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Roy N, Parra MF, Brown ML, Sleeper LA, Kossowsky J, Baumer AM, Blitz SE, Booth JM, Higgins CE, Nasr VG, Del Nido PJ, Brusseau R. Erector spinae plane blocks for opioid-sparing multimodal pain management after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2024; 168:1742-1750.e9. [PMID: 38493959 DOI: 10.1016/j.jtcvs.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 02/25/2024] [Accepted: 03/08/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE Peripheral regional anesthesia is proposed to enhance recovery. We sought to evaluate the efficacy of bilateral continuous erector spinae plane blocks (B-ESpB) for postoperative analgesia and the impact on recovery in children undergoing cardiac surgery. METHODS Patients aged 2 through 17 years undergoing cardiac surgery in the enhanced recovery after cardiac surgery program were prospectively enrolled to receive B-ESpB at the end of the procedure, with continuous infusions via catheters postoperatively. Participants wore an activity monitor until discharge. B-ESpB patients were retrospectively matched with control patients in the enhanced recovery after cardiac surgery program. Outcomes of the matched clusters were compared using exact conditional logistic regression and generalized linear modeling. RESULTS Forty patients receiving B-ESpB were matched to 78 controls. There were no major complications from the B-ESpB or infusions, and operating room time was longer by a median of 31 minutes. While blocks were infusing, patients with B-ESpB received fewer opioids in oral morphine equivalents than controls at 24 hours (0.60 ± 0.06 vs 0.78 ± 0.04 mg/kg; P = .02) and 48 hours (1.13 ± 0.08 vs 1.35 ± 0.06 mg/kg; P = .04), respectively. Both groups had low median pain scores per 12-hour period. There was no difference in early mobilization, length of stay, or complications. CONCLUSIONS B-ESpBs are safe in children undergoing cardiac surgery. When performed as part of a multimodal pain strategy in an enhanced recovery after cardiac surgery program, pediatric patients with B-ESpB experience good pain control and require fewer opioids in the first 48 hours.
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Affiliation(s)
- Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass.
| | - M Fernanda Parra
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Morgan L Brown
- Department of Anaesthesia, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Lynn A Sleeper
- Departrment of Pediatrics, Harvard Medical School, Boston, Mass; Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Joe Kossowsky
- Department of Anaesthesia, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Andreas M Baumer
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | | | - Jocelyn M Booth
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Connor E Higgins
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Viviane G Nasr
- Department of Anaesthesia, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Roland Brusseau
- Department of Anaesthesia, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Mass
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Wang W, Yang W, Liu A, Liu J, Yuan C. The Analgesic Effect of Ultrasound-guided Erector Spinae Plane Block in Median Sternotomy Cardiac Surgery in Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2024; 38:2792-2800. [PMID: 38890084 DOI: 10.1053/j.jvca.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 05/04/2024] [Accepted: 05/16/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVES To assess the analgesic effect of erector spinae plane block in adults undergoing median sternotomy cardiac surgery. DESIGN AND SETTING The Cochrane, Embase, and PubMed databases from inception to January 2024 were searched. The study has been registered in the International Prospective Register of Systematic Reviews (CRD42023470375). PARTICIPANTS Eight randomized controlled trials involving 543 patients, comparing with no block or sham block, were included, whether it was a single injection or continuous. MEASUREMENTS AND MAIN RESULTS The primary outcomes were pain scores and opioid consumption. Erector spinae plane block reduced pain scores immediately after extubation (mean difference [MD], -1.19; 95% confidence interval [CI], -1.67 to -0.71; p for heterogeneity = 0.10), at 6 hours after extubation (MD, -1.96; 95% CI, -2.85 to -1.08; p for heterogeneity < 0.0001), and at 12 hours after extubation (MD, -0.98; 95% CI, -1.55 to -0.40; p for heterogeneity < 0.00001). The decrease in pain scores reached the minimal clinically important difference within 6 hours. Opioid consumption 24 hours after surgery decreased by 35.72 mg of oral morphine equivalents (95% CI, -50.88 to -20.57; p for heterogeneity < 0.0001). Sensitivity analysis confirmed the stability of results. The quality of primary outcomes was rated as very low to moderate. CONCLUSIONS Erector spinae plane block decreased pain scores within 12 hours after extubation, reached the minimal clinically important difference within 6 hours, and decreased opioid consumption 24 hours after surgery, based on data of very low to moderate quality. However, high-quality randomized controlled trials are necessary to validate these findings.
