Regional Analgesia for Cardiac Surgery. Part 2: Peripheral Regional Analgesia for Cardiac Surgery

The introduction of regional analgesia in the past decades have revolutionized postoperative pain management for various types of surgery, particularly orthopedic surgery. Nowadays, they are being constantly introduced into other types of surgeries including cardiac surgeries. Neuraxial and paravertebral plexus blocks for cardiac surgery are considered as deep blocks and have the risk of hematoma formation in the setting of anticoagulation associated with cardiac surgeries. Moreover, hemodynamic compromise resulting from sympathectomy in patients with limited cardiac reserve further limits the use of neuraxial techniques. A multitude of fascial plane blocks involving chest wall have been developed, which have been shown the potential to be included in the regional analgesia armamentarium for cardiac surgery. In myofascial plane blocks, the local anesthetic spreads passively and targets the intermediate and terminal branches of intercostal nerves. They are useful as important adjuncts for providing analgesia and are likely to be included in “Enhanced Recovery after Cardiac Surgery (ERACS)” protocols. There are several small studies and case reports that have shown efficacy of the regional blocks in reducing opioid requirements and improving patient satisfaction. This review article discusses the anatomy of various fascial plane blocks, mechanism of their efficacy, and available evidence on outcomes after cardiac surgery.

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Current Status of Neuraxial and Paravertebral Blocks for Adult Cardiac Surgery

Seminars in Cardiothoracic and Vascular Anesthesia ◽

10.1177/10892532211023337 ◽

2021 ◽

pp. 108925322110233

Author(s):

Jagan Devarajan ◽

Sennaraj Balasubramanian ◽

Soheyla Nazarnia ◽

Charles Lin ◽

Kathirvel Subramaniam

Keyword(s):

Cardiac Surgery ◽

Enhanced Recovery ◽

Unit Length ◽

Pulmonary Complications ◽

Current Status ◽

Regional Analgesia ◽

Nerve Blocks ◽

Prolonged Intubation ◽

Fast Tracking ◽

Fascial Plane

Cardiac surgeries are known to produce moderate to severe pain. Pain management has traditionally been based on intravenous opioids. Poorly controlled pain can result in increased incidence of respiratory complications such as atelectasis and pneumonia leading to prolonged intubation and intensive care unit length of stay and subsequent prolonged hospital stay. Adequate perioperative analgesia improves hemodynamics and immunologic responses, which would result in better outcomes after cardiac surgery. Opioid sparing “Enhanced Recovery After Surgery” protocols are increasingly being incorporated into cardiac surgeries. This will reduce opioid requirements and opioid-related side effects and facilitate fast-tracking of patients. Regional analgesia can be provided by neuraxial blocks, fascial plane blocks, peripheral nerve blocks, or simply by the infiltration of the wound with local anesthetics for cardiac surgery. Neuraxial analgesia is provided through epidural, spinal, and paravertebral routes. Though they are being replaced by peripheral fascial plane blocks, epidural and spinal analgesia are still being used in some centers. In this article, neuraxial forms of analgesia are focused. We sought to review epidural analgesia and its impact in suppressing hemodynamic stress response, reducing pulmonary complications, and development of chronic pain. The relationship between intraoperative heparinization and potential neuraxial hematoma is discussed. Other neuraxial options such as spinal and paravertebral analgesia and their usefulness, benefits, and limitations are also reviewed.

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Nonopioid Analgesics in Postoperative Pain Management After Cardiac Surgery

Seminars in Cardiothoracic and Vascular Anesthesia ◽

10.1177/1089253221998552 ◽

2021 ◽

pp. 108925322199855

Author(s):

Soheyla Nazarnia ◽

Kathirvel Subramaniam

Keyword(s):

Cardiac Surgery ◽

Postoperative Pain ◽

Randomized Clinical Trials ◽

Postoperative Pain Management ◽

Multimodal Analgesia ◽

Opioid Use ◽

Regional Analgesia ◽

Beneficial Effects ◽

Recovery Profile ◽

Standard Of Practice

Opioid analgesia is still considered the standard of practice for cardiac surgery. In recent years, combinations of several nonnarcotic analgesics and regional analgesia have shown promise in restricting opioid use during and after cardiac surgery. Ketamine infusion, dexmedetomidine infusion, acetaminophen, ketorolac, and gabapentin are useful adjuvants in cardiac anesthesia practice and have opioid-sparing properties. The beneficial effects of nonnarcotic multimodal analgesia on intraoperative stress response, recovery profile, postoperative pain, and persistent opioid use after cardiac surgery are yet to be established, and further randomized clinical trials are required.

