Comparison of Intra- and postoperative effectiveness of erector spinae plane block and patient controlled analgesia in patients undergoing coronary artery bypass grafting surgery.

The aim of our study was to compare bilateral erector spinae plane block (ESPB) efficacy on pain management with patient controlled analgesia (PCA) during the perioperative period in patients scheduled for coronary artery bypass grafting (CABG). After ethics committee approval (2019-7/31 dated 09.04.2019) from the Bursa Uludag University Medical Trials Ethics Committee, (https://uludag.edu.tr/buuetikkurulu) ASA II-III, 50 patients aged between 18-80 years were included. They were randomly divided into two groups, ESPB (n=25) and control (n=25). In the preoperative period, bilateral ESPB with ultrasonography was applied to both groups with 0.25% bupivacaine (0.5 ml/kg) + dexamethasone (8 mg) or saline, respectively. PCA prepared with morphine was given to all patients postoperatively. Perioperative opioid use, extubation times, coughing/resting Visual Analog Scale (VAS) scores, duration for first PCA bolus dose requirement, rescue analgesia needs, mobilization times, and opioid side effects were evaluated. In the ESPB group, compared to the control group, intraoperative fentanyl consumption was lower (P=0.001). During the postoperative period; extubation time was shorter, the need for initial PCA was much later, morphine consumption and need for rescue analgesia was less (P=0.001; P<0.001; P<0.001; P=0.009, respectively). The postoperative VAS scores were lower for each measurement period (P<0.05). Opioid-related side effects were more common in the control group (P=0.040). First mobilization time in ESPB group was earlier (P<0.001). As a result, ESPB has a significant analgesic effect in CABG patients. It was concluded that bilateral ESPB reduces opioid requirement compared to intravenous morphine PCA alone and provides better pain management and more comfortable recovery.

Induction of anesthesia in coronary artery bypass graft surgery: the hemodynamic and analgesic effects of ketamine.

OBJECTIVE: The aim of this prospective, randomized study was to evaluate the hemodynamic and analgesic effects of ketamine by comparing it with propofol starting at the induction of anesthesia until the end of sternotomy in patients undergoing coronary artery bypass grafting surgery. INTRODUCTION: Anesthetic induction and maintenance may induce myocardial ischemia in patients with coronary artery disease. A primary goal in the anesthesia of patients undergoing coronary artery bypass grafting surgery is both the attenuation of sympathetic responses to noxious stimuli and the prevention of hypotension. METHODS: Thirty patients undergoing coronary artery bypass grafting surgery were randomized to receive either ketamine 2 mg.kg(-1) (Group K) or propofol 0.5 mg.kg(-1) (Group P) during induction of anesthesia. Patients also received standardized doses of midazolam, fentanyl, and rocuronium in the induction sequence. The duration of anesthesia from induction to skin incision and sternotomy, as well as the supplemental doses of fentanyl and sevoflurane, were recorded. Heart rate, mean arterial pressure, central venous pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, cardiac index, systemic and pulmonary vascular resistance indices, stroke work index, and left and right ventricular stroke work indices were obtained before induction of anesthesia; one minute after induction; one, three, five, and ten minutes after intubation; one minute after skin incision; and at one minute after sternotomy. RESULTS: There were significant changes in the measured and calculated hemodynamic variables when compared to their values before induction. One minute after induction, mean arterial pressure and the systemic vascular resistance index decreased significantly in group P (p<0.01). CONCLUSION: There were no differences between groups in the consumption of sevoflurane or in the use of additional fentanyl. The combination of ketamine, midazolam, and fentanyl for the induction of anesthesia provided better hemodynamic stability during induction and until the end of sternotomy in patients undergoing coronary artery bypass grafting surgery.

Induction of anesthesia in coronary artery bypass graft surgery: the hemodynamic and analgesic effects of ketamine

OBJECTIVE: The aim of this prospective, randomized study was to evaluate the hemodynamic and analgesic effects of ketamine by comparing it with propofol starting at the induction of anesthesia until the end of sternotomy in patients undergoing coronary artery bypass grafting surgery. INTRODUCTION: Anesthetic induction and maintenance may induce myocardial ischemia in patients with coronary artery disease. A primary goal in the anesthesia of patients undergoing coronary artery bypass grafting surgery is both the attenuation of sympathetic responses to noxious stimuli and the prevention of hypotension. METHODS: Thirty patients undergoing coronary artery bypass grafting surgery were randomized to receive either ketamine 2 mg.kg-1 (Group K) or propofol 0.5 mg.kg-1 (Group P) during induction of anesthesia. Patients also received standardized doses of midazolam, fentanyl, and rocuronium in the induction sequence. The duration of anesthesia from induction to skin incision and sternotomy, as well as the supplemental doses of fentanyl and sevoflurane, were recorded. Heart rate, mean arterial pressure, central venous pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, cardiac index, systemic and pulmonary vascular resistance indices, stroke work index, and left and right ventricular stroke work indices were obtained before induction of anesthesia; one minute after induction; one, three, five, and ten minutes after intubation; one minute after skin incision; and at one minute after sternotomy. RESULTS: There were significant changes in the measured and calculated hemodynamic variables when compared to their values before induction. One minute after induction, mean arterial pressure and the systemic vascular resistance index decreased significantly in group P (p<0.01). CONCLUSION: There were no differences between groups in the consumption of sevoflurane or in the use of additional fentanyl. The combination of ketamine, midazolam, ...

