الفهرس 
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Abstract
Median sternotomy is the best approach for a clear visualization of heart and associated viscera. Median sternotomy is a type of surgical procedure in which a midline vertical incision is made along the sternum after which the sternum itself is divided or cracked.
Cardiac procedure requiring median sternotomy includes coronary artery bypass grafting, valve replacement, repair of a variety of congenital cardiac diseases. Post sternotomy pain is mostly musculoskeletal & myofascial. These painful conditions are jointly called post sternotomy pain syndrome.
Pain after cardiac surgery is caused by several factors such as sternotomy, sternal or rib retraction, pericardiotomy, internal mammary artery harvesting, saphenous vein harvesting, surgical manipulation of the parietal pleura, chest tube insertion and other musculoskeletal trauma during surgery.
Pain has been indicated that pain is the fifth vital sign and should be measured and treated equally to other vital signs, as poorly managed pain leads to negative consequences for the organism.
Traditionally postoperative pain management after cardiac surgery has been based on opiate analgesics. However, opiates have some undesirable dose related side effects such as pruritus, nausea, constipation, vomiting. They also cause dizziness, mental confusion and respiratory depression which substantially influence patient recovery and may delay discharge after surgery and increased costs.
Although historically the cornerstone of postoperative analgesia is opioid based, there’s growing evidence to support a multimodal approach to attenuate opioid side effects, and reduce the level of pain scores, and to attenuate the duration of hospital stay, and encourage enhanced recovery techniques which give multimodal regimens as an important component for cardiac surgeries.
In our study, sixty patients were scheduled for elective open-heart surgeries with sternotomy and were allocated in two equal groups, thirty patients in each group. group (M): multimodal analgesia (dexamethasone, ketorolac, gabapentin, ibuprofen, and paracetamol) was administered to patients. group (C): morphine (IV) was administered to patients.
The aim of our study was to evaluate if an opiate sparing multi-modal regimen of (dexamethasone, gabapentin, ibuprofen, ketorolac and paracetamol) had similar analgesic effect, less side effects and was safe compared to a traditional opioid based regimen after open cardiac surgeries and to detect the primary and secondary outcomes.
Our results showed that that patients in the multimodal group had significantly lower pain scores (VAS) from the day of surgery to the fourth postoperative day. Patients in the multimodal regimen suffered less side effects compared to the morphine group after open cardiac surgery.
There was dramatically decreased complaint of nausea, vomiting, constipation, and respiratory depression in the multimodal group compared to the morphine group. In terms of renal complication, while no increase in individual levels of creatinine in the multimodal group, no dialysis safety concerns were observed. Furthermore, patients in the multimodal group had a shorter duration of hospital stays compared to the morphine group.
Conclusions
Each patient is unique in his or her perception of pain allowing for many combinations in the treatment of pain. The introduction of enhanced recovery programs has changed both physician and patient expectations in terms of perioperative pain management making the reduction of opiate intake a factor in meeting these expectations.
Non opioid adjuvant analgesia has a definite role in perioperative settings. These drugs act by modifying the peripheral and central changes in the nociceptive system that occurs as a result of tissue injury. Definitive high quality evidence for their use is variable, making it difficult to identify the best agents to use in individual patients. Targeting their use at patients most at risk of severe acute postoperative pain, of acute neuropathic component, or at a risk of developing (CPSP) seems to be the most logical way to use them.
In patients undergoing cardiac surgery, a multimodal regimen consisting of dexamethasone, gabapentin, ibuprofen and paracetamol offered better analgesia than a regimen consisting of IV morphine alone. Furthermore, nausea and vomiting complaints were reduced significantly in the multimodal group. Although there was no increase in individual creatinine levels in the multimodal group, no safety issues regarding dialysis.
So, this study concluded that, the use of multimodal regimen is effective, feasible and safe with certain precautions in patients under-going open heart surgeries, so we recommend to use the multimodal regimen (non-opioids) whenever is possible.