Post CABG Pain

• Prof & HOD Dept. of

• Anesthesia & Pain, B.H.I.M.S.,
Pain Physician, Lilavati, Raheja,
Shushrusha Hospital
• Ex.President, IndianSociety for
Study of Pain,
• Executive President, Pain
Management and Research
Foundation
Dr.D.K. Baheti • Hobbies-Music, Sports
• Email-dr.baheti@gmail.com
• Web-www.paincure.in
 Post CABG Pain
Dr.D.K.Baheti MD
Prof And HOD
Dept of Anaesthesiology and Pain,
B.H.I.M.S. Mumbai-India
 DECLARATION

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FOR THIS PRESENTATION

 Post CABG PAIN
• Common surgical procedure, its frequent complication,
the post-CABG pain (PCP) syndrome, remains poorly
documented
• 219 of the 387 respondents (56%) reported chest wall
pain.
• One hundred and forty-two (65%) of the patients with
PCP reported pain of at least moderate severity, and
151 (72%) reported that the pain interfered with their
daily activities. Eighty PCP patients were available for a
detailed evaluation. Left-sided chest wall pain was
noted by 53 subjects, midline scar pain by 47, and
right-sided pain by nine subjects
 POST CABG PAIN-Post Op Pain

• PSP-Nociceptive (visceral or somatic),

arising from tissue injury and inflammation,
• Neuropathic, resulting from direct injury to
nerves in either the central or PNS
• CABG surgery involves many pain-
sensitive structures, including sternotomy
and leg incisions with invasion of
subcutaneous muscle, bone, and visceral
tissues.
 POST CABG PAIN
• ACUTE

• CHRONIC
ACUTE PAIN
 ACUTE PAIN
• Incision Pain-At Rest , Movement, Physiotherapy

• Sternotomy pain

• Chest wall pain

• Scar pain :
• Persistent wound pain . Persistent pain was
defined as pain still present two or more months
after surgery,
 CHRONIC
Infection
Chest Pain, Uneasiness, Compression feeling
Rule out Unstable Angina
Neuropathic Pain- Pain , Burning, Allodynia,
Hyperalgesia
Scar Pain- Redness, Itching, Burning, Keloid
 WHY TO TREAT?

• Pulmonary and cardiovascular dysfunction;

• It is an exhausting experience that also causes
deconditioning, sleep deprivation, and poor
nutrition.
• Physiotherapy and Ambulation delayed
 Post Sternotomy Pain
• Overall incidence of non-cardiac pain after sternotomy
for cardiac surgery is high (28%). Most patients
experience a modest pain intensity but some (1%)
report severe pain, never being lower than 54 mm on
VAS. The study also indicates that the incidence of pain
after sternotomy is not only associated with harvest of
the ITA and additional aetiological factors must be
sought.
• Re-1: Multidisciplinary Pain Treatment Centre,
Department of Anaesthesiology, and Department of
Thoracic and 2: Cardiovascular Surgery, University
Hospital, Uppsala, Sweden
 Chronic Post-Surgical Pain(CPSP):
Epidemiology and clinical implications -
Eric J. Visser , Royal Perth Hospital, Australia

• CPSP is an under-recognised and prevalent healthcare problem

associated with significant morbidity and potential economic costs.
• Risk factors-type of surgery, pre-existing pain, re-operation, nerve
damage, moderate-to-severe acute post-operative pain, neurotoxic
radio or chemotherapy and psycho-social factors.
• CPSP has a multifactorial aetiology, principally nerve injury and
wound inflammatory response, leading to peripheral and central
sensitisation.
• The extent of wound hyperalgesia following abdominal surgery
correlates with the incidence of CPSP but not with acute pain
outcomes, reflecting the relative importance of central sensitisation
in the development of CPSP.
• The contributions of genetics, gender, age, opioid-induced
hyperalgesia, pre-existing pain disorders and psycho-social factors
to the pathogenesis of CPSP have yet to be clarified.
 CPSP-PREVENTION
• The prevention of CPSP includes limiting nerve and tissue
injury and in some cases using preventive analgesia
techniques such as
• regional neural blockade or low-dose ketamine infusion.
• Other strategies such as education, patient surveillance,
management of psycho-social factors and functional
rehabilitation may also be beneficial, although there are no
data to support this.
• Further research is required to develop ‘predictive tools’
and to examine the effects of multimodal “protective”
analgesia and multidisciplinary approaches in the
prevention and treatment of CPSP.
 MYOFASCIAL PAIN
• Myofascial pain at post-sternotomy patients after cardiac
surgery: A clinical study in 1226 patients -Nurettin L.et.al Turkey
• Conclusion: As a conclusion, the formation of trigger point in upper
trapezius and pectoralis major muscles in patients going under
CABG with LIMA is 31.9% in patients postoperatively. We believe
the reason for this incident is the graft harvesting of the internal
mammary artery. Besides we believe that there is a parallel relation
between the operation duration and trigger point formation, and
more prospective studies are needed to state the relation between
the formation of trigger points and the duration of the CABG.
 POST CABG PAIN
• A 61-year-old woman underwent coronary intervention via the right radial
artery for the treatment of unstable angina leading to complex regional pain
syndrome II (CRPS type II) in the hand.
• Pt. had serious regional pain with disability. After the operation she
complained of severe pain in the right hand, consistently felt along the
median nerve distribution.

• The nerve conduction study suggested carpal tunnel syndrome.

• Stellate ganglion blockade, Cervical epidural blockade, and administration

of amitriptyline and loxoprofen.

• The median nerve appeared to be damaged by local compression and

potential ischemia.
 POST CABG PAIN-Post Op Pain
• Treatment options

• Regional-Thoracic Epidural, Paravertebral

block
• Intercostal Nerve Block
• Intrapleural Analgesia
• Local infiltration
 TREATMENT OPTIONS
• PHARMACOLOGICAL

• INTERVENTIONAL
 PHARMACOLOGICAL-ROUTES
• IM/ IV
• SUBCUTANEOUS
• TRANSDERMAL
• SULINGUAL
• RECTAL
 MEDICATIONS
• ANALGESIC- Narcotics, Non narcotics
• Anticonvulsants
• Antidepressnts
KELOIDS