Vasoactive Inotropic Score compared to the sequential organ failure assessment cardiovascular score in intensive care.

BACKGROUND: The cardiovascular component of the sequential organ failure assessment (cvSOFA) score may be outdated because of changes in intensive care. Vasoactive Inotropic Score (VIS) represents the weighted sum of vasoactive and inotropic drugs. We investigated the association of VIS with mortality in the general intensive care unit (ICU) population and studied whether replacing cvSOFA with a VIS-based score improves the accuracy of the SOFA score as a predictor of mortality. METHODS: We studied the association of VIS during the first 24 h after ICU admission with 30-day mortality in a retrospective study on adult medical and non-cardiac emergency surgical patients admitted to Kuopio University Hospital ICU, Finland, in 2013-2019. We determined the area under the receiver operating characteristic curve (AUROC) for the original SOFA and for SOFAVISmax , where cvSOFA was replaced with maximum VIS (VISmax ) categories. RESULTS: Of 8079 patients, 1107 (13%) died within 30 days. Mortality increased with increasing VISmax . AUROC was 0.813 (95% confidence interval [CI], 0.800-0.825) for original SOFA and 0.822 (95% CI: 0.810-0.834) for SOFAVISmax , p < .001. CONCLUSION: Mortality increased consistently with increasing VISmax . Replacing cvSOFA with VISmax improved the predictive accuracy of the SOFA score.

Predictors of treatment limitations in Finnish intensive care units.

BACKGROUND: Few studies have examined the factors that predict the limitations of life-sustaining treatment (LST) to patients in intensive care units (ICUs). We aimed to identify variables associated with the decision of withholding of life support (WHLS) at admission, WHLS during ICU stay and the withdrawal of ongoing life support (WDLS). METHODS: This retrospective observational study comprised 17,772 adult ICU patients who were included in the nationwide Finnish ICU Registry in 2016. Factors associated with LST limitations were identified using hierarchical logistic regression. RESULTS: The decision of WHLS at admission was made for 822 (4.6%) patients, WHLS during ICU stay for 949 (5.3%) patients, and WDLS for 669 (3.8%) patients. Factors strongly predicting WHLS at admission included old age (adjusted odds ratio [OR] for patients aged 90 years or older in reference to those younger than 40 years was 95.6; 95% confidence interval [CI], 47.2-193.5), dependence on help for activities of daily living (OR, 3.55; 95% CI, 3.01-4.2), and metastatic cancer (OR, 4.34; 95% CI, 3.16-5.95). A high severity of illness predicted later decisions to limit LST. Diagnoses strongly associated with WHLS at admission were cardiac arrest, hepatic failure and chronic obstructive pulmonary disease. Later decisions were strongly associated with cardiac arrest, hepatic failure, non-traumatic intracranial hemorrhage, head trauma and stroke. CONCLUSION: Early decisions to limit LST were typically associated with old age and chronic poor health whereas later decisions were related to the severity of illness. Limitations are common for certain diagnoses, particularly cardiac arrest and hepatic failure.

Gelatin and the risk of acute kidney injury after cardiac surgery.

BACKGROUND: Gelatin has been used as a plasma volume expander because of its ability to preserve intravascular volume more effectively than crystalloids. However, gelatin may have detrimental effects on kidney function and increase the risk of acute kidney injury (AKI). METHOD: We investigated by retrospective analysis of prospectively collected data whether the administration of 4% succinyl gelatin is associated with an increased risk of AKI after cardiac surgery. We compared two propensity score-matched groups of 1,187 patients (crystalloid group and gelatin group). RESULTS: The incidence of AKI was similar in both groups (gelatin 21% and crystalloid 20%) (p = 0.414). The incidence of moderate AKI (8% vs. 6%) was higher in the gelatin group, but there was no difference in mild or severe AKI. Postoperative serum creatine on the first (70 vs. 70 µmol L-1 , p = 0.689) or fourth (71 vs. 70, p = 0.313) postoperative day was similar between groups and there was no difference in the need for new renal replacement therapy (p = 0.999). Patients in the gelatin group received less crystalloids (2080 ml vs. 4130 ml, p = 0.001) and total fluids (3760 ml vs. 4180 ml, p = 0.001), their fluid balance was less positive (p = 0.001) and they required less vasoactive and inotropic medication (p = 0.001). Gelatin was not associated with increased mortality compared to the crystalloid group. CONCLUSION: Gelatin was not associated with AKI after cardiac surgery.

