Sternal Pain Research Articles

The Analgesic Effect of Ultrasound-guided Bilateral Pectointercostal Fascial Plane Block on Sternal Wound Pain After Open Heart Surgeries: A Randomized Controlled Study.

We aimed to evaluate the analgesic efficacy of ultrasound-guided bilateral pectointercostal fascial plane block after open heart surgeries. Seventy patients aged above 18 years and scheduled for on-pump coronary artery bypass grafting or valve replacement or both through median sternotomy were enrolled in this study. Patients were randomly allocated into 2 groups of 35 (block group or control group). The block group had the block performed through 20 ml of a solution of 0.25% bupivacaine plus epinephrine (5 mcg/mL), and the control group received dry needling. The primary outcome was the 24-hour cumulative morphine consumption. The secondary outcomes were time to the first analgesic request, pain score, quality of oxygenation, intensive care unit stays, and hospital stay. The cumulative morphine consumption in the first 24 hours was significantly lower in the block group, with a mean difference of -3.54 (95% confidence interval=-6.55 to -0.53; P=0.015). In addition, the median estimate time to the first analgesic request was significantly longer in the block group than in the control group. Finally, during the postoperative period (4 to 24 h), mean sternal wound objective pain scores were, on average, 0.58 units higher in the block group. pectointercostal fascial block is an effective technique in reducing morphine consumption and controlling poststernotomy pain after cardiac surgeries. Also, it may have a role in better postoperative respiratory outcomes.

Assessment of Correlation Between Costochondritis and Vitamin D Insufficiency in School-age Children

Background: In children, vitamin D deficiency can result in the hypertrophy of costochondral junctions and sternal pain. Objectives: In this study, we aimed at determining the correlation between children’s vitamin D status and costochondritis. Methods: This cross-sectional study included a control group (100 healthy children) and a study group (100 children with costochondritis). Examination of patients included chest radiography, physical examination, history-taking, electrocardiography, echocardiography, and serum measurement of 25-hydroxyvitamin D, phosphorus, calcium, and alkaline phosphatase. The chi-square test, Spearman’s correlation test, and independent samples t-test were also performed for analyzing the data. Results: The groups showed no significant difference regarding age, gender, or body mass index (P = 0.315, P = 0.671, and P = 0.097, respectively). The history of patients experiencing idiopathic chest pain showed cardiac disease in 13% of their families, without report of death in the family. The pain was mainly located in the left precordium (64%), followed by the right precordium and the midsternal region (32% and 18%, respectively). A significantly lower level of 25-OHD was found in the study group than in the control group (P < 0.0001). Based on the findings, the groups were not significantly different regarding the evaluated biochemical parameters, except for alkaline phosphatase (P = 0.007). The results showed that pain duration and episodes were significantly associated with vitamin D insufficiency (r = -0.621, P = 0.002; r = -0.213, P = 0.021, respectively). Conclusions: Vitamin D insufficiency should be considered in costochondritis. Also, pain duration and episodes have associations with vitamin D insufficiency. This finding emphasizes the necessity of evaluating nutritional parameters in children with non-cardiac chest pain.

Bone Lysis Revealing Primary Malignant Melanoma of the Esophagus: Case Report and Review of the Literature

Primary malignant melanoma of the esophagus is a rare, very aggressive entity with a bad prognosis. It is metastatic in 40 to 80% of cases at diagnosis. The symptoms are non-specific and the diagnosis is confirmed by histology. The treatment of choice is surgery in the early forms. We report the case of a metastatic primary melanoma of the esophagus discovered by retro sternal pain.