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Affiliation(s)
- Wenzhu Wang
- Department of Anesthesiology, Jining No. 1 People's Hospital, Jining, Shandong, China
| | - Weilin Yang
- Department of Anesthesiology, Deyang People's Hospital, Deyang, Sichuan, China
| | - Ang Liu
- Department of Anesthesiology, Heze Municipal Hospital, Heze, Shandong, China
| | - Jian Liu
- Department of Emergency Surgery, Jining No. 1 People's Hospital, Jining, Shandong, China
| | - Changxiu Yuan
- Department of Anesthesiology, Jining No. 1 People's Hospital, Jining, Shandong, China.
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Sarhan K, Elshemy A, Mamdouh S, Salah M, Raheem AAE, Gamal M, Nawwar K, Bakry M. Effect of Bilateral Erector Spinae Plane Block versus Fentanyl Infusion on Postoperative Recovery in Cardiac Surgeries via Median Sternotomy: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2024; 38:2668-2674. [PMID: 39138089 DOI: 10.1053/j.jvca.2024.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 06/02/2024] [Accepted: 07/24/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVE To assess the effect of ultrasound-guided bilateral erector spinae plane block (ESPB) on the time to extubation in patients who had undergone cardiac surgery through a midline sternotomy. DESIGN Randomized controlled trial. SETTING Cairo University Hospital and National Heart Institute, Egypt. PARTICIPANTS Patients aged 18 to 70 years who underwent a cardiac surgical procedure through a midline sternotomy. INTERVENTIONS Recruited patients were randomized to receive either preoperative single-shot ultrasound-guided bilateral ESPB or fentanyl infusion. MEASUREMENTS The primary outcome was the time to extubation. Other outcomes included total perioperative fentanyl consumption, pain score using the numerical rating score (NRS), length of intensive care unit (ICU) stay, and incidence of perioperative complications. MAIN RESULTS Two hundred and nineteen patients were available for final analysis. The mean time to extubation was significantly shorter In the ESPB group compared to the control group (159.5 ± 109.5 minutes vs 303.2 ± 95.9 minutes; mean difference, -143.7 minutes; 95% confidence interval, -171.1 to -116.3 minutes; p = 0.0001). Ultra-fast track (immediate postoperative) extubation was achieved in 23 patients (21.1%) in the ESPB group compared to only 1 patient (0.9%) in the control group. The ICU stay was significantly reduced in the ESPB group compared to the control group (mean, 47.2 ± 13.3 hours vs 78.9 ± 25.2 hours; p = 0.0001). There was a more significant reduction in NRS in the ESPB group compared to the control group for up to 24 hours postoperatively (p = 0.001). CONCLUSIONS Among adult patients undergoing cardiac surgery through a midline sternotomy, the extubation time was halved in patients who received single-shot bilateral ESPB compared to patients who received fentanyl infusion.
