Erector Spinae Plane Block Decreases Chronic Postoperative Pain Severity in Patients Undergoing Coronary Artery Bypass Grafting.

Up to 56% of patients develop chronic postsurgical pain (CPSP) after coronary artery bypass grafting (CABG). CPSP can affect patients' moods and decrease daily activities. The primary aim of this study was to investigate CPSP severity in patients following off-pump (OP) CABG using the Neuropathic Pain Symptom Inventory (NPSI). This was a prospective cohort study conducted in a cardiac surgery department of a teaching hospital. Patients undergoing OP-CABG were enrolled in an erector spinae plane block (ESPB) group (n = 27) or a control (CON) group (n = 24). Before the induction of general anesthesia, ESPB was performed on both sides under ultrasound guidance using 0.375% ropivacaine. The secondary outcomes included cumulative oxycodone consumption, acute pain intensity, mechanical ventilation time, hospital length of stay, and postoperative complications. CPSP intensity was lower in the ESPB group than in the CON group 1, 3, and 6 months post-surgery (p < 0.001). Significant between-group differences were also observed in other outcomes, including postoperative pain severity, opioid consumption, mechanical ventilation time, and hospital length of stay, in favor of the ESPB group. Preemptive ESPB appears to decrease the risk of CPSP development in patients undergoing OP-CABG. Reduced acute pain severity and shorter mechanical ventilation times and hospital stays should improve patients' satisfaction and reduce perioperative complications.

Early removal of chest drains in patients following off-pump coronary artery bypass graft (OPCAB) is not inferior to standard care - study in the Enhanced Recovery After Surgery (ERAS) group.

INTRODUCTION: Only a few studies have concerned the timing of chest drains' removal in cardiac surgery patients following the coronary artery bypass graft (CABG). None of them pertained to the off-pump CABG (OPCAB) procedure. AIM: To compare thoracic drainage time in OPCAB patients before the implementation of the institutional Enhanced Recovery After Surgery (ERAS) protocol and after that. MATERIAL AND METHODS: It was a single-center observational study concerning patients following OPCAB. Two groups of patients were analyzed: after implementing the ERAS protocol, the ERAS group, and before this period, the standard care group (STAND group). The primary outcome of this study was to compare postoperative drainage time in the ERAS and STAND groups. The other outcomes included comparing transfused blood products, postoperative complications, surgical technique, postoperative ventilation and the intensive care unit stay time. RESULTS: Sixty patients in the ERAS and 112 in the STAND group were analyzed. The postoperative drainage time was shorter in the ERAS than in the STAND group: 20 (17-22) vs. 30 (27-35) h, p < 0.001. The number of transfused blood products was similar in both groups. No difference was noted between groups according to surgery and anesthesia time. However, patients in the ERAS group were ventilated for a significantly shorter time after the surgery and spent less time in the ICU than the STAND group. The number of postoperative complications in the ERAS and STAND group was 14 and 27, p = 1. CONCLUSIONS: The early removal of chest drains after OPCAB does not increase the risk of postoperative complications and demand for blood products. However, its impact on patients' morbidity needs further studies.

Remifentanil preconditioning protects against hypoxia-induced senescence and necroptosis in human cardiac myocytes in vitro.

Remifentanil and other opioids are suggested to be protective against ischemia-reperfusion injury in animal models and coronary artery bypass surgery patients, however the molecular basis of such protection is far from being understood. In the present study, we have used a model of human cardiomyocytes treated with the hypoxia-mimetic agent cobalt chloride to investigate remifentanil preconditioning-based adaptive responses and underlying mechanisms. Hypoxic conditions promoted oxidative and nitrosative stress, p21-mediated cellular senescence and the activation of necroptotic pathway that was accompanied by a 2.2-, 9.6- and 8.2-fold increase in phosphorylation status of mixed lineage kinase domain-like pseudokinase (MLKL) and release of pro-inflammatory cytokine IL-8 and cardiac troponin I, a marker of myocardial damage, respectively. Remifentanil preconditioning was able to lower hypoxia-mediated protein carbonylation and limit MLKL-based signaling and pro-inflammatory response to almost normoxic control levels, and decrease hypoxia-induced pro-senescent activity of about 21% compared to control hypoxic conditions. In summary, we have shown for the first time that remifentanil can protect human cardiomyocytes against hypoxia-induced cellular senescence and necroptosis that may have importance with respect to the use of remifentanil to diminish myocardial ischemia and reperfusion injury in patients undergoing cardiac surgery.

