Perioperative analgesia during thymectomy via median sternotomy

Efficacy of bilateral catheter superficial parasternal intercostal plane blocks using programmed intermittent bolus for opioid-sparing postoperative analgesia in cardiac surgery with sternotomy: A randomized, double-blind, placebo-controlled trial

STUDY OBJECTIVE

This study investigated whether catheter superficial parasternal intercostal plane (SPIP) blocks, using a programmed intermittent bolus (PIB) with ropivacaine, could reduce opioid consumption while delivering enhanced analgesia for a period exceeding 48 h following cardiac surgery involving sternotomy.

DESIGN

A double-blind, prospective, randomized, placebo-controlled trial.

SETTING

University-affiliated tertiary care hospital.

PATIENTS

60 patients aged 18 or older, scheduled for cardiac surgery via sternotomy.

INTERVENTIONS

The patients were randomly assigned in a 1:1 ratio to either the ropivacaine or saline group. After surgery, patients received bilateral SPIP blocks for 48 h with 0.4% ropivacaine (20 mL per side) for induction, followed by bilateral SPIP catheters using PIB with 0.2% ropivacaine (8 mL/side, interspersed with a 2-h interval) or 0.9% normal saline following the same administration schedule. All patients were administered patient-controlled analgesia with hydromorphone.

MEASUREMENTS

The primary outcome was the cumulative morphine equivalent consumption during the initial 48 h after the surgery. Secondary outcomes included postoperative pain assessment using the Numeric Rating Scale (NRS) at rest and during coughing at designated intervals for three days post-extubation. Furthermore, recovery indicators and ropivacaine plasma levels were diligently documented.

MAIN RESULTS

Cumulative morphine consumption within 48 h in ropivacaine group decreased significantly compared to saline group (25.34 ± 31.1 mg vs 76.28 ± 77.2 mg, respectively; 95% CI, -81.9 to -20.0, P = 0.002). The ropivacaine group also reported lower NRS scores at all recorded time points (P < 0.05) and a lower incidence of nausea and vomiting than the saline group (3/29 vs 12/29, respectively; P = 0.007). Additionally, the ropivacaine group showed significant improvements in ambulation (P = 0.018), respiratory exercises (P = 0.006), and self-reported analgesia satisfaction compared to the saline group (P = 0.016).

CONCLUSIONS

Bilateral catheter SPIP blocks using PIB with ropivacaine reduced opioid consumption over 48 h, concurrently delivering superior postoperative analgesia in adult cardiac surgery with sternotomy.

Postsurgical Analgesic Effectiveness of Ultrasound-Guided Parasternal Block After Auricular Reconstruction Using Autologous Costal Cartilage in Pediatric Patients: A Randomized Controlled Trial

OBJECTIVE

To study the efficacy of ultrasound-guided parasternal block (US-PSI) in pediatric patients undergoing auricular reconstruction surgery.

METHODS

For this study, the authors recruited 60 children between the ages of 5 and 12 years who underwent auricular reconstruction with autologous costal cartilage (ACC) to correct microtia. They were randomized to receive either ultrasound-guided modified parasternal block or periprostatic local infiltration anesthesia (PLIA), with 30 cases in each group. Ultrasound-guided parasternal block was administered following anesthesia induction, whereas PLIA was administered after ACC harvest. Lastly, following surgery, all children were provided with patient-controlled intravenous analgesia with sufentanil, and the numeric pain rating scale (NRS) was used to assess the intensity of pain. Our primary outcomes were the resting NRS pain scores and the NRS scores upon coughing at 1, 6, 12, 24, and 48 hours postsurgery. Sufentanil consumption within the first 24 hours of surgery, the mean duration to first ambulation, and the usage of rescue analgesics were our secondary outcomes. The authors also recorded the occurrence of undesirable side effects as well as more serious side effects like pneumothorax.

RESULTS

Pediatric patients who were administered US-PSI showed significantly reduced NRS chest pain scores at 6 and 12 hours postsurgery compared to those who received PLIA (P<0.05). In addition, sufentanil consumption within the first 24 hours postsurgery, duration to first ambulation, and use of rescue analgesics were significantly lower among patients in the US-PSI group when compared to those in the PLIA group (P<0.05).

