Effectiveness of analgesia in controlling acute postoperative pain following cardiac surgery. A systematic review.

Abstract

Background: Pain is a debilitating and ongoing issue following cardiac surgery that results in negative consequences in both the short term and long term. The objective of this review was to synthesise the best available evidence related to pain management following open cardiac surgery in the immediate (first 24 hours) postoperative period. Methods: This systematic review considered interventional studies evaluating either analgesic medications or the analgesic delivery mode. Patient outcomes from quality randomised controlled trials from 1990-2016 were analysed. Outcomes measured were: analgesic effectiveness measured by numerical pain scores, sedation scores, extubation times and medication side effects. The search strategy located studies using a three-step approach. Firstly relevant library databases were searched using specific search terms. Then the abstract of each identified study was reviewed according to the Joanna Briggs Institute quality checklist. Quantitative papers selected for retrieval were then assessed and scored by two independent reviewers for methodological quality prior to inclusion. Patient outcome data was then extracted and summarised using a structured data extraction tool. Results: Twenty-six randomised controlled trials were identified for inclusion in this review. The newer Fentanyl analogues Remifentanil, Sufentanil and Alfentanil were observed to more effectively reduce pain upon movement when compared to Morphine. The use of regular background analgesics such as paracetamol, tramadol and anti-inflammatories reduced overall opioid requirements and patient reported pain scores, but did not have a consistent effect on sedation levels or times to extubation. Patient-controlled analgesia (PCA) modes did not consistently demonstrate that PCA with a low dose background opioid infusion did result in greater pain reduction than PCA in isolation. Conclusion: Overall the evidence collated in this systematic review supports the use of multi-modal analgesic prescribing for optimal management of postoperative pain following cardiac surgery.