Rev. Soc. Esp. Dolor. 2020; 27(1): 24-36 / DOI: 10.20986/resed.2020.3747/2019
Neus Esteve Pérez, Javier Iborra-Escalona, German Gómez-Romero, Cristina Sansaloni-Perelló, Antonia M Verger-Bennasar, Silvia Tejada-Gavela, María Riera-Sagrera, Luis Carlos Mora-Fernandez
ABSTRACT
Introduction: The intensity of postoperative moderate/intense pain after cardiac surgery (CC), varies according to the different studies, from 45 % to 85 %. There is no evidence about which is the optimal analgesic regimen in the postoperative period.
The main objective of this study is to evaluate the effectiveness of the application of a multimodal analgesic protocol, based on patient-controlled analgesia (PCA) with morphine, in patients undergoing cardiac surgery with extracorporeal circulation (ECC).
Patients and methods: Prospective observational study of all patients undergoing CS with ECC, during the first 3 days postoperatively. There were included 102 patients in two periods, first, in November 2016 with conventional analgesia and second, in January - February 2017 with PCA.
Results: The pain at rest was controlled (median numerical scale <3). An average of 27 % of moderate and intense pain was recorded. There was no difference in pain intensity between patients with CA and those with PCA. The PCA group required less rescue analgesia in the first postoperative days (63 % vs. 44 % p = 0.0487). The incidence of Post-surgical Chronic Pain was 39 % at three months, and 3 % at one year. There was a correlation between preoperative pain and anxiety with the intensity of the dynamic pain (r = 0.287, p = 0.03).
Conclusions: PCA with on-demand opioids and multimodal analgesia is an effective alternative after cardiac surgery. Good control of postoperative pain is obtained without increasing adverse effects, and requiring less rescue analgesia administered by the nursing staff.
RESUMEN
Introducción: La intensidad del dolor postoperatorio moderado-intenso después de una cirugía cardiaca (CC) varía, según los estudios, de un 45 a un 85 %. No existe evidencia sobre cuál es la pauta analgésica óptima en el postoperatorio de estos pacientes.
El objetivo de este estudio es evaluar la efectividad de la aplicación de un protocolo analgésico multimodal, basado en la analgesia controlada por el paciente (PCA) con morfina, en pacientes sometidos a CC con circulación extracorpórea (CEC).
Pacientes y métodos: Estudio prospectivo de todos los pacientes sometidos a CC con CEC, durante los primeros 3 días del postoperatorio (DPO). Se incluyeron 102 pacientes en dos periodos, noviembre de 2016, con analgesia convencional (AC) y enero-febrero de 2017 con PCA.
Resultados: El dolor en reposo se mantuvo controlado (mediana escala numérica < 3). Se registró un 27 % de pacientes con dolor moderado e intenso. No hubo diferencias en la intensidad del dolor entre los pacientes con AC y los de PCA. El grupo de PCA precisó menos analgesia de rescate (63 vs. 44 %, p = 0,0487). La incidencia de dolor crónico postquirúrgico fue de un 39 % a los tres meses y un 3 % al año. El dolor y la ansiedad preoperatorios se correlacionaron con la intensidad del dolor dinámico (r = 0,287, p = 0,03).
Conclusiones: La PCA con opioides a demanda y analgesia multimodal es una alternativa efectiva después de la CC. Se obtiene un buen control del dolor postoperatorio sin incrementar los efectos adversos y precisando menos analgesia de rescate administrada por enfermería.
Nuevo comentario
Comentarios
No comments in this article
Bibliografía
1. Kehlet H. Postoperative pain, analgesia, and recovery-bedfellows that cannot be ignored. Pain. 2018;159(Suppl 1):S11-S16.
2. Rawal N. Current issues in postoperative pain management. Eur J Anaesthesiol. 2016;33(3):160-71.
3. Gewandter JS, Dworkin RH, Turk DC, Farrar JT, Fillingim RB, Gilron I, et al. Research design considerations for chronic pain prevention clinical trials: IMMPACT recommendations. Pain. 2015;156(7):1184-97.
