New PROSPECT recommendations about postoperative pain management – median sternotomy and elective craniotomy - ESRA

ESRA Updates

December 2023 | Issue 14

New PROSPECT recommendations about postoperative pain management – median sternotomy and elective craniotomy

Clara Lobo (Editor of ESRA Updates; Cleveland Clinic Abu Dhabi, UAE) @claralexlobo

In the pursuit of enhancing patient outcomes and ensuring optimal recovery after cardiac surgery via median sternotomy (1) and craniotomy (2), the recent PROSPECT publications brings forth valuable insights into pain management strategies. The recommendations are rooted in rigorous evidence. To know more, please follow the link.

Cardiac Surgery via median sternotomy

The PROSPECT publication emphasizes a paradigm shift towards non-opioid analgesics, acknowledging the efficacy of paracetamol and NSAIDs as fundamental postoperative analgesics. The guideline underlines the overall recommendation of NSAIDs as basic analgesics, while cautioning against the use of COX-2 specific inhibitors due to insufficient evidence and safety concerns. This endorsement signifies a significant departure from conventional practices, steering practitioners towards a more nuanced approach in pain management.

Dexmedetomidine and magnesium emerge as promising additions to the postoperative analgesic arsenal. The publication suggests their use, especially in scenarios where basic analgesics are either contraindicated or not administered.

Highlighting the importance of targeted pain relief, the PROSPECT guidelines commend the use of parasternal blocks and local infiltration. These interventions showcase a dual benefit of reducing opioid consumption and improving pain scores. This localized precision in analgesic interventions not only contributes to enhanced patient comfort but also aligns with the broader healthcare goals of minimizing opioid-related complications.

While advocating for a reduced reliance on opioids, the guidelines underscore their role as rescue medications. This nuanced approach acknowledges the necessity of opioids in managing acute pain episodes, ensuring that patient discomfort is promptly addressed while avoiding unnecessary opioid exposure.

The document also sheds light on interventions not recommended due to insufficient evidence or safety concerns. The ESP block, for instance, finds itself in the former category, signaling the need for further investigation. Conversely, epidural analgesia with or without opioids and/or intrathecal opioids face cautionary notes, particularly in patients on high doses of anticoagulants, underscoring the imperative for cautious consideration in such cases.

Looking ahead, the guidelines pinpoint areas for future studies, with a focal point on assessing the effects of analgesic interventions for fast-track cardiac surgery. The emphasis lies on interventions that facilitate early tracheal extubation and ambulation, aligning with the evolving landscape of cardiac care that prioritizes swift recovery.

In addition to pharmacological interventions, the publication recognizes the value of non-pharmacological approaches, such as massage therapy and music therapy as effective adjuncts to traditional analgesic strategies. This holistic perspective acknowledges the multifaceted nature of pain management and encourages a comprehensive, patient-centered approach.

Pain Management after elective craniotomy

This new review synthesizes key findings, shedding light on effective strategies and areas requiring further exploration considering elective craniotomy under general anesthesia.

According to the latest evidence, a “basic analgesia regimen” comprising paracetamol and NSAIDs or COX-2 inhibitors proves to be a cornerstone in achieving significant analgesia while concurrently reducing opioid consumption. Importantly, NSAIDs and COX-2 inhibitors, integral components of this regimen, do not pose an increased risk of bleeding or interfere with bone healing. However, caution is advised in patients with renal impairment, where these agents should be used judiciously.
Dexmedetomidine emerges as a promising adjunct for pain relief, though its administration demands careful titration to mitigate potential hemodynamic instability and increased sedation. Scalp nerve blocks and incisional surgical infiltration, whether administered pre- or post-surgery, stand out as effective measures in reducing pain scores and opioid use. Both techniques should not be combined, due to the high risk of local anesthetic systemic toxicity (LAST).
Gabapentinoids’ role remains a subject of debate; while they show a mild reduction in opioid consumption, concerns over increased sedation and other side effects warrant reservations for recommending their use.
Systemic opioids should be reserved as rescue analgesics in the postoperative period. Acupuncture, suggested as an alternative when basic analgesics are impractical, presents an intriguing avenue for further exploration.

The PROSPECT publication advocates reserving systemic opioids as rescue analgesics in the postoperative period, emphasizing a move towards multimodal approaches that minimize opioid reliance.
Notably, the review recommends the cautious use of i.v. dexamethasone despite the absence of specific evidence. This underscores the need for ongoing research to solidify the role of this intervention in enhancing postoperative pain management.
Identifying interventions not recommended for pain management in craniotomy patients, the publication adds a layer of clarity. Moreover, it underscores the necessity for high-quality studies to delineate the efficacy of recommended approaches within the context of enhanced recovery pathways.

In conclusion, the PROSPECT publication serves as a compass guiding healthcare practitioner towards evidence-based and patient-centered postoperative pain management strategies. By endorsing novel approaches and cautioning against certain practices, these guidelines contribute to the continuous refinement of patient care, ultimately steering the field towards improved patient outcomes and enhanced recovery.

For those seeking a deeper understanding, the full text of the PROSPECT publications can be accessed through the provided links in this review or PROSPECT webpage. As we delve into this evolving landscape, the publication serves as a guidepost, steering practitioners toward evidence-based practices while prompting critical inquiry into the intricacies of postoperative pain management.

  1. Maeßen, T., Korir, N., van de Velde, M., Kennes, J., Pogatzki-Zahn, E., & Joshi, G. P. (2023). Pain management after cardiac surgery via median sternotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations. European Journal of Anaesthesiology40(10), 758–768.
  2. Mestdagh, F. P., Lavand’homme, P. M., Pirard, G., Joshi, G. P., Sauter, A. R., & van de Velde, M. (2023). Pain management after elective craniotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations. European Journal of Anaesthesiology40(10), 747–757.
Topics: PROSPECT , craniotomy , sternotomy , postoperative pain management

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