Sexual Quality of Life in Men

To explore the effect of undergoing coronary artery bypass grafting on sexual quality of life as an integral part of patients' health-related quality of life. This cross-sectional study included 265 men ages 18 to 60 years (median age, 55) who underwent coronary artery bypass grafting 1 to 5 years before the study. Standardized questionnaires were implemented to evaluate participant pre- and postoperative sexual quality of life and the quality of counseling provided to patients. Among the patients, 77% were in a steady relationship. The general health score was 5.5 ± 2.8 (mean ± standard deviation) preoperatively and 6 ± 2.2 at follow-up (P = .01). No sexual counseling was given to 83% and 77% of the patients pre- and postoperatively, respectively. The mean sexual satisfaction score dropped from 6.5 ± 2.6 preoperatively to 4.7 ± 3 postoperatively (P < .001). The decline in sexual intercourse frequency and masturbation frequency was significant (P < .001 and P = .006, respectively). Linear regression analysis showed that general health status (P = .008), higher-quality counseling (P = .027), and preoperative sexual quality of life (P < .001) correlated positively with sexual quality of life, whereas sternal pain (P < .001), erectile dysfunction (P < .001), and fear of excessive cardiac burden (P < .001) correlated negatively. Middle-aged men experience decreased sexual quality of life after coronary artery bypass grafting. Preoperative sexual quality of life, general health, and higher-quality counseling positively affect postoperative sexual quality of life, whereas sternal pain, fear, and erectile dysfunction play a negative role. Pre- and postoperative care guidelines should be improved. Further prospective large cohort studies for males and females are required.

Does the speed of sternal retraction during coronary artery bypass graft surgery affect postoperative pain outcomes? A randomized controlled trial protocol

Background: Chronic pain is a serious health issue impacting both the quality of life and productivity of patients.Chronic post-sternotomy pain (CPSP) is characterized by numbness, severe tenderness on palpation, allodynia, as well as constant pain across the anterior chest wall that can persist for months to years after sternotomy. All patients experience early post-operative pain following coronary artery bypass graft (CABG); unfortunately, approximately 30-40% of CABG patients subsequently develop CPSP. Methods: The current study is a prospective, double-blinded, randomized controlled trial. A sample size of 316 randomly assigned patients (n=158 per group) will provide an 80% power at a 2-sided α of 0.05 to detect a 40% decrease in CPSP incidence at 6 months. Eligible patients scheduled for elective, primary coronary artery bypass graft surgery will be randomly assigned to the CONTROL group, in which sternal retraction is conducted over 30 seconds (as per standard practice); or the SLOW group, in which sternal retraction is achieved over 15 minutes. Surgical and perioperative anesthesia protocols between the two groups are otherwise the same. Our primary outcome is the incidence of CPSP at 6 months. Secondary outcomes are: CPSP incidence at 3 and 12 months, daily sternal incision pain intensity (numeric rating scale (NRS)) at rest and while coughing, and daily analgesic consumption while in hospital and at 7 days postoperatively; pain quality, quality of life, and pain interference with daily function at 3, 6, and 12 months post-operatively.Discussion: Our randomized controlled trial will determine whether retracting the sternum more slowly for exposure of the heart during CABG surgery will decrease the incidence and/or severity of CPSP.ClinicalTrials.gov registration:NCT02697812 (03/03/2016

Scheduled Prophylactic 6-Hourly IV AcetaminopheN to Prevent Postoperative Delirium in Older CaRdiac SurgicAl Patients (PANDORA): protocol for a multicentre randomised controlled trial

IntroductionPostoperative delirium is common among older cardiac surgery patients. Often difficult to predict and address prophylactically, delirium complicates the postoperative course by increasing morbidity and mortality as well as prolonging...

Acute Coronary Syndromes in Niger: (West Africa): Epidemiological, Clinical, Para clinical and Therapeutic Aspects