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Affiliation(s)
- Khaled Sarhan
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Anas Elshemy
- Department of Anesthesia, National Heart Institute, Cairo, Egypt
| | - Sherif Mamdouh
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Maged Salah
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ashraf Abd El Raheem
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Medhat Gamal
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Kareem Nawwar
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mohammed Bakry
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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Bălan C, Boroş C, Moroşanu B, Coman A, Stănculea I, Văleanu L, Şefan M, Pavel B, Ioan AM, Wong A, Bubenek-Turconi ŞI. Nociception level index-directed superficial parasternal intercostal plane block vs erector spinae plane block in open-heart surgery: a propensity matched non-inferiority clinical trial. J Clin Monit Comput 2024:10.1007/s10877-024-01236-0. [PMID: 39470954 DOI: 10.1007/s10877-024-01236-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 10/15/2024] [Indexed: 11/01/2024]
Abstract
This single-center study explored the efficacy of superficial parasternal intercostal plane block (SPIPB) versus erector spinae plane block (ESPB) in opioid-sparing within Nociception Level (NOL) index-directed anesthesia for elective open-heart surgery. After targeted propensity matching, 19 adult patients given general anesthesia with preincisional SPIPB were compared to 33 with preincisional ESPB. We hypothesized that SPIPB is non-inferior to ESPB in reducing total intraoperative fentanyl consumption, with a non-inferiority margin (δ) set at 0.1 mg. Intraoperative fentanyl dosing targeted a NOL index ≤ 25. Postoperatively, paracetamol 1 g 6-hourly and morphine for numeric rating scale (NRS) ≥ 4 were administered. This study could not demonstrate that SPIPB was inferior to ESPB for total intraoperative fentanyl consumption, as the confidence interval for the median difference of 0.1 mg (95% CI 0.05-0.15) crossed the predefined δ, with the lower bound falling below and the upper bound exceeding δ, p = 0.558. SPIPB led to higher postoperative morphine use at 24 and 48 h: 0 (0-40.6) vs. 59.5 (28.5-96.1) µg kg-1, p < 0.001 and 22.2 (0-42.6) vs. 63.5 (28.5-96.1) µg kg-1, p = 0.001. Four times fewer SPIPB patients remained morphine-free at 48 h, p < 0.001, and their time to first morphine dose was three times shorter compared to ESPB patients, p = 0.001. SPIPB led to higher time-weighted average NRS scores at rest, 1 (0-1) vs. 1 (1-2), p = 0.004, and with movement, 2 (1-2) vs. 3 (2-3), p = 0.002, calculated over the 48-h period post-extubation. The SPIPB group had a significantly higher average NOL index, p = 0.003, and greater NOL index variability, p = 0.027. This study could not demonstrate that SPIPB was inferior to ESPB for intraoperative fentanyl consumption. Significant differences were observed in secondary outcomes, with SPIPB leading to higher postoperative morphine use, higher pain scores, and reduced nociception control.
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Affiliation(s)
- Cosmin Bălan
- 1st Department of Cardiovascular Anaesthesia and Intensive Care Medicine, Prof. Dr. C.C Iliescu Institute for Emergency Cardiovascular Diseases, 022328, Bucharest, Romania.
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
| | - Cristian Boroş
- 1st Department of Cardiovascular Anaesthesia and Intensive Care Medicine, Prof. Dr. C.C Iliescu Institute for Emergency Cardiovascular Diseases, 022328, Bucharest, Romania
| | - Bianca Moroşanu
- 1st Department of Cardiovascular Anaesthesia and Intensive Care Medicine, Prof. Dr. C.C Iliescu Institute for Emergency Cardiovascular Diseases, 022328, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Antonia Coman
- 1st Department of Cardiovascular Anaesthesia and Intensive Care Medicine, Prof. Dr. C.C Iliescu Institute for Emergency Cardiovascular Diseases, 022328, Bucharest, Romania
| | - Iulia Stănculea
- 1st Department of Cardiovascular Anaesthesia and Intensive Care Medicine, Prof. Dr. C.C Iliescu Institute for Emergency Cardiovascular Diseases, 022328, Bucharest, Romania
| | - Liana Văleanu
- 1st Department of Cardiovascular Anaesthesia and Intensive Care Medicine, Prof. Dr. C.C Iliescu Institute for Emergency Cardiovascular Diseases, 022328, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mihai Şefan
- 2nd Department of Cardiovascular Anaesthesia and Intensive Care Medicine, Prof. Dr. C.C Iliescu Institute for Emergency Cardiovascular Diseases, Bucharest, Romania
| | - Bogdan Pavel
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Intensive Care Unit, Clinical Hospital of Infectious and Tropical Diseases "Dr. Victor Babes", Bucharest, Romania
| | - Ana-Maria Ioan
- Department of Intensive Care Medicine, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Adrian Wong
- Department of Critical Care, King's College Hospital, London, UK
| | - Şerban-Ion Bubenek-Turconi
- 1st Department of Cardiovascular Anaesthesia and Intensive Care Medicine, Prof. Dr. C.C Iliescu Institute for Emergency Cardiovascular Diseases, 022328, Bucharest, Romania