4. Peláez R, Hortal FJ, Riesgo M. Tratamiento del dolor postoperatorio en cirugía cardíaca. Rev Esp Anestesiol Reanim. 2002;49(9):474-84.
5. Rafiq S, Steinbrüchel DA, Wanscher MJ, Andersen LW, Navne A, Lilleoer NB, et al. Multimodal analgesia versus traditional opiate based analgesia after cardiac surgery, a randomized controlled trial. J Cardiothorac Surg. 2014;9:52.
6. Navarro MA, Irigoyen MI, De Carlos V, Martínez A, Elizondo A, Indurain S, et al. Evaluación del dolor postoperatorio agudo tras cirugía cardiaca. Enferm Intensiva. 2011;22(4):150-9.
7. Keawnantawat P, Thanasilp S, Preechawong S. Translation and Validation of the Thai Version of a Modified Brief Pain Inventory: A Concise Instrument for Pain Assessment in Postoperative Cardiac Surgery. Pain Pract. 2017;17(6):763-73.
8. Bjørnnes AK, Rustøen T, Lie I, Watt-Watson J, Leegaard M. Pain characteristics and analgesic intake before and following cardiac surgery. Eur J Cardiovasc Nurs. 2016;15(1):47-54.
9. Bignami E, Castella A, Pota V, Saglietti F, Scognamiglio A, Trumello C, et al. Perioperative pain management in cardiac surgery: a systematic review. Minerva Anestesiol. 2018;84(4):488-503. DOI: 10.23736/S0375-9393.17.12142-5.
10. Badia X, Muriel C, Gracia A, Núñez-Olarte JM, Perulero N, Gálvez R, et al; Grupo Vesbpi. Validation of the Spanish version of the Brief Pain Inventory in patients with oncological pain. Med Clin (Barc). 2003;120(2):52-9.
11. Díez-Alvarez E, Arrospide A, Mar J, Cuesta M, Martínez Mdel C, Beitia E, et al. Assessment of acute postoperative pain. Rev Calid Asist. 2009;24(5):215-21. DOI: 10.1016/j.cali.2008.12.001.
12. González-Escalada JR, Camba A, Muriel C, Rodriguez M, Contreras D, Barutell C. Validation of the Lattinen Index for the assessment of chronic pain patients. Rev Soc Esp Dolor. 2012;19(4):181-8.
13. Doğan Bakı E, Kavrut Ozturk N, Ayoğlu RU, Emmiler M, Karsl B, Uzel H. Effects of Parasternal Block on Acute and Chronic Pain in Patients Undergoing Coronary Artery Surgery. Semin Cardiothorac Vasc Anesth. 2016;20(3):205-12.
14. Regenbogen SE, Mullard AJ, Peters N, Brooks S, Englesbe MJ, Campbell DA Jr, et al. Hospital Analgesia Practices and Patient-reported Pain After Colorectal Resection. Ann Surg. 2016;264(6):1044-50.
15. McEvoy MD, Scott MJ, Gordon DB, Grant SA, Thacker JKM, Wu CL, et al. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1-from the preoperative period to PACU. Perioper Med (Lond). 2017;6:8.
16. Roca J, Valero R, Gomar C. Pain locations in the postoperative period after cardiac surgery: Chronology of pain and response to treatment. Rev Esp Anestesiol Reanim. 2017;64(7):391-400.
17. Khan RS, Skapinakis P, Ahmed K, Stefanou DC, Ashrafian H, Darzi A, et al. The association between preoperative pain catastrophizing and postoperative pain intensity in cardiac surgery patients. Pain Med 2012;13(6):820-7.
18. Ruetzler K, Blome CJ, Nabecker S, Makarova N, Fischer H, Rinoesl H, et al. A randomised trial of oral versus intravenous opioids for treatment of pain after cardiac surgery. J Anesth. 2014;28(4):580-6.
