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252
10.2 Prevention Strategies
10.2.1 Pharmacologic Neuroprotection
Though a number of pharmaceutical agents have been proposed as neuroprotective
agents, none has been fully proved yet; however, the following agents have been
demonstrated to be effective in suppressing the ischemic penumbra in some studies
(Hogue et al. 2007 ; Nelson et al. 2008 ; Mitchell et al. 2009 ; Lombard and Mathew
2010 ; Benggon et al. 2012 ; Dabbagh and Rajaei 2012 ; Zhang et al. 2012 ;
Bruggemans 2013 ):
• Intraoperative lidocaine might have neuroprotective effects through suppressing
the infl ammatory response in cardiac surgery patients.
• Thiopental mainly decreases the embolic load (possibly due to cerebral
vasoconstriction).
• Propofol might decrease the oxygen consumption during ischemic period.
• Postoperative donepezil might have therapeutic (rather than preventive) effects
for postoperative cognitive dysfunction.
• 17β-estradiol might limit ischemic injury of the neuronal tissue in women under-
going cardiac surgery.
• In some studies, antagonists of N-methyl- d -aspartate have been demonstrated
as neuroprotective agents; among them, anesthetics could be mentioned as the
prototype of these drugs used for cardiac surgery patients. Usually, these phar-
maceuticals are blamed for their neuroapoptotic effects; however, some agents
like xenon and dexmedetomidine may have neuroprotective effects; on the
other hand, although ketamine might have adverse neurodevelopmental effects
in neonatal animal brain studies, it might be effective in decreasing postopera-
tive neurocognitive dysfunction after cardiac surgery. Magnesium is another
agent with potential have anti-infl ammatory effects, being an antagonist of
NMDA.
• Dextromethorphan, nimodipine, aprotinin, remacemide, beta blockers, pexeli-
zumab, and a number of other agents have been proposed; however, none have
been conclusive yet.
Duration of CPB
Amount of bleeding and the volume of transfused blood
Readmission to the operating theater for control of acute postoperative bleeding
Only one fi fth (20 %) of postoperative CNS complications of cardiac surgery occur due to
postoperative events
Hyperthermia after CPB
Hypotension
Amount of bleeding and the volume of transfused blood
Readmission to the operating theater for control of acute postoperative bleeding
Table 10.1 (continued)
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10.2.2 CPB-Related Equipment
A full description of the CPB-related factors affecting the CNS is discussed in detail
in this book in a separate chapter titled “Cardiopulmonary Bypass: Postoperative
Effects” (Chap. 12 ).
10.3 Neurologic Monitoring
Novel and older technologies are used to improve the CNS outcome. These moni-
toring are used more commonly nowadays. A full description of the neurologic
monitoring in cardiac surgery is discussed in detail in this book in a separate chapter
titled “Central Nervous System Monitoring” (Chap. 5 ). However, a brief discussion
is presented here. The main currently available CNS monitoring are the following:
• Clinical assessment of CNS status and of sedation in postoperative period
(Intensive Care Unit)
• Classic electroencephalogram (EEG) including multichannel or uni-channel EEG
• Monitoring depth of anesthesia
• Evoked potentials (including motor evoked potential, somatosensory evoked
potential, and auditory evoked potential)
• Regional cerebral oximetry (rSO
2
) by near-infrared spectroscopy technique
(NIRS)
• Jugular vein oxygen saturation (SjvO
2
)
• Transcranial Doppler (TCD)
• Other modes for assessment of cerebral blood fl o w
A full description of these devices is found in this book in the chapter discussing
“Central Nervous System Monitoring” (Chap. 5 ) .