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Makkad B, Heinke TL, Sheriffdeen R, Meng ML, Kachulis B, Grant MC, Popescu WM, Brodt JL, Khatib D, Wu CL, Kertai MD, Bollen BA. Practice Advisory for Postoperative Pain Management of Cardiac Surgical Patients: A Report by Society of Cardiovascular Anesthesiologists. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00798-5. [PMID: 39855959 DOI: 10.1053/j.jvca.2024.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2024] [Accepted: 10/04/2024] [Indexed: 01/27/2025]
Abstract
Moderate to severe pain after cardiac surgery is relatively common, which increases the risk of postoperative cardiopulmonary complications and delays hospital discharge. Opioids have been useful agents for postoperative pain control after cardiac surgery, but are associated with serious adverse effects. As a result, multimodal analgesia has been adopted widely to decrease reliance on opioids for treating postoperative pain, reduce opioid-related adverse effects, and promote early recovery. The advent of fascial plane blocks has expanded the use of regional analgesia for pain management after cardiac surgery that was otherwise limited due to the fear of devastating neurological sequelae in the setting of systemic anticoagulation. This practice advisory reviews and evaluates the recent literature related to the use of pharmacological and non-pharmacological therapies to treat pain after cardiac surgery to help providers with the selection of appropriate pain management interventions for their patients.
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Affiliation(s)
- Benu Makkad
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Timothy Lee Heinke
- Department of Anesthesia and Perioperative Medicine Medical University of South Carolina, Charleston, SC
| | - Raiyah Sheriffdeen
- Department of Anesthesiology, Medstar Washington Hospital Center, Washington, DC
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Bessie Kachulis
- Department of Anesthesiology, Columbia University, New York, NY
| | - Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wanda Maria Popescu
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT; VA Connecticut Health Care System, West Haven, CT
| | - Jessica Louise Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | - Diana Khatib
- Department of Anesthesiology, Weil Cornell Medical College, New York, NY
| | - Christopher L Wu
- Department of Anesthesiology, Hospital of Special Surgery, Weill Cornell Medical College, New York, NY
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232
| | - Bruce Allen Bollen
- Department of Anesthesiology, Missoula Anesthesiology and The International Heart Institute of Montana, Missoula, MT
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Mogahed MM, Abd El-Ghaffar MS, Elkahwagy MS. Bilateral Ultrasound-Guided Erector Spinae Plane Block for Management of Acute Postoperative Surgical Pain After Pediatric Cardiac Surgeries Through a Midline Sternotomy. Ann Card Anaesth 2024; 27:316-323. [PMID: 39365129 PMCID: PMC11610791 DOI: 10.4103/aca.aca_210_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/29/2024] [Accepted: 05/11/2024] [Indexed: 10/05/2024] Open
Abstract
BACKGROUND Ultrasound (US) guided erector spinae plane block (ESPB) is a safe and effective technique in providing perioperative pain management in pediatrics with a high success rate. THE AIM OF THIS STUDY Was to compare the efficacy of bilateral ultrasound-guided erector spinae plane block for management of acute postoperative surgical pain after pediatric cardiac surgeries through a midline sternotomy. METHODS One hundred patients aged 4-12 years were randomly assigned into two groups, both groups received general anesthesia followed by bilateral sham erector spinae plane block at the level of T6 transverse process using 0.4 ml/kg normal saline on each side in the control group (group C) or bilateral ultrasound-guided erector spinae plane block at the level of T6 transverse process using 0.4 ml/kg ropivacaine 0.2% with a maximum dose of 2 mg/kg mixed with adrenaline 2 mcg/ml in erector spinae plane block group (group E). The postoperative pain scores were evaluated immediately post-extubation, at 1 hour, 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, and 24 hours after extubation, total consumption of intraoperative fentanyl and time to first rescue analgesic administration were also recorded. RESULTS There was a statistically high significant delay in the group E (314.72 ± 45.94) compared with the group C (36.7 ± 7.22) as regards to the mean (SD) of the time of the rescue analgesia (P < 0.001) (with 95% CI), moreover; the number of rescue analgesic was significantly higher in the group C compared with the group E (P < 0.001) (with 95% CI) and the mean (SD) of total intraoperative and postoperative levels fentanyl requirements in the group C were significantly higher compared with the group E (6.47 ± 0.98 and 5.09 ± 0.83) (with 95% CI) in group C versus (4.69 ± 0.71 and 2.31 ± 0.66) (with 95% CI) in group E respectively (P < 0.001) (with 95% CI). CONCLUSION Ultrasound-guided bilateral ESPB with ropivacaine and adrenaline delays the postoperative need of analgesia and reduces postoperative fentanyl consumption at 24 h in pediatric patients undergoing cardiac surgery through midline sternotomy.
