Brandi A. Bottiger

Pain Management Strategies for Thoracotomy and Thoracic Pain Syndromes

Pain after thoracic surgery can be severe and, in the acute phase, contribute to perioperative morbidity and mortality. Unfortunately, patients also incur a significant risk of chronic pain. Although there are guidelines for postoperative pain management in these patients, there is no widespread surgical or anesthetic “best practice.” Here, we review the recent literature on techniques specific to perioperative pain control for thoracic patients, including medical management, neuraxial blockade, and other regional techniques, and suggest an algorithm for developing a multimodal pain management strategy.

Bloodless Orthotopic Heart Transplantation in a Jehovah's Witness.

We present the case of a 53-year-old female Jehovahs Witness with nonischemic cardiomyopathy who successfully underwent a bloodless heart transplantation using fibrinogen concentrate (RiaSTAP; CSL Behring, King of Prussia, PA) and other blood-conservation methods. With a multidisciplinary team and the use of preoperative erythropoietin-stimulating drugs, normovolemic hemodilution, cell salvage, and pharmacotherapy to prevent and treat coagulopathy, we were able to maintain hemoglobin levels greater than 11 g/dL without the need for blood transfusion. We conclude that orthotopic heart transplants may be performed successfully in select Jehovahs Witness patients using standard and novel blood conservation methods.

Pectoral Fascial (PECS) I and II Blocks as Rescue Analgesia in a Patient Undergoing Minimally Invasive Cardiac Surgery

Introduction Patients undergoing minimally invasive cardiac surgery have the potential for significant pain from the thoracotomy site. We report the successful use of pectoral nerve block types I and II (Pecs I and II) as rescue analgesia in a patient undergoing minimally invasive mitral valve repair. Case Report In this case, a 78-year-old man, with no history of chronic pain, underwent mitral valve repair via right anterior thoracotomy for severe mitral regurgitation. After extubation, he complained of 10/10 pain at the incision site that was minimally responsive to intravenous opioids. He required supplemental oxygen because of poor pulmonary mechanics, with shallow breathing and splinting due to pain, and subsequent intensive care unit readmission. Ultrasound-guided Pecs I and II blocks were performed on the right side with 30 mL of 0.2% ropivacaine with 1:400,000 epinephrine. The blocks resulted in near-complete chest wall analgesia and improved pulmonary mechanics for approximately 24 hours. After the single-injection blocks regressed, a second set of blocks was performed with 266 mg of liposomal bupivacaine mixed with bupivacaine. This second set of blocks provided extended analgesia for an additional 48 hours. The patient was weaned rapidly from supplemental oxygen after the blocks because of improved analgesia. Conclusions Pectoral nerve blocks have been described in the setting of breast surgery to provide chest wall analgesia. We report the first successful use of Pecs blocks to provide effective chest wall analgesia for a patient undergoing minimally invasive cardiac surgery with thoracotomy. We believe that these blocks may provide an important nonopioid option for the management of pain during recovery from minimally invasive cardiac surgery.

CASE 8—2015Paravertebral Catheter-Based Strategy for Primary Analgesia After Minimally Invasive Cardiac Surgery

ORT-ACCESS MINIMALLY INVASIVE cardiac surgery (PACS) has potential advantages when compared with traditional sternotomy techniques. These include smaller surgical incision, reduced trauma and blood loss, and shorter length of hospital stay. 1,2 Typically, PACS procedures are performed through a right anterior minithoracotomy or hemisternotomy, and postoperative pain commonly is managed primarily using intravenous analgesics, usually with an on-demand opioid or opioid-based patient-controlled analgesia (PCA). When an opioid is chosen as the primary strategy, particularly an intravenous PCA, benefits include ease of use, availability, and improved patient satisfaction, compared with on-demand pain treatment. Common adverse effects to opioidbased strategies include respiratory depression, delirium, and gastrointestinal dysfunction, which substantially can inhibit postoperative recovery and potentially cause harm to the aging and comorbid population that represents many cardiac surgery patients. In addition, minithoracotomy incisions used during PACS procedures also involve an increased risk of chronic pain, which is not prevented or reduced by an opioid-only strategy. 2–4 Analgesic strategies that reduce opioid consumption and improve long-term outcome after PACS, including regional or neuraxial anesthetic techniques, are desirable to reduce this complication and improve outcomes from PACS procedures. For thoracic surgery patients, regional analgesia delivered through thoracic paravertebral (PV) or epidural catheters provides high-quality analgesia for post-thoracotomy pain and is associated with reduced overall complication rates relative to parenteral opioids. 5–14 Published studies indicate that thoracic PV and epidural-based analgesia delivery of continuous local anesthetic infusions are approximately of equal value for pain control, but PV catheters are associated with fewer side effects, including hypotension. 15–17 The advantages of regional techniques involving the neuraxis always must be contrasted against their associated risk of epidural hematoma, particularly related to anticoagulation used during cardiopulmonary bypass (CPB). To avoid the risk of epidural hematoma, an alternate approach to neuraxial regional analgesia includes PV catheter placement. Although the usefulness of PV catheters have been confirmed for post-lung resection thoracotomy analgesia, their value for PACS patients is unclear. Here, the clinical course of 3 cardiac surgery patients undergoing PACS with PV catheters inserted for primary analgesia is described. These examples are reviewed in the context of existing literature and also serve to highlight the challenges of postoperative analgesia for PACS patients.