Preoperative multiple-injection thoracic paravertebral blocks reduce postoperative pain and analgesic requirements after video-assisted thoracic surgery.

OBJECTIVE: The hypothesis was tested that preoperative multiple-injection thoracic paravertebral blocks reduce opioid requirements and promote early ambulation after video-assisted thoracic surgery procedures. DESIGN: Prospective, randomized, controlled, blinded study. SETTING: Single-university hospital. PARTICIPANTS: Fifty consenting patients undergoing video-assisted thoracic surgery. INTERVENTIONS: Patients were randomly assigned to receive preoperative multiple-injection thoracic paravertebral blocks (PVB group, n = 25) or preoperative multiple subcutaneous saline injections at the same site as in the PVB group (control group, n = 25). MEASUREMENTS AND MAIN RESULTS: Intraoperative fentanyl consumption was lower in the PVB group (p < 0.01). The time to first analgesic requirement was longer, and pain score at this time was lower in the PVB group (p < 0.05 and p < 0.01, respectively). Postoperative pain scores both at rest and coughing were lower during the first 4 hours in the PVB group than those in the control group (p < 0.01 for 0 hours and p < 0.05 for 1, 2, and 4 hours). Cumulative morphine consumption was significantly less in the PVB group at all time points (p < 0.05 for 12 hours and p < 0.01 for all other time points), but there were no significant differences in sedation scores between the 2 groups. There were no complications because of the blocks. Patient satisfaction with the analgesia was significantly greater (p < 0.05), and first mobilization and hospital discharge were quicker (p < 0.01 and p < 0.05, respectively) in the PVB group. CONCLUSION: Perioperative multiple-injection thoracic paravertebral blocks with bupivacaine containing epinephrine provided effective pain relief and a significant reduction in opioid requirements. This approach may also contribute to earlier postoperative ambulation after video-assisted thoracic surgery.

Combination of intrathecal morphine and remifentanil infusion for fast-track anesthesia in off-pump coronary artery bypass surgery.

OBJECTIVE: The purpose of this study was to assess the combination of intrathecal morphine and remifentanil infusion with isoflurane in off-pump coronary artery surgery, with a focus on postoperative analgesia and fast-tracking. DESIGN: Prospective, randomized, controlled, blinded clinical study. SETTING: University hospital. PARTICIPANTS: Forty-six patients who underwent elective off-pump coronary artery bypass grafting. INTERVENTIONS: Patients were randomly assigned to receive remifentanil infusion alone (control group, n = 23) or remifentanil infusion plus 10 microg/kg of intrathecal morphine (ITM group, n = 23). Induction and maintenance anesthesia were the same in both groups. Maintenance therapy was remifentanil infusion (0.25-1 microg/kg/min) and 0.5% to 1.5% isoflurane, with adjustments according to hemodynamics. After extubation, intravenous patient-controlled analgesia with morphine (1-mg bolus and 5-minute lockout) was administered, and Wilson sedation scores, visual analog pain scores (scale, 0-100 mm) at rest and during coughing, and cumulative morphine consumption were assessed at 1, 2, 4, 8, 12, 24, and 48 hours. Examiners were unaware of patients' group identities. Anesthetic recovery parameters and opioid-related, spinal anesthesia-related, and cardiac complications were recorded. MEASUREMENTS AND MAIN RESULTS: There were no differences between the groups' intraoperative hemodynamic or anesthetic recovery findings. Pain scores and morphine consumption were significantly lower in the ITM group at all time points after extubation (p = 0.0001-0.05). Group frequencies of opioid-related and cardiac complications were similar. No patient had central neuroaxial hematoma or post-spinal tap headache. CONCLUSION: In the setting of isoflurane anesthesia for off-pump coronary artery bypass grafting, ITM combined with remifentanil infusion provides better postoperative analgesia than does remifentanil infusion alone, and does not improve or negatively affect fast-tracking.

Comparison of lumbar epidural tramadol and lumbar epidural morphine for pain relief after thoracotomy: a repeated-dose study.

