Friday, August 12, 2022

Nerve Pain After Open-heart Surgery

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Pain management is a big concern for most people who undergo heart surgery. There are many things to think about and we want you to know that you are not alone! Nikhil Kumar MD and Angelia Nadiak, CNP, talk about how your care team works together to make sure your pain is managed. Each person is different and each pain plan is unique to each patient.

Kevin Hodges MD, joins the discussion to add a surgeons perspective on pain management and goals for helping our patients have a smooth recovery.

What to Expect After Open Heart Surgery Pain Management

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Blog Post from My Journey with Familial Hypercholesterolemia and Heart Disease

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Blog Post by A.W.About this Blog

In this blog I will follow my everyday journey of living with familial hypercholesterolemia . I am sharing my own experience with this inherited disorder, and how I manage it daily from what literature I read on the topic and what my doctors say to how I live my life . This is solely a personal account that might or might not offer some insight on what to expect when diagnosed with this condition. This blog does not offer advice, in any way, to anyone suffering from this disease.

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Role Of Endothelial Cells In Ima Patency

The IMA endothelium shows fewer fenestrations and lower intercellular junction permeability as compared to SVG, which could prevent lipoproteins from entering the subendothelial space. Segments of IMA collected at the time of surgery show a preserved morphology without any disturbance of endothelial cells or cautery burns, with uniform platelet endothelial cell adhesion molecule-1 staining, and strong expression of glucose transporter 1. Conversely, inducible nitric oxide synthase and intercellular adhesion molecule-1 are only moderately expressed on the luminal surface as well as on vasa vasorum of IMAs removed from patients with acute coronary syndrome or chronic stable angina . Endothelial cells of the IMA are rich in heparin sulfate and endothelial nitric oxide synthase , and release a greater amount of nitric oxide that contributes to the antithrombotic properties and endothelial homeostasis which confers protection from atherosclerosis.

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Still Having Chest Pain Even After Your Coronary Bypass Surgery

Its understandable for a person, fresh from coronary bypass surgery, or even several weeks out, to think hes having a heart attack or something wrong with his heart, when he has chest pain.

Chest wall pain after cardiac surgery may normally last 3-6 weeks, but may last as long as 12 weeks on rare occasions, says Dr. Michael Fiocco, Chief of Open Heart Surgery at Union Memorial Hospital in Baltimore, Maryland, one of the nations top 50 heart hospitals.

Think of it this way:

A surgeon just cut open your chest. This involves cracking open the sternum and using a crank-like device to pry it apart to expose the sac that surrounds the heart.

After the bypass surgery, the surgeon reattaches the sternum, which is bone, using wire. Of course you will have chest pain after bypass surgery!

Dr. Fiocco explains, This pain has a different quality from angina and most patients know the difference without question.

Post-op pain is also related to movement, coughing, and normally can be reproduced with palpation of the chest wall, none of which occur with ischemic pain .

Palpation means feeling and pressing with your fingers against your chest.

Its extremely rare to have angina following CABG , and differentiating between angina and post-op pain should be simple with just a physical exam, continues Dr. Fiocco.

Verbal Pain Rating Score

Chest Muscle Pain After Open Heart Surgery

Three types of pain were evaluated at the examination: whole body pain pain in the sternotomy site and worst ever pain at any site since their surgery. For each of these the patient was asked to quantify the severity of their pain by a four-point, categorical, verbal rating scale: no pain, 0 mild pain, 1 moderate pain, 2 severe pain, 3.

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Results Compared To Stent Placement

CABG or stent placement is indicated when medical management â anti-angina medications, statins, antihypertensives, smoking cessation, and/or tight blood sugar control in diabetics â do not satisfactorily relieve ischemic symptoms.

A 2018 meta-analysis with over 4000 patient cases found hybrid coronary revascularization to have significant advantages compared with conventional CABG. Reduced incidence of blood transfusion, reduced hospital stay duration and reduced intubation duration were all reported. In contrast, HCR was found to be significantly more expensive compared to CABG.

Youll Play A Key Role In Managing Your Pain

Post-surgical pain is unavoidable but can be managed in a variety of ways. Because of recent national legislation changes, physicians can prescribe no more than a seven-day supply of opioids to patients at the time of their hospital discharge.

Weaning yourself off opioids as soon as possible is important. You may need less than a seven-day supply, depending on your condition. Some patients do not require any opioids for pain management.

Other options for pain management include:

  • Oral and topical analgesics such as acetaminophen and Salonpas patches

  • Applying a warm cloth to the area, using caution near the incision because nerve sensitivity may be decreased, causing the skin to burn

  • Relaxation techniques such as meditation and guided imagery

If you are on long-term opioids, you should meet with your prescribing physician to begin to wean down to the lowest dose possible before surgery.

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Indications Of Sternal Wires Removal

  • To gain reentry either for redo surgery or in acute postoperative situation
  • Deep sternal wound infection and localized infection related to the sternal wires
  • In skinny patients and those who lose weight, sternal wires can be palpable or even seen or rarely can erode through the skin, in those patients wire removal may be indicated to alleviate their discomfort
  • Sternal wire removal is indicated as a measure to treat post sternotomy chronic pain.