References
Bartels K, McDonagh DL, Newman MF, Mathew JP (2013) Neurocognitive outcomes after car-
diac surgery. Curr Opin Anaesthesiol 26:91–97
Benggon M, Chen H, Applegate R, Martin R, Zhang JH (2012) Effect of dexmedetomidine on
brain edema and neurological outcomes in surgical brain injury in rats. Anesth Analg
115:154–159
Bruggemans EF (2013) Cognitive dysfunction after cardiac surgery: pathophysiological mecha-
nisms and preventive strategies. Neth Heart J 21:70–73
Bucerius J, Gummert JF, Borger MA, Walther T, Doll N, Falk V, Schmitt DV, Mohr FW (2004)
Predictors of delirium after cardiac surgery delirium: effect of beating-heart (off-pump) sur-
gery. J Thorac Cardiovasc Surg 127:57–64
Carrascal Y, Casquero E, Gualis J, Di Stefano S, Florez S, Fulquet E, Echevarria JR, Fiz L (2005)
Cognitive decline after cardiac surgery: proposal for easy measurement with a new test. Interact
Cardiovasc Thorac Surg 4:216–221
Coburn M, Fahlenkamp A, Zoremba N, Schaelte G (2010) Postoperative cognitive dysfunction:
incidence and prophylaxis. Anaesthetist 59:177–184, quiz 185
10 Postoperative CNS Care
https://t.me/med1917
254
Dabbagh A, Rajaei S (2012) Xenon: a solution for anesthesia in liver disease? Hepat Mon 12:e8437
Fahy BG, Sheehy AM, Coursin DB (2009) Glucose control in the intensive care unit. Crit Care
Med 37:1769–1776
Funder KS, Steinmetz J, Rasmussen LS (2009) Cognitive dysfunction after cardiovascular sur-
gery. Minerva Anestesiol 75:329–332
Grigore AM, Murray CF, Ramakrishna H, Djaiani G (2009) A core review of temperature regi-
mens and neuroprotection during cardiopulmonary bypass: does rewarming rate matter?
Anesth Analg 109:1741–1751
Grocott HP (2009) PRO: Temperature regimens and neuroprotection during cardiopulmonary
bypass: does rewarming rate matter? Anesth Analg 109:1738–1740
Heckman GA, Patterson CJ, Demers C, St Onge J, Turpie ID, McKelvie RS (2007) Heart failure
and cognitive impairment: challenges and opportunities. Clin Interv Aging 2:209–218
Hedberg M, Engstrom KG (2012) Stroke after cardiac surgery – hemispheric distribution and
survival. Scand Cardiovasc J 47(3):136–144
Hedberg M, Boivie P, Engstrom KG (2011) Early and delayed stroke after coronary surgery – an
analysis of risk factors and the impact on short- and long-term survival. Eur J Cardiothorac
Surg 40:379–387
Hogue CW Jr, Murphy SF, Schechtman KB, Davila-Roman VG (1999) Risk factors for early or
delayed stroke after cardiac surgery. Circulation 100:642–647
Hogue CW Jr, Freedland K, Hershey T, Fucetola R, Nassief A, Barzilai B, Thomas B, Birge S,
Dixon D, Schechtman KB, Davila-Roman VG (2007) Neurocognitive outcomes are not
improved by 17beta-estradiol in postmenopausal women undergoing cardiac surgery. Stroke
38:2048–2054
Hogue CW, Fucetola R, Hershey T, Freedland K, Davila-Roman VG, Goate AM, Thompson RE
(2008a) Risk factors for neurocognitive dysfunction after cardiac surgery in postmenopausal
women. Ann Thorac Surg 86:511–516
Hogue CW, Gottesman RF, Stearns J (2008b) Mechanisms of cerebral injury from cardiac surgery.
