Evaluation of the Effect of New Multimodal Analgesia Regimen for Cardiac Surgery: A Prospective, Randomized Controlled, Single-Center Clinical Study [Response to Letter]
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SUBMITTER: Jin L
PROVIDER: S-EPMC10460160 | biostudies-literature | 2023 Jan
REPOSITORIES: biostudies-literature
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Project description:BackgroundTo evaluate if an opiate sparing multimodal regimen of dexamethasone, gabapentin, ibuprofen and paracetamol had better analgesic effect, less side effects and was safe compared to a traditional morphine and paracetamol regimen after cardiac surgery.MethodsOpen-label, prospective randomized controlled trial. 180 patients undergoing cardiac procedures through median sternotomy, were included in the period march 2007-August 2009. 151 patients were available for analysis. Pain was assessed with the 11-numeric rating scale (11-NRS).ResultsPatients in the multimodal group demonstrated significantly lower average pain scores from the day of surgery throughout the third postoperative day. Extensive nausea and vomiting, was found in no patient in the multimodal group but in 13 patients in the morphine group, p < 0.001. Postoperative rise in individual creatinine levels demonstrated a non-significant rise in the multimodal group, 33.0±53.4 vs. 19.9±48.5, p = 0.133. Patients in the multimodal group suffered less major in-hospital events in crude numbers: myocardial infarction (MI) (1 vs. 2, p = 0.54), stroke (0 vs. 3, p = 0.075), dialysis (1 vs. 2, p = 0.54), and gastrointestinal (GI) bleeding (0 vs. 1, p = 0.31). 30-day mortality was 1 vs. 2, p = 0.54.ConclusionsIn patients undergoing cardiac surgery, a multimodal regimen offered significantly better analgesia than a traditional opiate regimen. Nausea and vomiting complaints were significantly reduced. No safety issues were observed with the multimodal regimen.Trial registrationClinicaltrials.gov identifier: NCT01966172.
| S-EPMC3975463 | biostudies-literature
Project description:Intravenous patient-controlled analgesia (IV PCA; IVA) is the most widely used method for postoperative pain management. An appropriate IVA regimen is required, depending on the expected intensity of pain after surgery. This study expected that a decrease in the second prescription rate of IVA after elective cesarean section (CS) would help establish an appropriate regimen for the initial IVA. We retrospectively reviewed the records of 632 patients who were prescribed IVA after CS. We classified patients into phase 1 (basal rate 15.00 mcg/hours, bolus dose 15.00 mcg, total volume 100 mL) and phase 2 (basal rate 31.25 mcg/hours, bolus dose 31.25 mcg, nefopam 60 mg, paracetamol 3 g, total volume 160 mL) according to the IVA regimen, and patients in phase 2 were classified into the basal 15 group and basal 30 group according to the basal rate of IVA. We compared the rates of second prescription, drug removal, and side effects of IVA between the 2 phases and the 1 group. We analyzed the data of 631 eligible patients. The second prescription rate of IVA in phase 2 was 3.77%, a significant decrease compared to that in phase 1 (27.48%); however, the incidence of complications in phase 2 was 6.92%, a significant increase compared to that in phase 1 (0.96%). Within phase 2, in the basal 30 group, the basal rate was almost double that in the basal 15 group. However, there were no significant differences in the rate of second prescription, removed drug IVA, or adverse events between the basal 15, and 30 groups. In the case of CS, which has a high degree of postoperative pain, it is beneficial to control acute pain by properly setting the regimen of the initial IVA with a basal rate infusion to nullify a second prescription.
| S-EPMC10101246 | biostudies-literature
Project description:BackgroundSurgery can lead to curation in colorectal cancer (CRC) but is associated with significant morbidity. Prehabilitation plays an important role in increasing preoperative physical fitness to reduce morbidity risk; however, data from real-world practice is scarce. This study aimed to evaluate the change in preoperative physical fitness and to evaluate which patients benefit most from prehabilitation.Materials and methodsIn this single-arm prospective cohort study, consecutive patients undergoing elective colorectal oncological surgery were offered a 3- to 4-week multimodal prehabilitation program (supervised physical exercise training, dietary consultation, protein and vitamin supplementation, smoking cessation, and psychological support). The primary outcome was the change in preoperative aerobic fitness (steep ramp test (SRT)). Secondary outcomes were the change in functional walking capacity (6-minute walk test (6MWT)), and muscle strength (one-repetition maximum (1RM) for various muscle groups). To evaluate who benefit most from prehabilitation, participants were divided in quartiles (Q1, Q2, Q3, and Q4) based on baseline performance.ResultsIn total, 101 patients participated (51.4% male, aged 69.7 ± 12.7 years). The preoperative change in SRT was +28.3 W, +0.36 W/kg, +16.7% (P<0.001). Patients in all quartiles improved at the group level; however, the relative improvement decreased from Q1-Q2, Q2-Q3, and Q3-Q4 (P=0.049). Change in 6MWT was +37.5 m, +7.7% (P<0.001) and 1RM improved with 5.6-33.2 kg, 16.1-32.5% for the various muscle groups (P<0.001).ConclusionPrehabilitation in elective oncological colorectal surgery is associated with enhanced preoperative physical fitness regardless of baseline performance. Improvements were relatively larger in less fit patients.