CONCLUSIONS

This study found that US-PSI was a highly efficacious and safe technique for postsurgical analgesia following auricular reconstruction with ACC in pediatric patients.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Optimal techniques of ultrasound-guided superficial and deep parasternal intercostal plane blocks: a cadaveric study

INTRODUCTION

The optimal techniques of a parasternal intercostal plane (PIP) block to cover the T2-T6 intercostal nerves have not been elucidated. This pilot cadaveric study aims to determine the optimal injection techniques that achieve a consistent dye spread over the second to sixth intercostal spaces after both ultrasound-guided superficial and deep PIP blocks. We also investigated the presence of the transversus thoracis muscle at the first to sixth intercostal spaces and its sonographic identification agreement, as well as the location of the internal thoracic artery in relation to the lateral border of the sternum.

METHODS

Ultrasound-guided superficial or deep PIP blocks with single, double, or triple injections were applied in 24 hemithoraces (three hemithoraces per technique). A total volume of dye for all techniques was 20 mL. On dissection, dye distribution over the first to sixth intercostal spaces, the presence of the transversus thoracis muscle at each intercostal space and the distance of the internal thoracic artery from the lateral sternal border were recorded.

RESULTS

The transversus thoracis muscles were consistently found at the second to sixth intercostal spaces, and the agreement between sonographic identification and the presence of the transversus thoracis muscles was >80% at the second to fifth intercostal spaces. The internal thoracic artery is located medial to the halfway between the sternal border and costochondral junction along the second to sixth intercostal spaces. Dye spread following the superficial PIP block was more localized than the deep PIP block. For both approaches, the more numbers of injections rendered a wider dye distribution. The numbers of stained intercostal spaces after superficial block at the second, fourth, and fifth intercostal spaces, and deep block at the third and fifth intercostal spaces were 5.3±1.2 and 5.7±0.6 levels, respectively.

CONCLUSION

Triple injections at the second, fourth, and fifth intercostal spaces for the superficial approach and double injections at the third and fifth intercostal spaces for the deep approach were optimal techniques of the PIP blocks.

Comparison of the effects of transversus thoracic muscle plane block and pecto-intercostal fascial block on postoperative opioid consumption in patients undergoing open cardiac surgery: a prospective randomized study

BACKGROUND

There is an association exists between cardiac surgery, performed through median sternotomy, and a considerable postoperative pain.

OBJECTIVES

The aim of the current study is to compare the effects of transversus thoracic muscle plane block (TTMPB) and pecto-intercostal fascial plane block (PIFB) upon postoperative opioid consumption among the patients who underwent open cardiac surgery.

METHODS

The present prospective, randomized, comparative study was conducted among 80 patients who underwent elective on-pump cardiac surgery with sternotomy. The subjects were randomly assigned to two groups with each group containing 40 individuals. For the TTMPB group, bilateral ultrasound-guided TTMPB was adopted in which 20 ml of 0.25% bupivacaine was used on each side. In case of PIFB group, bilateral ultrasound-guided PIFB was adopted with the application of 20 ml of 0.25% bupivacaine on each side. The researchers recorded the first time for rescue analgesia, the overall dosage of rescue analgesia administered in the first 24 h after the operation and the postoperative complications.

RESULTS

The PIFB group took significantly longer time to raise the first request for rescue analgesia (7.8 ± 1.7 h) than the TTMPB group (6.7 ± 1.4 h). Likewise, the PIFB group subjects had a remarkably lower 'overall morphine usage' in the first 24 h after the operation (4.8 ± 1.0 mg) than TTMPB group (7.8 ± 2.0 mg).

CONCLUSION

Bilateral ultrasound-guided PIFB provided a longer time for the first analgesic demand than bilateral ultrasound-guided TTMPB in patients undergoing open cardiac surgery. In addition to this, the PIFB reported less postoperative morphine usage than the TTMPB and increases satisfaction in these patients.

TRIAL REGISTRATION

This study was registered at Clinical Trials.gov on 28/11/2022 (registration number: NCT05627869).

Perioperative Pain Management With Bilateral Pecto-intercostal Fascial Block in Pediatric Patients Undergoing Open Cardiac Surgery

Purposes

Pediatric open cardiac surgical patients usually suffer from acute pain after operation. The current work aimed to explore the impact of bilateral PIFB in children suffering from open cardiac surgery.