Introduction: Coronary artery disease is the leader in cardiovascular disease. An estimated 7.5 million deaths from cardiovascular disease are due to coronary heart disease. WHO estimates that by 2030, nearly 23.6 million people will die from cardiovascular disease? Over 80% of deaths attributed to cardiovascular disease occur in low- and middle-income developing countries. The CORONAFRIC survey done in 1991 and which gathered 13 West African countries with 16 centers found a prevalence of coronary heart disease of 3, 17%. In Niger an over survey done in 2013 shows a prevalence of coronary heart disease at 5.60%. The main cause of coronary pathologies is atherosclerosis or atheroma and its sudden complication thrombosis. This review aims to study the local specificities of ACS through its epidemiological, clinical, Para clinical and therapeutic aspects at the level of the LAMORDE National Teaching Hospital (LNTH), in the absence of a cardiology technical platform intervention and in the absence of pre-hospital care, in order to formulate recommendations for the prevention of coronary artery diseases in low income countries. Patients and Methods: This is a retro and prospective study over a period (July 01, 2014 to December 31, 2019) of 66 months and concerns cases of ACS hospitalized in the internal medicine and cardiology department of LNTH. Were included in our study patients with angina pain, and electrocardiographic signs (ischemia, lesion or necrosis) with or without a confirmed past history of MI but admitted with biological signs. Results: At the end of our study, the prevalence of ACS is 10.67% compared to cardiovascular disease, CI 51.24%, stroke 26.24% and thromboembolic disease 2.84%. ACS is predominantly male in 63.77% of cases. The sex ratio is 1.76 -the age ≥50 years represents 86.98% of the subjects, with an average age of 60.98 years; -The months of November, December, January and February represent the favorable period for the onset of acute coronary syndromes with 23.20% of cases. - Retro sternal chest pain is by far the most common symptom with 67.63% of cases. Troponin was measured in 75 of our patients, ie 36.23% of which 35.27% had a high level.- ECG, troponin allowed us to identify forms of ACS with 70.05% of ACS ST +; 21.74% unstable angina and 8.21% Q- wave of MI. - The most affected territory was anterior with 153 cases (73.91%) followed by the lower territory 46 cases (22.22%) then the lateral territory 16 cases (7.73%) associated. In our study, hypertension was encountered in 34.48% of cases, diabetes (11.11%), hypercholesterolemia 4.35%), smoking (with 4.83%), obesity (with 2.90%), menopause (with 84.93%) were recognized as risk factors favoring the occurrence of ACS. In 96.14% of the cases, the patients were put on aspirin and clopidogrel followed by the ICE in 93.24% of the cases; Beta blocking in 92.75% of cases; statin in 89.86% of cases; of diuretics in 55.56% of cases and heparin in 52.17% of cases. In our study, 80.68% of our patients left hospital after clinical improvement. We have a high mortality rate of 19.32%. 80% of patients had HF as a complication, and conduction disorders are noted in 16% of cases and recurrence of pain in 8% of patients.

Effect of TENS on Post-operative Sternal Pain (Post Cardiac Surgery): A Narrative Review

Transcutaneous electrical nerve stimulation TENS is a modality that blocks the pain by pain gate mechanism and is documented to be safe and effective. Sternum pain signifies the pain in the thoracic cavity that contains the sternum and the cartilage connecting it to the ribs. Patients who experience pain after any cardiac surgery may also experience prolonged immobilization insufficient respiratory functions and the inability to cough as a result of the surgical procedure specifically post median sternotomy. TENS has been shown to be effective in acute and chronic pain in both medical and surgical conditions in multiple studies conducted since 1970. This review was conducted to document the effectiveness and also the parameters of TENS used post Coronary Artery Bypass Graft CABG to relieve pain and improve parameters like functional capacity cardiopulmonary endurance length of hospital stay etc. The review concluded that many studies documented the effectiveness in post-operative CABG patients however some studies stated that it was less effective than other forms of pain relief. The parameters of TENS used in all the randomised control trials have been documented in the results.The clinical application of this review is that TENS can be used as an adjunct treatment in post-operative sternal pain patients on an inpatient and outpatient basis which will be working on other parameters functional capacity cardiopulmonary endurance length of hospital stay apart from pain relief and eventually helps in improving the quality of life of the patients.

Sternal cavernous hemangioma and reconstruction of the anterior chest wall: a case report

BackgroundThe sternum is considered an unusual tumor site, corresponding to 15% of all thoracic wall tumors. Primary sternal tumors are even rarer and most commonly malignant. We present the case of a young man who consulted with a painful sternal mass, which after its resection is confirmed to be a cavernous hemangioma.Case presentationA 39-year-old man, with unremarkable medical history besides a 2-year-long sternal pain, non-irradiated, which worsens over the last few months and is accompanied by the appearance of a sternal palpable mass. On physical exam, there was a bulging of the sternal manubrium, with no inflammatory changes. Thoracic CT scan shows an expansive and lytic lesion of the sternum, compromising the manubrium and extending to the third sternocostal joint, without intrathoracic compromise nor cleavage plane with mediastinal vascular structures. The patient is taken to resection of the mass and sternal reconstruction using prosthetic material and pectoral and fasciocutaneous muscular flaps. Histopathological findings: cavernous hemangioma with negative borders and no other malignant findings.ConclusionsSternal hemangiomas can cause defects in the bone structure and show an expansive growth, challenging the differentiation between a benign or malignant lesion. Therefore, they should be considered malignant until shown otherwise. Management involves radical surgery with curative purposes and posterior reconstruction to improve quality of life, as shown with our patient.