Bioavailability of oxycodone by mouth in coronary artery bypass surgery patients - a randomized trial.

OBJECTIVE: Pain after coronary artery by-pass (CAB) surgery is severe. Analgesic administration by mouth is unreliable until after gastrointestinal function has recovered. We evaluated the bioavailability of oxycodone co-administered with naloxone by mouth in patients after CAB surgery using either a conventional extracorporeal circulation (CECC) or off-pump surgery (OPCAB). METHODS: Twenty-four patients, 50-73 years, 12 with CECC and 12 with OPCAB, were administered a 10/5 mg oxycodone-naloxone controlled-release tablet by mouth on the preoperative day and for the first seven postoperative days (PODs) thereafter. Blood samples were collected up to 24 h after the preoperative administration, and then randomly either on POD1 and POD3 or on POD2 and POD4. The oxycodone concentration in plasma was analyzed using liquid chromatography-mass spectrometry. RESULTS: On POD1 oxycodone absorption was markedly delayed in five of six patients after CECC and in all six patients after OPCAB surgery; median of tmax after CECC 630 [range 270-1420] minutes and after OPCAB 1020 [720-1410] minutes, compared to median of 120-315 min preoperatively and on POD2-POD4. The carry-over corrected AUC0-24 values on the PODs did not differ from the preoperative values, but were higher on POD3 compared with POD1 in both CECC and OPCAB groups. The rate and extent of oxycodone absorption equaled preoperative values on POD2 and onwards in patients with CAB surgery. CONCLUSIONS: Bioavailability of oxycodone by mouth was similar after CAB surgery via CECC or having OPCAB. Data indicate that POD2 is an appropriate time to start oxycodone administration by mouth after CAB surgery.

Gelatin and the risk of bleeding after cardiac surgery.

BACKGROUND: Gelatins has been used in cardiac surgery because of their ability to preserve intravascular volume better than crystalloids. Unfortunately, gelatin has been associated with impaired coagulation and hemostasis, that may cause increased bleeding. We investigated whether the administration of gelatin increases postoperative bleeding after cardiac surgery. METHODS: Retrospective, observational single-center cohort study in the intensive care unit of a tertiary teaching hospital. Postoperative bleeding, chest tube drainage volume and consumption of blood products were compared between groups. RESULTS: Cohort included 3067 consecutive patients who underwent cardiac surgery. First 1698 patients received gelatin (gelatin group), and 1369 patients did not (crystalloid group). The characteristics of the patients in the gelatin and crystalloid groups were comparable. Postoperative chest tube drainage was 18% (95% CI 11%-20%) greater during the first 12 hours (P < .001) and 15% (95% CI 7%-17%) greater during the first 24 hours (P < .001) in the gelatin group compared to the crystalloid group. Severe and massive postoperative bleeding was more common in the gelatin group compared to the crystalloid group (21% vs 16%, P < .001). Patients in the gelatin group received red blood cells (40% vs 20%, P < .001) and platelets (12% vs 8%, P < .001) more frequently than patients in the crystalloid group. However, the number of administered fresh-frozen plasma transfusions did not differ between the groups. CONCLUSION: Gelatin may increase postoperative bleeding and the need for blood product transfusions after cardiac surgery.

Intensive care patient survival after limiting life-sustaining treatment-The FINNEOL* national cohort study.

BACKGROUND: Few studies have examined survival in intensive care unit (ICU) patients after the restriction of life-sustaining treatment (LST). We aimed to analyse independent factors associated with hospital and 12-month survival rates in ICU patients after treatment restrictions. METHODS: This retrospective observational study examined all patients treated in adult ICUs from 1 January 2016 until 31 December 2016 included in the Finnish ICU Registry. Multivariable logistic regression analysis was performed to explain the effect on survival. RESULTS: Decisions to limit LST were made for 2444 patients (13.7%; 95% CI 13.2-14.2). ICU, hospital, and 12-month survival rates were 71% (95% CI 69-73), 49% (95% CI 47-51), and 24% (95% CI 22-26), respectively. In patients for whom life support was withheld, increased 12-month survival rates were associated with admission from the operating theatre (OR 1.9, 95% CI 1.1-3.4), good pre-hospital physical fitness (OR 4.7, 95% Cl 1.2-16.8) and being housed at home (OR 2.0, 95% Cl 1.4-2.8). Decreased survival rates were associated with admission from a hospital ward (OR 0.67, 95% Cl 0.5-0.9), higher comorbidity (OR 0.6, 95% Cl 0.4-0.9), cancer (OR 0.4, 95%CI 0.2-0.9), greater illness severity (SAPS II; OR 0.98, 95% Cl 0.98-0.99), and higher care intensity (TISS-76; OR 0.93, 95% Cl 0.92-0.95). CONCLUSION: Survival among ICU patients with limited treatment was higher than expected. Advanced age was not associated with higher mortality, potentially because treatment restrictions may be set more easily for older patients.