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The role of regional analgesia in personalized postoperative pain management

Korean Journal of Anesthesiology ◽

10.4097/kja.20323 ◽

2020 ◽

Vol 73 (5) ◽

pp. 363-371 ◽

Cited By ~ 2

Author(s):

Shruti S. Chitnis ◽

Raymond Tang ◽

Edward R. Mariano

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Regional Anesthesia ◽

Nerve Block ◽

Enhanced Recovery ◽

Postoperative Pain Management ◽

Multimodal Analgesia ◽

Regional Analgesia ◽

Perioperative Pain Management ◽

Personalized Approach

Pain management plays a fundamental role in enhanced recovery after surgery pathways. The concept of multimodal analgesia in providing a balanced and effective approach to perioperative pain management is widely accepted and practiced, with regional anesthesia playing a pivotal role. Nerve block techniques can be utilized to achieve the goals of enhanced recovery, whether it be the resolution of ileus or time to mobilization. However, the recent expansion in the number and types of nerve block approaches can be daunting for general anesthesiologists. Which is the most appropriate regional technique to choose, and what skills and infrastructure are required for its implementation? A multidisciplinary team-based approach for defining the goals is essential, based on each patient's needs, and incorporating patient, surgical, and social factors. This review provides a framework for a personalized approach to postoperative pain management with an emphasis on regional anesthesia techniques.

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Partial Adrenal Suppression with Prolonged Use of Depo-Provera

Journal of Clinical and Health Sciences ◽

10.24191/jchs.v4i1.7284 ◽

2019 ◽

Vol 4 (1) ◽

pp. 64

Author(s):

Nur Aisyah Zainordin ◽

Fatimah Zaherah Mohamed Shah ◽

Rohana Abdul Ghani

Keyword(s):

Weight Gain ◽

Medroxyprogesterone Acetate ◽

Side Effect ◽

Case Reports ◽

Adrenal Incidentaloma ◽

Adrenal Suppression ◽

Private Pharmacy ◽

Significant Weight Gain ◽

The Past ◽

Depo Provera

A 49-year old patient presented with symptoms of adrenal suppression following an attempt to withdraw Depo-Provera or Depot Medroxyprogesterone Acetate (DMPA) injection. She had been receiving DMPA injections for the past 16 years for contraception. She was initially prescribed DMPA by her gynaecologist but later on began obtaining the medication directly from a private pharmacy without prior consultation from her gynaecologist. Clinically, she had been experiencing significant weight gain and appeared cushingoid. Blood investigations confirmed partial adrenal suppression with presence of an adrenal incidentaloma. This case reports a known side effect of DMPA but occurring at a much lower dose than previously described. It also highlights the need to increase the awareness of the insidious side effect of DMPA and to avoid unsupervised use of the drug.

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Digital Glomus Tumor: Bibliographic Review of the Studies Published over the Past 10 Years

Revista Iberoamericana de Cirugía de la Mano ◽

10.1055/s-0041-1730392 ◽

2021 ◽

Vol 49 (01) ◽

pp. 046-055

Author(s):

Victoria Hernández ◽

Tania Lena ◽

Eliana Camacho ◽

Matías Craviotto

Keyword(s):

Glomus Tumor ◽

Case Reports ◽

Low Frequency ◽

Benign Neoplasm ◽

Surgical Excision ◽

Soft Tissue Tumors ◽

Glomus Tumors ◽

The Past ◽

Pubmed Search ◽

Magnetic Resonance Imaging Mri

AbstractGlomus tumors are a mostly benign neoplasm that constitutes less than 4% of upper-limb soft-tissue tumors. Its unspecific clinical presentation, added to its low frequency, leads to a late diagnosis.The objective of the present study is to update the clinical-paraclinical approach and the surgical technique used in the treatment.We carried out a literature review from 2014 to 2019 on digital glomus tumor in the hand in adult patients using the PubMed search engine.In most of the publications analyzed, the diagnosis was clinical, with a delay of 1 to 10 years. Plain radiography is the most requested study; of the 16 articles reporting its indication, only half evidenced compatible changes. Magnetic resonance imaging (MRI) was requested in 15 articles, presenting normal results in 3 of them. The treatment of choice was surgical excision using a transungual approach. Only 4 articles report recurrence after excision.Although there is diversity in the approach to these tumors, we conclude that the diagnosis is clinical, and the treatment surgical, and there is no consensus regarding the paraclinical indication. The information available comes mainly from case reports, publications that contribute to the generation of evidence for the clinical practice in rare diseases such as this one.