Response to the Time

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Wire Cerclage Versus Cable Closure After Sternotomy for Dehiscence and DSWI: A Systematic Review and Meta-Analysis.

Cable closure has been introduced as a potential alternative to traditional wire cerclage (WC) for closure of median sternotomy. To evaluate whether cable closure improves patient outcomes, we conducted a systematic review and meta-analysis of the literature. Ovid versions of Medline and Embase, and Google Scholar were used for the literature search. This yielded 7 studies (n = 2,758), which compared traditional WC to cable closure systems. Outcomes included deep sternal wound infection, sternal dehiscence, postoperative pain score, and sternal wound infection. We found significantly lower incidence of sternal dehiscence for cable closure compared to WC (risk ratio [RR] 0.14, 95% confidence interval [CI]: 0.03 to 0.59, P < 0.01, I 2 = 0%) but no difference in DSWI (RR 0.97, 95% CI: 0.39 to 2.42, P = 0.95, I 2 = 33%). Cable closure was also associated with lower pain when compared with the WC group (mean difference -1.04 points, 95% CI: -1.89 to -0.19, P = 0.02, I 2 = 87%). This study suggests that cable closure results in less incidence of sternal dehiscence and pain compared to WC. Nonetheless, there remains a limited number of studies on this topic and further high-quality studies are required to confirm the results of this meta-analysis.

Single-fraction stereotactic ablative body radiotherapy for sternal metastases in oligometastatic breast cancer: Technique and single institution experience.

Due to size and close proximity to skin, the sternum is a complicated target for stereotactic ablative body radiotherapy (SABR). This is a retrospective case series of single-fraction SABR to sternal metastasis in patients with oligometastatic breast cancer. Between June 2014 and June 2018, ten breast cancer patients received 20Gy in 1 fraction to a solitary sternal metastasis. Eligible patients had Eastern Cooperative Oncology Group performance status of 0-2, oligometastatic disease (defined as 1-5 metastases) and a controlled primary site. Patients were treated with 3-dimensional conformal radiotherapy, each patient case comprising of>6 coplanar beams and 2-6 non-coplanar beams. Local control, pain response and adverse events were retrospectively reviewed. The median planned target volumes were 84.75cc (range, 14.4-197.8cc). The median conformity index was 1.29 (range, 1.2-1.49). At a median follow-up of 32months, nine patients achieved in-field control. Two patients had triple negative disease, one of them developed marginal recurrence, and the other had in-field recurrence. Seven patients had sternal pain prior to SABR, and within 3months after SABR treatment, the pain improved (n=3) or resolved (n=2). Four patients developed acute grade 1 and 2 skin reactions, and two patients had late grade 1 skin reactions. There were no grade 3 or 4 toxicities. Our case series demonstrates safety of SABR with associated disease control and analgesic benefit in selected patients with oligometastatic breast cancer. The marginal recurrence observed in this cohort suggests wider margins could be beneficial to account for microscopic disease.

Comparison of Stability And Sternum Healing Rate in Clinical and Ultrasonography (USG) between Stainless Steel Wire and Polydioxanone Yarn in Children Heart Surgery Operation