Impact of minimal invasive extracorporeal circulation on the need of red blood cell transfusion.

OBJECTIVE: Minimal invasive extracorporeal circulation may decrease the need of packed red blood cell transfusions and reduce hemodilution during cardiopulmonary bypass. However, more data are needed on the effects of minimal invasive extracorporeal circulation in more complex cardiac procedures. We compared minimal invasive extracorporeal circulation and conventional extracorporeal circulation methods of cardiopulmonary bypass. METHODS: A total of 424 patients in the minimal invasive extracorporeal circulation group and 844 patients in the conventional extracorporeal circulation group undergoing coronary artery bypass grafting and more complex cardiac surgery were evaluated. Age, sex, type of surgery, and duration of perfusion were used as matching criteria. Hemoglobin <80 g/L was used as red blood cell transfusion trigger. The primary endpoint was the use of red blood cells during the day of operation and the five postoperative days. Secondary endpoints were hemodilution (hemoglobin drop after the onset of perfusion) and postoperative bleeding from the chest tubes during the first 12 hours after the operation. RESULTS: Red blood cell transfusions were needed less often in the minimal invasive extracorporeal circulation group compared to the conventional extracorporeal circulation group (26.4% vs. 33.4%, p = 0.011, odds ratio 0.72, 95% confidence interval 0.55-0.93), especially in coronary artery bypass grafting subgroup (21.3% vs. 35.1%, p < 0.001, odds ratio 0.50, 95% confidence interval 0.35-0.73). Hemoglobin drop after onset of perfusion was also lower in the minimal invasive extracorporeal circulation group than in the conventional extracorporeal circulation group (24.2 ± 8.5% vs. 32.6 ± 12.6%, p < 0.001). Postoperative bleeding from the chest tube did not differ between the groups (p = 0.808). CONCLUSION: Minimal invasive extracorporeal circulation reduced the need of red blood cell transfusions and hemoglobin drop when compared to the conventional extracorporeal circulation group. This may have implications when choosing the perfusion method in cardiac surgery.

Vasoactive-inotropic score and the prediction of morbidity and mortality after cardiac surgery.

BACKGROUND: The vasoactive-inotropic score (VIS) predicts mortality and morbidity after paediatric cardiac surgery. Here we examined whether VIS also predicted outcome in adults after cardiac surgery, and compared predictive capability between VIS and three widely used scoring systems. METHODS: This single-centre retrospective cohort study included 3213 cardiac surgery patients. Maximal VIS (VISmax) was calculated using the highest doses of vasoactive and inotropic medications administered during the first 24 h post-surgery. We established five VISmax categories: 0-5, >5-15, >15-30, >30-45, and >45 points. The predictive accuracy of VISmax was evaluated for a composite outcome, which included 30-day mortality, mediastinitis, stroke, acute kidney injury, and myocardial infarction. RESULTS: VISmax showed good prediction accuracy for the composite outcome [area under the curve (AUC), 0.72; 95% confidence interval (CI), 0.69-0.75]. The incidence of the composite outcome was 9.6% overall and 43% in the highest VISmax group (>45). VISmax predicted 30-day mortality (AUC, 0.76; 95% CI, 0.69-0.83) and 1-yr mortality (AUC, 0.70; 95% CI, 0.65-0.74). Prediction accuracy for unfavourable outcome was significantly better with VISmax than with Acute Physiology and Chronic Health Evaluation II (P=0.01) and Simplified Acute Physiological Score II (P=0.048), but not with the Sequential Organ Failure Assessment score (P=0.32). CONCLUSIONS: In adults after cardiac surgery, VISmax predicted a composite of unfavourable outcomes and predicted mortality up to 1 yr after surgery.

Continuous Ropivacaine Infusion Offers No Benefit in Treating Postoperative Pain After Cardiac Surgery.