Methods

This work randomized altogether 110 child patients as bilateral PIFB (PIF) and non-nerve block (SAL) groups. This work adopted post-operative pain at exercise and rest statuses as the primary endpoint, whereas time-to-drain removal/extubation/initial defecation, intraoperative/post-operative fentanyl use, and length of ICU and hospital stay as the secondary endpoints.

Results

MOPS were significantly higher at 24-h post-operatively at coughing and rest statuses in SAL group compared with PIF group. Meanwhile, PIF group exhibited markedly lower intraoperative/post-operative fentanyl use amounts, as well as markedly reduced time-to-extubation/initial flatus, and length of ICU/hospital stay.

Conclusion

Bilateral PIFB in pediatric open cardiac surgical patients provide effective analgesia and lower the length of hospital stay.

Ultrasound-guided parasternal blocks: techniques, clinical indications and future prospects: a narrative review

Fascial plane blocks represent anesthetic procedures performed to manage perioperative and chronic pain. Recently, many fascial blocks techniques have been described increasing their field of applications. They offer anesthetic and analgesic efficacy, easy of execution and low risk of complications. The newest techniques recently described are the ultrasound parasternal blocks (USPSB) which provide analgesia to the antero-medial chest wall. In particular, the antero-medial chest wall blocks are performed to provide analgesia and anesthesia in several and different surgeries such as median sternotomy, breast surgery, implantable cardioverter-defibrillator implantation and in the management of acute and chronic pain. The nervous target for these blocks is represented by the anterior branches of the intercostal nerves which enter the intercostal (ICM) and pectoralis major (PMM) muscles innervating the antero-medial region of chest wall, the main cause of poststernotomy pain. Local anesthetic is injected deep to PMM and superficial to the ICM or between the internal thoracic muscle (IIM) and transversus thoracis muscle (TTM). So, essentially these blocks may be described as superficial or deep parasternal-intercostal plane blocks, based on where the target nerves are hunted. Even if they all provide analgesia to the antero-medial chest wall, the anatomical injection site represents the main peculiarity that differentiates these techniques. To date, a common nomenclature for antero-medial chest wall blocks or parasternal-intercostal plane blocks is not yet well defined and a standardized nomenclature is needed to ensure an adequate communication among anesthesiologists.

Continuous Pecto-Intercostal Fascial Block Provides Effective Analgesia in Patients Undergoing Open Cardiac Surgery: A Randomized Controlled Trial

BACKGROUND

The optimal analgesia regimen after open cardiac surgery was unclear. The aim of this study was to investigate the beneficial effects of continuous Pecto-Intercostal Fascial Block (PIFB) blocks initiated before surgery on outcomes following open cardiac surgery.

METHODS

A group of 116 patients were randomly allocated to either receive bilateral continuous PIFB (PIF group) or the same block with saline (SAL group). The primary endpoint was postoperative pain at 4, 8, 16, 24, 48, and 72 h after extubation at rest and exercise. The secondary outcome measures included analgesia requirements (sufentanil and flurbiprofen consumption), time to extubation, length of stay in the ICU, incidence of postoperative nausea and vomiting (PONV), time until return of bowel function, time to mobilization, urinary catheter removal and the length of hospital stay.

RESULTS

The length of stay in the ICU (29 ± 7 h vs 13 ± 4 h, p < 0.01) and length of hospital stay (8.9 ± 0.9 d vs 6.5 ± 1.1 d, p < 0.01) was significantly longer in the SAL group than in the PIF group. Resting pain scores (2 h after extubation : 1.1 vs 3.3, p < 0.01; 4 h after extubation : 1.0 vs 3.5, p < 0.01; 8 h after extubation : 1.2 vs 3.7, p < 0.01; 16 h after extubation : 1.3 vs 3.7, p < 0.01; 24 h after extubation : 1.4 vs 2.8, p < 0.01; 48 h after extubation : 0.9 vs 2.2, p < 0.01; 72 h after extubation : 0.8 vs 2.1, p < 0.01) and dynamic pain scores (2 h after extubation : 1.4 vs 3.7, p < 0.01; 4 h after extubation : 1.3 vs 3.8, p < 0.01; 8 h after extubation : 1.4 vs 3.5, p < 0.01; 16 h after extubation : 1.2 vs 3.4, p < 0.01; 24 h after extubation : 1.1 vs 3.1, p < 0.01; 48 h after extubation : 1.0 vs 2.9, p < 0.01; 72 h after extubation: 0.9 vs 2.8, p < 0.01) were significantly lower in PIF group compared with SAL group at all time points. The PIF group required significantly less intraoperative (123 ± 32 μg vs 63 ± 16 μg, p < 0.01) and postoperative sufentanil (102 ± 22 μg vs 52 ± 17 μg, p < 0.01) consumption, postoperative flurbiprofen consumption (350 ± 100 mg vs 100 ± 100 mg, p < 0.01) than the SAL groups. Time to extubation (8.9 ± 2.4 h vs 3.2 ± 1.3 h, p < 0.01), time to first flatus (43 ± 6 h vs 30 ± 7 h, p < 0.01), time until mobilization (35 ± 5 h vs 24 ± 7 h, p < 0.01), time until urinary catheter removal (47 ± 9 h vs 31 ± 4 h, p < 0.01) was significantly earlier in the PIF group than in the SAL group. The incidence of PONV was significantly lower in the PIF group (9.1% vs 27.3%, p < 0.01).

