Perioperative Pain Management in the Cardiac Patient

Abstract

Pain is the perception of an unpleasant sensation to warn the body of tissue injury.  Nociceptors send stimuli to the central nervous system via neurons that enter the spinal cord via the dorsal horn.  The signal is then processed, integrated, and relayed to higher centres for interpretation.  Surgery stimulates pain pathways due to the tissue injury that it creates and in this way a neuroendocrine cascade is set into action as a protective mechanism by the body.  Cardiac patients and patients with cardiac risk factors pose a special risk when undergoing surgery.  They exist in a state of altered vascular responsiveness due to endothelial injury and chronic inflammation of the vasculature.   The physiologic response to pain may put cardiac patients at risk for cardiac events in the perioperative period.  More recent methods in pain control, such as epidural anaesthesia, can be used to decrease the risk of cardiac events in these patients.  Pain transmission and analgesia will be explored in this paper.  Furthermore, the current American College of Cardiology and American Heart Association Task Force guidelines on the management of cardiac patients undergoing noncardiac surgery as well as the literature published since the release of these guidelinte will be discussed.