability: 27.2 %). Education, Music, Massage, Eye masks, and Handholding were effective in alleviating pain intensity, with Education being most likely to successfully reduce postoperative pain (cumulative ranking curve area: 0.92; probability: 54.3 %), followed by Music (cumulative ranking curve area: 0.91; probability: 54 %).

CONCLUSIONS

Our findings can be utilized to optimize strategies for managing post-thoracic surgery sleep disturbances and to develop evidence-based approaches for this purpose. Benson's relaxation technique, Progressive muscle relaxation, Education, Aromatherapy, Acupressure, Massage, and Eye masks significantly improve sleep quality in postoperative patients. KEY: disorders of initiating and maintaining sleep, sleep wake disorders, thoracic surgical procedures, cardiac surgical procedures, sleep quality, pain, network meta-analysis.

Effectiveness of non-pharmacological interventions in improving sleep quality after cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Sleep disturbance is highly prevalent among post-operative cardiac patients, with negative impacts on surgical recovery and rehabilitation. Post-operative pain and anxiety commonly seen in cardiac surgery patients are associated with poor sleep. Sleep medications commonly used are not ideal with prolonged usage, and non-pharmacological interventions can be good alternatives or complements.

AIM

To examine effectiveness of non-pharmacological interventions in post-operative cardiac settings on sleep quality, pain intensity and anxiety.

DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, CENTRAL, Embase, CINAHL, Scopus, CNKI and ProQuest Dissertations and Theses were searched on 12 October 2022. Randomised controlled trials of non-pharmacological interventions examining sleep quality for adult post-operative cardiac patients were included. Included studies were appraised using Cochrane Risk of Bias tool version 1. Meta-analysis was conducted using RevMan version 5.4.1, and heterogeneity was assessed using I2 statistics and Cochran Q's test.

RESULTS

Eighteen studies involving 1701 participants were identified. Coronary artery bypass graft was most common. Non-pharmacological interventions varied in types and duration. All intervention groups were compared to usual care, placebo, no interventions or active comparators. Statistically significant improvement in sleep quality (SMD = -.91, 95% CI = -1.17 to -.65) was found among intervention groups that explored cognitive behavioural therapy, relaxation techniques, exercise, massage, acupressure, aromatherapy, music, eye mask and earplugs. Pain intensity was reduced (SMD = -.63, 95% CI = -1.05 to -.20) with cognitive behavioural therapy, relaxation techniques, massage, music and eye mask. Anxiety was improved (SMD = -.21, 95% CI = -.38 to -.04) with exercise and music.

CONCLUSION

The overall use of non-pharmacological interventions can optimise sleep after cardiac surgery. Further research with greater methodological rigour is needed to investigate different intervention-related characteristics while considering potential confounders.

RELEVANCE TO CLINICAL PRACTICE

Post-operative cardiac settings can consider incorporating non-pharmacological interventions. Patients and healthcare providers can be better informed about the use of such interventions to improve sleep.

REGISTRATION

PROSPERO CRD42022384991.

Non-pharmacological strategies to reduce stress and anxiety in endovascular procedures: A scoping review

AIM

This study aimed to identify and map the production of knowledge on non-pharmacological strategies to reduce stress and anxiety in patients undergoing endovascular procedures.

DESIGN

Scoping review.

METHODS

The review was performed using the PRISMA-ScR guidelines. The searches were conducted in Scopus, PubMed, Web of Science, Wiley Online Library, BVS/BIREME, Lilacs, Gale Academic OneFile, SciELO, Cochrane Library, CAPES Catalog of Dissertations and Theses, Oswaldo Cruz Foundation Portal of Theses and Dissertations, and Theses and Dissertations from Latin America.

RESULTS

Twenty-two articles were selected. The articles were published from 2001 to 2022, mostly in Iran, and there was a predominance of randomized clinical trials. The Spielberger State-Trait Anxiety Inventory was the most used instrument. The findings indicated that music therapy, educational guidelines or videos on the procedure, massage, psychological preparation and aromatherapy were the main non-pharmacological therapies used to reduce anxiety and stress in patients undergoing vascular procedures.