For sedation and pain management in the ICU after cardiac surgery

1. SEDATION AND ANALGESIA
FOR POST-CARDIAC SURGERY
PATIENTS
Presenter: Dr Shimels Getaneh EMCC PGY2
Moderator: Dr meron Tesfaye EMCCC

2. Outline
 Introduction
 Pain assessment tools
 Opioid analgesics
 Non opioid analgesics
 Sedation
 Reference

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

33. Preferred sedative agents
Short-acting IV
used to facilitate early extubation

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

40. Reference

41. Thank you