CONCLUSION

Bilateral continuous PIFB reduced the length of hospital stay and provided effective postoperative pain for three days.

Effects of bilateral Pecto-intercostal Fascial Block for perioperative pain management in patients undergoing open cardiac surgery: a prospective randomized study

BACKGROUND

Open cardiac surgical patients may experience severe acute poststernotomy pain. The ultrasound-guided Pecto-intercostal Fascial Block (PIFB) can cover anterior branches of intercostal nerves from T2 to T6. The aim of this study was to investigate the effect of bilateral PIFB in patients undergoing open cardiac surgery.

METHODS

A group of 108 patients were randomly allocated to either receive bilateral PIFB (PIFB group) or no nerve block (SALI group). The primary endpoint was postoperative pain. The secondary outcome measures included intraoperative and postoperative sufentanil and parecoxib consumption, time to extubation, time to first feces, length of stay in the ICU and the length of hospital stay. Insulin, glucose, insulin resistance and interleukin (IL)-6 at 1, 2, 3 days after surgery were mearsured. The homeostasis model assessment (HOMA-IR) was used to measure perioperative insulin resistance.

RESULTS

The PIFB group reported significantly less sufentanil and parecoxib consumption than the SALI group. Compared to the PIFB group, the SALI group had higher Numerical Rating Scale (NRS) pain scores at 24 h after operation both at rest and during coughing. The time to extubation, length of stay in the ICU and length of hospital stay were significantly decreased in the PIFB group compared with the SALI group. The PIFB group had a lower insulin, glucose, IL-6, HOMA-IR level than the SALI group 3 days after surgery.

CONCLUSION

Bilateral PIFB provides effective analgesia and accelerates recovery in patients undergoing open cardiac surgery.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry ( ChiCTR 2000030609 ) on 08/03/2020.

Ultrasound-guided parasternal intercostal nerve block for postoperative analgesia in mediastinal mass resection by median sternotomy: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Ultrasound-guided parasternal intercostal nerve block is rarely used for postoperative analgesia, and its value remains unclear. This study aimed to evaluate the effectiveness of ultrasound-guided parasternal intercostal nerve block for postoperative analgesia in patients undergoing median sternotomy for mediastinal mass resection.

METHODS

This randomized, double-blind, placebo-controlled trial performed in Renmin Hospital, Wuhan University, enrolled 41 participants aged 18-65 years. The patients scheduled for mediastinal mass resection by median sternotomy were randomly assigned were randomized into 2 groups, and preoperatively administered 2 injections of ropivacaine (PSI) and saline (control) groups, respectively, in the 3rd and 5th parasternal intercostal spaces with ultrasound-guided (USG) bilateral parasternal intercostal nerve block. Sufentanil via patient-controlled intravenous analgesia (PCIA) was administered to all participants postoperatively. Pain score, total sufentanil consumption, and postoperative adverse events were recorded within the first 24 h.

RESULTS

There were 20 and 21 patients in the PSI and control group, respectively. The PSI group required 20% less PCIA-sufentanil compared with the control group (54.05 ± 11.14 μg vs. 67.67 ± 8.92 μg, P < 0.001). In addition, pain numerical rating scale (NRS) scores were significantly lower in the PSI group compared with control patients, both at rest and upon coughing within 24 postoperative hours. Postoperative adverse events were generally reduced in the PSI group compared with controls.

