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J Thorac Cardiovasc Surg 2003;126:1261-1264
© 2003 The American Association for Thoracic Surgery

Editorials

No pain, much gain?

^a Department of Anesthesiology and Cardiothoracic Surgery, Drexel University College of Medicine, Philadelphia, Pa, USA
^b Department of Anesthesia and Critical Care, University of Chicago, Chicago, IllUSA

Received for publication June 18, 2003; accepted for publication June 23, 2003.

^* Address for reprints: Nanette M. Schwann, MD, Drexel University School of Medicine, Mail Stop 310, 245 N 15th St, Philadelphia, PA 19102, USA
schwann@drexel.edu

The first 300 words of the full text of this article appear below.

Dr Schwann

See related article on page 1271.

 

The goal of anesthesia is to erase the reality of the surgical insult and to restore patients as quickly as possible to their premorbid state. The safest and most cost-effective anesthetic technique with the greatest salutary effect on cardiac surgical outcome is a subject of current debate. Economic and social realities have rendered the hemodynamically stable, high-dose, narcotic-based anesthetic technique pioneered by Edward Lowenstein in the early 1970s fiscally prohibitive. In addition, societal expectations for minimally invasive surgery and rapid recovery fuel the growth and ubiquity of fast-track anesthesia for all but the most critical of patients. As a result, shorter-acting anesthetic agents are currently used to restore consciousness and spontaneous unassisted ventilation within hours of termination of the cardiac surgical procedure. With the line between anesthetics for cardiac surgery and anesthetics for other major surgical procedures becoming increasingly faint, the importance of pain control in the early postoperative period is emerging.

The natural history of pain after cardiac surgery remains inadequately described and traditionally dismissed as of minor clinical consequence. Undoubtedly, this perception has evolved from the long history of prolonging general anesthesia into the postoperative period, a practice that is now no longer economically viable. Pain and the ensuing stress response are being increasingly recognized for their contributory role in postoperative complications and their profound cumulative economic effect.¹ Yet the majority of cardiac intensive care units in the United States still adhere to the antiquated, highly subjective, and inefficient paradigm of intravenous, nurse-administered postoperative analgesia. Few of the regional anesthetic techniques (spinal, epidural, and nerve block) or supplementary adjuvants (nonsteroidal anti-inflammatories and patient-controlled analgesia) widely used in the general surgical population to attenuate postoperative pain have been adopted into mainstream cardiac care. Thus the sophistication, technologic advancements, and customization of . . . [Full Text of this Article]