OBJECTIVE: One multimodal pain management method for reducing postoperative opioid need after cardiac surgery is to continuously infuse local anesthetic into a median sternotomy wound. Previous studies have shown contradictory results with this method; therefore, no consensus exists on its effectiveness. The authors tested the effectiveness of continuous 0.2% ropivacaine infusion into a sternotomy wound after cardiac surgery. DESIGN: Prospective, randomized, double-blinded, placebo-controlled trial. SETTING: Single-institution, tertiary-level, university hospital. PARTICIPANTS: Total of 90 patients undergoing coronary artery bypass grafting or heart valve surgery. INTERVENTIONS: Patients were assigned randomly to receive 0.2% ropivacaine or placebo into a sternotomy wound for 48 hours postoperatively. Pain was controlled with standardized oxycodone boluses after surgery and patient-controlled analgesia oxycodone after extubation; total oxycodone consumption was recorded. Pain was assessed 3  times daily, at rest and during deep breathing, with the visual analogue scale. MEASUREMENTS AND MAIN RESULTS: Forty-seven patients were assigned to receive ropivacaine and 43 to receive placebo infusion. Cumulative oxycodone consumption was 97 ± 27 mg with ropivacaine and 96 ± 29 mg with placebo (p = 0.813). Pain scores were similar between groups, both at rest (p = 0.630) and during deep breathing (p = 0.793). Adverse event incidences and surgical wound infection rates were similar between groups. CONCLUSION: Continuous 0.2% ropivacaine infusions at the median sternotomy wound did not reduce postoperative pain or opioid consumption during the first 48 hours after cardiac surgery. This technique apparently was not beneficial for post-sternotomy pain treatment.

Levosimendan increases bleeding risk after heart valve surgery: a retrospective analysis of a randomized trial.

OBJECTIVE: To investigate whether levosimendan, an inotrope with cardioprotective properties, increases postoperative bleeding after cardiac surgery. DESIGN: Retrospective analysis of a randomized, prospective clinical study. SETTING: Post-anesthesia care unit (PACU) and surgical ward in a university hospital. PARTICIPANTS: Two hundred heart valve surgery patients. INTERVENTIONS: The patients were randomized to receive either a 24-hour intravenous infusion of levosimendan or placebo. Infusion was administered as a 24 µg/kg bolus over 30 minutes and then continued at a dose of 0.2 µg/kg/min. MEASUREMENTS AND MAIN RESULTS: Postoperative bleeding was approximately 31% greater in the levosimendan group (1050 mL) compared to the placebo group (880 mL, p = 0.008). Serious bleeding exceeding 1000 mL was more common in the levosimendan group than the placebo group (51 v 38 patients, p = 0.044, risk ratio (RR) 1.37, 95% CI 1.00-1.87). However, the risk of reoperation for bleeding did not increase if patients received levosimendan (RR 1.52, 95% CI 0.77-2.97, p = 0.309). This result did not change after excluding patients who received clopidogrel preoperatively (RR 2.13, 95% CI 0.98-4.65, p = 0.145). The groups did not differ regarding transfused blood products. Eight patients, including seven from the levosimendan group, had delayed (diagnosed>48 hours after the surgery) cardiac tamponade and underwent re-exploration (7 v 1, p = 0.031). CONCLUSIONS: Levosimendan increased the risk of postoperative bleeding after cardiac valve surgery. In addition, the risk of postoperative cardiac tamponade was increased in patients who received levosimendan compared to placebo.

Levosimendan reduces heart failure after cardiac surgery: a prospective, randomized, placebo-controlled trial.