Crit Care Clin 24:83–98, viii–xi
Hogue CW Jr, Fucetola R, Hershey T, Nassief A, Birge S, Davila-Roman VG, Barzilai B, Thomas
B, Schechtman KB, Freedland K (2008c) The role of postoperative neurocognitive dysfunction
on quality of life for postmenopausal women 6 months after cardiac surgery. Anesth Analg
107:21–28
Karkouti K, Djaiani G, Borger MA, Beattie WS, Fedorko L, Wijeysundera D, Ivanov J, Karski J
(2005) Low hematocrit during cardiopulmonary bypass is associated with increased risk of
perioperative stroke in cardiac surgery. Ann Thorac Surg 80:1381–1387
Knipp SC, Kahlert P, Jokisch D, Schlamann M, Wendt D, Weimar C, Jakob H, Thielmann M
(2013) Cognitive function after transapical aortic valve implantation: a single-centre study
with 3-month follow-up. Interact Cardiovasc Thorac Surg 16:116–122
Lazar HL, McDonnell M, Chipkin SR, Furnary AP, Engelman RM, Sadhu AR, Bridges CR, Haan
CK, Svedjeholm R, Taegtmeyer H, Shemin RJ (2009) The Society of Thoracic Surgeons prac-
tice guideline series: blood glucose management during adult cardiac surgery. Ann Thorac Surg
87:663–669
Liu YH, Wang DX, Li LH, Wu XM, Shan GJ, Su Y, Li J, Yu QJ, Shi CX, Huang YN, Sun W (2009)
The effects of cardiopulmonary bypass on the number of cerebral microemboli and the incidence of
cognitive dysfunction after coronary artery bypass graft surgery. Anesth Analg 109:1013–1022
Lombard FW, Mathew JP (2010) Neurocognitive dysfunction following cardiac surgery. Semin
Cardiothorac Vasc Anesth 14:102–110
Marasco SF, Sharwood LN, Abramson MJ (2008) No improvement in neurocognitive outcomes
after off-pump versus on-pump coronary revascularisation: a meta-analysis. Eur J Cardiothorac
Surg 33:961–970
Mashour GA, Avitsian R, Lauer KK, Soriano SG, Sharma D, Koht A, Crosby G (2013)
Neuroanesthesiology fellowship training: curricular guidelines from the Society for
Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 25:1–7
A. Dabbagh
https://t.me/med1917
255
Mathew JP, Mackensen GB, Phillips-Bute B, Grocott HP, Glower DD, Laskowitz DT, Blumenthal
JA, Newman MF (2009) Randomized, double-blinded, placebo controlled study of neuropro-
tection with lidocaine in cardiac surgery. Stroke 40:880–887
McKhann GM, Grega MA, Borowicz LM Jr, Bailey MM, Barry SJ, Zeger SL, Baumgartner WA,
Selnes OA (2005) Is there cognitive decline 1 year after CABG? Comparison with surgical and
nonsurgical controls. Neurology 65:991–999
McKhann GM, Grega MA, Borowicz LM Jr, Baumgartner WA, Selnes OA (2006) Stroke and
encephalopathy after cardiac surgery: an update. Stroke 37:562–571
Messerotti Benvenuti S, Zanatta P, Longo C, Mazzarolo AP, Palomba D (2012a) Preoperative
cerebral hypoperfusion in the left, not in the right, hemisphere is associated with cognitive
decline after cardiac surgery. Psychosom Med 74:73–80
Messerotti Benvenuti S, Zanatta P, Valfre C, Polesel E, Palomba D (2012b) Preliminary evidence
for reduced preoperative cerebral blood fl ow velocity as a risk factor for cognitive decline three
months after cardiac surgery: an extension study. Perfusion 27:486–492
Mitchell SJ, Merry AF, Frampton C, Davies E, Grieve D, Mills BP, Webster CS, Milsom FP,
Willcox TW, Gorman DF (2009) Cerebral protection by lidocaine during cardiac operations:
a follow-up study. Ann Thorac Surg 87:820–825
Moller CH, Penninga L, Wetterslev J, Steinbruchel DA, Gluud C (2012) Off-pump versus on-
pump coronary artery bypass grafting for ischaemic heart disease. Cochrane Database Syst Rev
3, CD007224
Nathan HJ, Rodriguez R, Wozny D, Dupuis JY, Rubens FD, Bryson GL, Wells G (2007)
Neuroprotective effect of mild hypothermia in patients undergoing coronary artery surgery
with cardiopulmonary bypass: fi ve-year follow-up of a randomized trial. J Thorac Cardiovasc
Surg 133:1206–1211
Nelson DP, Andropoulos DB, Fraser CD, Jr. 2008. Perioperative neuroprotective strategies. Semin
Thorac Cardiovasc Surg Pediatr Card Surg Annu:49–56.
