Perioperative Pain Management for Thoracic Surgery: A Multi-Layered Approach.

Cardiothoracic surgeries frequently pose unique challenges in the management of perioperative acute pain that require a multifaceted and personalized approach in order to optimize patient outcomes. This article discusses various analgesic strategies including regional anesthesia techniques such as thoracic epidurals, erector spinae plane blocks, and serratus anterior plane blocks and underscores the significance of perioperative multimodal medications, while providing nuanced recommendations for their use. This article further attempts to provide evidence for the efficacy of the different modalities and compares the effectiveness of the choice of analgesia. The roles of Acute Pain Services (APS) and Transitional Pain Services (TPS) in mitigating opioid dependence and chronic postsurgical pain are also discussed. Precision medicine is also presented as a potential way to offer a patient tailored analgesic strategy. Supported by various randomized controlled trials and meta-analyses, the article concludes that an integrated, patient-specific approach encompassing regional anesthesia and multimodal medications, while also utilizing the services of the Acute Pain Service can help to enhance pain management outcomes in cardiothoracic surgery.

Expression of TNF-related apoptosis-inducing ligand (TRAIL) in megakaryocytes and platelets.

OBJECTIVE: Platelets are known to play an important role in hemostasis, thrombosis, wound healing, and inflammation. Platelet-induced modulation of inflammation and adaptive immune responses are mediated in part through tumor necrosis factor (TNF) family member ligands, including CD154, Fas ligand, and TNFalpha, that are expressed upon platelet activation. The present study investigated whether platelets and megakaryocytes also express TNF-related apoptosis-inducing ligand (TRAIL), another pro-apoptotic member of the TNF superfamily. MATERIALS AND METHODS: Immunoprecipitation, enzyme-linked immunosorbent assay, and flow cytometry were used to assess TRAIL protein expression on isolated platelets, in vitro-derived megakaryocytes and premegakaryocyte cell lines. Reverse-transcription polymerase chain reaction and transient transfection of TRAIL promoter/reporter constructs were used to elucidate mechanisms of TRAIL regulation during megakaryocyte differentiation. TRAIL-dependent cytotoxicity assays were performed to determine if platelet-derived TRAIL induces apoptosis of TRAIL sensitive target cells. RESULTS: Activated platelets expressed both membrane-bound and soluble TRAIL. TRAIL was also expressed by megakaryocytes, and in vitro studies showed that TRAIL expression was induced upon megakaryocyte differentiation. TRAIL expression was mediated by increased transcriptional activity of the TRAIL promoter, suggesting lineage-specific regulation of TRAIL during megakaryocyte differentiation. Abundant detergent-extractable, full-length TRAIL protein was observed in the lysates of platelets and megakaryocytes, but only low concentrations of TRAIL were released by nondetergent extraction methods. CONCLUSION: The data reported herein show that platelets express TRAIL that is synthesized by megakaryocytes and was expressed by activated platelets. While these data expand the spectrum of TNF family proteins expressed in platelets, the function of platelet-derived TRAIL is not known.