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Affiliation(s)
- Mona M. Mogahed
- Department of Anesthesiology, Faculty of Medicine, Tanta University, Egypt
| | | | - Mohamed S. Elkahwagy
- Department of Cardiothoracic Surgery, Faculty of Medicine, Tanta University, Egypt
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Xin L, Wang L, Feng Y. Ultrasound-guided erector spinae plane block for postoperative analgesia in patients undergoing minimally invasive direct coronary artery bypass surgery: a double-blinded randomized controlled trial. Can J Anaesth 2024; 71:784-792. [PMID: 37989939 PMCID: PMC11233300 DOI: 10.1007/s12630-023-02637-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/30/2023] [Accepted: 06/03/2023] [Indexed: 11/23/2023] Open
Abstract
PURPOSE Minimally invasive direct coronary artery bypass (MIDCAB) surgery is associated with significant postoperative pain. We aimed to investigate the efficacy of ultrasound-guided erector spinae plane block (ESPB) for analgesia after MIDCAB. METHODS We conducted randomized controlled trial in 60 patients undergoing MIDCAB who received either a single-shot ESPB with 30 mL of ropivacaine 0.5% (ESPB group, n = 30) or normal saline 0.9% (control group, n = 30). The primary outcome was numerical rating scale (NRS) pain scores at rest within 48 hr postoperatively. The secondary outcomes included postoperative NRS pain scores on deep inspiration within 48 hr, hydromorphone consumption, and quality of recovery-15 (QoR-15) score at 24 and 48 hr. RESULTS Compared with the control group, the ESPB group had lower NRS pain scores at rest at 6 hr (estimated mean difference, -2.1; 99% confidence interval [CI], -2.7 to -1.5; P < 0.001), 12 hr (-1.9; 99% CI, -2.6 to -1.2; P < 0.001), and 18 hr (-1.2; 99% CI, -1.8 to -0.6; P < 0.001) after surgery. The ESPB group also showed lower pain scores on deep inspiration at 6 hr (-2.9; 99% CI, -3.6 to -2.1; P < 0.001), 12 hr (-2.3; 99% CI, -3.1 to -1.5; P < 0.001), and 18 hr (-1.0; 99% CI, -1.8 to -0.2; P = 0.01) postoperatively. Patients in the ESPB group had lower total intraoperative fentanyl use, lower 24-hr hydromorphone consumption, a shorter time to extubation, and a shorter time to intensive care unit (ICU) discharge. CONCLUSION Erector spinae plane block provided early effective postoperative analgesia and reduced opioid consumption, time to extubation, and ICU discharge in patients undergoing MIDCAB. TRIAL REGISTRATION www.chictr.org.cn (ChiCTR2100052810); registered 5 November 2021.
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Affiliation(s)
- Ling Xin
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Lu Wang
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Yi Feng
- Department of Anesthesiology, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, China.
