Pub Date : 2022-03-01Epub Date: 2021-09-02DOI: 10.1177/10892532211043313
David J Douin, Martin Krause, Cynthia Williams, Kenji Tanabe, Ana Fernandez-Bustamante, Aurora N Quaye, Adit A Ginde, Karsten Bartels
Objective: Recent clinical trials confirmed the corticosteroid dexamethasone as an effective treatment for patients with COVID-19 requiring mechanical ventilation. However, limited attention has been given to potential adverse effects of corticosteroid therapy. The objective of this study was to determine the association between corticosteroid administration and impaired glycemic control among COVID-19 patients requiring mechanical ventilation and/or veno-venous extracorporeal membrane oxygenation.
Design: Multicenter retrospective cohort study between March 9 and May 17, 2020. The primary outcome was days spent with at least 1 episode of blood glucose either >180 mg/dL or <80 mg/dL within the first 28 days of admission.
Setting: Twelve hospitals in a United States health system.
Measurements and main results: We included 292 mechanically ventilated patients. We fitted a quantile regression model to assess the association between steroid administration ≥320 mg methylprednisolone (equivalent to 60 mg dexamethasone) and impaired glycemic control. Sixty-six patients (22.6%) died within 28 days of intensive care unit admission. Seventy-one patients (24.3%) received a cumulative dose of least 320 mg methylprednisolone equivalents. After adjustment for gender, history of diabetes mellitus, chronic liver disease, sequential organ failure assessment score on intensive care unit day 1, and length of stay, administration of ≥320 mg methylprednisolone equivalent was associated with 4 additional days spent with glucose either <80 mg/dL or >180 mg/dL (B = 4.00, 95% CI = 2.15-5.85, P < .001).
Conclusions: In this cohort study of 292 mechanically ventilated COVID-19 patients, we found an association between corticosteroid administration and higher incidence of both hyperglycemia and hypoglycemia.
目的:最近的临床试验证实皮质类固醇地塞米松是治疗COVID-19需要机械通气患者的有效方法。然而,对皮质类固醇治疗的潜在不良反应的关注有限。本研究的目的是确定在需要机械通气和/或静脉-静脉体外膜氧合的COVID-19患者中皮质类固醇给药与血糖控制受损之间的关系。设计:2020年3月9日至5月17日之间的多中心回顾性队列研究。主要终点是至少1次血糖≥180mg /dL的天数,或设定:美国卫生系统的12家医院。患者:确诊为COVID-19的成年人,需要有创机械通气和/或静脉-静脉体外膜氧合。干预措施:没有。测量方法及主要结果:纳入292例机械通气患者。我们拟合了一个分位数回归模型来评估类固醇给药≥320 mg甲基强的松龙(相当于60 mg地塞米松)与血糖控制受损之间的关系。66例(22.6%)患者在重症监护病房入住28天内死亡。71名患者(24.3%)接受了至少320 mg甲基强的松龙当量的累积剂量。在调整性别、糖尿病史、慢性肝病、重症监护病房第1天序性器官衰竭评估评分和住院时间后,给药≥320 mg甲基强龙当量与额外4天葡萄糖≥180 mg/dL相关(B = 4.00, 95% CI = 2.15-5.85, P < 0.001)。结论:在这项对292例机械通气的COVID-19患者的队列研究中,我们发现皮质类固醇给药与高血糖和低血糖的高发生率之间存在关联。
{"title":"Corticosteroid Administration and Impaired Glycemic Control in Mechanically Ventilated COVID-19 Patients.","authors":"David J Douin, Martin Krause, Cynthia Williams, Kenji Tanabe, Ana Fernandez-Bustamante, Aurora N Quaye, Adit A Ginde, Karsten Bartels","doi":"10.1177/10892532211043313","DOIUrl":"https://doi.org/10.1177/10892532211043313","url":null,"abstract":"<p><strong>Objective: </strong>Recent clinical trials confirmed the corticosteroid dexamethasone as an effective treatment for patients with COVID-19 requiring mechanical ventilation. However, limited attention has been given to potential adverse effects of corticosteroid therapy. The objective of this study was to determine the association between corticosteroid administration and impaired glycemic control among COVID-19 patients requiring mechanical ventilation and/or veno-venous extracorporeal membrane oxygenation.</p><p><strong>Design: </strong>Multicenter retrospective cohort study between March 9 and May 17, 2020. The primary outcome was days spent with at least 1 episode of blood glucose either >180 mg/dL or <80 mg/dL within the first 28 days of admission.</p><p><strong>Setting: </strong>Twelve hospitals in a United States health system.</p><p><strong>Patients: </strong>Adults diagnosed with COVID-19 requiring invasive mechanical ventilation and/or veno-venous extracorporeal membrane oxygenation.