Frailty in the End-Stage Lung Disease or Heart Failure Patient: Implications for the Perioperative Transplant Clinician

The syndrome of frailty for patients undergoing heart or lung transplantation has been a recent focus for perioperative clinicians because of its association with postoperative complications and poor outcomes. Patients with end-stage cardiac or pulmonary failure may be under consideration for heart or lung transplantation along with bridging therapies such as ventricular assist device implantation or venovenous extracorporeal membrane oxygenation, respectively. Early identification of frail patients in an attempt to modify the risk of postoperative morbidity and mortality has become an important area of study over the last decade. Many quantification tools and risk prediction models for frailty have been developed but have not been evaluated extensively or standardized in the cardiothoracic transplant candidate population. Heightened awareness of frailty, coupled with a better understanding of distinct cellular mechanisms and biomarkers apart from end-stage organ disease, may play an important role in potentially reversing frailty related to organ failure. Furthermore, the clinical management of these critically ill patients may be enhanced by waitlist and postoperative physical rehabilitation and nutritional optimization.

Phenylephrine infusion for spinal-induced hypotension in elective cesarean delivery: Does preload make a difference?

Background and Aims: Patients undergoing elective cesarean delivery (CD) have a high-risk of spinal-induced hypotension (SIH). We hypothesized that a colloid preload would further reduce SIH when compared with a crystalloid preload. Material and Methods: Eighty-two healthy parturients undergoing elective CD were included in the study. Patients were randomly assigned to two groups (41 patients in each group) to receive either Lactated Ringers solution (1500 ml) or hydroxyethyl starch (6% in normal saline, 500 ml) 30 min prior to placement of spinal anesthesia. All patients were treated with a phenylephrine infusion (100 mcg/min), titrated during the study. Results: There was no statistical difference between groups with regards to the incidence of hypotension (10.8% in the colloid group vs. 27.0% in the crystalloid group, P = 0.12). There was also no difference between groups with respect to bradycardia, APGAR scores, and nausea and vomiting. Significantly less phenylephrine (1077.5 ± 514 mcg) was used in the colloid group than the crystalloid group (1477 ± 591 mcg, P = 0.003). Conclusion: The preload with 6% of hydroxyethyl starch before CD might be beneficial for the prevention of SIH.

Intraoperative Monitoring of Pulmonary Artery Physiology With Transesophageal Echocardiography in a Patient With an Extensive Pulmonary Aneurysm Undergoing Partial Nephrectomy.

Surgical patients with pulmonary hypertension present a significant challenge to the anesthesiologist. Continuous perioperative monitoring of pulmonary artery (PA) pressure is recommended and most often accomplished with a PA catheter. Placement of a PA catheter may be difficult or contraindicated, and in these cases, transesophageal echocardiography is a useful alternative to monitor dynamic PA physiology. In this case, we used intraoperative transesophageal echocardiography to detect changes in peak PA pressure and guide clinical treatment in a patient with pulmonary hypertension and an extensive PA aneurysm undergoing partial nephrectomy.

Acute Management of the Opioid-Dependent Patient

Seventy million patients are afflicted by and treated for chronic pain in the United States and treated more frequently with long-term opioids, particularly morphine, oxycodone, and methadone in the treatment of non-cancer pain. Many of these patients will arrive for surgical procedures, and pain management will be a major part of their hospital stay. According to various sources, approximately 40 % of all surgical patients still experience moderate to severe pain and almost a quarter of them experience inadequate pain relief. Allowing patients to suffer from poorly controlled pain not only may be considered a breach of human rights but may result in emotional and cognitive problems, negatively impacting postoperative rehabilitation and quality of life.