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Li Q, Yang Y, Leng Y, Yin X, Liu J, Zhou C. Dexmedetomidine with different concentrations added to local anesthetics in erector spinae plane block: a meta-analysis of randomized controlled trials. Front Med (Lausanne) 2024; 11:1326566. [PMID: 38841587 PMCID: PMC11150627 DOI: 10.3389/fmed.2024.1326566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 05/03/2024] [Indexed: 06/07/2024] Open
Abstract
Background Dexmedetomidine has been used as a perineural local anesthetic (LA) adjuvant to facilitate the potency of erector spinal plane block (ESPB). This quantitative review aimed to evaluate whether perineural dexmedetomidine for ESPB can improve the effects of analgesia compared to LA alone. Methods Randomized controlled trials (RCTs) that investigated the addition of dexmedetomidine to LA compared to LA alone in ESPB were included. The pain scores, duration of sensory block, the time to first analgesia requirement, postoperative morphine consumption, rescue analgesia, and dexmedetomidine-related side effects were analyzed and combined using random-effects models. Results A total of 823 patients from 13 RCTs were analyzed. Dexmedetomidine was used at the concentration of 0.5 μg/kg in three trials and 1 μg/kg in nine trials, and both in one trial. Both concentrations of dexmedetomidine perineurally administrated significantly reduced the rest VAS scores postoperatively at 12 h (0.5 μg/kg dexmedetomidine: MD = -0.86; 95% CI: -1.59 to -0.12; p = 0.02; 1 μg/kg dexmedetomidine: MD = -0.49; 95% CI: -0.83 to -0.16; p = 0.004), and 24 h (0.5 μg/kg dexmedetomidine: MD = -0.43; 95% CI: -0.74 to -0.13; p = 0.005; 1 μg/kg dexmedetomidine: MD = -0.62; 95% CI: -0.84 to -0.41; p < 0.00001). Both concentrations of dexmedetomidine added in LAs improved the dynamic VAS scores postoperatively at 12 h (0.5 μg/kg dexmedetomidine: MD = -0.55; 95% CI: -0.95 to -0.15; p = 0.007; 1 μg/kg dexmedetomidine: MD = -0.66; 95% CI: -1.05 to -0.28; p = 0.0006) and 24 h (0.5 μg/kg dexmedetomidine: MD = -0.52; 95% CI: -0.94 to -0.10; p = 0.01; 1 μg/kg dexmedetomidine: MD = -0.46; 95% CI: -0.75 to -0.16; p = 0.002). Furthermore, perineural dexmedetomidine prolonged the duration of the sensory block and the time to first analgesia requirement, reduced postoperative morphine consumption, and lowered the incidence of rescue analgesia and chronic pain. Conclusion The meta-analysis showed that using perineural dexmedetomidine at either 0.5 μg/kg or 1 μg/kg doses in ESPB can effectively and safely enhance pain relief. Systematic review registration PROSPERO (CRD42023424532: https://www.crd.york.ac.uk/PROSPERO/).
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Affiliation(s)
- Qian Li
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Yaoxin Yang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Yu Leng
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaowei Yin
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Jin Liu
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Cheng Zhou
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
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Liang TW, Shen CH, Wu YS, Chang YT. Erector spinae plane block reduces opioid consumption and improves incentive spirometry volume after cardiac surgery: A retrospective cohort study. J Chin Med Assoc 2024; 87:550-557. [PMID: 38501787 DOI: 10.1097/jcma.0000000000001086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Effective postoperative pain management is vital in cardiac surgery to prevent opioid dependency and respiratory complications. Previous studies on the erector spinae plane (ESP) block have focused on single-shot applications or immediate postoperative outcomes. This study evaluates the efficacy of continuous ESP block vs conventional care in reducing opioid consumption and enhancing respiratory function recovery postcardiac surgery over 72 hours. METHODS A retrospective study at a tertiary hospital (January 2021-July 2022) included 262 elective cardiac surgery patients. Fifty-three received a preoperative ESP block, matched 1:1 with a control group (n = 53). The ESP group received 0.5% ropivacaine intraoperatively and 0.16% ropivacaine every 4 hours postoperatively. Outcomes measured were cumulative oral morphine equivalent (OME) dose within 72 hours postextubation, daily maximum numerical rating scale (NRS) ≥3, incentive spirometry volume, and %baseline performance, stratified by surgery type (sternotomy or thoracotomy). RESULTS Significant OME reduction was observed in the ESP group (sternotomy: median decrease of 113 mg, 95% CI: 60-157.5 mg, p < 0.001; thoracotomy: 172.5 mg, 95% CI: 45-285 mg, p = 0.010). The ESP group also had a lower risk of daily maximum NRS ≥3 (adjusted OR sternotomy: 0.22, p < 0.001; thoracotomy: 0.07, p < 0.001), a higher incentive spirometry volumes (sternotomy: mean increase of 149 mL, p = 0.019; thoracotomy: 521 mL, p = 0.017), and enhanced spirometry %baseline (sternotomy: mean increase of 11.5%, p = 0.014; thoracotomy: 26.5%, p < 0.001). CONCLUSION Continuous ESP block was associated with a reduction of postoperative opioid requirements, lower instances of pain scores ≥3, and improve incentive spirometry performance following cardiac surgery. These benefits appear particularly prominent in thoracotomy patients. Further prospective studies with larger sample size are required to validate these findings.