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We included 292 mechanically ventilated patients. We fitted a quantile regression model to assess the association between steroid administration ≥320 mg methylprednisolone (equivalent to 60 mg dexamethasone) and impaired glycemic control. Sixty-six patients (22.6%) died within 28 days of intensive care unit admission. Seventy-one patients (24.3%) received a cumulative dose of least 320 mg methylprednisolone equivalents. After adjustment for gender, history of diabetes mellitus, chronic liver disease, sequential organ failure assessment score on intensive care unit day 1, and length of stay, administration of ≥320 mg methylprednisolone equivalent was associated with 4 additional days spent with glucose either <80 mg/dL or >180 mg/dL (B = 4.00, 95% CI = 2.15-5.85, <i>P</i> < .001).</p><p><strong>Conclusions: </strong>In this cohort study of 292 mechanically ventilated COVID-19 patients, we found an association between corticosteroid administration and higher incidence of both hyperglycemia and hypoglycemia.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"26 1","pages":"32-40"},"PeriodicalIF":1.4,"publicationDate":"2022-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8927893/pdf/10.1177_10892532211043313.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39374958","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-03-01Epub Date: 2022-02-12DOI: 10.1177/10892532221076655
Benjamin Abrams, Markus Kowalsky, Nathaen Weitzel, Miklos D Kertai
Specialists in cardiothoracic and abdominal transplant anesthesia offer unique expertise and a vast breadth of knowledge that contribute to the management of these notably complex patients. Furthermore, these contributions extend beyond intraoperative management, to include leadership throughout the perioperative period, critical care medicine, and even global health. This issue of Seminars in Cardiothoracic and Vascular Anesthesia highlights this broad spectrum of expertise through original research, review articles, and case reports, spanning topics as diverse as airway management, coagulopathy, pediatric heart failure, echocardiography, and educational milestones for fellowship training for abdominal transplant. In the first article of the Original Research section, Auci et al present a retrospective, single-center, observational trial evaluating the optimal time to assess platelet dysfunction during cardiac surgery through the use of platelet aggregometry. In this trial of 63 patients, they utilized an adenosine-50-diphosphate (ADP)-test to compare platelet function at four separate time periods (baseline, aortic declamping, 10 minutes after protamine administration, and end of surgery). There were statistically significant differences in ADP-test results between almost all time periods, with one notable exception: aortic de-clamping vs 10 minutes following protamine. Clinically, this study demonstrates potential value in early identification of platelet dysfunction through assessment at the time of aortic de-clamping, thus allowing timely recognition and thus more effective treatment of platelet impairment following cardiopulmonary bypass (CPB). Anesthesiologists play an essential role for teams performing congenital cardiac surgery in resource-poor conditions throughout the world. To better characterize this work with the goal of improving participation and directing resources, Hubbard et al surveyed members of the Congenital Cardiac Anesthesia Society (CCAS). Survey participants (n = 108) reported 115 total trips to 41 countries spanning 5 continents. The survey covered a broad range of topics, including the nature of the work, trends in geographic locations, and factors that may influence an anesthesiologist’s participation in these efforts. Notably, many of the barriers that interested individuals reported facing stemmed from a lack of institutional support. Not surprisingly, there was also a sharp decline in participation for the year 2020 due to pandemicrelated factors, generating a backlog of cases and further expanding the need for participation in this work in the years to come. With the understanding of dexamethasone’s benefits in treating severe COVID-19 infections, Douin et al performed a multicenter retrospective cohort study to investigate the association between corticosteroid administration and impaired glycemic control in critically ill COVID-19 patients. The study included 292 patients from 12 centers in the United States w
