Post-Sternotomy Pain

Resources

Pain after median sternotomy can be difficult to treat, and poorly controlled is associated with complications:

Sequelae of poor pain control after sternotomy

MI or other cardiac complications

Impaired wound healing

Prolonged length of stay

Chronic post-sternotomy pain syndrome (a form of CPSP)

Post-operative massage improves short-term pain scores although objective outcome measures often not reported
Music therapy reduces pain scores without reducing opioid consumption
Patient education does not improve opioid consumption or pain scores whether performed pre- or post-operatively

Paracetamol

Use associated with improvement pain scores ± reduction in opioid consumption vs. placebo
Should be regularly used in the pre-, intra- and post-operative periods

NSAIDs

NSAIDs are recommended for pre- or intra-operative use, where not contraindicated, in combination with paracetamol
Evidence suggests low risk of AKI, cardiac adverse events or significant bleeding with short duration of use
In our CICU, 100mg rectal diclofenac is administered prior to extubation
COX-2 specific inhibitors are not recommended by PROSPECT guidance

Opioids

No evidence to support use of one opioid over any other
Should generally be reserved as rescue analgesia post-operatively
In our CICU, regular dihydrocodeine is often used alongside PRN immediate release enteral opioid

NMDA antagonists

No difference in pain score or opioid use from two studies where ketamine was used intraoperatively
On this basis, not recommended by PROSPECT guidance

Dexmedetomidine

Intra- or post-operative infusions may improve outcomes, reduce pain scores and opioid requirements
Has negative cardiovascular effects (hypotension, bradycardia), which may preclude its use
Optimal dosing unknown; one study infused 0.5 μg kg−1 h−1 from initiation of anaesthesia until tracheal extubation in ICU

Gabapentinoids

Should be resumed in patients who are on the drugs long-term
Not associated with shorter duration of extubation or length of ICU stay in two trials of pregabalin vs. placebo in cardiac surgery
Quality of evidence of routine use after cardiac surgery is low; not recommended by PROSPCET guidance due to 'inconsistent procedure-specific evidence'

Others

Lidocaine patches; often used for pain arising from chest drain sites or severe post-operative sternotomy pain, but not robustly evidence based
Nefopam; may be used to reduce opioid consumption and opioid-related side effects, but not always available, itself has limiting side-effects and lacks robust evidence
Entonox; sometimes used for chest drain or cardiac pacing wire removal, but not recommended by PADIS guidelines due to low quality evidence

Block	Advantages	Disadvantages
Surgical site LA infusion	↓ pain score ↓ opioid consumption
Parasternal block	↓ pain score ↓ opioid consumption Safe in anticoagulated patient
Paravertebral block		Analgesia no better than TEA Debatable effect on pain score and opioid use
Transversus thoracis plane block	↓ pain score	No ↓ opioid consumption May be inappropriate if LIMA grafted
Erector spinae block	↓ pain score ↓ opioid consumption Non-inferior to TEA	Limited evidence in cardiac surgery
Thoracic epidural Intrathecal opioids	↓ pain score ↓ opioid consumption	Standard risks of neuraxial intervention Meta-analyses don't show clear analgesic benefit No significant ↓ in POPC Safety concerns in anticoagulated patients
Lidocaine infusions		No improvement in pain or organisational outcomes Lack of procedure-specific evidence