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Affiliation(s)
- Ting-Wei Liang
- Department of Anesthesiology, Show Chwan Memorial Hospital, Changhua, Taiwan, ROC
| | - Ching-Hui Shen
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yung-Szu Wu
- Department of Cardiac Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Yi-Ting Chang
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
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10
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Demir AZ, Özgök A, Balcı E, Karaca OG, Şimşek E, Günaydin S. Preoperative ultrasound-guided bilateral thoracic erector spinae plane block within an enhanced recovery program is associated with decreased intraoperative lactate levels in cardiac surgery. Perfusion 2024; 39:324-333. [PMID: 36408617 DOI: 10.1177/02676591221140754] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
INTRODUCTION In the perioperative period, regional analgesia techniques may play an increasingly important role in "Enhanced Recovery After Surgery (ERAS)" programs, as they can facilitate recovery. We hypothesized that Erector Spinae Plane (ESP) block could improve regional perfusion, thereby limiting blood lactate increase. Therefore, we aimed to evaluate the effect of ESP block on intraoperative blood lactate levels in patients scheduled for elective on-pump cardiac surgery with ERAS protocol. METHODS A total of 68 adult patients scheduled for on-pump cardiac surgery were included. All patients were randomized to the ESP group and the non-ESP group. Blood lactate analyses were performed at intraoperative five-time points. C-Reactive protein (CRP) values were also measured. RESULTS Blood lactate values were significantly lower in the ESP group than in the Non-ESP group, at the end of CPB [1.78 (1.23-2.78) mmol L-1 to 2.63 (1.70-3.12) mmol L-1] and during the sternal closure period [1.78 (1.27-2.42) mmol L-1 to 2.40 (2.14-2.80) mmol L-1] (p = 0.039, p = 0.009). In addition, CRP values were significantly lower in the ESP group in the postoperative period [0.048 (0.036-0.105) g L-1 to 0.090 (0.049-0.154) g L-1] (p = 0.035). CONCLUSIONS This study showed that preoperative bilateral single-shot ESP block significantly reduces intraoperative final blood lactate and postoperative CRP values. We consider that these results are related to the attenuation of intraoperative hypoperfusion and the alleviation of surgery-related postoperative inflammation. ERAS programs aim to achieve the rapid recovery of patients, a decrease in inflammation, and high-quality analgesia with less opioid consumption. Therefore, our results also prove that it is easier to reach the primary goals of ERAS programs with the application of ESP block in cardiac surgery.