Newman MF, Grocott HP, Mathew JP, White WD, Landolfo K, Reves JG, Laskowitz DT, Mark
DB, Blumenthal JA (2001) Report of the substudy assessing the impact of neurocognitive func-
tion on quality of life 5 years after cardiac surgery. Stroke 32:2874–2881
Reinsfelt B, Westerlind A, Blennow K, Zetterberg H, Ricksten SE (2013) Open-heart surgery
increases cerebrospinal fl uid levels of Alzheimer-associated amyloid beta. Acta Anaesthesiol
Scand 57:82–88
Roach GW, Kanchuger M, Mangano CM, Newman M, Nussmeier N, Wolman R, Aggarwal A,
Marschall K, Graham SH, Ley C (1996) Adverse cerebral outcomes after coronary bypass
surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia
Research and Education Foundation Investigators. N Engl J Med 335:1857–1863
Rudolph JL, Schreiber KA, Culley DJ, McGlinchey RE, Crosby G, Levitsky S, Marcantonio ER
(2010) Measurement of post-operative cognitive dysfunction after cardiac surgery: a system-
atic review. Acta Anaesthesiol Scand 54:663–677
Sato Y, Laskowitz DT, Bennett ER, Newman MF, Warner DS, Grocott HP (2002) Differential
cerebral gene expression during cardiopulmonary bypass in the rat: evidence for apoptosis?
Anesth Analg 94:1389–1394, table of contents
Selnes OA, McKhann GM (2005) Neurocognitive complications after coronary artery bypass sur-
gery. Ann Neurol 57:615–621
Selnes OA, Grega MA, Borowicz LM Jr, Barry S, Zeger S, Baumgartner WA, McKhann GM
(2005) Cognitive outcomes three years after coronary artery bypass surgery: a comparison of
on-pump coronary artery bypass graft surgery and nonsurgical controls. Ann Thorac Surg
79:1201–1209
Sheehy AM, Coursin DB, Keegan MT (2009) Risks of tight glycemic control during adult cardiac
surgery. Ann Thorac Surg 88:1384–1385; author reply 1385–1386
Sun X, Lindsay J, Monsein LH, Hill PC, Corso PJ (2012) Silent brain injury after cardiac surgery:
a review: cognitive dysfunction and magnetic resonance imaging diffusion-weighted imaging
fi ndings. J Am Coll Cardiol 60:791–797
10 Postoperative CNS Care
https://t.me/med1917
256
van Dijk D, Spoor M, Hijman R, Nathoe HM, Borst C, Jansen EW, Grobbee DE, de Jaegere PP,
Kalkman CJ (2007) Cognitive and cardiac outcomes 5 years after off-pump vs on-pump coro-
nary artery bypass graft surgery. JAMA 297:701–708
Zhang XY, Liu ZM, Wen SH, Li YS, Li Y, Yao X, Huang WQ, Liu KX (2012) Dexmedetomidine
administration before, but not after, ischemia attenuates intestinal injury induced by intestinal
ischemia-reperfusion in rats. Anesthesiology 116:1035–1046
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A. Dabbagh et al. (eds.), Postoperative Critical Care for Cardiac Surgical Patients,
DOI 10.1007/978-3-642-40418-4_11, © Springer-Verlag Berlin Heidelberg 2014
A. Dabbagh , MD
Department of Anesthesiology and Anesthesiology Research Center, Faculty of Medicine ,
Shahid Beheshti University of Medical Sciences , Tehran , Iran
e-mail: alidabbagh@yahoo.com, alidabagh@sbmu.ac.ir
1 1
Postoperative Pain Management
in Cardiac Surgery
Ali Dabbagh
Contents
11.1 Introduction: The Effects of Acute Postoperative Pain and the
Benefi ts of Acute Pain Management in Postoperative Period ....................................... 258
11.2 The Effects of Acute Postoperative Pain and the Benefi ts of Acute
Pain Management in Postoperative Period .................................................................... 259
11.3 Patient Satisfaction and Patients’ Expectations ............................................................ 260
11.4 The Pathophysiology of Acute Pain in Cardiac Surgery Patients ................................. 260
11.5 The Etiologic Factors Aggravating Pain After Cardiac Surgery ................................... 261
11.6 Chronic Pain in Cardiac Surgery Patients ..................................................................... 262
11.6.1 Chronic Chest Pain.......................................................................................... 264
11.6.2 Chronic Leg Pain ............................................................................................ 264
11.7 Different Analgesic Methods ........................................................................................ 264
11.8 Pharmacologic Alternatives Used for Treatment of Acute Cardiac