| S-EPMC11332481 | biostudies-literature
Project description:Introduction: The aims of this study were to assess the concordance of different tools and to describe the accuracy of a multimodal approach to predict unfavorable neurological outcome (UO) in cardiac arrest patients. Methods: Retrospective study of adult (>18 years) cardiac arrest patients who underwent multimodal monitoring; UO was defined as cerebral performance category 3-5 at 3 months. Predictors of UO were neurological pupillary index (NPi) ≤ 2 at 24 h; highly malignant patterns on EEG (HMp) within 48 h; bilateral absence of N20 waves on somato-sensory evoked potentials; and neuron-specific enolase (NSE) > 75 μg/L. Time-dependent decisional tree (i.e., NPi on day 1; HMp on day 1-2; absent N20 on day 2-3; highest NSE) and classification and regression tree (CART) analysis were used to assess the prediction of UO. Results: Of 137 patients, 104 (73%) had UO. Abnormal NPi, HMp on day 1 or 2, the bilateral absence of N20 or NSE >75 mcg/L had a specificity of 100% to predict UO. The presence of abnormal NPi was highly concordant with HMp and high NSE, and absence of N20 or high NSE with HMp. However, HMp had weak to moderate concordance with other predictors. The time-dependent decisional tree approach identified 73/103 patients (70%) with UO, showing a sensitivity of 71% and a specificity of 100%. Using the CART approach, HMp on EEG was the only variable significantly associated with UO. Conclusions: This study suggests that patients with UO had often at least two predictors of UO, except for HMp. A multimodal time-dependent approach may be helpful in the prediction of UO after CA. EEG should be included in all multimodal prognostic models.
| S-EPMC8303816 | biostudies-literature
Project description:BackgroundMinimally invasive cardiac surgery (MICS) is increasingly performed due to faster recovery time and lower postoperative complications when compared with the traditional open surgery. However, hypoxemia in lung isolation duration after cardiopulmonary bypass (CPB) surgery has been the focus of anesthesiologists' attention. In the present study, we designed a novel lung isolation strategy to improve oxygenation using a bronchial blocker (BB) to isolate the right middle and lower lobes and preserve the ventilated right upper lobe without affecting the surgical field.MethodsPatients who had undergone right lateral mini-thoracotomy, a MICS, between August 2018 and February 2019, were enrolled in this randomized controlled study. Patients were randomly divided into a modified lung isolation group (group M) and a conventional lung isolation group (group C). In group M, BBs were used to block the bronchus intermedius, while left-sided double lumen endotracheal tubes were used in group C to isolate the right lung. The primary outcome was to determine the number of patients who required an increase in ventilation volume due to hypoxemia during lung isolation after CPB.ResultsSixty-one patients (30 in group C and 31 in group M) were enrolled. Five patients in group M were converted to right lung isolation due to poor surgical field exposure. During lung isolation after CPB, the number of patients with hypoxemia was lower in group M than group C (5/31 vs. 15/30, P=0.005).ConclusionsThe novel modified lung isolation strategy reduced the incidence of hypoxemia after CPB.
| S-EPMC7940934 | biostudies-literature
Project description:Enhanced recovery after surgery (ERAS) are specially designed multimodal perioperative care pathways which are intended to attain and improve rapid recovery after surgical interventions by supporting preoperative organ function and attenuating the stress response caused by surgical trauma, allowing patients to get back to normal activities as soon as possible. Evidence-based protocols are prepared and published to implement the conception of ERAS. Although they vary amongst health care institutions, the main three elements (preoperative, perioperative, and postoperative components) remain the cornerstones. Postoperative pain influences the quality and length of the postoperative recovery period, and later, the quality of life. Therefore, the optimal postoperative pain management (PPM) applying multimodal analgesia (MA) is one of the most important components of ERAS. The main purpose of this article is to discuss the concept of MA in PPM, particularly reviewing the use of opioid-sparing measures such as paracetamol, nonsteroid anti-inflammatory drugs (NSAIDs), other adjuvants, and regional techniques.