OBJECTIVE: The purpose of this study was to compare lumbar epidural morphine and lumbar epidural tramadol with respect to onset and duration of analgesia, analgesic efficacy, and drug-related side effects after muscle-sparing thoracotomy. DESIGN: Prospective, randomized, double-blind, clinical study. SETTING: Single university hospital. PARTICIPANTS: Forty patients who underwent elective muscle-sparing thoracotomy. INTERVENTIONS: Before anesthesia induction, an epidural catheter was placed in the L2-3 or L3-4 interspace using the loss-of-resistance technique. On arrival at the intensive care unit, patients were randomized to receive doses of either 100 mg of tramadol (group T) or 4 mg of morphine (group M) via the lumbar epidural catheter. Each dose was diluted in 10 mL of normal saline. On awakening from anesthesia, if the patient's pain score on a 0- to 100-mm visual analog scale was above 40 mm, the initial epidural drug dose was administered. The initial injection in each case was taken as time 0. Subsequent pain scores above 40 mm were considered indications for epidural dosing; each patient was allowed 2 doses in the first 12 hours postoperatively and 2 more in the second 12 hours. MEASUREMENTS AND MAIN RESULTS: The groups' analgesia onset times were similar, but duration of analgesia was significantly shorter in group T than in group M (p < 0.01). There were no differences between the groups with respect to pain scores at rest or during coughing at any of the time points investigated. Sedation scores were lower in group T than in group M at 1, 2, 3, 4, and 8 hours (p value range, 0.0001-0.05). Compared with group T, group M showed significantly greater drops in arterial oxygen tension from baseline at 3, 4, 8, and 12 hours (p value range, 0.0001-0.05). The group means for arterial carbon dioxide tension and respiratory rate were similar at all time points investigated. CONCLUSION: The study revealed that the quality of analgesia achieved with repeated doses of lumbar epidural tramadol after muscle-sparing thoracotomy is comparable to that achieved with repeated doses of lumbar epidural morphine. Compared with morphine, lumbar epidural tramadol results in less sedation and a less-pronounced decrease in oxygenation.

Declines in serum free and bound choline concentrations in humans after three different types of major surgery.

We examined the changes in circulating choline status in humans in response to major surgery by measuring serum free and phospholipid-bound choline concentrations before, during and 1-72 h after total abdominal hysterectomy, off-pump coronary artery graft surgery or brain tumor surgery. Preoperatively, the mean serum free and phospholipid-bound choline concentrations in patients scheduled for abdominal hysterectomy (n = 26), off-pump coronary artery grafting surgery (n = 34) or brain tumor surgery (n = 24) were 12.3 +/- 0.5, 12.1 +/- 0.4 and 11.4 +/- 0.4 micromol/l, and 2495 +/- 75, 2590 +/- 115 and 2625 +/- 80 micromol/l, respectively. Serum free choline and phospholipid-bound choline concentrations decreased from these baseline values to 8.8 +/- 0.7 (p < 0.001), 8.8 +/- 0.5 (p < 0.001) and 8.2 +/- 0.4 micromol/l (p < 0.001), and 2050 +/- 108 (p < 0.001), 2166 +/- 59 (p < 0.001) and 1884 +/- 104 micromol/l (p < 0.001) at 1 h after hysterectomy, off-pump bypass graft surgery or brain tumor surgery, respectively. They remained at these low levels for 24 h and then gradually increased towards the preoperative values at 48-72 h postoperatively. Serum cortisol increased postoperatively in all surgical patients for 24 h and its levels were inversely correlated with serum free and bound choline concentrations. These results show that circulating free and bound choline concentrations decrease for 72 h after total abdominal hysterectomy, off-pump coronary artery graft surgery or brain tumor surgery in humans.

Comparison of analgesic effects of morphine, fentanyl, and remifentanil with intravenous patient-controlled analgesia after cardiac surgery.

OBJECTIVE: The purpose of this study was to compare the analgesic effects of remifentanil with 2 other opioid agents, morphine and fentanyl, after cardiac surgery. DESIGN: Prospective, randomized, and double-blinded study. SETTINGS: This study was performed at Uludag University hospital. PARTICIPANTS: Seventy-five patients undergoing off-pump coronary artery bypass surgery were included in the study. INTERVENTIONS: Anesthesia was standardized. Cases were randomized into 3 groups consisting of 25 patients in each. Groups M, F, and R were given morphine HCl (1 mg/mL) with an infusion rate of 0.3 mg/h and 1-mg bolus doses; fentanyl (50 microg/mL) with an infusion rate of 1 microg/kg/h and 10-microg bolus; and, remifentanil (50 microg/mL) with an infusion rate of 0.05 microg/kg/min and 0.5-microg/kg bolus, respectively. Continuous infusion was started immediately after the completion of the surgery. MEASUREMENTS AND MAIN RESULTS: Pain was assessed by using a visual analog scale (0-10), and sedation was assessed with the Ramsey sedation score (1-6) 30 minutes, 1, 2, 4, 12, and 24 hours after extubation. The number of boluses and demands, time to extubation, and side effects were analyzed. Visual analog scale, sedation scores, and mean extubation times were similar in all groups. Total number of boluses and demands were statistically more in the remifentanil group. Regarding the side effects, nausea and vomiting was higher in group M (p < 0.05), whereas itching was prominent in group F (p < 0.05). CONCLUSIONS: Despite the different durations of these 3 opioid agents, the infusion dose of remifentanil was as effective as morphine and fentanyl after OPCAB surgery with fewer side effects.