Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2

Abstract

Patients after cardiac surgery experience moderate to severe pain in the immediate postoperative period as a result of surgical interventions, such as incision, sternotomy, sternal retraction, pericardiotomy, tissue dissection, and the presence of chest tubes. 1 Poorly controlled acute pain increases suffering, cardiovascular stress, and respiratory complications and may develop into persistent postoperative pain, which adversely affects patients' daily activities, psychological well-being, and quality of life. 2

In Response

“…The diagnosis of generalized peritonitis is primarily established based on the patient's symptoms, physical examination, and abdominal imaging, rather than relying on intraoperative findings. 2,3 Furthermore, the literature does not support the contention that laparoscopy increases the rate of diagnosis of peritonitis in complicated appendicitis. 4,5 Missing a diagnosis of generalized peritonitis could have led to higher rates of septic complications in Colombia compared to the United States.…”

“…In Response W e thank Drs Magoon and Jose 1 for their interest and comments related to our recent "Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients" (practice advisory). 2 We do acknowledge the value of standardized regional analgesia nomenclature established by the American Society of Regional Anesthesia and Pain Medicine and European Society of Regional Anaesthesia and Pain Therapy (ASRA-ESRA) in 2021. 3 We chose not to use this nomenclature because (1) the advisory design process was developed and initiated before publication of the ASRA-ESRA 2021 nomenclature and (2) many of the studies referenced in the advisory did not use the ASRA-ESRA 2021 nomenclature and were performed before the ASRA-ESRA publication.…”

Perioperative Pain Management in Cardiac Surgery: Learning More From the Experts

“…The practice advisory by Makkad et al 1 provides useful recommendations for perioperative pain management in cardiac surgery. Discussing other pertinent aspects may provide further insight into this evolving subject.…”

“…2 Its use may be appropriate to the scope of the practice advisory. 1,2 Second, the advisory rightfully points towards persistent postoperative pain in patients undergoing coronary artery bypass using internal mammary artery (IMA) graft, 1 and the need for effective yet safe parasternal regional analgesia in cardiac surgery cannot be underestimated. In this context, it would be helpful to investigate the comparative risk of deep and superficial parasternal intercostal plane blocks, since the initial experiences hint at a higher risk of IMA-pleural injury with transversus thoracis muscle plane block compared to pecto-intercostal fascial block.…”

“…In this context, it would be helpful to investigate the comparative risk of deep and superficial parasternal intercostal plane blocks, since the initial experiences hint at a higher risk of IMA-pleural injury with transversus thoracis muscle plane block compared to pecto-intercostal fascial block. 1–3 Finally, it would be equally opportune to know of the experts’ feedback on the role of rectus sheath blocks for subxiphoid drain-related pain in the cardiac surgical subset, with the goal of multimodal analgesic regimes in this cohort to be carefully formulated to cater to a peculiarly multifactorial postoperative pain. 1,4,5…”