Managing pain in the cardiac surgical patient

1. By: Dr Farwa

2. What is pain?
 "an unpleasant sensory and emotional
experience associated with actual or potential
tissue damage”.

3. •Discuss postop pain management.

4. Chronic Pain
• Lasts longer than 3-6 months
• Serves no purpose
• Cannot identify a cause
• Can lead to pain behaviors
• Very difficult to treat

5. •Injury triggers release of bio-chemicals
•Inflammation takes place
•Stimulation of nerve fibers
•Bio-chemicals causes pain impulses to begin

6. •Persistent acute postoperative pain:
•Decreases the body’s physiologic
reserves
•May exacerbate co-morbid conditions (e.g.) increase risk
of MI in patients with CAD
•Contributes to pulmonary complications

7. •Impairs rehabilitation and functional
outcome
• May lead to development of chronic pain
syndromes and long-term disability.
• Increases hospital stay and the cost of
patient care
• Decreases patient satisfaction.

8. •Surgical insult results in post op pain
•Increased circulating catecholamines
•Resulting in tachycardia and hypertension
•Leading to increased cardiac work
•Resulting in increased myocardial oxygen consumption

9. Cardiovascular
• ↑ HR, ↑ BP, ↑ SVR, altered regional blood flow, ↑CMO2, ↑
DVT
Respiratory:
•– ↓ VL (atelectasis), ↓ cough (sputum retention)
•– hypoxemia and infection

10. Gastrointestinal:
•– ↓ gastric and bowel motility, nausea, vomiting
• Genitourinary: urinary retention
• Neuroendocrine: ↑ catabolic hormones
•– ↑ blood glucose, Na + H20 retention

11. Musculoskeletal: Muscle spasm,
immobility (↑ DVT)
Psychological: fear, anxiety, insomnia

12. Transduction: Conversion of a noxious stimuli
(chemical, mechanical, or thermal) into electrical
energy
Transmission: Electrical stimulus is sent to the
dorsal horn of the spinal cord and synapse at
the 2nd order neuron
Modulation: Inhibition vs amplification of signal
Perception: Conscious awareness of pain as a
culmination of previous processes in the
context of the individuals experiences

13.  Chest surgery... among the most debilitating
for patients due to pain/respiratory
dysfunction.
 Important sources of postoperative
discomfort after cardiothoracic surgery…..
 incisional pain.
 indwelling thoracostomy tubes.
 rib/sternal Fx.
 costovertebral joint pain.

14.  Chronic pain d/t…..
 intercostal nerve injury develops in
approximately 50% of postthoracotomy
patients.
 in 5% becomes severe and disabling.

15.  patients should be warned in advance of this
complication….. As…..
 No single thoracotomy technique has been
shown to reduce the incidence of chronic
postthoracotomy pain.