{"title":"Cardiac Anesthesiology - Paving the Way across Multiple Subspecialties.","authors":"Benjamin Abrams, Markus Kowalsky, Nathaen Weitzel, Miklos D Kertai","doi":"10.1177/10892532221076655","DOIUrl":"https://doi.org/10.1177/10892532221076655","url":null,"abstract":"Specialists in cardiothoracic and abdominal transplant anesthesia offer unique expertise and a vast breadth of knowledge that contribute to the management of these notably complex patients. Furthermore, these contributions extend beyond intraoperative management, to include leadership throughout the perioperative period, critical care medicine, and even global health. This issue of Seminars in Cardiothoracic and Vascular Anesthesia highlights this broad spectrum of expertise through original research, review articles, and case reports, spanning topics as diverse as airway management, coagulopathy, pediatric heart failure, echocardiography, and educational milestones for fellowship training for abdominal transplant. In the first article of the Original Research section, Auci et al present a retrospective, single-center, observational trial evaluating the optimal time to assess platelet dysfunction during cardiac surgery through the use of platelet aggregometry. In this trial of 63 patients, they utilized an adenosine-50-diphosphate (ADP)-test to compare platelet function at four separate time periods (baseline, aortic declamping, 10 minutes after protamine administration, and end of surgery). There were statistically significant differences in ADP-test results between almost all time periods, with one notable exception: aortic de-clamping vs 10 minutes following protamine. Clinically, this study demonstrates potential value in early identification of platelet dysfunction through assessment at the time of aortic de-clamping, thus allowing timely recognition and thus more effective treatment of platelet impairment following cardiopulmonary bypass (CPB). Anesthesiologists play an essential role for teams performing congenital cardiac surgery in resource-poor conditions throughout the world. To better characterize this work with the goal of improving participation and directing resources, Hubbard et al surveyed members of the Congenital Cardiac Anesthesia Society (CCAS). Survey participants (n = 108) reported 115 total trips to 41 countries spanning 5 continents. The survey covered a broad range of topics, including the nature of the work, trends in geographic locations, and factors that may influence an anesthesiologist’s participation in these efforts. Notably, many of the barriers that interested individuals reported facing stemmed from a lack of institutional support. Not surprisingly, there was also a sharp decline in participation for the year 2020 due to pandemicrelated factors, generating a backlog of cases and further expanding the need for participation in this work in the years to come. With the understanding of dexamethasone’s benefits in treating severe COVID-19 infections, Douin et al performed a multicenter retrospective cohort study to investigate the association between corticosteroid administration and impaired glycemic control in critically ill COVID-19 patients. The study included 292 patients from 12 centers in the United States w","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"26 1","pages":"5-7"},"PeriodicalIF":1.4,"publicationDate":"2022-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39914027","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-03-01Epub Date: 2021-12-10DOI: 10.1177/10892532211059885
Melissa L McKittrick, Frederick W Lombard
A bedridden patient with empyema presented for thoracoscopic decortication. During the procedure, despite a post-tetanic count (PTC) of 0 via calibrated quantitative neuromuscular monitoring, persistent diaphragmatic movement impaired operating conditions, so rocuronium was re-dosed. After surgery, the patient had 0 PTC. Sugammadex was titrated to achieve baseline neuromuscular strength, monitoring the effect of each 200-mg dose. Ultimately, 1200 mg was required to achieve baseline strength. We describe monitor troubleshooting, considerations with unexpectedly deep neuromuscular blockade, the importance of routine quantitative neuromuscular monitoring, and one strategy for sugammadex reversal in patients with profound paralysis outside of the standard dosing guidelines.