Background: The closing of the sternum bone is often used today by using stainless steel wire material and Polydioxanone yarn continuous suture. To objectives to be achieved for sternal healing after heart surgery without complications resulting from the failure of sternal healing. The bone healing process itself is influenced by mechanical stress and movement. Objectives: To compare the effects of sternum closure techniques on surgical patients The heart of the child uses Polydioxanone and Stainless Steel Wire threads against clinical stability and rate of healing which are evaluated clinically and Ultrasonography. Methods: Performed sternal closure of pediatric patients after cardiac surgery with sternal wire (n = 8) and PDS (n = 8). Performed sternal pain and stability evaluation with the physical examination. Further sternum ultrasonographyund was performed to assess displacement, gap and callus picture. Evaluations were performed at weeks 6, 9 and 12 postoperatively. Results: Week 6 and 9 degrees of pain were higher in sternal wire compared with polydioxanone (p = 0.03 and p = 0.01). The 12th week of sternal wire and polydioxanone did not find any difference in pain (p = 1,000). Week 6, 9 and 12 there was no clinical stability difference between wire and PDS (p = 0.143, p = 0.264, p = 0.063). 9th, 9th and 12th Sternum ultrasonography of examination appears to be displacement in polydioxanone (p = 0.025, p = 0.009, p = 0.009). The gap increased significantly from 6th to 9th weeks in the polydioxanone group, while the addition at week 9 to 12 was statistically insignificant but it appears that polydioxanone had a wider gap addition range than the sternal wire. Week 9 and 12 callus were seen more often in sternal wire patients but not significant (P = 0.602, p = 0.333) Conclusion: Clinically, sternal steal wire stability is proportional to polydioxanone. Radiologically, the stability of sternal wire is better than polydioxanone. The rate of sternal cure in polydioxanone is proportional to the sternal wire.

Effect of Applying Cold Gel Pack to the Sternum Region on the Postoperative Pain after Open-Heart Surgery

Aim: The present study was performed at investigating the effects of cold gel pack applied to the sternum on the pain associated with deep breathing and coughing after open-heart surgery. Material-Methods : The study sample included 46 participants. While the study data were collected, the “Patient Information Form” prepared by the researcher based on the pertinent literature was used to question the sociodemographic characteristics of the patients, the “Visual Analogue Scale-VAS” was used to assess the severity of the patient's pain, and the “Pain Monitoring Form” was used to record the patient's pain associated with deep breathing and coughing exercises before and after cold gel pack application. Pain scores after deep breathing and coughing were measured and compared warm (room temperature) (placebo) gel pack, with (intervention) and without (control) the gel pack. Results: The intergroup analysis showed that the difference between the experimental, control and placebo groups in terms of their mean VAS scores obtained before the procedure and after the procedure was not statistically significant. But in the experimental group; in terms of their mean VAS scores obtained before the procedure and after the procedure was determined statistically significant. Conclusions : The results of this study showed that cold therapy is an effective method for management of sternal incision pain associated with coughing and deep breathing in open heart surgery patients. Key words: Postoperative Pain , Breathing Exercises, Cardiac Surgery , Post-Surgical Nursing .

COVID-19 у детей в мегаполисе: клинико-эпидемиологические и терапевтические аспекты

The pandemic of a new coronavirus infection in the world, including in Russia, was the basis for a detailed analysis of the disease features in children hospitalized in the only specialized hospital in Saint Petersburg. The purpose — is to analyze clinical and epidemiological data and approaches to the treatment of COVID-19 in children based on the functioning of the specialized infectious hospital, which was the first in such a megalopolis as Saint Petersburg to be deployed to work with the new coronavirus infection from January 2020 to the present. Material and methods. Based on a retrospective continuous single-center study, we analyzed 206 medical records of inpatient children aged 0 to 18 years who were treated in the Infectious Department № 7 of the Filatov municipal hospital № 5 in Saint Petersburg with a diagnosis of COVID-19 from March to June 2020. The mandatory selection criterion was laboratory confirmation of the COVID-19 diagnosis — a positive result of PCR of SARS-Cov-2 RNA in nasopharyngeal and oropharyngeal smears. The article is descriptive in nature. Results. It was found that children older than 3 years prevailed among the patients (71,5%, n = 147). Family contact with adults prevailed (54,9%, n = 113). COVID-19-ARVI was diagnosed in 81,4% (n = 168) of children, pneumonia was diagnosed in 18,6% (n = 38) of cases, and in 1,9% (n = 4) of cases it was asymptomatic. Mild forms of the disease prevailed (76,2%, n = 157), severe ones occurred only in 1,9% (n = 4) of patients. In 30,7% (n = 63) of cases, patients were admitted to a hospital late (in the second week of the disease). It was found that the clinical picture was dominated by fever (78,6%, n = 162), which lasted more than 5 days in 22,3% (n = 46) of cases, pharyngeal hyperemia — 84,5% (n = 174), cough — 51,2% (n = 105), symptoms of intestinal dysfunction — 19,4% (n = 40), anosmia — 9,9% (n = 20), exanthema — 7,8% (n = 16), sternal pain — 9,9% (n = 20). Recombinant interferon alpha-2b, umifenovir, lopinavir/ritonavir, anticoagulants, macrolides, and cephalosporins were used in the treatment of children. All patients showed positive dynamics with favorable outcome after treatment. All patients were discharged with clinical recovery. In 84,4% (n = 174) of patients sanation of nasopharynx и and fauces took place in hospital, in 62,1% (n = 128) of cases virus discharge took place on the 10–12 day, in other cases after 2–4 weeks. Conclusion. COVID-19 in children in a megalopolis has specific features compared with other ARVIs, but therapy principles are similar, implying taking into account the disease severity and early start of etiotropic treatment with the whole range of available antivirus drugs allowed for children and having an evidential basis, which was confirmed in the present research.