19. Mota FA, Marcolan JF, Pereira MH, Milanez AM, Dallan LA, Diccini S. Comparison study of two different patient-controlled anesthesia regiments after cardiac surgery. Rev Bras Cir Cardiovasc. 2010;25(1):38-44.
20. Bainbridge D, Cheng DC, Martin JE, Novick R; Evidence-Based Perioperative Clinical Outcomes Research (EPiCOR) Group. NSAID-analgesia, pain control and morbidity in cardiothoracic surgery. Can J Anaesth. 2006;53(1):46-59.
21. Nachiyunde B, Lam L. The efficacy of different modes of analgesia in postoperative pain management and early mobilization in postoperative cardiac surgical patients: A systematic review. Ann Card Anaesth. 2018;21(4):363-70.
22. Peng L, Ren L, Qin P, Su M. The impact of patient-controlled analgesia on prognosis of patients receiving major abdominal surgery. Minerva Anestesiol. 2016;82(8):827-38.
23. Ziyaeifard M, Azarfarin R, Golzari SE. A Review of Current Analgesic Techniques in Cardiac Surgery. Is Epidural Worth it? J Cardiovasc Thorac Res. 2014;6(3):133-40.
24. Rovira I. Analgesia postoperatoria para cirugía cardiaca mínimamente invasiva: ¿cuál es la técnica ideal? Rev Esp Anestesiol Reanim. 2012;59(9):467-9.
25. Jakobsen CJ. High thoracic epidural in cardiac anesthesia: a review. Semin Cardiothorac Vasc Anesth. 2015;19(1):38-48.
26. Joshi SS, Jagadeesh AM. Efficacy of perioperative pregabalin in acute and chronic post-operative pain after off-pump coronary artery bypass surgery: a randomized, double-blind placebo controlled trial. Ann Card Anaesth. 2013;16(3):180-5.
27. Ruetzler K, Blome CJ, Nabecker S, Makarova N, Fischer H, Rinoesl H, et al. A randomised trial of oral versus intravenous opioids for treatment of pain after cardiac surgery. J Anesth. 2014;28(4):580-6.
28. Ho AM, Karmakar MK, Ng SK, Wan S, Ng CS, Wong RH, et al. Local anaesthetic toxicity after bilateral thoracic paravertebral block in patients undergoing coronary artery bypass surgery. Anaesth Intensive Care. 2016;44(5):615-9.
29. Gjeilo KH, Stenseth R, Klepstad P. Risk Factors and Early Pharmacological Interventions to Prevent Chronic Postsurgical Pain Following Cardiac Surgery. Am J Cardiovasc Drugs 2014;14(5):335-42.
30. de Hoogd S, Valkenburg AJ, van Dongen EPA, Daeter EJ, van Rosmalen J, Dahan A, et al. Short- and long-term impact of remifentanil on thermal detection and pain thresholds after cardiac surgery: A randomised controlled trial. Eur J Anaesthesiol. 2019;36(1):32-9. DOI: 10.1097/EJA.0000000000000887.
31. Lahtinen P, Kokki H, Hynynen M. Pain after cardiac surgery: A prospective cohort study of 1-year incidence and intensity. Anesthesiology. 2006;105(4):794-800.
32. Setälä P, Kalliomäki ML, Järvelä K, Huhtala H, Sisto T, Puolakka P. Postoperative hyperalgesia does not predict persistent post-sternotomy pain; observational study based on clinical examination. Acta Anaesthesiol Scand. 2016;60(4):520-8.
33. de Hoogd S, Ahlers SJGM, van Dongen EPA, van de Garde EMW, Daeter EJ, Dahan A, et al. Randomized controlled trial on the influence of intraoperative remifentanil versus fentanyl on acute and chronic pain after cardiac surgery. Pain Pract. 2018;18:443-51.