{"title":"Unanticipated Profound Paralysis and Sugammadex Dosing Implications After Videoscopic Thoracic Surgery.","authors":"Melissa L McKittrick, Frederick W Lombard","doi":"10.1177/10892532211059885","DOIUrl":"https://doi.org/10.1177/10892532211059885","url":null,"abstract":"<p><p>A bedridden patient with empyema presented for thoracoscopic decortication. During the procedure, despite a post-tetanic count (PTC) of 0 via calibrated quantitative neuromuscular monitoring, persistent diaphragmatic movement impaired operating conditions, so rocuronium was re-dosed. After surgery, the patient had 0 PTC. Sugammadex was titrated to achieve baseline neuromuscular strength, monitoring the effect of each 200-mg dose. Ultimately, 1200 mg was required to achieve baseline strength. We describe monitor troubleshooting, considerations with unexpectedly deep neuromuscular blockade, the importance of routine quantitative neuromuscular monitoring, and one strategy for sugammadex reversal in patients with profound paralysis outside of the standard dosing guidelines.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"26 1","pages":"86-89"},"PeriodicalIF":1.4,"publicationDate":"2022-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39800998","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-12-01Epub Date: 2021-11-17DOI: 10.1177/10892532211058494
Kathirvel Subramaniam, Ibrahim Sultan, Nathaen Weitzel, Miklos D Kertai
Opioids are reliable and effective analgesics for treating acute postoperative pain following any surgical procedure, including cardiac surgery. Recent concerns about persistent opioid use after discharge from the hospital have triggered changes in the way patients’ pain is managed during their perioperative period. This has led to the widespread use of various regional analgesic techniques, as well as anesthesia techniques based on non-narcotic analgesics for cardiac surgery. Multi-modal analgesia has been an accepted component of enhanced recovery after surgery (ERAS) protocols and implementation of ERAS in cardiac surgery has been shown to decrease opioid consumption, duration of mechanical ventilation, and length of intensive care unit and hospital stay. Seminars in Cardiothoracic and Vascular Anesthesia (SCVA) invited submissions related to painmanagement after cardiac surgery and published a series of impressive articles dedicated to this important topic for the December issue. Devarajan et al explored evidence behind the use of various neuraxial and non-neuraxial regional analgesic techniques in a two-part review. It is clear that epidural blocks will not be re-entering the cardiac surgical arena because of concerns over epidural hematoma, despite their advantages. However, spinal opioids are making a comeback, with renewed interest in their clinical use and research for ERAS protocols. Tissue plane blocks (erector spinae block, pecto-intercostal block, and transverse thoracic plane block) are becoming popular, as they can be administered easily with ultrasound guidance and have been found to be safe compared to central neuraxial blocks in cardiac surgery. In this issue of SCVA, two original articles are published on the use of these tissue plane blocks in cardiothoracic surgery. Cardinale et al studied transverse thoracic plane blocks in elective cardiac surgery along with multimodal analgesia. The authors reported increased early extubations and shortened length of intensive care unit and hospital stay. Dunham et al published on the utility of intercostal nerve blocks with standard and liposomal bupivacaine in thoracic surgical patients. While these studies add evidence to support the incorporation of these blocks into clinical practice, there is a need for large, well-controlled, and randomized clinical studies with meaningful patient outcomes before perioperative physicians can declare victory and adopt them into a new standard of care. The use of various non–opioid-based analgesics (ketamine, dexmedetomidine, lidocaine, acetaminophen, ketorolac, and gabapentin) in cardiac surgery is another topic of debate. Nazarnia et al reviewed and reported the evidence behind the use of non–opioid-based analgesics in cardiac surgery practice. While the cardiac anesthesia community has widely adopted the use of these medications as alternatives to opioids, the review pointed out the lack of clear evidence supporting the efficacy and safety of many
{"title":"Is It Time for Paradigm Shift in Pain Management for Cardiac Surgery Patients?","authors":"Kathirvel Subramaniam, Ibrahim Sultan, Nathaen Weitzel, Miklos D Kertai","doi":"10.1177/10892532211058494","DOIUrl":"https://doi.org/10.1177/10892532211058494","url":null,"abstract":"Opioids are reliable and effective analgesics for treating acute postoperative pain following any surgical procedure, including cardiac surgery. Recent concerns about persistent opioid use after discharge from the hospital have triggered changes in the way patients’ pain is managed during their perioperative period. This has led to the widespread use of various regional analgesic techniques, as well as anesthesia techniques based on non-narcotic analgesics for cardiac surgery. Multi-modal analgesia has been an accepted component of enhanced recovery after surgery (ERAS) protocols and implementation of ERAS in cardiac surgery has been shown to decrease opioid consumption, duration of mechanical ventilation, and length of intensive care unit and hospital stay. Seminars in Cardiothoracic and Vascular Anesthesia (SCVA) invited submissions related to painmanagement after cardiac surgery and published a series of impressive articles dedicated to this important topic for the December issue. Devarajan et al explored