OBJECTIVE: To investigate whether levosimendan diminishes the incidence of heart failure after cardiac surgery. DESIGN: Prospective, randomized, placebo-controlled clinical study. SETTING: Cardiac surgery operating room and postanesthesia care unit in a university hospital. PATIENTS: Two hundred patients assigned to undergo heart valve or combined heart valve and coronary artery bypass grafting surgery. INTERVENTIONS: Patients were randomized to receive a 24-hr infusion of placebo or levosimendan administered as a 24 µg/kg bolus over 30-mins and thereafter at a dose of 0.2 µg/kg/min. MEASUREMENTS AND MAIN RESULTS: Heart failure was defined as cardiac index<2.0 L/min/m or failure to wean from cardiopulmonary bypass necessitating inotrope administration for at least 2 hrs postoperatively. Heart failure was less frequent in the levosimendan compared to the placebo group: 15 patients (15%) in the levosimendan and 59 patients (58%) in the placebo group experienced heart failure postoperatively (risk ratio 0.26; 95% confidence interval 0.16-0.43; p<.001). Accordingly, a rescue inotrope (adrenaline) was needed less frequently in the levosimendan compared to the placebo group (risk ratio 0.11; 95% confidence interval 0.01-0.89), p=.005. Intra-aortic balloon pump was utilized in one patient (1%) in the levosimendan and in nine patients (9%) in the placebo group (risk ratio 0.11; 95% confidence interval 0.01-0.87), p=.018. The hospital and the 6-month mortality were comparable between groups. There were no significant differences in major organ failures postoperatively. Eighty-three patients were hypotensive and needed noradrenaline in the levosimendan compared to 52 patients in the placebo group, p<.001. The cardiac enzymes (creatine kinase MB isoenzyme mass) indicating myocardial damage were lower in the levosimendan group on the first postoperative day, p=.011. CONCLUSIONS: In the present study, levosimendan infusion reduced the incidence of heart failure in cardiac surgery patients but was associated with arterial hypotension and increased requirement of vasopressor agents postoperatively. Improved mortality or morbidity was not demonstrated.

Comparison of spectral entropy and BIS VISTA™ monitor during general anesthesia for cardiac surgery.

OBJECTIVES: We compared the primary metrics of the Spectral entropy M-ENTROPY™ module and BIS VISTA™ monitor-i.e., bispectral index (BIS), state entropy (SE), and response entropy (RE) in terms of agreement and correlation during general anesthesia for cardiac surgery. We also evaluated responsiveness of electroencephalogram (EEG)-based and hemodynamic parameters to surgical noxious stimulation, skin incision, and sternotomy, hypothesizing that RE would be a better responsiveness predictor. METHODS: BIS and entropy sensors were applied before anesthesia induction in 32 patients having elective cardiac surgery. Total intravenous anesthesia was standardized and guided by the BIS index with neuromuscular blockade tested with train-of-four monitoring. Parameters included SE, RE, BIS, forehead electromyography (EMG), and hemodynamic variables. Time points for analyzing BIS, entropy, and hemodynamic values were 1 min before and after: anesthesia induction, intubation, skin incision, sternotomy, cannulation of the aorta, cardiopulmonary bypass (CPB), cross-clamping the aorta, de-clamping the aorta, and end of CPB; also after starting the re-warming phase and at 10, 20, 30, and 40 min following. RESULTS: The mean difference between BIS and SE (Bland-Altman) was 2.14 (+16/- 11; 95% CI 1.59-2.67), and between BIS and RE it was 0.02 (+14/- 14; 95% CI 0.01-0.06). BIS and SE (r(2) = 0.66; P = 0.001) and BIS and RE (r(2) = 0.7; P = 0.001) were closely correlated (Pearson's). EEG parameters, EMG values, and systolic blood pressure significantly increased after skin incision, and sternotomy. The effect of surgical stimulation (Cohen's d) was highest for RE after skin incision (-0.71; P = 0.0001) and sternotomy (-0.94; P = 0.0001). CONCLUSION: Agreement was poor between the BIS index measured by BIS VISTA™ and SE values at critical anesthesia time points in patients undergoing cardiac surgery. RE was a good predictor of arousal after surgical stimulation regardless of the surgical level of muscle relaxation. Index differences most likely resulted from different algorithms for calculating consciousness level.

Is external jugular vein cannulation feasible in emergency care? A randomised study in open heart surgery patients.

UNLABELLED: The optimal intravenous catheterisation site for emergencies is unknown. The external jugular vein might be preferable route compared to cubital veins in emergencies due to more rapid circulation time to heart and faster cardiac responses. However, the feasibility of the different venous catheterisation sites has not been compared in relation to catheterisation time and success rate. METHODS: We examined the time differences and success rates of external jugular compared to antecubital vein catheterisations. 32 paramedics and 28 emergency department residents performed external jugular and antecubital venous catheterisations on anesthetized patients scheduled for elective cardiac surgery. The primary outcome was catheterisation time and the secondary outcomes the failure rate and catheterisation times needed to succeed. RESULTS: Antecubital venous catheterisation was faster (113+/-89s) compared to external jugular vein catheterisation (156+/-112s), p=0.008 and the success rate was higher (93% compared to 68%, respectively, p=0.001). Less attempts were needed for antecubital vein catheterisations compared to external jugular vein catheterisations (p=0.002). For the antecubital vein, subjects needed two attempts in 6 patients and three attempts in 6 patients. For the external jugular vein, subjects needed two attempts in 13 patients and three attempts in 20 patients. Two (6%) paramedics and two (7%) residents failed to catheterise the antecubital vein. Nine (28%) paramedics and 10 (36%) residents failed to catheterise the external jugular vein. CONCLUSIONS: Antecubital vein catheterisation was faster and had a superior success rate compared to external jugular vein catheterisation.