| S-EPMC6037254 | biostudies-other
Project description:IntroductionMore than 30 000 cardiac surgery procedures are performed in the UK each year, however, postoperative complications and long-term failure of interventions are common, leading to repeated surgeries. This represents a significant burden on the patient and health service.Routinely, patients are discharged to their general practitioner 6 weeks postoperatively and research studies typically only report short-term outcomes up to 1 year after surgery, together this makes long-term outcomes of cardiac surgery difficult to monitor. Further, traditional research methods have yet to advance understanding of what causes early complications and why surgical interventions fail.Methods and analysisThis prospective cohort study will characterise participants undergoing cardiac surgery at baseline, describe short-term, medium-term and long-term health outcomes postoperatively and collect tissue samples.All eligible adult patients undergoing cardiac surgery at the Bristol Heart Institute, UK will be approached for consent. Recruitment is expected to continue for up to 10 years resulting in the largest cohort of cardiac patients reported to date. Blood, urine and waste tissue samples will be collected during admission. Samples, along with anonymised data, will be used to investigate outcomes and inform predictive models of complications associated with cardiac surgery.Data about the surgical admission will be obtained from hospital databases and medical notes. Participants may be monitored up to 5 years postoperatively using data obtained from NHS digital. Participants will complete health questionnaires 3 months and 12 months postoperatively.The analysis of data and tissue samples to address specific research questions will require separate research protocols and ethical approval.Ethics and disseminationThis study was approved by the East Midlands Nottingham 2 Research Ethics Committee.Findings will be disseminated through peer-reviewed publications and presentation at national and international meetings. Participants will be informed of results in annual newsletters.Trial registration numberISRCTN90204321.
| S-EPMC9764648 | biostudies-literature
Project description:A multimodal analgesic method was known to avoid the high-dose requirements and dose-dependent adverse events of opioids, and to achieve synergistic effects. The purpose of this study was to compare the efficacy of our multimodal analgesia (MMA) regimen with that of the patient-controlled analgesia (PCA) method for acute postoperative pain management. Patients who underwent one or two-level posterior lumbar fusion (PLF) followed by either MMA or PCA administration at our hospital were compared for pain score, additional opioid and non-opioid consumption, side effects, length of hospital stay, cost of pain control, and patient satisfaction. From 2016 through 2017, a total 146 of patients were screened. After propensity score matching, 66 remained in the PCA and 34 in the MMA group. Compared with the PCA group, the MMA group had a shorter length of hospital stay (median (interquartile range): 7 days (5-8) vs. 8 (7-11); P = 0.001) and lower cost of pain control (70.6 ± 0.9 USD vs. 173.4 ± 3.3, P < 0.001). Baseline data, clinical characteristics, pain score, additional non-opioid consumption, side effects, and patient subjective satisfaction score were similar between the two groups. The MMA seems to be a good alternative to the PCA after one or two-level PLF.
| S-EPMC7230859 | biostudies-literature
Project description:BackgroundCardiac surgery is a technically demanding field with an appreciable learning curve that extends beyond formal training. Minimally invasive congenital cardiac surgery has one of the steepest learning curves. Early complications often discourage surgeons, particularly those at lower volume centers, from pursuing innovative approaches. Over the past three years, we have utilized a number of minimally invasive approaches including pulmonary valve replacement, anomalous aortic origin coronary artery repair, atrial septal defect repair, epicardial lead placement, and partial anomalous pulmonary venous return. Herein we report on our experience performing minimally invasive congenital cardiac surgery, lessons learned, and how our approach has evolved.MethodsWe performed a single institution, retrospective review, wherein continuous variables were reported as median (interquartile range).ResultsBetween September 2017 and May 2020, minimally invasive approaches were attempted on 49 patients with a median age of 19 years (14-47 years) for nine distinct congenital cardiac diagnoses. Seven patients (14%) required conversion to larger incisions, including four patients or 36% of those undergoing anomalous aortic origin of a coronary artery repair. Patients who were converted had a higher body mass index 33.1 (31.7-37.8) than those who were not (24.2, 20.8-29.3) (P=0.009).ConclusionsMinimally invasive approaches for congenital cardiac conditions require a team approach. Patients with a body mass index greater than 30 should be counseled on the higher rate of conversion. We no longer perform minimally invasive anomalous aortic origin of a coronary artery repair given the high rate of conversions and complications. Surgeons attempting this procedure should do so cautiously.
| S-EPMC8575860 | biostudies-literature
Project description:BackgroundCardiac surgery is a high-risk setting for heparin-induced thrombocytopenia (HIT). However, large differences in its incidence, rate of thrombotic complications, and mortality have been reported in this context. Few studies address the pharmacologic management of HIT specifically in this setting.ObjectivesTo describe the incidence, outcomes, and management of patients with HIT in our cohort and to compare them with patients presenting platelet factor 4/heparin antibodies but without platelet-activating capacity.MethodsA retrospective observational study was conducted over a period of 10 years and 6 months on 13,178 cardiac operations in a single high-volume cardiac surgery center.ResultsHIT was diagnosed in 0.22% of patients. HIT with associated thromboembolic complications occurred in 0.04% of cases. Two deaths at 30 days were registered, both in patients with associated thrombosis. The 4T score showed a 99.9% negative predictive value. The immunoglobulin G-specific chemiluminescence test positivity rate was highly predictive of HIT. Warfarin was often started early after surgery, and although it was rarely stopped when the diagnosis of HIT was made, no new thromboembolic complications subsequently occurred. Thrombocytopenia appeared to be a poor prognostic sign, whatever the cause.ConclusionAlthough rare, HIT is characterized by high mortality in this setting, especially if thrombotic complications occur. Large multicentric studies or an international registry should be created to enhance the scientific evidence on HIT diagnosis and management in this context.
| S-EPMC11260323 | biostudies-literature