Volume 31, Issue 1 (3-2024)
RJMS 2024, 31(1): 1-15 |
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Mehrabanian M, Dehghani firoozabadi M, Hosseini K, Mehrani M, Mansourian S, Kavand B, et al . The Impact of Pregabalin Prescription as a Pre-Medication in Postoperative Pain Management Following Coronary Artery Bypass Grafting: A Systematic Review. RJMS 2024; 31 (1) :1-15
URL: http://rjms.iums.ac.ir/article-1-8497-en.html
URL: http://rjms.iums.ac.ir/article-1-8497-en.html
Mohammadjavad Mehrabanian 
, Mehdi Dehghani firoozabadi , Kaveh Hosseini , Mehdi Mehrani , Soheil Mansourian , Babak Kavand , Mehdi Rahab , Sahar Kianmehr , Mehrdad Malekshoar , Ashkan Taghizadeh Imani , Afarin Zamani , Behrang Nooralishahi
, Mehdi Dehghani firoozabadi , Kaveh Hosseini , Mehdi Mehrani , Soheil Mansourian , Babak Kavand , Mehdi Rahab , Sahar Kianmehr , Mehrdad Malekshoar , Ashkan Taghizadeh Imani , Afarin Zamani , Behrang Nooralishahi
Assistant Professor, Anesthesia, Critical Care and Pain Management Research Center, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran , b-nooralishahi@sina.TUMS.ac.ir
Abstract: (204 Views)
Bakcground & Aims: Advancements in coronary artery disease treatment via Coronary Artery Bypass Grafting (CABG) have been substantial, yet post-operative pain management remains a significant challenge. Pregabalin, known for its unique mechanism of action, has gained attention for its potential in reducing post-CABG pain. The complexity of post-CABG pain involves multiple factors, including surgical incision sites and chest wall trauma, which, if poorly managed, can lead to various complications, emphasizing the importance of effective pain management (1-5). This systematic review aims to evaluate the efficacy of Pregabalin in this context. Advancements in coronary artery disease treatment via Coronary Artery Bypass Grafting (CABG) have been substantial and revolutionized the treatment landscape of coronary artery diseases. Despite its widespread adoption and procedural success, effective postoperative pain management post-CABG remains a formidable clinical challenge (1). The complexity of post-CABG pain involves multiple factors, including surgical incision sites and chest wall trauma (2, 3). The etiology of this pain is complex, involving nociceptive and neuropathic components, originating from various anatomical regions affected during surgery. Inadequate pain control can disrupt essential postoperative activities like coughing and deep breathing, increasing the risk of pulmonary complications, and can adversely affect the cardiovascular system, leading to hypertension and tachycardia, further burdening the heart and grafts. Post-CABG pain is typically acute and occasionally chronic, influencing immediate recovery and potentially impacting long-term rehabilitation and patient well-being (4). Additionally, the psychological impact of unmanaged pain can contribute to prolonged hospital stays, delayed mobilization, and diminished overall patient experience (5).
Over the years, various pharmacological and non-pharmacological methods have been employed for managing post-CABG pain. These include opioids, non-steroidal anti-inflammatory drugs (NSAIDs), local anesthetics, and adjunctive therapies. However, each modality comes with its limitations and potential side effects (4). In this context, Pregabalin, primarily used for neuropathic pain, has attracted attention for its potential role in managing postoperative pain due to its unique mechanism of action, which involves binding to the α2δ subunit of voltage-gated calcium channels in the central nervous system, modulating the release of several neurotransmitters (6-8). This systematic review aims to evaluate the efficacy of Pregabalin in the management of post-CABG pain, considering the variability in results which might be attributed to differences in methodologies, patient populations, and pain management protocols across different studies.
Methods: A systematic search in Scopus, Google scholar, researchgate, Trip database, cochrane and science direct databases were made using the appropriate search phrase. Relevant published or conferenced clinical trials with the effect of using preoperative usual doses of pregabalin (75-150 mg) on pain reduction after CABG surgery with or without the use of a cardiopulmonary bypass pump were selected.
Results: In the studies found in the systematic review, there was a high heterogeneity in methodology and results, so meta-analysis was avoided due to the difference in methods. Nine randomized clinical trial studies in full, and two abstracts of randomized clinical trials were included in the review. In most studies, pregabalin was started at a dose of 150 mg one or two hours before the operation and was continued at a dose of 75 mg twice a day for different periods (from 2 to 14 days after the operation). First 24 Hours Post-Surgery: Pre-medication with Pregabalin did not significantly affect intraoperative and immediate postoperative fentanyl requirements, nor did it influence the duration of intubation (17-23). However, its primary goal, pain reduction post-surgery, yielded mixed results. While five studies reported significant pain reduction compared to placebo (18, 20, 23-25), four others found no significant difference (17, 19, 22, 24). Reduction in Postoperative Analgesics Usage: Varied outcomes were reported regarding the impact of pre-medication on postoperative analgesic consumption. Some studies observed a significant reduction in morphine usage among patients who received Pregabalin (18, 23, 26), while others reported no significant differences (17, 19, 22, 24).