Remifentanil infusion does not induce opioid tolerance after cardiac surgery.

OBJECTIVE: Remifentanil is being used increasingly during fast-track cardiac surgery. Postoperative hyperalgesia and opioid tolerance have been reported in volunteer studies and in patients after major abdominal surgery with remifentanil infusion. In the present study, the authors evaluated whether high-dose remifentanil infusion induces opioid tolerance in 90 patients undergoing coronary artery bypass surgery with sternotomy. DESIGN: Prospective, randomized, and double-blind study. SETTING: Single-institution, tertiary level, university hospital. PARTICIPANTS: Ninety patients undergoing coronary artery bypass surgery. INTERVENTIONS: Patients were randomized to receive a 3-hour infusion of remifentanil (0.3 microg/kg/min, n = 45) or placebo (n = 45) intraoperatively as adjunct to a standardized sufentanil/propofol-based general anesthesia. MEASUREMENTS AND MAIN RESULTS: Opioid consumption, pain, and sedation scores, as well as adverse events and patients' satisfaction with pain therapy, were recorded for 48 postoperative hours. There were no differences in postoperative opioid consumption between the groups (median oxycodone consumption in the remifentanil group, 98 mg [range, 29-166] and in the placebo group, 99 mg [42-219]). Pain scores were comparable at rest, but during a deep breath pain scores were lower in the remifentanil group (p = 0.020). Sedation scores, satisfaction with analgesia, and adverse events were similar between the 2 groups. The most common adverse event was nausea, with a 33% incidence in the placebo and 40% incidence in the remifentanil group. CONCLUSION: Three-hour remifentanil infusion did not increase postoperative pain or opioid consumption in cardiac surgery patients. The present results suggest that high-dose remifentanil does not elicit opioid tolerance when given during cardiac surgery.

Pain after cardiac surgery: a prospective cohort study of 1-year incidence and intensity.

BACKGROUND: Persistent chest pain may originate from cardiac surgery. Conflicting results have been reported on the incidence of persistent poststernotomy pain with considerable discrepancies between the retrospective reports and the one prospective study conducted to assess this pain. Therefore, the authors conducted a follow-up survey for the first 12 months after cardiac surgery in 213 patients who had a sternotomy. METHODS: The authors performed a prospective inquiry of acute and chronic poststernotomy pain both before and after cardiac surgery. Two hundred thirteen coronary artery bypass patients received a questionnaire preoperatively, 4 days postoperatively, and 1, 3, 6, and 12 months postoperatively. All patients were asked about their expectations, their preferences, and the location and intensity of postoperative pain. RESULTS: The return rates for the postal questionnaires were 203 (95%) and 186 (87%) after 1 and 12 months, respectively. Patients experienced more pain postoperatively at rest than they had expected to preoperatively. At rest, the worst actual postoperative pain was 6 (0-10), and the worst expected pain as assessed preoperatively was 5 (0-10) (P = 0.013). The worst reported postoperative pain was severe (numeric rating scale score 7-10) in 49% at rest, in 78% during coughing, and in 62% of patients on movement. One year after the operation, 26 patients (14%) reported mild chronic poststernotomy pain at rest, 1 patient (1%) had moderate pain, and 3 patients (2%) had severe pain. Upon movement, persistent pain was even more common: 45 patients (24%) had mild, 5 patients (3%) had moderate, and 7 patients (4%) had severe pain. Patients who experienced moderate to severe acute postoperative pain also reported any chronic poststernotomy pain (numeric rating scale score 1-10) more frequently. CONCLUSIONS: Although common, the incidence of persistent pain after sternotomy was lower than previously reported. Also, reassuringly, 1 year after surgery this pain was mostly mild in nature both at rest and on movement.