Surgery Patients............................................................................................................. 265
11.8.1 Opioids ............................................................................................................ 266
11.8.2 Alpha 2 Agonists ............................................................................................. 273
11.8.3 Nonsteroidal Anti-infl ammatory Drugs (NSAIDs) ......................................... 273
11.8.4 Other Pharmaceutical Agents ......................................................................... 275
11.8.5 Multimodal Analgesia ..................................................................................... 276
11.8.6 Patient-Controlled Analgesia .......................................................................... 276
11.9 Regional Anesthetic Techniques for Acute Pain Suppression in Cardiac Surgeries .... 277
11.9.1 Infi ltration of Local Anesthetics in Wound ..................................................... 277
11.9.2 Intercostals Nerve Block ................................................................................. 278
11.9.3 Intrapleural Infi ltration of Local Anesthetics .................................................. 278
11.9.4 Neuraxial Blocks (Paravertebral, Intrathecal, Thoracic Epidural) .................. 278
References ................................................................................................................................ 283
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Abstract
Postoperative pain management is not only a medical concern but also among the
human rights; this challenging issue would be much more diffi cult in postopera-
tive period of cardiac surgery patients in whom the burden of the cardiac disease
and the complex perioperative events impose their heavy shadow on the deci-
sion-making process for selection of analgesic remedies for acute pain
suppression.
In this chapter, a brief discussion about the pathologic mechanisms of pain
and their possible risk factors and potential mechanisms is presented fi rst, and
then, analgesia methods are discussed in two main categories: pharmacologic
methods (including opioids, alpha 2 agonists, nonsteroidal anti-infl ammatory
drugs “NSAIDs,” paracetamol, ketamine, MgSO4, gabapentin, pregabalin, mul-
timodal analgesia, and patient-controlled analgesia) and non-pharmacologic
interventions (mainly infi ltration of local anesthetics, intercostal nerve block,
intrapleural infi ltration of local anesthetics, and neuraxial blocks, “paravertebral,
intrathecal, thoracic epidural”).
11.1 Introduction: The Effects of Acute Postoperative Pain
and the Benefits of Acute Pain Management in
Postoperative Period
Today, a considerable number of patients experience acute postoperative pain and it
has been demonstrated that between 30 and 80 % of patients complain of acute
“moderate to severe postsurgical pain”; so the health-care team still have to consider
postoperative pain as a challenge of care making acute postoperative pain manage-
ment among the highest priorities, both for the patients and the health-care team.
According to the NIH report, the annual pain-related health-care costs in the United
States was more than one hundred billion dollars ($100,000,000,000) in 1998, esti-
mated to be doubled now. According to the thirteenth World Congress on Pain in
Montreal, Quebec, Canada, Access to Pain Management is a Fundamental Human
Right ; it has been mentioned in Article 3, “ The right of all people with pain to have
access to appropriate assessment and treatment of the pain by adequately trained
health care professionals ”, while there are millions of patients who tolerate pain
without experiencing the unpleasant sensation of acute pain unnecessarily due to
acute, chronic, or cancer pain. The importance of acute pain management is that lack
of its treatment would change in a considerable number of patients to chronic pain,
fi nally causing “irreversible changes in the nervous system” ending in “progressive
biopsychosocial epiphenomena” with further impairments, incapacities, and chronic
health (Dolin et al. 2002 ; Popping et al. 2008b ; Lippe et al. 2010 ; International Pain
Summit of the International Association for the Study of Pain 2011 ).