Figure 1

Sternal wires can provoke damage of the anterior rami of the intercostal nerves during insertion at the sternal margin of the intercostal spaces Defalque and Bromley suggest that results in a neuralgia associated with scar-entrapped neuromas .

Wire factors for development of chronic pain includes eversion of the twisted portion of the sternal wires, friction between the wires and tissues and wire fracture with the resultant broken parts or dehiscence can be also a source of post sternotomy pain. Rarely allergic reaction to the wire can be the source of chronic pain. Once other causes of anterior chest pain such as sternal instability, mediastinitis, and cardiac causes such as ischemia are excluded, sternal wire removal is usually recommended.

In their study Zanavaros et al. studied 165 patients who received sternal wire removal, the majority of the patients had relief from pain, while only 9 patients reported no change or worsening of the pain after wire removal .

How Long Does It Take For Nerves To Repair After Surgery

Common Complications of Spine Surgery

Most episodes of nerve damage after surgery last for a few weeks to a few months. If they last longer, then the rate of nerve regrowth is about an inch a month. Therefore, if the nerve is able to regrow, a nerve injury in the back could take years to regenerate the entire nerve from your back to your foot . However, many times scarring in or around the nerve prevents regrowth .

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Resuming Normal Activities After Open Heart Surgery

Its important to remember that not everyone heals at the same rate. People who have diabetes or are taking steroids may take longer to heal after surgery. Age can play a role, too, as recovery may take longer in adults who are older. Complete recovery takes about three to six months.

At any phase in your recovery, using common sense is the best way to keep yourself from overdoing it, Dr. Tong says.

If an activity causes pressure or pain, stop. If your sternum doesnt heal properly after surgery, it can cause you a lot of pain and complicate the healing process.

If you arent sure an activity is safe, check with your surgeon first. And contact your doctor right away if you experience:

  • Redness on your chest larger than a quarter or drainage that resembles pus. This might signal an infection.
  • A clicking noise in your chest when you cough or breathe deeply. This could mean the wire holding your sternum together has broken.
  • Abnormal pain.

Overall, give yourself time to heal, while gradually doing a little more each week. Continue to work with your doctor until youre up to speed on your normal activities.

Latest Chronic Pain News

MONDAY, Feb. 24, 2014 — About one in 10 heart surgery patients has persistent pain for up to two years after the operation, a new study reveals.

The study included more than 1,200 patients aged 18 and older who had heart procedures — such as bypass or valve replacement — at four cardiac surgery centers in Canada.

Postoperative pain was felt by 40 percent of patients after three months, 22 percent of patients after six months, 17 percent after one year, and 10 percent of patients after two years, according to the study in the current issue of the CMAJ .

“These prevalence rates are not negligible given that more than 400,000 patients undergo annually in the U.S.,” wrote Dr. Manon Choiniere, a researcher with the University of Montreal Hospital Research Centre, and colleagues.

The researchers also found that those with increased risk of pain two years after heart surgery included: younger patients those who had chronic pain before the operation those who were more anxious before the procedure and those who had higher levels of pain during the first week after surgery.

“It is noteworthy that acute pain levels were quite high in this study,” the authors wrote. “It is troublesome that similar observations have been made over and over again in the past three decades and that postoperative pain continues to be undertreated despite numerous awareness campaigns, pain care guidelines and educational efforts.”

— Robert Preidt

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Experiencing Chest Pain After Surgery

Jennifer Schwartz, MD, is a board-certified surgeon and Assistant Professor of Surgery at the Yale School of Medicine.

Chest pain should always be taken seriously, and that is especially true if you have recently had surgery.

However, there’s the chest pain that can mean you’re having a heart attack and then there’s pain that happens to be located in the chest. Knowing the difference is key to protecting your health and having a full recovery.

The good news is that chest pain after surgery isnt always a life-threatening emergency.

Depending on the type of surgery you had, chest pain may be a normal part of the healing process, especially if your incision was in the chest area. Chest pain can also be a result of:

Management Of Chest Pain After Bypass

Opioid Use Disorder Associated With Greater Complications After Cardiac ...

Patient should always report of pain in chest even if it is minor after bypass surgery. While in most cases, pain is due to manipulation of muscles, nerves and incising of the breastbone, there is high index of suspicion of myocardial ischemia even though it is rare after the bypass surgery. If the EKG and hemodynamics are stable and normal, doctors usually prescribe pain killers for pain management.

To reduce the incidence of pain, patient should stay active during the recovery period at home. Avoid sitting for long time in one place. Walking is a good exercise although in the beginning it may be slow. It helps the heart to lungs to get strengthen. Patient should also perform light household activities such as folding clothes, climbing slowly few staircases etc.

