Gregory Alexander J, Arora Rakesh C, Chatterjee Subhasis, Crisafi Cheryl, Morton-Bailey Vicki, Rea Amanda, Salenger Rawn, Engelman Daniel T, Grant Michael C
Department of Anesthesiology, Cumming School of Medicine & Libin Cardiovascular, Institute, University of Calgary, Calgary, Canada.
Division of Cardiac Surgery, Department of Surgery, Harrington Heart and Vascular, Institute, University Hospitals, Case Western Reserve University, Cleveland, Ohio.
JTCVS Open. 2024 Sep 6;22:14-24. doi: 10.1016/j.xjon.2024.08.018. eCollection 2024 Dec.
Optimal perioperative pain management is an essential component of perioperative care for the cardiac surgical patient. This turnkey order set is part of a series created by the Enhanced Recovery After Surgery Cardiac Society, first presented at the Annual Meeting of The American Association for Thoracic Surgery in 2023. Several guidelines and expert consensus documents have been published to provide guidance on pain management and opioid reduction in cardiac surgery. Our objective is to consolidate that guidance into an evidence-based order set that will assist in the implementation of a comprehensive multimodal approach to pain management.
Subject matter experts were consulted to translate existing guidelines and peer-reviewed literature into a sample turnkey order set for pain management. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the order set in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type.
Opioid-based analgesia is associated with delayed recovery and opioid-related adverse events. Several multimodal medications have been shown to reduce reliance upon opioids. These include the scheduled use of acetaminophen, gabapentinoids, and nonsteroidal anti-inflammatory drugs. In addition, intravenous analgesics such as dexmedetomidine, ketamine, magnesium, and lidocaine have been shown to both complement the maintenance of anesthesia as well as optimize pain control postoperatively. Long-acting opioids remain a key component of pain management when provided to reduce the overall use of short-acting synthetic opioids or in direct response to break though pain after exhausting other alternatives. When applied in a bundled fashion, several studies have demonstrated a reduction in overall opioid administration and improved rates of postoperative recovery.
There has been increased awareness regarding the potential short- and long-term adverse effects of both inadequate analgesia and excessive opioid administration after cardiac surgery. This turnkey order set aims to facilitate implementation of a comprehensive approach toward provision of multimodal, opioid-sparing medications to optimize pain management in cardiac surgery.
优化围手术期疼痛管理是心脏手术患者围手术期护理的重要组成部分。这个交钥匙式医嘱集是由心脏手术后加速康复学会创建的系列的一部分，于2023年在美国胸外科医师协会年会上首次展示。已经发布了几份指南和专家共识文件，以提供心脏手术疼痛管理和减少阿片类药物使用的指导。我们的目标是将该指导整合为一个循证医嘱集，以协助实施全面的多模式疼痛管理方法。
咨询了主题专家，将现有指南和同行评审文献转化为疼痛管理的样本交钥匙式医嘱集。源自参考指南和共识手稿中一致的I类、IIA类或同等推荐的医嘱以粗体字出现在医嘱集中。选定的不一致为I类或IIA类、IIB类或有已发表证据支持的医嘱也以斜体字列出。
基于阿片类药物的镇痛与恢复延迟和阿片类药物相关不良事件有关。几种多模式药物已被证明可减少对阿片类药物的依赖。这些药物包括定期使用对乙酰氨基酚、加巴喷丁类药物和非甾体抗炎药。此外，静脉镇痛药如右美托咪定、氯胺酮、镁和利多卡因已被证明既可以补充麻醉维持，又可以优化术后疼痛控制。当用于减少短效合成阿片类药物的总体使用量或在穷尽其他替代方法后直接应对突破性疼痛时，长效阿片类药物仍然是疼痛管理的关键组成部分。当以捆绑方式应用时，多项研究表明总体阿片类药物使用量减少，术后恢复率提高。
人们越来越意识到心脏手术后镇痛不足和阿片类药物过量使用的潜在短期和长期不良影响。这个交钥匙式医嘱集旨在促进实施一种全面的方法，提供多模式、节省阿片类药物的药物，以优化心脏手术中的疼痛管理。