Besides, it should be kept in mind that among a number of factors which could
affect the patient outcome, the quality of “acute postoperative pain management”
is an important and considerable one; since if we manage acute postoperative pain
in a qualitative manner, we could help prevent a number of unwanted
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hemodynamic, neuroendocrine, hemostatic, and immunologic side effects, possi-
bly decreasing the prevalence of postoperative morbidities (Peters et al. 2007 ;
Caputo et al. 2011 ).
In 2012, The American Society of Anesthesiologists has published the updated
version of “the American Society of Anesthesiologists’ Practice Guideline for Acute
Pain Management in the Perioperative Setting.” According to this guideline,
“ Anesthesiologists and other healthcare providers should use standardized , vali-
dated instruments to facilitate the regular evaluation and documentation of pain
intensity , the effects of pain therapy , and side effects caused by the therapy .” Also,
the guideline emphasizes that “ Anesthesiologists responsible for perioperative
analgesia should be available at all times to consult with ward nurses , surgeons , or
other involved physicians ” ( 2012 ).
In this chapter a brief explanation of the pathophysiologic mechanisms in patients
is explained fi rst. Then, different pharmacologic and non-pharmacologic approaches
of acute pain management are discussed with a brief explanation of their usage
methods, risks, and benefi ts.
11.2 The Effects of Acute Postoperative Pain and the
Benefits of Acute Pain Management in Postoperative
Period
Acute postoperative pain imposes undesirable perioperative surgical stress response;
the effects of perioperative insults to the body causes modifi cations in a number of
body systems including the immune system and its infl ammatory components and,
also, the metabolic and neurohormonal systems; the collective response is called
“the stress response”; this response would directly and indirectly affect many of the
body organs. The sympathetic system is affected by the effects of acute pain –
though age and sex could signifi cantly infl uence the sympathetic response – although
some studies have neglected the exact relationship between postoperative pain and
sympathetic tone to consider other factors such as the severity of surgical lesion and
“surgical trauma” much more important than the amount of sympathetic tone sever-
ity (Liu and Wu 2007 ; Ledowski et al. 2011 ; Wolf 2012a , b ).
Suppressing acute postoperative pain would alter patient satisfaction, prevent
unnecessary patient discomfort, and decrease the duration of postoperative hospital
length of stay, patient costs, overall morbidity, and even mortality; most are allevi-
ated after adequate postoperative pain management. Hence, postoperative analgesia
is a major indicator of postoperative care needing “early aggressive perioperative
care” (Jayr 1998 ; Popping et al. 2008a ).
Acute postoperative pain in adult cardiac surgery has some special features
compared with the other patients, both regarding the patient factors and the anal-
gesic methods, while often severe and undertreated which might cause severe
and prolonged chronic pain; hence, the pain management strategy should be “tai-
lored” to each patient in order to have satisfactory results. However, the newly
adopted fast- track anesthesia approach in cardiac surgeries necessitates more
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aggressive postoperative pain management in these patients. Multimodal analge-
sic methods are highly effective and possibly the best technique in the manage-
ment of acute postoperative pain. However, this approach has very important
considerations due to the specifi c type of cardiac procedures. For example, neur-
axial analgesia has its own limitations due to the coagulation disturbances after
administration of anticoagulation and antiplatelet agents to be discussed later in
this chapter (Schwann and Chaney 2003 ; Milgrom et al. 2004 ; Stritesky et al.
2004 ; Lena et al. 2008 ; Popping et al. 2008a , b ; Campos 2009 ; Katz and Seltzer
2009 ; Cogan 2010 ; Muehling et al. 2011 ; Huffmyer et al. 2012 ; Mugabure
Bujedo 2012 ; Nishimori et al. 2012 ; Romeyke and Stummer 2012 ; Usichenko
et al. 2013 ).