Hospital Stay Duration: Regarding the length of hospital and ICU stays, the majority of studies reported no significant differences between the Pregabalin and control groups (17, 19, 20, 24, 27). This outcome indicates that while Pregabalin may aid in pain management, its effect on reducing the length of hospitalization, particularly in ICU settings, is not conclusively established. 3-6 Months Postoperative outcomes: An intriguing aspect of Pregabalin’s impact is its long-term benefits post-surgery. Studies pointed out improvements in patient satisfaction, quality of life, and reductions in neuropathic pain over a 3-6 month period post-surgery (19, 21, 23, 26, 27). These findings are significant as they suggest that Pregabalin may contribute to better long-term recovery and patient well-being after CABG. However, only a single study did not observe a significant long-term benefit, highlighting the heterogeneity in patient responses and the multifactorial nature of postoperative pain and recovery (20).
Conclusion: The synthesis of evidence from various studies reveals a notable heterogeneity in the therapeutic efficacy of Pregabalin. This variability in pain alleviation and analgesic requirements post-CABG potentially is due to diverse methodological approaches, patient demographics, and the varying pain management protocols adopted across different healthcare settings. Our review of the current literature indicates that Pregabalin, with its argueable efficacy in ameliorating pain during the initial 24 hours post-surgery and in reducing subsequent analgesic consumption, demonstrates promising outcomes in enhancing patient satisfaction, quality of life, and in the diminution of pain across a 3-6 month postoperative timeframe. However, these observations underscore the necessity for individualized therapeutic strategies. The decision to incorporate Pregabalin into the pain management regimen should be judiciously calibrated, taking into account the patient's unique clinical profile and specific perioperative circumstances.
Over the years, various pharmacological and non-pharmacological methods have been employed for managing post-CABG pain. These include opioids, non-steroidal anti-inflammatory drugs (NSAIDs), local anesthetics, and adjunctive therapies. However, each modality comes with its limitations and potential side effects (4). In this context, Pregabalin, primarily used for neuropathic pain, has attracted attention for its potential role in managing postoperative pain due to its unique mechanism of action, which involves binding to the α2δ subunit of voltage-gated calcium channels in the central nervous system, modulating the release of several neurotransmitters (6-8). This systematic review aims to evaluate the efficacy of Pregabalin in the management of post-CABG pain, considering the variability in results which might be attributed to differences in methodologies, patient populations, and pain management protocols across different studies.
Methods: A systematic search in Scopus, Google scholar, researchgate, Trip database, cochrane and science direct databases were made using the appropriate search phrase. Relevant published or conferenced clinical trials with the effect of using preoperative usual doses of pregabalin (75-150 mg) on pain reduction after CABG surgery with or without the use of a cardiopulmonary bypass pump were selected.
Results: In the studies found in the systematic review, there was a high heterogeneity in methodology and results, so meta-analysis was avoided due to the difference in methods. Nine randomized clinical trial studies in full, and two abstracts of randomized clinical trials were included in the review. In most studies, pregabalin was started at a dose of 150 mg one or two hours before the operation and was continued at a dose of 75 mg twice a day for different periods (from 2 to 14 days after the operation). First 24 Hours Post-Surgery: Pre-medication with Pregabalin did not significantly affect intraoperative and immediate postoperative fentanyl requirements, nor did it influence the duration of intubation (17-23). However, its primary goal, pain reduction post-surgery, yielded mixed results. While five studies reported significant pain reduction compared to placebo (18, 20, 23-25), four others found no significant difference (17, 19, 22, 24). Reduction in Postoperative Analgesics Usage: Varied outcomes were reported regarding the impact of pre-medication on postoperative analgesic consumption. Some studies observed a significant reduction in morphine usage among patients who received Pregabalin (18, 23, 26), while others reported no significant differences (17, 19, 22, 24).
Hospital Stay Duration: Regarding the length of hospital and ICU stays, the majority of studies reported no significant differences between the Pregabalin and control groups (17, 19, 20, 24, 27). This outcome indicates that while Pregabalin may aid in pain management, its effect on reducing the length of hospitalization, particularly in ICU settings, is not conclusively established. 3-6 Months Postoperative outcomes: An intriguing aspect of Pregabalin’s impact is its long-term benefits post-surgery. Studies pointed out improvements in patient satisfaction, quality of life, and reductions in neuropathic pain over a 3-6 month period post-surgery (19, 21, 23, 26, 27). These findings are significant as they suggest that Pregabalin may contribute to better long-term recovery and patient well-being after CABG. However, only a single study did not observe a significant long-term benefit, highlighting the heterogeneity in patient responses and the multifactorial nature of postoperative pain and recovery (20).
Conclusion: The synthesis of evidence from various studies reveals a notable heterogeneity in the therapeutic efficacy of Pregabalin. This variability in pain alleviation and analgesic requirements post-CABG potentially is due to diverse methodological approaches, patient demographics, and the varying pain management protocols adopted across different healthcare settings. Our review of the current literature indicates that Pregabalin, with its argueable efficacy in ameliorating pain during the initial 24 hours post-surgery and in reducing subsequent analgesic consumption, demonstrates promising outcomes in enhancing patient satisfaction, quality of life, and in the diminution of pain across a 3-6 month postoperative timeframe. However, these observations underscore the necessity for individualized therapeutic strategies. The decision to incorporate Pregabalin into the pain management regimen should be judiciously calibrated, taking into account the patient's unique clinical profile and specific perioperative circumstances.
Keywords: Pain, Pregabalin, Coronary Artery Bypass Grafting, CABG, Postoperative pain, Coronary artery surgery
Type of Study: review article |
Subject:
Anesthesiology
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