3. Pain
an unpleasant sensation localized to a part of the body.
stabbing, burning, twisting, tearing, and squeezing
associated with behavioral arousal and a stress response
increased blood pressure
heart rate, pupil diameter
and plasma cortisol levels
4. Pain assessment Tools
Pain is a subjective experience
Visual analog scale (VAS)
Numerical rating scale (NRS)
Verbal rating scale (VRS)
FACES pain rating scale
5. always considered
acute postoperative pain could be due to residual
ischemia and/or incomplete revascularization
most commonly originates from the chest wall
including the muscles, bony structures, tendons, and
ligaments
6. etiologic risk factors for acute pain sources:
• Incision site pain after sternotomy or thoracotomy
• Intraoperative tissue retraction and surgical
dissection
• The arterial and venous vascular cannulation sites
• The site of vein harvesting
• The chest and abdominal sites for chest tubes
7. Factor increase acute postoperative pain
gender
Age young age
prolonged surgical duration and
anatomical surgery location
8. Management Of Pain
Multimodal pain management is a critical
component of routine early postoperative
management for cardiac surgical patients
administration of more than one single drug
1 opioids
2 NSAIDs
3 Acetaminophen
4 Local anesthetics
9. Postoperative management
goal
alter patient satisfaction,
Prevent unnecessary patient discomfort, and
decrease the duration of postoperative ICU length of stay
patient costs,
overall morbidity, and even mortality
10. Adequate pain control is mandatory to improve
pulmonary function, decrease delirium, and
increase patient satisfaction
Pulmonary complications: Respiratory splinting
secondary to pain leads to inadequate pulmonary
toilet
predisposing the patient to pneumonia, atelectasis,
and possible reintubation.
11. Cardiovascular complications: Pain is associated
with increased sympathetic outflow through
increased levels of circulating catecholamines.
After cardiac surgery, this state of elevated
sympathetic outflow
both increasing myocardial oxygen demand and
predisposing patients to arrhythmias
12. 1. Opioids
opioids interact with many different body systems
through the receptors. Such as delta, kappa, and mu
The analgesic effects of opioids in the central nervous
system are exerted through these receptors.
opioids could have many beneficial effects in
counteracting the unwanted effects of surgical stress
response after cardiac surgery, which would help the
body in the maintenance of homeostasis;
13. gold standard of suppression of acute postoperative
pain in cardiac surgery
14. Morphine
the most popular analgesic used in patients after
cardiac surgery
morphine sulfate which are more water-soluble.
Morphine has 30–40% plasma protein binding and
has primarily hepatic metabolism
Elimination half-life of morphine is 2–3 h
15. Synthetic opioid agents
four main synthetic opioid agonists used for acute
pain management
fentanyl
Sufentanil
alfentanil and
remifentanil.
16. Fentanyl
a very potent opioid is about 80–120 times more
potent than morphine
receptor affinity is three times more than morphine.
150 times more lipid-soluble than morphine
bypass BBB much faster than the water-soluble
morphine
creating its analgesic effects more rapidly than
morphine
administered as IV or IM
17. due to its high lipophilicity, fentanyl infusion leads to
accumulated amounts of the drug in adipose tissues,
and when the infusion is disconnected, the infused
amounts of fentanyl are released into plasma
To prevent prolonged residual effects
a primary bolus dose of 1–2 μg/Kg of the drug.
At the same time, start an IV infusion of 1–3 μg/Kg/h.
Depending on patient needs, adjust the infusion dose
18. Sufentanil
another opioid synthetic compound which is about
five to ten times more potent than fentanyl.
extremely lipid-soluble with a very high plasma
protein-binding capacity,
metabolized mainly in the liver
Alfentanil is another opioid compound similar to
fentanyl but five to ten times less potent than
fentanyl. Its clinical effects are presented very shortly
19. Remifentanil is the newest version of synthetic
opioids
having an analgesic potency equal to fentanyl and
20–30 times more potent than alfentanil.
very fast onset
used as a continuous infusion as long as the patient
has pain.
20. Opioids side effect
Respiratory system: opioids cause respiratory depression
1. Decreased respiratory rate.
2. Decreased tidal volume
3. Disturbed rhythmic function and generation of the
respiration.
4 Change in the pattern of respiration.
5. Decreased sensitivity to hypoxia leading to decreased
ventilator drive to hypoxia.
6. Finally, apnea
21. Nonsteroidal Anti-inflammatory Drugs
(NSAIDs)
Having analgesic and anti-inflammatory properties
NSAIDs are used frequently in the perioperative period.
NSAIDs are clinically effective in suppressing acute
postoperative pain in decreasing the need for
postoperative opioid use and
improving the clinical outcome.