evidence behind the use of various neuraxial and non-neuraxial regional analgesic techniques in a two-part review. It is clear that epidural blocks will not be re-entering the cardiac surgical arena because of concerns over epidural hematoma, despite their advantages. However, spinal opioids are making a comeback, with renewed interest in their clinical use and research for ERAS protocols. Tissue plane blocks (erector spinae block, pecto-intercostal block, and transverse thoracic plane block) are becoming popular, as they can be administered easily with ultrasound guidance and have been found to be safe compared to central neuraxial blocks in cardiac surgery. In this issue of SCVA, two original articles are published on the use of these tissue plane blocks in cardiothoracic surgery. Cardinale et al studied transverse thoracic plane blocks in elective cardiac surgery along with multimodal analgesia. The authors reported increased early extubations and shortened length of intensive care unit and hospital stay. Dunham et al published on the utility of intercostal nerve blocks with standard and liposomal bupivacaine in thoracic surgical patients. While these studies add evidence to support the incorporation of these blocks into clinical practice, there is a need for large, well-controlled, and randomized clinical studies with meaningful patient outcomes before perioperative physicians can declare victory and adopt them into a new standard of care. The use of various non–opioid-based analgesics (ketamine, dexmedetomidine, lidocaine, acetaminophen, ketorolac, and gabapentin) in cardiac surgery is another topic of debate. Nazarnia et al reviewed and reported the evidence behind the use of non–opioid-based analgesics in cardiac surgery practice. While the cardiac anesthesia community has widely adopted the use of these medications as alternatives to opioids, the review pointed out the lack of clear evidence supporting the efficacy and safety of many ","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"249-251"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39721110","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-12-01Epub Date: 2021-06-23DOI: 10.1177/10892532211023337
Jagan Devarajan, Sennaraj Balasubramanian, Soheyla Nazarnia, Charles Lin, Kathirvel Subramaniam
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.
{"title":"Regional Analgesia for Cardiac Surgery Part 1. Current status of neuraxial and paravertebral blocks for adult cardiac surgery.","authors":"Jagan Devarajan, Sennaraj Balasubramanian, Soheyla Nazarnia, Charles Lin, Kathirvel Subramaniam","doi":"10.1177/10892532211023337","DOIUrl":"https://doi.org/10.1177/10892532211023337","url":null,"abstract":"<p><p>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.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"252-264"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10892532211023337","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39119214","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-12-01Epub Date: 2021-08-20DOI: 10.1177/10892532211041320
James C Krakowski, Matthew J Hallman, Alan M Smeltz
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.
{"title":"Persistent Pain After Cardiac Surgery: Prevention and Management.","authors":"James C Krakowski, Matthew J Hallman, Alan M Smeltz","doi":"10.1177/10892532211041320","DOIUrl":"https://doi.org/10.1177/10892532211041320","url":null,"abstract":"<p><p>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.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"289-300"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8669213/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39330455","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-12-01Epub Date: 2020-09-09DOI: 10.1177/1089253220957484
Jeffrey P Cardinale, Ryan Latimer, Candace Curtis, Yana Bukovskaya, Logan Kosarek, Jason Falterman, Danielle M Tatum, Jay Trusheim
Background: The aim for early extubation remains an important goal in cardiac surgical patients. Therefore, employment of a multimodal approach to pain management that includes a transverse thoracic plane block was retrospectively examined at a single-center tertiary care hospital on the effects of time to extubation, opioid consumption, and length of stay in patients undergoing cardiac surgery via median sternotomy.
Methods: Blocks were performed on all cardiac surgical patients except for those undergoing left ventricular assist device placement, thoracic transplant, emergent surgery, or redo sternotomy. Following additional exclusions for intra- and postoperative complications unrelated to anesthesia, final analysis was conducted on 75 patients per group. Multimodal pain management included intravenous analgesics and transverse thoracic plane block where patients received 15 mL 0.5% bupivacaine + epinephrine bilaterally under ultrasound guidance prior to incision.
Results: Following transverse thoracic plane block and multimodal analgesics, 50.6% of patients were extubated in the operation room versus 8.6% in the control group. Intraoperative opioids were decreased, and intensive care unit and total length of stay were reduced by 5 hours and 1 day, respectively, in block patients as compared with controls. Postoperative opioids were not significantly different. There were no reported complications directly attributed to the block.
Conclusions: The transverse thoracic plane block and multimodal regimen for patients undergoing median sternotomy resulted in a significant number of patients extubated in the operation room without an increase in postoperative re-intubations. Moreover, the block appears to be a quick and safe procedure to utilize on cardiac surgery patients.