11.3 Patient Satisfaction and Patients’ Expectations
When dealing with pain in cardiac surgery patients, it should be considered that
cardiac surgery patients usually expect a greater amount of postoperative pain than
the real pain. So, when they make a comparison between anticipated pain and
experienced pain (which is the actual pain), the patients usually express an accept-
able and high level of satisfaction, although they really experience severe pain. So,
there is a good level of patient satisfaction in such patients in the postoperative
period. However, the health-care team should describe all aspects of postoperative
pain with each patient, especially the potential for occurrence of chronic pain syn-
dromes and its risk factors before the surgery. Of course, the different activities of
the patients have different pain thresholds. One study demonstrated the following
decreasing order of postoperative pain in cardiac surgical patients: “coughing,
moving or turning in bed, getting up, deep breathing or using the incentive spirom-
eter, and resting,” while the pain intensity was decreased after removal of chest
tubes. Also, the patients expect the health-care team to help them improve the tol-
erance of acute pain in order to gain their normal life (Simpson et al. 1996 ; Aida
et al. 2002 ; Milgrom et al. 2004 ; Leal et al. 2005 ; Anderson and Cutshall 2007 ;
Ballan and Lee 2007 ; Lee 2008 ; Aslan et al. 2009 ; Azzopardi and Lee 2009 ; Parry
et al. 2010 ).
11.4 The Pathophysiology of Acute Pain in Cardiac
Surgery Patients
It should be always considered as an alerting note that in patients undergoing car-
diac surgery, the acute postoperative pain could be due to residual ischemia and/or
incomplete revascularization; so acute postoperative pain in these patients should
always lead the health-care team to a very important differential diagnosis: residual
ischemia. This differentiation is so much important . After ruling out the above con-
dition, we would focus on the most common source of acute postoperative pain in
these patients which is mainly with a myofascial origin and originates from many
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sources, most commonly originating from the chest wall (including the muscles,
bony structures, tendons, and ligaments) (Jayr 1998 ; Acharya and Dunning 2010 ;
Borgermann et al. 2010 ).
Usually in patients undergoing surgical procedures, the perioperative surgical
stress response will increase to its uppermost levels just in the immediate postopera-
tive period when it produces its many major pathophysiologic effects (including
postoperative pain). This is the same after cardiac surgery with even more severe
degrees of stress response due to the nature of cardiac surgery patients; most of
them often tolerate the imposed infl ammatory response due to cardiopulmonary
bypass.
In patients undergoing cardiac surgery, there are considerable homeostatic dis-
turbances which could lead to a number of great pathophysiologic changes in many
of the major organ systems, including (but not limited to) the cardiovascular system,
the lungs, the gastrointestinal system, the urinary system, the endocrine system,
oxygen consumption, the immunologic system, and, fi nally, the central nervous sys-
tem; these unwanted effects of cardiac surgery may lead to substantial postoperative
morbidity and possibly to increased mortality. On the other hand, there are many
studies that have clearly demonstrated potentially improved clinical benefi ts after
adequate postoperative analgesia, which is due to increased level of stability in
hemodynamic, metabolic, immunologic, and homeostatic factors and also more lev-
els of stress response attenuation (Jayr 1998 ; Ledowski et al. 2011 , 2012 ; Bodnar
2011 ; Brock et al. 2012 ; Nishimori et al. 2012 ; Oderda 2012 ; Torigoe et al. 2012 ;
Urell et al. 2012 ; van Ojik et al. 2012 ).
11.5 The Etiologic Factors Aggravating Pain
After Cardiac Surgery
There are a number of different potential etiologic risk factors for acute pain in these
patients which are presented in Table 11.1 .
Usually the pain location varies being a function of time; in other words, during
the early postoperative days (usually the three postoperative days), the pain is mainly
in the thoracic area, while, afterwards, it immigrates to the legs (i.e., the location of
vein harvesting in CABG patients) and would be dominant there up to the end of the
fi rst postoperative week. During this transition, the type of pain will often change
from a radicular chest pain to osteoarticular type leg pain at the end of the fi rst week.
Table 11.1 A summary of etiologic risk factors for acute pain in cardiac surgery patients and
their pain sources
Etiologic factor
1 Incision site pain after sternotomy or thoracotomy
2 Intraoperative tissue retraction and surgical dissection
3 The arterial and venous vascular cannulation sites
4 The site of vein harvesting
5 The chest and abdominal sites for chest tubes
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