Background Intrathecal morphine decreases postoperative pain in standard cardiac surgery. Its safety and effectiveness have not been adequately evaluated in minimally invasive cardiac surgery. The authors hypothesized that intrathecal morphine would decrease postoperative morphine consumption after minimally invasive cardiac surgery. Methods In this randomized, placebo-controlled, double-blinded clinical trial, patients undergoing robotic totally endoscopic coronary artery bypass received either intrathecal morphine (5 mcg/kg) or intrathecal saline before surgery. The primary outcome was postoperative morphine equivalent consumption in the first 24 h after surgery; secondary outcomes included pain scores, side effects, and patient satisfaction. Pain was assessed via visual analog scale at 1, 2, 6, 12, 24, and 48 h after intensive care unit arrival. Opioid-related side effects (nausea/vomiting, pruritus, urinary retention, respiratory depression) were assessed daily. Patient satisfaction was evaluated with the Revised American Pain Society Outcome Questionnaire. Results Seventy-nine patients were randomized to receive intrathecal morphine (n = 37) or intrathecal placebo (n = 42), with 70 analyzed (morphine 33, placebo 37). Intrathecal morphine patients required significantly less median (25th to 75th percentile) morphine equivalents compared to placebo during first postoperative 24 h (28 [16 to 46] mg vs. 59 [41 to 79] mg; difference, –28 [95% CI, –40 to –18]; P < 0.001) and second postoperative 24 h (0 [0 to 2] mg vs. 5 [0 to 6] mg; difference, –3.3 [95% CI, –5 to 0]; P < 0.001), exhibited significantly lower visual analog scale pain scores at rest and cough at all postoperative timepoints (overall treatment effect, –4.1 [95% CI, –4.9 to –3.3] and –4.7 [95% CI, –5.5 to –3.9], respectively; P < 0.001), and percent time in severe pain (10 [0 to 40] vs. 40 [20 to 70]; P = 0.003) during the postoperative period. Mild nausea was more common in the intrathecal morphine group (36% vs. 8%; P = 0.004). Conclusions When given before induction of anesthesia for totally endoscopic coronary artery bypass, intrathecal morphine decreases use of postoperative opioids and produces significant postoperative analgesia for 48 h. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New
Heart failure (HF) continues to be a pervasive problem both nationally and globally, and with an aging population its prevalence is only increasing. It is estimated that ~6 million Americans over 20 years old were diagnosed with HF between 2015 and 2018, and projections estimate that the number will be > 8 million by 2030. 1 There have been multiple classification systems developed to help risk stratify, prognosticate, and determine treatment for HF patients. These include the New York Heart Association (NYHA) functional classification, the American College of Cardiology (ACC) and American Heart Association (AHA) stages, and The Interagency Registry for Mechanically Assisted Circulation (INTERMACS) profiles. 2,3 The ultimate goal of these systems is to provide early identification and create a pathway for intervention whether in the form of medical therapy, mechanical circulatory support (MCS), or a combination of both. The term MCS encompasses a wide variety of options ranging from percutaneous temporary devices used as a bridge-to-transplantation (BTT) or myocardial recovery to permanent implantable devices meant as destination therapy (DT). The MCS devices commonly used today include the intraaortic balloon pump (IABP), Impella (Abiomed, Danvers, MA), TandemHeart (LivaNova, London, UK), total artificial heart (TAH), venoarterial and veno-venous extracorporeal membrane oxygenation (VA-ECMO and VV-ECMO), durable left ventricular assist devices (LVAD), and percutaneous right ventricular assist devices (RVAD). Various models and configurations of these listed devices can be used to support the left or right ventricle individually (LV, RV), and some can be used to provide biventricular support. The who, what, and when of MCS requires a multidisciplinary team approach, considering numerous variables in order to provide the optimal therapy for each individual patient. This article presents an overview of the history and indications for MCS, as well as how to select patients for MCS and a brief explanation of available devices.
An estimated 92 million adults in the United States have cardiovascular disease, costing about $316 billion dollars in annual health care expenditures. Furthermore, it is estimated that about 16 million Americans greater than 20 years old have coronary artery disease (CAD), which results in a disruption of the oxygen supply-demand relationship in the myocardium and can have adverse effects on the function of the heart. Management of CAD involves both nonsurgical and surgical interventions, of which coronary artery bypass grafting (CABG) is the main surgical option. The majority of CABG surgery is done with the assistance of the cardiopulmonary bypass circuit (CPB), although in the last 30 years there has been a trend toward performing CABG without CPB, also known as off-pump CABG. Many cardiac surgical patients have other medical comorbidities that make significant contributions to their ability to recover. Management of the patient requiring CABG, both with and without CPB, poses several challenges for the cardiac anesthesiologist. These include planning for appropriate monitoring of hemodynamics and oxygenation, obtaining adequate intravascular access, and anticipating and reacting to changes in pathophysiology related to CPB.
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