After few months patient should increase the intensity of activities. Avoid lifting any heavy objects, and exposure to extreme cold and hot weather. Avoid driving for 2 months after the surgery as it may aggravate pain. Sexual activity should be restrained for 2 months after the surgery.

Wear loose clothing and a brace around the chest as suggested by the physician. Wearing surgical bra helps to relieve pain in women. It helps to reduce the discomfort that is felt at the incision site due to the weight of breasts while lying down.

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Importance And Incidence Of Chronic Post Sternotomy Pain

A significant number of patients who undergo median sternotomy for heart surgery suffer from persistent pain defined as chronic post-sternotomy pain . In the immediate period after surgery severe uncontrolled pain negatively affects patient recovery after cardiac surgery. Untreated pain may lead to adverse hemodynamic consequences such as tachycardia, arrhythmias and hypertension can lead to pulmonary complications such as atelectasis, pneumonia and coagulation disorders such as hypercoagulability and platelet activation, it also can lead to sleep, mode and behavioral changes, all of these consequences of pain can result in increased intensive care unit or hospital length of stay, hospital readmission, prolonged recovery and negatively affect quality of life on those affected .

In literature, there is a wide variation of the incidence of chronic post-sternotomy pain, this variation can be attributed to variations in definitions, different patient characteristics and retrospective nature of these studies. Chronic pain after coronary artery bypass surgery, was estimated to occur in 2550% of patients and the incidence of severe pain is 510% of them .

Studies reported a 20.6% brachial damage during cardiac surgery that can result in chronic pain post sternotomy .

I Still Have Dreadful Pain In My Breasts After Open Heart Surgery It’s Nin

I still have dreadful pain in my breasts after open heart surgery. it’s nine weeks, is this normal ?

No, it’s not … definitely go and see your doctor or the surgeon. That said you can certainly expect discomfort … but not pain. The discomfort should easy around 3 months.

Hey SusanIt’s normal . I had a quad in May andI still have pain.If you left your breast it relaxthe muscles. I asked the same questions after 4 months to my doctor. You will have over the shoulder pains after but it doesn’t last long.

Good Luck

Beverly, it’s a matter of degree … no-one should be suffering excruciating pain after surgery. Pain, maybe, but not excruciating. Treating it as “normal” is a risky thing … there could be all kinds of possible reasons for pain and some are serious. Pain is our smoke detector. You say “it’s only burning toast” without checking, at your own risk

Hello StuartI had surgery in May 2015 I still have pain. I take Norco aleasr 3 times a month. My doctor said evetyone heals differently. I didnt have pain 3 weeks later and then it begin. Right under my breasr after a xray and echo nothing found. The pain can also be a result of nerve going back into to place. I received that medication and I no longer have pain in my breast.

Thanks

Hey StuartI agree to get it check by all means, I just want her to know it happens. I always get a doctors opinion.Bev

I would love to know if you are still having this problem……..and if so, what is it like now?.

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Your Eating Habits May Change

You may notice that youve lost your appetite or you just feel too tired to eat. This is common, so be patient. Your appetite will soon be back to normal.

We suggest you try eating frequent, small meals throughout the day. You need proper nutrition to enable your body to heal and get stronger.

We recommend a diet low in fat, cholesterol and sodium and high in protein. Good sources of protein include fish, eggs, dairy, beans and nuts. Limit the amount of salt in your diet to 2,000 milligrams a day. Foods known to be high in salt include restaurant food, soups, pizza, bacon and other processed meats.

Six To 10 Weeks After Surgery

Pain Associated with Nerve Damage

If you had open heart surgery and your surgeon divided your sternum, it will be about 80% healed after six to eight weeks. By that time, youll generally be strong enough to get back to normal activities, such as driving, Dr. Tong says. You can probably also return to work, unless your job is physically strenuous.

Most importantly, this is the time to start a cardiac rehabilitation program. This is a monitored exercise program designed to increase your hearts endurance. Through cardiac rehabilitation, you can gradually increase your activities, and your doctors will watch your progress closely. Youll also learn more about how you can change your lifestyle and diet to keep your heart healthy.

Working through a cardiac rehabilitation program is the best way to find out when youre strong enough to resume the more strenuous activities you enjoy.

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What Happens When Your Nerves Are Damaged

Think of a nerve as a garden hose. If you constrict one area, less water comes out. This is what happens when scar tissue forms around a nerve after surgery. The scar tissue constricts the nerve which reduces the transport of critical chemicals that the nerve needs to stay healthy.

A nerve can also be damaged by killing some or all of its fibers. The image below shows that a nerve is made up of bundles of neurons called fascicles. Groups of these fascicles make up the bigger nerve . In addition, the nerve is surrounded by a fatty sheath that acts like an insulator covering a wire. When this sheath gets damaged there can also be a problem with nerve function.

Alila Medical Media/Shutterstock

There are three types of nerve damage:

  • Neurapraxia: damage to the covering of the wire, or myelin sheath
  • Axonotmesis: damage to the wire itself, or the neurons
  • Neurotmesis: the nerve is torn or cut in half

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