010 Resistance Training Avoidance- a Benefit or Barrier to Recovery following Cardiac Surgery Via Median Sternotomy?

Sternal precautions typically restrict upper limb movement for 1-6 weeks and resistance training for 6-12 weeks post-sternotomy. This is based on the belief that mechanical forces generated by upper limb movements act in direct opposition to the wire suture holding strength, seen in early cadaver studies. However, the safety, feasibility and reliability of resistance training on sternal micromotion is unknown. This is a nested study within a pilot randomised controlled trial comparing standard care to a 12-week resistance training program. Sixteen adults following first-time cardiac surgery via median sternotomy, who were randomised to the resistance training group participated. Sternal micromotion was assessed using sternal ultrasound of the mid- and lower- sternum during a cough and six dynamic bilateral upper limb resistance exercises at 2-, 8- and 14- weeks postoperatively, performed on CAM-machines at a base resistance of 20lbs (9kg). Participant-reported pain was recorded using a Visual Analogue Scale. Intra-class correlation coefficients (ICC) were used to calculate inter-rater reliability of sternal ultrasound image analysis. The biceps curl (M=1.5mm; IQR=1.9mm) and shoulder pulldown (M=0.5mm; IQR=1.1mm) resulted in the greatest median micromotion in the lateral and anterior-posterior directions, respectively. No increase in pain from rest was reported by any participant. Inter-rater reliability for lateral (ICC=0.73; 95% CI=0.58-0.83) and anterior-posterior (ICC=0.83; 95% CI=0.73-0.89) sternal edge micromotion was moderate-to-good. Physical and functional postoperative recovery is impacted by movement restrictions recommended within current sternal precautions. This study determined that bilateral upper limb exercises performed on CAM-resistance machines is safe in regard to sternal micromotion (<2mm) and pain as early as two weeks post-sternotomy.

Infra-Abdominal Muscles Activation Brings Benefits to the Pulmonary Function of Patients with Sternal Instability after Cardiac Surgery.

ObjectiveTo compare physical therapy strategies involving abdominal muscle stabilization, with and without upper limb movement, in patients with sternal instability after heart surgery and during in-hospital care.MethodsThis prospective, longitudinal, randomized, and comparative clinical study included 20 patients, which were divided into two groups: ARM, the arm group (n=10), and LEG, the leg group (n=10). The study involved the evaluation of scores of visual analog scales for sternal instability, pain, discomfort, functional impairment, lung function, and maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) before and after the interventions. Two protocols consisting of abdominal exercises in both groups with upper limb movements (ARM) and just abdominal activation with leg movements (LEG) were used for three weeks.ResultsThere were statistically significant (P≤0.01) improvements in pain, discomfort, and functional impairment scores, and in MIP (P=0.04) and MEP (P≤0.01) after intervention in both groups and just LEG showed improvement in forced vital capacity (P=0.043) and forced expiratory volume in one second (P=0.011).ConclusionBoth strategies promoted improvement in pain, discomfort, and functional impairment scores and in the values of inspiratory and expiratory pressures. Perhaps they were influenced by the time and resolution of the infection process, although exercises with upper limb movements seem to be safe in this population. The activation of the infra-abdominal muscles through leg movements seems to bring more benefits to lung function.