S(+)-ketamine as an analgesic adjunct reduces opioid consumption after cardiac surgery.

There are no studies evaluating S(+)-ketamine for pain management after sternotomy. In this prospective, randomized, double-blind, placebo-controlled clinical trial, we evaluated the efficacy and feasibility of S(+)-ketamine as an adjunctive analgesic after cardiac surgery. Ninety patients scheduled for elective coronary artery bypass grafting (CABG) were randomized to receive either a 75 microg/kg bolus of S(+)-ketamine followed by a continuous infusion of 1.25 microg . kg(-1) . min(-1) for 48 h (n = 44) or placebo (normal saline bolus and infusion) (n = 46). From the time of tracheal extubation, patients could access an opioid (oxycodone) via a patient-controlled analgesia device, and the cumulative oxycodone doses were measured over 48 h. Pain was evaluated on a visual analog scale three times daily. The quality of recovery, patient satisfaction with pain management, and adverse effects were recorded. The cumulative oxycodone consumption during the first 48 postoperative hours was less in the S(+)-ketamine group (103 +/- 44 mg) than in the placebo group (125 +/- 45 mg; mean difference, 22 mg; 95% confidence interval for the difference, 3-40 mg; P = 0.023). Pain scores did not differ between the groups at rest (P = 0.17) or during a deep breath (P = 0.23). Patient satisfaction was superior in S(+)-ketamine-treated patients: 26 (60%) of 44 in the S(+)-ketamine group compared with 16 (35%) of 46 in the placebo group were very satisfied with the analgesic management (P = 0.032). Nausea and vomiting were the most common adverse events, with similar frequencies in both groups. Four patients in the S(+)-ketamine group developed transient hallucinations during the infusion, versus none in the placebo group. In conclusion, small-dose S(+)-ketamine decreased opioid consumption in CABG patients during the first 48 h after surgery.

Propacetamol as adjunctive treatment for postoperative pain after cardiac surgery.

UNLABELLED: Postoperative pain management after cardiac surgery has been mainly based on parenteral opioids. However, because opioids have numerous side effects, coadministration of non-opioid analgesics has been introduced as a method of reducing opioid dose. In this prospective, randomized, double-blinded study, we evaluated the efficacy of propacetamol, an IV administered prodrug of acetaminophen (paracetamol), as an adjunctive analgesic after cardiac surgery. Seventy-nine patients scheduled for elective coronary artery bypass grafting were randomized to receive either propacetamol 2 g (n = 40) or placebo (n = 39) IV in 6-h intervals for 72 h. From the time of extubation, patients had access to an opioid (oxycodone) via a patient-controlled analgesia device. Pain was evaluated on a visual analog scale four times daily, whereas respiratory function tests (forced vital capacity, forced expiratory volume in 1 s, peak expiratory flow, and arterial blood gas measurements) were performed once a day. The prespecified primary efficacy variable (cumulative oxycodone consumption at the end of the 72-h postoperative period) was 123.5 mg (51.3 mg) (mean [SD]) in the propacetamol group and 141.8 mg (57.5 mg) in the placebo group (difference in mean, 18.3 mg = 13%; 95% confidence interval, 6.1-42.7 mg; P = 0.15). Pain scores did not differ between the groups at rest (P = 0.65) or during a deep breath (P = 0.72). The groups were also similar in terms of pulmonary function tests, postoperative bleeding, and hepatic function tests, and no significant differences were noted in the incidences of adverse effects. After completion of the study, apost hoc analysis was also performed analyzing the first 24 h as split into 6-h intervals. This analysis showed a significantly (P = 0.036) smaller consumption of oxycodone in the propacetamol group at 24 h (47.1 mg [20.7 mg] versus 57.9 mg [23.9 mg]; difference in mean, 10.8 mg; 95% confidence interval, 0.7-20.9 mg). In conclusion, propacetamol did not enhance opioid-based analgesia in coronary artery bypass grafting patients, nor did it decrease cumulative opioid consumption or reduce adverse effects within 3 days after surgery. However, post hoc analysis showed that oxycodone requirement was reduced within the first 24 h in the propacetamol group. IMPLICATIONS: This is the first placebo-controlled study to investigate the efficacy of propacetamol as a complementary analgesic to opioids after cardiac surgery. Propacetamol did not enhance analgesia, nor did it decrease cumulative opioid consumption or reduce adverse effects in a dose of 2 g given every sixth hour for 3 days after surgery.