Best Practices
Cardiac Surgery via Sternotomy
All best practices are subject to change and may require modifications depending on a patient’s history and status. Healthcare practitioners should always defer to their clinical judgement and, whenever appropriate, consult with additional resources for further guidance.
| Preoperative | Intraoperative | Postoperative (Inpatient) | Discharge Strategies |
|---|---|---|---|
| •Acetaminophen •Gabapentinoids (single, low-dose, adjust dose or consider the risk-benefit in elderly & patients w/ renal dysfunction)^ •Consider a fascial plane block ...oErector spinae block ...oPectoralis nerve block ...oPecto-intercostal fascial plane block ...oTransverse thoracic muscle plane block | •Parasternal block (consider catheter infusion) •Chest tube site local infiltration •Consider IV ketamine •IV acetaminophen if not given preop •Magnesium | •Acetaminophen •Gabapentinoids (up to 14 days; adjust dose or consider the risk-benefit in elderly & patients w/ renal dysfunction)^ •IV opioids but transition to PO opioids ASAP •Consider parasternal catheter infusion •Consider NSAIDs (controversial, definitely avoid COX-2 inhibitors) •Consider ketamine •Magnesium •Consider dexemedetomidine | MANAGEMENT OF PAIN W/O MEDICATION: While there are various studies for non-pharmacologic strategies (including TENS, acupuncture, music, massage therapy, educational material, relaxation/cognitive behavioural therapy),for the immediate postop/ICU/admission period following for cardiac surgery, results are mixed. These strategies can be considered but cannot be strongly recommended. CO-ANALGESICS: •Acetaminophen •Gabapentinoids (total 14-day course; adjust dose or consider the risk-benefit in elderly & patients w/ renal dysfunction)^ •Longer term NSAID use is not suggested OPIOID PRESCRIPTION: 20-30 tablets* |
^Gabapentinoids are often recommended for acute pain management in certain surgeries based on small studies. However, based on recent systematic reviews and meta-analysis there is limited evidence to support universal use. A provider’s clinical judgement is recommended on an individual case basis.
*All tabs for discharge are oxycodone, 5mg. To convert this dosage, please visit this page. For conversions involving oxycodone, please note that it is 50% more potent than morphine. We encourage prescribers to consider discharge prescriptions of short-acting opioids at the lowest effective dose, with the lowest potency, for the shortest duration.
Before surgery, and at the surgical safety checklist time, the surgical and anesthesia team should work together to develop a multimodal pain management plan with active strategies to optimize perioperative pain management.
Healthcare practitioners are also encouraged to help patients set realistic expectations around pain management, including the use of prescription medications. Additional useful information to enhance recovery after surgery can be found at Enhanced Recovery Canada.
See our full disclaimer here.
References
Bainbridge D, Martin J, Arango M, Cheng D. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet. 2012 Sep 22;380(9847):1075-81.
Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016 Feb;17(2):131-57.
Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011 Dec 6;124(23):2610-42.
Raouf M, Atkinson TJ, Crumb MW, Fudin J. Rational dosing of gabapentin and pregabalin in chronic kidney disease. J Pain Res. 2017;10:275-8.
Tawfic QA, Bellingham G. Postoperative pain management in patients with chronic kidney disease. J Anaesthesiol Clin Pharmacol. 2015 Jan-Mar;31(1):6-13.
Verret M, Lauzier F, Zarychanski R, Perron C, Savard X, Pinard AM, et al. Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis. Anesthesiology. 2020 08;133(2):265-79.
Treatment Altering Factors
Below are a few of the more common and/or impactful health factors that may result in deviation from the above best practices. Please note that the following list is not exhaustive and that the remarks for each factor are not surgery-specific. Healthcare practitioners should always defer to their clinical judgement and, if appropriate, consult with additional resources for further guidance. See our full disclaimer here.
Organ Dysfunction
Hepatic dysfunction/Excessive alcohol intake
| •In general: Limit or avoid acetaminophen altogether, depending on degree of hepatic dysfunction •Preoperative: Avoid or reduce dose of acetaminophen •Intraoperative: Decrease dose of opioids, benzodiazepines, meperdine •Postoperative: Reduce dose of acetaminophen •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Renal dysfunction
| •In general: Limit or avoid NSAIDs altogether, depending on degree of renal dysfunction •Preoperative: Avoid NSAIDs and use gabapentinoids cautiously •Intraoperative: Avoid morphine and meperidine •Postoperative: Avoid NSAIDs and use lower dose of gabapentin •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Patient Specific Factors
Advanced age
| •Preoperative: Due to the frequency of multiple comorbidities in advanced age, anesthesia preoperative consult as needed to preoptimize. Also, manage anticoagulants where indicated; avoid long delays in hip fracture patients and practice preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated •Postoperative: Regular dose acetaminophen; oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities |
Chronic pain and/or long-term opiate use
| •In general: May attempt to wean chronic opioids if surgery is to treat issues contributing to the chronic pain but otherwise continue chronic pain medication perioperatively if patient uses it •Preoperative: Anesthesia consult where indicated; continue preop opioids on day of surgery and give preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated; use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance •Postoperative: Use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance; regular dose acetaminophen and oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities and avoid opioid dose escalation from preop, if possible |
History of difficulty with postop pain management
| •Consider regional anesthetic techniques, if feasible for specific surgical procedure |
Substance abuse/IV drug abuse related endocarditis
| •In general: Although not common, this factor was included as these patients are extremely challenging; consider analgesic management with the help of a pain specialist/pain service •Preoperative: Assess for opioid dependency and/or addiction, continue long-acting opioids preop and assess for other recreational drug use and alcohol; strongly consider a fascial plane block •Intraoperative: High opioid tolerance is common •Postoperative: High opioid tolerance is common but reluctance to initiate IV PCA; use caution when prescribing NSAIDs as renal dysfunction, hepatic dysfunction and thrombocytopenia are common •Discharge: High opioid tolerance is common; use caution when prescribing NSAIDs as renal dysfunction, hepatic dysfunction and thrombocytopenia are common |
Uncontrolled anxiety/depressive symptoms
| •Preoperative: Consider anxiolytics prior to administration of anesthetic •Discharge: While reviewing expected duration of opioid use, as well as opioid safety strategies including the appropriate storage and disposal of unused pills, should be standard practice, it is of paticular importance with patients who have uncontrolled anxiety/depressive symptoms Special note for paediatric surgeries: Given the risk of opioid misuse in youth with depressive symptoms, consider heightened opioid safety factors including reviewing with caregivers at discharge |
System Disorders
Coagulopathy
| •Avoid neuraxial techniques if any abnormal coagulation; consider following ASRA guidelines |
Obstructive sleep apnea
| •Preoperative: Use multi-modal analgesia; reduce or avoid use of gabapentinoids •Intraoperative: Reduce or avoid benzodiazepines; reduce doses of opioid medications •Postoperative: Use multi-modal analgesia; reduce use of opioids and gabapentinoids •Discharge: Reduce opioid dosing |