Remifentanil and sevoflurane based anesthesia combined with bilateral erector spinae plane block in patients undergoing off-pump coronary artery bypass graft surgery.

INTRODUCTION: Working on the institutional Enhanced Recovery After Surgery (ERAS Cardio) protocol for off-pump coronary artery bypass graft surgery (OP-CABG) we have noticed that patients treated according to the modified anesthesia protocol had not only significantly shorter time of respiratory support and intensive care unit stay but also lower postoperative troponin T concentration than patients who had standard fentanyl/sevoflurane-based anesthesia. AIM: To compare the perioperative course of patients undergoing OP-CABG surgery and receiving standard fentanyl/sevoflurane anesthesia and those anesthetized according to the institutional ERAS Cardio protocol with remifentanil, sevoflurane, and bilateral extensor spinae plane (ESP) block. MATERIAL AND METHODS: Design: a prospective, open-label, observational study performed in a tertiary health center. Participants: 30 consecutive patients undergoing off-pump coronary bypass graft surgery. Interventions: 15 patients had standard anesthesia with etomidate, fentanyl, and rocuronium for induction and fentanyl/sevoflurane for maintenance (standard group); 15 others had bilateral single shot ESP block, then etomidate, remifentanil and rocuronium for induction, and remifentanil/sevoflurane for maintenance of anesthesia. RESULTS: Median time to extubation was 7.6 (5.5-12.5) h and 1.7 (1-3.25) h in "standard care" and ERAS groups, respectively (p = 0.00002). Length of stay in the intensive care unit was also shorter for patients in the ERAS group 20.5 (18-24) vs. 48 (42-48) h (p = 0.00001). Troponin concentration increased to a lesser extent in patients from the ERAS group: an increase of 151.8 (71.9-174.3) ng/ml vs. 253.8 (126.6-373.1) ng/ml, p = 0.008. CONCLUSIONS: Remifentanil/sevoflurane anesthesia combined with bilateral ESP block shortens mechanical ventilation time and ICU stay, and decreases postoperative troponin-T concentration in patients undergoing off-pump coronary bypass graft surgery.

Implementation of Enhanced Recovery After Surgery (ERAS) protocol in off-pump coronary artery bypass graft surgery. A prospective cohort feasibility study.

BACKGROUND: Coronary artery bypass graft (CABG) is the most commonly performed cardiac surgery procedure. Although some complications related to the cardiopulmonary bypass circuit are avoided during off-pump CABG (OP-CABG) procedures, prolonged mechanical ventilation and severe postoperative pain are still important issues. METHODS: This prospective cohort study aimed to assess the impact of the institutional Enhanced Recovery After Surgery (ERAS) protocol in patients undergoing OP-CABG. This protocol contained several modifications to the perioperative period, among which bilateral erector spinae plane block, remifentanil infusion, and patient-controlled analgesia (PCA) with oxycodone were the most important factors (ERAS group). The ERAS group was compared with the retrospective cohort (same surgeon) before the ERAS protocol was implemented (standard care group). The outcomes measured included the postoperative mechanical ventilation time, ICU and hospital stay, postoperative drainage time, postoperative troponin T level, pain severity evaluated via a numerical rating scale, and the total consumption of opioids in both groups of patients. RESULTS: Overall, 57 patients were analyzed - 29 in the ERAS group and 28 in the standard care group. The time of mechanical ventilation, thoracic drainage, and ICU and hospital stay was shorter in the ERAS group than in the standard care group. The pain was less intense in the ERAS patients, and the postoperative opioid demand was reduced. Moreover, the increase of the postoperative troponin T concentration was lower in the ERAS group. CONCLUSIONS: Our study showed that ERAS protocol implementation could improve patient outcomes after OP-CABG surgery.