In response to: Non opioid analgesics for managing postoperative pain after cardiothoracic surgeries.

To the Editor,

This is in response to the letter addressed to you about the use of nonopioid analgesics for managing postoperative pain.[1]

For a long time, opioids were indeed considered the cornerstone of pain management post cardiac surgery.[2]

As mentioned in the letter, the role of gabapentin cannot be ignored. Sihoe et al.[3] demonstrated the safe use of gabapentin in patients with persistent postoperative and posttraumatic pain after thoracic surgery and suggested that more studies were required in cardiac patients. Ucak et al.[4] proved the effectiveness of gabapentin when they used it perioperative and immediate postoperative after cardiac surgery.

Zubrzycki et al.[5] reviewed the assessment and pathophysiology of pain in cardiac surgery. In their review, they recognized why cardiac patients have acute pain in intensive care immediate post surgery and effects of inadequately treated postoperative pain. They recognized the pharmacological and nonpharmacological therapies used post cardiac surgery. They noted the most commonly used nonopioids, including nonsteroidal antiinflammatory drugs (NSAIDs) metamizole and paracetamol, and how their effect, when used in conjunction with opioids and patient-controlled analgesics (which are usually opioids), reduced the side effects such as drowsiness, respiratory depression, delayed extubation, and prolonged intensive care stay. They suggested the use of multimodal therapy such as paracetamol/NSAIDs with opioids and local analgesic techniques depending on individual indications as “balanced analgesia.” Patient-controlled analgesia is known to maintain a steady serum drug concentration leading to a more effective relief of postoperative pain.[6]

The article by Nachiyunde and Lam[7] reviewed articles specific to the use of opioids, ketamine, and local anesthetic infusions in the immediate 4–6 h up to 72 h post cardiac surgery. This discussion was confined to mostly a comparison between opioids and local anesthetic infusions, as they are commonly used immediate postoperatively as pharmacological therapy post cardiac surgery as also suggested by Zubrzycki et al.[5] In our review (Nachiyunde and Lam), we suggested the use of multimodal (Mixed methods) in patients’ immediate post cardiac surgery using local anesthetics and opioid infusions including patient-controlled analgesics. The emphasis in our conclusion was a consideration in adding regional anesthetic infiltrations and infusions to opioid administration, which would, in turn, reduce opioid consumption.

We do agree that this is a parameter in cardiac surgery that still requires considerable research, that is, the use of nonopioid analgesics post cardiac surgery. Indeed, there has been a reduction in opioid use post cardiac surgery. We conclude that the use of mixed techniques including local anesthetic infiltrations and infusions will reduce the effect of large doses of opioids, which also lead to oversedation and delayed extubation in patients post cardiac surgery in intensive care.

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Conflicts of interest

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