Enhanced Recovery After Surgery for Cardiac Surgery: Will We Have the Techniques Needed to Reduce Opioid Use and Still Provide Appropriate Analgesia?

Jellish, W. Scott; Oftadeh, Mina

doi:10.1053/j.jvca.2018.10.022

Cited by 10 publications

(12 citation statements)

References 14 publications

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“…42 Multimodal analgesics have often been combined with targeted regional anesthetic techniques to reduce opioid requirements, enhance pain control, and potentially reduce systemic analgesics and their accompanying side effects including delirium, hypotension, bradycardia, bleeding, and sedation. 43 Neuraxial anesthesia serves as one regional technique that may be considered in cardiac surgery via thoracic epidural analgesia (TEA) or spinal anesthesia. 16,43,44 TEA has been shown to provide effective analgesia with decreased VAS scoring and reduced opioid consumption postoperatively, 16,27 yet no evidence supports a definitive decrease in developing chronic pain following TEA or intrathecal opioid administration.…”

Section: Rationale For Opioid-sparing Techniquesmentioning

confidence: 99%

“…43 Neuraxial anesthesia serves as one regional technique that may be considered in cardiac surgery via thoracic epidural analgesia (TEA) or spinal anesthesia. 16,43,44 TEA has been shown to provide effective analgesia with decreased VAS scoring and reduced opioid consumption postoperatively, 16,27 yet no evidence supports a definitive decrease in developing chronic pain following TEA or intrathecal opioid administration. 27 The risk of spinal hematoma has historically been shown to be 1:1528 for TEA and 1:3610 for spinal anesthesia, 45 but the risk for TEA has more recently been shown to be as low as 1:3552.…”

Section: Rationale For Opioid-sparing Techniquesmentioning

confidence: 99%

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Persistent Pain After Cardiac Surgery: Prevention and Management

Hallman

Smeltz

2021

Semin Cardiothorac Vasc Anesth

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Persistent postoperative pain (PPP) after cardiac surgery is a significant complication that negatively affects patient quality of life and increases health care system burden. However, there are no standards or guidelines to inform how to mitigate these effects. Therefore, in this review, we will discuss strategies to prevent and manage PPP after cardiac surgery. Adequate perioperative analgesia may prove instrumental in the prevention of PPP. Although opioids have historically been the primary analgesic approach to cardiac surgery, an opioid-sparing strategy may prove advantageous in reducing side effects, avoiding secondary hyperalgesia, and decreasing risk of PPP. Implementing a multimodal analgesic plan using alternative medications and regional anesthetic techniques may offer superior efficacy while reducing adverse effects.

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Section: Rationale For Opioid-sparing Techniquesmentioning

confidence: 99%

Section: Rationale For Opioid-sparing Techniquesmentioning

confidence: 99%

Persistent Pain After Cardiac Surgery: Prevention and Management

Hallman

Smeltz

2021

Semin Cardiothorac Vasc Anesth

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“…With the increasing popularity of enhanced recovery after surgery programmes, the use of regional anaesthesia continues to expand. 1 In cardiac surgery, however, traditional regional anaesthesia techniques such as thoracic epidural anaesthesia or paravertebral thoracic blocks are not routinely implemented in postoperative pain protocols due to the concerns of perioperative heparinisation and the resulting risk of a spinal or epidural haematoma. 2 Furthermore, many cardiac surgery patients are under antiplatelet therapy, which represents another contraindication for these neuraxial anaesthesia techniques.…”

Section: Introductionmentioning

confidence: 99%

Erector spinae plane block for minimally invasive mitral valve surgery: a double-blind, prospective, randomised placebo-controlled trial—a study protocol

et al. 2021

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IntroductionIn the context of enhanced recovery after cardiac surgery, surgical techniques for mitral valve surgery have witnessed substantial modifications, from approaching the heart using open approaches with traditional sternotomy to thoracoscopic access via minithoracotomy. After cardiac surgery, acute postoperative pain is frequent and caused by surgical incision and retraction. Perioperative analgesia in cardiac surgery still relies mainly on opioids. Although neuraxial techniques could be a valuable non-opioid-based analgesia regimen, they can be associated with devastating complications in situations with (iatrogenic) coagulation abnormalities. Only two randomised clinical trials describe the erector spinae plane (ESP) block to provide sufficient postoperative analgesia following cardiac surgery with median sternotomy. Regarding postoperative analgesia after cardiac surgery with a minithoracotomy approach, adequately designed trials are still lacking. We, therefore, designed a double-blind, placebo-controlled trial to prove the hypothesis that the ESP block reduces opioid consumption in patients undergoing minimally invasive mitral valve surgery (MIMVS).Methods and analysisSixty-four patients undergoing MIMVS will be included in this double-blind, prospective, placebo-controlled trial. Patients will be randomised to receive an ESP block with a catheter with either intermittent ropivacaine 0.5% (ropi group) or normal saline 0.9% (placebo group). Both groups will receive patient-controlled intravenous analgesia with morphine following extubation. Primary endpoint is the 24-hour cumulative morphine consumption after extubation. Multiple secondary endpoints will be evaluated.Ethics and disseminationThe study is approved by the ethics committee of the University Hospitals Leuven, the Clinical Trials Centre of the University Hospitals Leuven and the ‘Federaal Agentschap voor Geneesmiddelen en Gezondheidsproducten’. Dissemination of the study results will be via scientific papers.Trial registration numberEudraCT identifier: 2019-001125-27.

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“…Several studies have examined its opioid-sparing effects in the perioperative context, which has led some to advocate for its inclusion as part of an enhanced recovery after cardiac surgery protocol. 2,3 The current body of literature regarding ketamine's use as a perioperative analgesic agent is a mixed bag of specific formulation (racemic mixture v S-enantiomer only), surgical intervention, dosing protocol (bolus, infusion, or bolus followed by infusion), and dosing regimen. Perhaps unsurprisingly, this has led to mixed results.…”

mentioning

confidence: 99%