背景:早期拔管仍然是心脏外科患者的一个重要目标。因此,我们在一家单中心三级医院对拔管时间、阿片类药物使用和胸骨正中切开术心脏手术患者住院时间的影响进行了回顾性研究,其中包括胸椎横切面阻滞。方法:除了接受左心室辅助装置放置、胸腔移植、紧急手术或重做胸骨切开术的患者外,对所有心脏手术患者进行阻滞。在排除与麻醉无关的内、术后并发症后,每组对75例患者进行最终分析。多模式疼痛管理包括静脉镇痛和胸横平面阻滞,患者在切口前超声引导下双侧接受15 mL 0.5%布比卡因+肾上腺素。结果:经胸横平面阻滞加多模式镇痛后,50.6%的患者在手术室拔管,对照组为8.6%。与对照组相比,阻滞患者术中阿片类药物减少,重症监护病房和总住院时间分别减少了5小时和1天。术后阿片类药物无明显差异。没有直接归因于阻滞的并发症报道。结论:胸骨正中切开术患者采用胸横平面阻滞和多模式方案,术后拔管人数显著增加,且术后再插管次数未增加。此外,阻滞似乎是一种快速和安全的程序,用于心脏手术患者。
{"title":"Incorporation of the Transverse Thoracic Plane Block Into a Multimodal Early Extubation Protocol for Cardiac Surgical Patients.","authors":"Jeffrey P Cardinale, Ryan Latimer, Candace Curtis, Yana Bukovskaya, Logan Kosarek, Jason Falterman, Danielle M Tatum, Jay Trusheim","doi":"10.1177/1089253220957484","DOIUrl":"https://doi.org/10.1177/1089253220957484","url":null,"abstract":"<p><strong>Background: </strong>The aim for early extubation remains an important goal in cardiac surgical patients. Therefore, employment of a multimodal approach to pain management that includes a transverse thoracic plane block was retrospectively examined at a single-center tertiary care hospital on the effects of time to extubation, opioid consumption, and length of stay in patients undergoing cardiac surgery via median sternotomy.</p><p><strong>Methods: </strong>Blocks were performed on all cardiac surgical patients except for those undergoing left ventricular assist device placement, thoracic transplant, emergent surgery, or redo sternotomy. Following additional exclusions for intra- and postoperative complications unrelated to anesthesia, final analysis was conducted on 75 patients per group. Multimodal pain management included intravenous analgesics and transverse thoracic plane block where patients received 15 mL 0.5% bupivacaine + epinephrine bilaterally under ultrasound guidance prior to incision.</p><p><strong>Results: </strong>Following transverse thoracic plane block and multimodal analgesics, 50.6% of patients were extubated in the operation room versus 8.6% in the control group. Intraoperative opioids were decreased, and intensive care unit and total length of stay were reduced by 5 hours and 1 day, respectively, in block patients as compared with controls. Postoperative opioids were not significantly different. There were no reported complications directly attributed to the block.</p><p><strong>Conclusions: </strong>The transverse thoracic plane block and multimodal regimen for patients undergoing median sternotomy resulted in a significant number of patients extubated in the operation room without an increase in postoperative re-intubations. Moreover, the block appears to be a quick and safe procedure to utilize on cardiac surgery patients.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"301-309"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1089253220957484","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38361082","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-12-01DOI: 10.1177/10892532211065082
{"title":"Corrigendum to \"Current Status of Neuraxial and Paravertebral Blocks for Adult Cardiac Surgery\".","authors":"","doi":"10.1177/10892532211065082","DOIUrl":"https://doi.org/10.1177/10892532211065082","url":null,"abstract":"","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"324"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39577810","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-12-01Epub Date: 2020-08-17DOI: 10.1177/1089253220949434
Wills C Dunham, Frederick W Lombard, David A Edwards, Yaping Shi, Matthew S Shotwell, Kara Siegrist, Susan S Eagle, Mias Pretorius, Matthew D McEvoy, Erin A Gillaspie, Jonathan C Nesbitt, Jonathan P Wanderer, Miklos D Kertai
Background: We examined how intercostal nerve block (ICNB) with standard bupivacaine and ICNB with extended-release liposomal bupivacaine, compared with thoracic epidural analgesia (TEA), were associated with postoperative opioid pain medication consumption and hospital length of stay (LOS) after thoracic surgery.
Methods: We studied 1935 patients who underwent thoracic surgery between January 1, 2010, and November 30, 2017, at a tertiary academic center. Primary and secondary outcomes were postoperative opioid consumption expressed as morphine milligram equivalents (MMEs) at 24, 48, and 72 hours after surgery, the LOS, and total MME consumption from surgery to discharge.
