Summary Recommendations - ESRA
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Sternotomy 2020

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Summary Recommendations

PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

Pain after median sternotomy can be debilitating and difficult to treat (Lahtinen 2006; Kelava 2020). Furthermore, inadequately managed pain may increase the risk of postoperative pulmonary complications, cardiac complications and long-term complications such as poststernotomy pain syndrome (Szelkowski 2015; Bordoni 2017).

The aim of this PROSPECT review (Maeßen 2023) was to evaluate the available literature about the effects of analgesic, anaesthetic and surgical interventions on pain after cardiac surgery via median sternotomy, and to develop evidence-based, procedure-specific recommendations for pain management.

The unique PROSPECT methodology is available at https://esraeurope.org/prospect-methodology/. The methodology considers clinical practice, efficacy and adverse effects of analgesic techniques.

Literature databases were searched up to November 2020.

Summary of recommendations and key evidence for pain management in patients undergoing cardiac surgery via median sternotomy

Pharmacological treatment
A combination of paracetamol and NSAID is recommended pre-operatively or intra-operatively, and should be continued into the postoperative period, unless there are contra-indications

  • Procedure-specific evidence supports the use of paracetamol (Mamoun 2016; Douzjian and Kulik 2016; Arslan 2018) and NSAIDs (Rapanos 1999; Dhawan 2009; Koizuka 2004; Kulik 2004) as basic analgesics
  • COX-2 specific inhibitors could not be recommended due to lack of evidence and safety concerns (more wound infections after 14 days of continuous use) (Ott 2003; Nussmeier 2005)
  • Recent evidence on NSAID-related adverse events indicates that this is related to their prolonged use at higher doses and/or in inappropriate patient populations. Short courses of nonselective NSAIDs may be relatively well tolerated in this patient population (Chang 2021)
  • It is suggested that the risk of acute kidney injury or increase in the incidence of cardiac adverse events with a short duration of NSAID use after cardiac surgery is low (Chang 2021)
  • A systematic review questioned common concerns about NSAID-induced bleeding (Bongiovanni 2021)
Intra-operative magnesium and dexmedetomidine infusions may be considered as adjuncts, particularly when basic analgesics are not administered

  • Importantly, it is not clear if combining dexmedetomidine and magnesium would provide superior pain relief as compared with either drug alone. The optimal combination of these agents and their dosing remains unclear (Shanthanna 2021)
  • Studies of dexmedetomidine reported analgesic benefit, but basic analgesics were not administered (Abdel-Meguid 2013; Hashemian 2017; Priye 2015; Aziz 2011; Anvaripour 2018)
  • A concern with dexmedetomidine is the associated prolonged bradycardia and hypotension, which may extend into the postoperative period (Demiri 2019). Also, dexmedetomidine can cause airway obstruction, and increase the risk of postoperative hypoxia (Lodenius 2019)
  • Magnesium is often used in cardiac surgery for its antiarrhythmic properties. Studies in this systematic review found analgesic benefits with use of magnesium (Ahmad 2018; Bolcal 2005; Ferasatkish 2005; Mostafa 2011; Steinlechner 2006); however, basic analgesics were not used
  • Similar to dexmedetomidine, magnesium can potentiate hypotensive effects of other adjuncts and potentiate neuromuscular blockade and increase the risk of residual paralysis (Soave 2009). Therefore, careful consideration is needed when using dexmedetomidine and magnesium, particularly in patients at risk of haemodynamic instability
Opioids should be reserved for rescue analgesia

Regional analgesic strategies
Parasternal block/surgical wound infiltration is recommended

Non-pharmacological therapies
Non-pharmacological therapy, such as music and massage, is recommended as adjunct to pharmacological therapy

COX, cyclooxygenase; NSAID, non-steroidal anti-inflammatory drug.

Analgesic interventions that are not recommended for pain management in patients undergoing cardiac surgery via median sternotomy.

Intervention

Reason for not recommending
COX-2 specific inhibitors Limited procedure-specific evidence and safety concerns
Gabapentinoids Inconsistent procedure-specific evidence
Ketamine Lack of procedure-specific evidence
Epidural analgesia Inconsistent evidence, safety concerns
Intrathecal opioids Inconsistent evidence, safety concerns
Lidocaine infusion Lack of procedure-specific evidence
Nefopam Lack of procedure-specific evidence
Methadone Limited procedure-specific evidence
Kinesio tape Limited procedure-specific evidence
Preoperative physiotherapeutic instructions Lack of procedure-specific evidence
Acupuncture Limited procedure-specific evidence
Classical chest physiotherapy Lack of procedure-specific evidence
Hypnosis Limited procedure-specific evidence
Aromatherapy (lavender oil) Lack of procedure-specific evidence
Reiki Lack of procedure-specific evidence
Psychological interventions Limited procedure-specific evidence
Early extubation Lack of procedure-specific evidence

NSAIDs, non-steroidal anti-inflammatory drugs.

PROSPECT recommendations for cardiac surgery via median sternotomy-infographic