Use of continuous subcutaneous anesthetic infusion in cardiac surgical patients after median sternotomy

Abstract

The use of opioid analgesics to control pain after median sternotomy in cardiac surgical patients is worldwide accepted and established. However, opioids have a wide range of possible side effects, concerning prolonged extubation time, gastrointestinal tract dyskinesia and urinary tract disorders mostly retention. All these may lead to a prolonged ICU stay or overall hospitalization time increase.Objective: To determine whether a continuous subcutaneous regional anesthetic infusion delivered directly to the sternotomy site would result in decreased levels of postoperative pain and opioid requirements in cardiac surgical patients undergoing median sternotomy. Method:The continuous subcutaneous infusion (OnQ Painbuster system) was applied in 37 patients. 3 patients were exempted due to prolonged ICU stay. 29 patients underwent CABG, 5 had AVR, 1 MVR and modified Maze, 1 patient had a 3-valve repair due to endocarditis and another one had reconstruction of the left ventricle. Requirements of opioid analgesics were recorded for 96 hours after operation. Pain was assessed using the visual analog scale and the total postoperative hospital length of stay was also measured. Results:The postoperative pain was significantly diminished (0 -3 at VAS). The mean postoperative length of stay was 5,8 days, rather improved compared to the average stay of 6,7 days. Conclusion:Continuous subcutaneous infusion of ropivacaine directly at the median sternotomy significantly diminishes postoperative pain and the need for opioid analgesic use. Moreover, it seems to reduce overall postoperative length of stay for all cardiac surgical patients.

The Analgesic Effects of a Bilateral Sternal Infusion of Ropivacaine After Cardiac Surgery

“…7,12 We chose ropivacaine because (1) it has been considered safer than bupivacaine 17 ; (2) presternal bupivacaine, at a significantly effective concentration (0.5%), led to quite high bupivacaine serum levels 10 ; and (3) good analgesia was provided with presternal administration of ropivacaine. 9,11 The 0.2% concentration of ropivacaine was the smallest effective block in the presternal studies. 9,11 The administration rate was kept the same as in previous studies, that is, 4 mL/hr.…”

“…9,11 The 0.2% concentration of ropivacaine was the smallest effective block in the presternal studies. 9,11 The administration rate was kept the same as in previous studies, that is, 4 mL/hr. 9Y11 The 270-mL elastomeric pump allowed at least 48 hrs of administration without need of refilling, which avoided manipulations that could increase the risk of infection.…”

“…In 1 study, the drug tested was bupivacaine, 0.25% and 0.5% 10 ; in the other 2 studies, ropivacaine was preferred for safety reasons, and the concentration tested was 0.2% 9 or 0.3375%. 11 All studies showed that the technique reduced pain at rest and opiate consumption. Beneficial effects of the treatment on other morbidity outcomes or length of stay in the hospital were also noted, although the benefits were not always significant.…”

Prolonged Amelioration of Experimental Postoperative Pain by Bupivacaine Released From Microsphere-Coated Hernia Mesh

“…Several studies have been published on the use of the catheter-based ON-Q PainBuster postoperative pain management system, which provides a constant infusion of anesthetic(s) to a target anatomical site, spanning a variety of surgical procedures. [20][21][22] Published clinical evidence shows improved postoperative pain outcomes after surgical procedures (both open and laparoscopic), including cardiothoracic (thoracotomy 41 and sternotomy 42 ), ob-gyn (cesarean section 43 and hysterectomy 44 ), orthopedic (spine, 45 joint 20 ), bariatric, 46 urological, 47 plastic, 22 as well as abdominopelvic surgical procedures (eg, hernia). 48 The key benefits achieved over the more traditional opioidbased treatments were reduced pain scores, reduced opioid requirements (and thus reduced side effects), and shortened hospital stay.…”

Impact of beliefs about pain control on perceptions of illness in surgical patients

“…Other essential elements of personal freedom are spiritual freedom and beliefs about health and pain control. Chronic non-cancer pain research is evident and abundant in the literature of clinical medicine and the psychology of medicine [1,7,9,11,13,14,15,16,17,18]. It can be hypothesized that redefining beliefs about pain control by a person with a surgical disease is an essential psychological mechanism of overcoming the otherness of his/her body and the disorder itself.…”