Results: Of these patients, 888 (45.9%) received TEA, 730 (37.7%) ICNB with standard bupivacaine, 127 (6.6%) ICNB with liposomal bupivacaine, and 190 (9.8%) no regional analgesia. Compared with epidural analgesia, in 2017, ICNB liposomal bupivacaine provided similar pain control in terms of MME consumption at 24 and 72 hours, but decreased MME consumption at 48 hours (odds ratio [OR] = 0.33; confidence interval [CI] = 0.14-0.81) and at discharge (OR = 0.28; CI = 0.12-0.68) and was associated with a higher likelihood for a shorter LOS (hazard ratio = 3.46; CI = 2.42-4.96). Compared with TEA, ICNB with standard bupivacaine and no regional analgesia use showed varying impact on MME consumption between 24 and 72 hours after surgery, and their use was not associated with a significantly reduced MME consumption at discharge but with a shorter hospital LOS.
Conclusions: Multimodal analgesia involving regional anesthetic alternatives to TEA could help manage postoperative pain in thoracic surgery patients.
{"title":"Effect of Regional Analgesia Techniques on Opioid Consumption and Length of Stay After Thoracic Surgery.","authors":"Wills C Dunham, Frederick W Lombard, David A Edwards, Yaping Shi, Matthew S Shotwell, Kara Siegrist, Susan S Eagle, Mias Pretorius, Matthew D McEvoy, Erin A Gillaspie, Jonathan C Nesbitt, Jonathan P Wanderer, Miklos D Kertai","doi":"10.1177/1089253220949434","DOIUrl":"https://doi.org/10.1177/1089253220949434","url":null,"abstract":"<p><strong>Background: </strong>We examined how intercostal nerve block (ICNB) with standard bupivacaine and ICNB with extended-release liposomal bupivacaine, compared with thoracic epidural analgesia (TEA), were associated with postoperative opioid pain medication consumption and hospital length of stay (LOS) after thoracic surgery.</p><p><strong>Methods: </strong>We studied 1935 patients who underwent thoracic surgery between January 1, 2010, and November 30, 2017, at a tertiary academic center. Primary and secondary outcomes were postoperative opioid consumption expressed as morphine milligram equivalents (MMEs) at 24, 48, and 72 hours after surgery, the LOS, and total MME consumption from surgery to discharge.</p><p><strong>Results: </strong>Of these patients, 888 (45.9%) received TEA, 730 (37.7%) ICNB with standard bupivacaine, 127 (6.6%) ICNB with liposomal bupivacaine, and 190 (9.8%) no regional analgesia. Compared with epidural analgesia, in 2017, ICNB liposomal bupivacaine provided similar pain control in terms of MME consumption at 24 and 72 hours, but decreased MME consumption at 48 hours (odds ratio [OR] = 0.33; confidence interval [CI] = 0.14-0.81) and at discharge (OR = 0.28; CI = 0.12-0.68) and was associated with a higher likelihood for a shorter LOS (hazard ratio = 3.46; CI = 2.42-4.96). Compared with TEA, ICNB with standard bupivacaine and no regional analgesia use showed varying impact on MME consumption between 24 and 72 hours after surgery, and their use was not associated with a significantly reduced MME consumption at discharge but with a shorter hospital LOS.</p><p><strong>Conclusions: </strong>Multimodal analgesia involving regional anesthetic alternatives to TEA could help manage postoperative pain in thoracic surgery patients.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"310-323"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1089253220949434","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"38489764","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-12-01Epub Date: 2021-04-08DOI: 10.1177/10892532211002382
Jagan Devarajan, Sennaraj Balasubramanian, Ali N Shariat, Himani V Bhatt
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.
{"title":"Regional Analgesia for Cardiac Surgery. Part 2: Peripheral Regional Analgesia for Cardiac Surgery.","authors":"Jagan Devarajan, Sennaraj Balasubramanian, Ali N Shariat, Himani V Bhatt","doi":"10.1177/10892532211002382","DOIUrl":"https://doi.org/10.1177/10892532211002382","url":null,"abstract":"<p><p>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.</p>","PeriodicalId":46500,"journal":{"name":"Seminars in Cardiothoracic and Vascular Anesthesia","volume":"25 4","pages":"265-279"},"PeriodicalIF":1.4,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10892532211002382","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"25567747","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}