22. Their main mechanism of action is the blockade of
cyclooxygenase (COX) enzyme leading to
prostaglandin synthesis inhibition
23. Potential contraindications of NSAIDs are
elderly people
heart failure
hypovolemic states
cirrhotic patients
renal failure
history of active GI tract disease and peptic ulcer
disease
active bleeding diathesis, and pregnant patients
24. The most important adverse effects of NSAIDs are
1. Gastrointestinal complications could lead to
serious and life-threatening hemorrhage due to
concomitant administration of anticoagulants.
2. Increased risk of bleeding
3. Acute renal ischemia, especially if administered
concomitantly with diuretics, angiotensin-
converting enzyme inhibitors, and/or angiotensin
receptor antagonists”
25. Paracetamol (N-Acetyl-P-Aminophenol)
one of the most common analgesics used
worldwide, mainly acting through central blockade
of acute pain pathways and
creating mild to moderate analgesia and mild anti-
inflammatory effect
IV or PO
the drug is recommended as part of a multimodal
analgesic regimen
26. Regional Anesthetic for Acute Pain Suppression
in Cardiac Surgeries
Infiltration of local anesthetic in wound
Intercostal nerve block
Intrapleural infiltration of local anesthetics
Neuraxial analgesia (paravertebral, intrathecal,
thoracic epidural)
27. 1. Infiltration of Local Anesthetics in Wound
This is an effective method in cardiac surgery
patients especially when used with other analgesic
methods for controlling acute postoperative pain.
Infusion of a local anesthetic directly into the
surgical wound.
28. 2. Intercostal Nerve Block
a simple and efficient method for the administration
of local anesthetic agents into the intercostal
neurovascular bundle
effective adjuvant analgesic method for acute
postoperative pain suppression
29. 3. Intrapleural Infiltration of Local Anesthetics
This method involves administration of local
anesthetics between the visceral and parietal pleura.
Local anesthetics may be administered as a single
shot or continuous infusion through a catheter
30. Sedation
is the process of relieving anxiety and establishing a
state of calm
Distress generally presents as agitation. It is common
among critically ill patients, especially those who are
intubated or having difficulty communicating with their
caregivers
31. Patients are typically sedated upon arrival to ICU
Most patients extubated within 6hr after routine
cardiac surgery
32. In the early period hemodynamic instability lasting
approximately 6 to 12 hours, followed by a period of
recovery
Depends on
1. Severity of the patient's underlying cardiac disease
2. intraoperative events
34. Dexmedetomidine
an alpha-2 adrenergic agonist with sedative,
analgesic, anxiolytic, and sympatholytic properties,
commonly used to sedate patients after cardiac
surgery
The mechanism of action in these agents is the
creation of sedation through stimulation of α2
receptors in the locus coeruleus and the creation of
analgesia through stimulation of α2 receptors within
the locus coeruleus and the spinal cord.
35. Weaning from mechanical ventilation is possible
during sedation with lower dose infusions 0.2 to
0.4mcg/kg per hour.
a good substitute for propofol in cardiac patients and
may result in faster extubation and decreased
mortality
36. Dexmedetomidine can cause significant
bradycardia and hypotension and must be used with
caution
37. propofol
a potent IV anesthetic agent with a very short half-life.
commonly used as a continuous infusion
commonly used and, when combined with intermittent
narcotic doses, results in faster postoperative extubation.
10 to 50 mcg/kg per minute
38. Ketamine
produces an altered state of consciousness (dissociation),
amnesia, and analgesia
ketamine causes an increase in catecholamine release
and cholinergic receptor stimulation.
often used in asthmatic patients as well as in
hemodynamically unstable patients or patients with
congenital heart disease
a negative inotrope and administration to patients who
are catecholamine depleted can cause profound
hypotension and shock.
Other adverse effects of ketamine include hallucinations,
myoclonic movements, and excessive salivation
39. Agents to avoid
avoid benzodiazepines in the postoperative setting
after routine cardiac surgery
association with delirium, especially when
delivered as a continuous infusion
increased duration of MV and
length of ICU stay
It is often described in terms of a penetrating or tissue-destructive process (e.g.,
Cardiac surgery is a complex and often painful procedure that requires careful postoperative care
he American Society of Anesthesiologists’
mainly as intravenous and/or neuraxial routes
from normal regular breath to irregular gasping pattern of spontaneous ventilation; this pattern is the characteristic pattern for the patients with diagnosis of opioid overdose
if pain is refractory to opioids and acetaminophen, an NSAID with combined cyclooxygenase (COX) 1 and COX-2 activity may be used for a limited duration in selected patients who have good renal function and are not at risk for significant bleeding or acute kidney injury
less respiratory depression than propofol and other sedative/hypnotic regimens
shorter ICU length of stay
propofol has no analgesic propertie
s. Thus, a multimodal analgesic regimen including an IV opioid is typically necessary
typically for cardiac surgery who may have a more prolonged duration of MV or for patients with severe hemodynamic instability who require deeper levels of sedation