Influence of volatile anesthesia versus total intravenous anesthesia on chronic postsurgical pain after cardiac surgery using the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials criteria: study protocol for a prospective randomized controlled trial

BackgroundMany patients develop chronic postsurgical pain (CPSP) after cardiac surgery, which interferes with their sleep, mood, and quality of life. Studies have suggested that propofol improves postoperative analgesia compared with volatile anesthetics, but its preventive effect on CPSP following cardiac surgery is still unknown. This study compares the incidence of CPSP following cardiac surgery for those receiving volatile anesthesia and those receiving propofol-based total intravenous anesthesia (TIVA) using criteria recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT).Methods/designThis is a prospective randomized controlled trial. In total, 500 adults undergoing cardiac surgery will be randomly allocated to the volatile or the TIVA group. The volatile group will receive sevoflurane or desflurane during surgery as general anesthesia. The TIVA group will receive propofol-based intravenous agents and no volatile agents during surgery. The primary outcomes will be the frequency of CPSP at 3 months, 6 months, and 1 year after surgery. In this case, CPSP is sternal or thoracic pain. It is defined as either (1) numerical rating scale (NRS) > 0 or (2) meeting all six IMMPACT criteria for CPSP. The IMMPACT criteria are validated pain instruments.DiscussionTo our knowledge, this is the first prospective randomized controlled trial to investigate the prevention of CPSP following cardiac surgery for patients receiving volatile anesthesia compared to those receiving propofol-based TIVA using validated pain instruments in accordance with the IMMPACT recommendations. This study will provide important information on which of these two anesthetic regimens is better for preventing CPSP after cardiac surgery.Trial registrationChictr.org.cn, ChiCTR1900020747. Registered on 16 January 2019.

Osteopathic approach with a patient undergoing cardiac transplantation: the five diaphragms.

The case report presents a patient with a possible neuropathic sternal pain associated with a recent heart transplant procedure. The patient could not breathe deeply and move the upper limbs, with a trunk torsion, feeling a sharp pain under and around the left breastbone. A fascial osteopathic approach in the treatment of the pelvic floor, the respiratory diaphragm, the thoracic outlet, the tongue and the tentorium cerebelli allowed the patient to access to a cardiovascular rehabilitation program. In osteopathic medicine, these anatomical parts of the body are called the five diaphragms. To our best knowledge, this is the first case report that uses osteopathic treatment in a patient with sternal pain associated with an undergoing cardiac transplantation. The clinical importance of the case report is added to other osteopathic research with patients undergoing cardiac surgery (coronary artery bypass graft) and with multiple benefits, without side effects. One of the main goals of osteopathic treatment is to provide the patient with well-being, from many clinical points of view, allowing the person to be discharged from the hospital more quickly and/or with less pain.

Mo1046 DELAYED GASTRIC EMPTYING SECONDARY TO POEM PROCEDURE: A RARE CASE OF GASTROPARESIS

A 42-year-old man came to our clinic complaining recurrent difficult swallowing for 18 years and upper abdominal fullness for 2 years. He has been suffered from difficult swallowing, regurgitation, vomiting and occasional posterior sternal pain since 2000. He was diagnosed of achalasia (Eckardt score: 8) (Figure 1) and the symptoms were greatly relieved after balloon dilation (BD) (Eckardt score: 2) in 2010. Unfortunately, he relapsed into achalasia (Eckardt score: 8) and then underwent peroral endoscopic myotomy (POEM) (Eckardt score: 7). However, although the pre-operation barium meal showed no sign of gastric retention, the patient began to develop some new symptoms of delayed gastric emptying such as gastral pattern and early satiety which cannot be aniseed by prokinetic drugs (GCSI score: 24). Gastric retention was first confirmed by gastric endoscopy in March 2017, while pylorus stenosis was confirmed by both barium meal and gastric endoscopy in June 2017. Electrogastrogram revealed a gastric dysrhythmia before and after meal, and gastric emptying after 5 h was only 5% (normal: ≥ 50%) (Figure 2, left). Multiple blood test (glycemia, cancer biomarkers, immune parameters), CT and biopsy exclude carcinoma, diabetes or autoimmune disease. To eliminate the symptoms, the patient received gastric peroral endoscopic myotomy (G-POEM) procedure in April 2018. Barium meal showed normal gastric emptying (Figure 2, right), and pyloric was round without stricture under gastric endoscopy in 7 months follow-up (GCSI score: 11). Nevertheless, his Eckardt score remained at 6 and BD was performed recently in our institution. The post-operation barium meal and patients’ symptoms were improved after BD.