CONCLUSIONS

USG bilateral parasternal intercostal nerve block effectively reduces postoperative pain and adjuvant analgesic requirement, with good patient satisfaction, therefore constituting a good option for mediastinal mass resection by median sternotomy.

Avoiding the Internal Mammary Artery During Parasternal Blocks: Ultrasound Identification and Technique Considerations

Fascial plane chest wall blocks are an integral component to optimal multimodal postoperative analgesia in breast and cardiothoracic surgery, facilitating faster functional recovery and earlier discharge. Pectoral nerves block and serratus plane block have been used to treat postsurgical pain after breast and cardiothoracic surgeries; however, they cannot be used to anesthetize the anterior chest wall. Ultrasound parasternal block, or pectointercostal fascial block and transversus thoracis muscle plane block are two novel ultrasound-guided anesthetic and analgesic techniques that block the anterior cutaneous branches T2 to T6 intercostal nerves, providing anesthesia and analgesia to the anterior chest wall. Ultrasound parasternal block/pectointercostal fascial block and transversus thoracis muscle plane block are performed in the region of the internal mammary artery and could be considered to treat post-thoracotomy pain. This anatomic region is innervated by the anterior cutaneous branches T2-to-T6 intercostal nerves, which are obliterated during cardiac surgery artery harvesting. At the level of the fourth parasternal rib interspace, the internal mammary artery can be identified between the internal intercostal muscle and transversus thoracis muscle as a longitudinal pulsatile structure approximately 1.5 cm from the lateral border of the sternum. The transversus thoracis muscle is variable in many people and, thus, is an unreliable target and is difficult to visualize with ultrasound. Moreover, patients with a history of coronary artery bypass grafting could have tissue disruption in the transversus thoracis plane because of the internal mammary artery harvest, making transversus thoracis muscle identification more difficult. Despite ultrasound parasternal block and transversus thoracis muscle plane block having good safety profiles and reduced risk of complications, pneumothorax, local anesthetic systemic toxicity, and internal mammary artery injury or hematoma should be considered. If the block is performed before cardiac surgery, both the right and left internal mammary arteries could be damaged. The injury could render the internal mammary artery unusable for bypass grafting. If the block is performed after left internal mammary artery harvesting at the end of coronary artery bypass grafting, only the right internal mammary artery could be damaged. In patients in whom the internal mammary artery has been surgically used and the transversus thoracis muscle is difficult to visualize, ultrasound parasternal block should be considered. In patients in whom the internal mammary artery could be difficult to visualize or considering that it is in the vicinity of the transversus thoracis muscle plane block target and that the transversus thoracis muscle is difficult to visualize with ultrasound after internal mammary artery harvesting, then ultrasound parasternal block should be considered. The authors believe that ultrasound parasternal block is the safer regional technique for protecting the internal mammary artery and the pleura because it is more superficial. For this reason, ultrasound parasternal block also could be performed by inexperienced anesthesiologists. Although ultrasound parasternal block is more superficial, its superiority in terms of safety is yet to be proven. Additional studies are warranted to validate the authors' hypothesis.

Parasternal Intercostal Block Complementation Contributes to Postoperative Pain Relief in Modified Radical Mastectomy Employing Pectoral Nerve Block I and Serratus-Intercostal Block: A Randomized Trial

Purpose

Pectoral nerve block I (PECS I) and serratus-intercostal plane block (SIPB) can anesthetize the majority mammary region, while parasternal intercostal block (PSI) targets the internal area during breast resection surgery. The aim of this study was to determine whether including PSI with PECS I and SIPB is more effective compared to PECS I and SIPB alone.

Patients and Methods

Sixty-two adult females undergoing unilateral modified radical mastectomy (MRM) were randomly assigned to receive either PECS I and SIPB (PS group, n=31) or a combination of PECS I, SIPB, and PSI (PSP group, n=31). The outcomes were measured with a numerical rating scale (NRS) score, and in terms of opioid consumption and anesthesia-related complications within 48 h after surgery.

Results

Although there were no differences in the NRS scores between the two groups during the inactive periods, the combination of three nerve blocks significantly reduced the NRS scores during movement. In addition, morphine equivalent consumption was lower in the PSP group compared to the PS group. Postoperative adverse events were similar in both groups in terms of regional anesthesia-related complications.

Conclusion

The combination of PECS I block, SIPB, and PSI block provides superior pain relief and postoperative recovery for patients undergoing MRM.