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Expert Consensus of Data Elements for Collection for Enhanced Recovery After Cardiac Surgery

World Journal of Surgery ◽

10.1007/s00268-021-05964-1 ◽

2021 ◽

Cited By ~ 1

Author(s):

Sameer A. Hirji ◽

Rawn Salenger ◽

Edward M. Boyle ◽

Judson Williams ◽

V. Seenu Reddy ◽

...

Keyword(s):

Cardiac Surgery ◽

Enhanced Recovery ◽

Expert Consensus ◽

Data Elements

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Results from an enhanced recovery program for cardiac surgery

Journal of Thoracic and Cardiovascular Surgery ◽

10.1016/j.jtcvs.2019.05.035 ◽

2020 ◽

Vol 159 (4) ◽

pp. 1393-1402.e7 ◽

Cited By ~ 12

Author(s):

Michael C. Grant ◽

Tetsuro Isada ◽

Pavel Ruzankin ◽

Glenn Whitman ◽

Jennifer S. Lawton ◽

...

Keyword(s):

Cardiac Surgery ◽

Enhanced Recovery ◽

Enhanced Recovery Program ◽

Recovery Program

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Enhanced Recovery for Cardiac Surgery

Journal of Cardiothoracic and Vascular Anesthesia ◽

10.1053/j.jvca.2018.01.045 ◽

2018 ◽

Vol 32 (6) ◽

pp. 2760-2770 ◽

Cited By ~ 43

Author(s):

Christopher Noss ◽

Christopher Prusinkiewicz ◽

Gregg Nelson ◽

Prakash A. Patel ◽

John G. Augoustides ◽

...

Keyword(s):

Cardiac Surgery ◽

Enhanced Recovery

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Advances in Antiplatelet Therapy for Dentofacial Surgery Patients: Focus on Past and Present Strategies

Materials ◽

10.3390/ma12091524 ◽

2019 ◽

Vol 12 (9) ◽

pp. 1524 ◽

Cited By ~ 16

Author(s):

Gabriele Cervino ◽

Luca Fiorillo ◽

Ines Paola Monte ◽

Rosa De Stefano ◽

Luigi Laino ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Oral Surgery ◽

Case Reports ◽

Case Series ◽

Antiplatelet Agents ◽

Preventive Therapy ◽

Antiplatelet Drugs ◽

Risk Of Bleeding ◽

The Past ◽

Increased Risk

Background: Nowadays, patients involved in antiplatelet therapy required special attention during oral surgery procedures, due to the antiplatelet drugs assumption. The motivations of the assumption may be different and related to the patient’s different systemic condition. For this reason, accordingly to the current international guidelines, different protocols can be followed. The aim of this work is to analyze how the dentist’s approach to these patients has changed from the past to the present, evaluating the risk exposure for the patients. Methods: This review paper considered different published papers in literature through quoted scientific channels, going in search of “ancient” works in such a way as to highlight the differences in the protocols undertaken. The analyzed manuscripts are in the English language, taking into consideration reviews, case reports, and case series in such a way as to extrapolate a sufficient amount of data and for evaluating the past therapeutic approaches compared to those of today. Results: Colleagues in the past preferred to subject patients to substitution therapy with low molecular weight anticoagulants, by suspending antiplatelet agents to treatment patients, often for an arbitrary number of days. The new guidelines clarify everything, without highlighting an increased risk of bleeding during simple oral surgery in patients undergoing antiplatelet therapy. Conclusion: Either patients take these medications for different reasons, because of cardiovascular pathologies, recent cardiovascular events, or even for simple prevention, although the latest research shows that there is no decrease of cardiovascular accidents in patients who carry out preventive therapy. Surely, it will be at the expense of the doctor to assess the patient’s situation and risk according to the guidelines. For simple oral surgery, it is not necessary to stop therapy with antiplatelet agents because the risk of bleeding has not increased, and is localized to a post-extraction alveolus or to an implant preparation, compared to patients who do not carry out this therapy. From an analysis of the results it emerges that the substitutive therapy should no longer be performed and that it is possible to perform oral surgery safely in patients who take antiplatelet drugs, after a thorough medical history. Furthermore, by suspending therapy, we expose our patients to more serious risks, concerning their main pathology, where present.

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