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Affiliation(s)
- Aslı Z Demir
- Anesthesiology Department, The University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Ayşegül Özgök
- Anesthesiology Department, The University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Eda Balcı
- Anesthesiology Department, The University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Okay G Karaca
- Cardiovascular Surgery Department, The University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Erdal Şimşek
- Cardiovascular Surgery Department, The University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Serdar Günaydin
- Cardiovascular Surgery Department, The University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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11
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Wong HMK, Chen PY, Tang GCC, Chiu SLC, Mok LYH, Au SSW, Wong RHL. Deep Parasternal Intercostal Plane Block for Intraoperative Pain Control in Cardiac Surgical Patients for Sternotomy: A Prospective Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2024; 38:683-690. [PMID: 38148266 DOI: 10.1053/j.jvca.2023.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/13/2023] [Accepted: 11/26/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVES Sternotomy pain is common after cardiac surgery. The deep parasternal intercostal plane (DPIP) block is a novel technique that provides analgesia to the anterior chest wall. The aim of this study was to investigate the analgesic effect of bilateral DPIP blocks on intraoperative pain control in cardiac surgery. DESIGN This is a double-blinded, prospective randomized controlled trial (Oct 2020-Dec 2022). SETTINGS This study was conducted in a single institution, which is an academic university hospital. PARTICIPANTS Eighty-six elective cardiac surgical patients with median sternotomy were recruited. INTERVENTIONS Patients were randomly divided into DPIP or control group. Either 20ml 0.25% levobupivacaine or 0.9% normal saline was injected for the DPIP under ultrasound guidance after induction of general anaesthesia. MEASUREMENTS AND MAIN RESULTS The primary outcome was intraoperative opioids consumption and hemodynamic changes at sternotomy. Secondary outcomes included postoperative morphine consumption, postoperative pain and time to tracheal extubation. Intraoperative opioids requirement was reduced from a median (IQR) intravenous morphine equivalence of 21.4mg (13.8-24.3mg) in control group to 9.5mg (7.3-11.2mg) in the DPIP group (P<0.001). Hemodynamic parameters were more stable in DPIP group at sternotomy, as evidenced by lower percentage increase in systolic, diastolic and mean arterial blood pressure from baseline. No difference was observed in time to tracheal extubation, postoperative morphine consumption, postoperative pain score and spirometry. CONCLUSIONS Bilateral DPIP block provides effective intraoperative analgesia and opioid-sparing. It may be included as part of the multimodal analgesia for enhanced recovery in cardiac surgery.
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Affiliation(s)
- Henry M K Wong
- Department of Anesthesia and Intensive Care, Prince of Wales Hospital, New Territories, Hong Kong, China.
| | - P Y Chen
- Department of Anesthesia and Intensive Care, Prince of Wales Hospital, New Territories, Hong Kong, China
| | - Geoffrey C C Tang
- Department of Anesthesia and Intensive Care, Prince of Wales Hospital, New Territories, Hong Kong, China
| | - Sandra L C Chiu
- Department of Anesthesia and Intensive Care, the Chinese University of Hong Kong, Hong Kong, China
| | - Louis Y H Mok
- Department of Anesthesia and Intensive Care, Prince of Wales Hospital, New Territories, Hong Kong, China
| | - Sylvia S W Au
- Department of Anesthesia and Intensive Care, Prince of Wales Hospital, New Territories, Hong Kong, China
| | - Randolph H L Wong
- Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, New Territories, Hong Kong, China
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12
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Birnbaums JV, Ozoliņa A, Solovjovs L, Glāzniece-Kagane Z, Nemme J, Logina I. Efficacy of erector spine plane block in two different approaches to lumbar spinal fusion surgery: a retrospective pilot study. Front Med (Lausanne) 2024; 11:1330446. [PMID: 38420357 PMCID: PMC10900103 DOI: 10.3389/fmed.2024.1330446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/15/2024] [Indexed: 03/02/2024] Open
Abstract
Background Erector spine plane block (ESPB) has been widely used in spinal surgery, although there are variable data about its efficacy. Objectives This study aimed to evaluate the efficacy of ESPB in elective lumbar spinal fusion surgery patients with two different surgical approaches. Materials and methods Retrospectively, 45 elective lumbar transpedicular fusion (TPF) surgery patients undergoing open surgery with different approaches [posterior transforaminal fusion approach (TLIF) or combined posterior and anterior approach (TLIF+ALIF)] were divided into 2 groups: general anesthesia (GA, n = 24) and general anesthesia combined with ESPB (GA + ESPB, n = 21). The primary outcome was to analyze the efficacy of ESPB in two different surgical approaches in terms of pain intensity in the first 48 h. Secondary: Fentanyl-free patients and opioid consumption in the first 24 h postoperatively. Comparative analysis was performed (SPSS® v. 28.0) (p < 0.05). Results Out of 45 patients (27 female), 21 received GA + ESPB and 24 received GA. The average age was 60.3 ± 14.3 years. Chronic back pain before the operation was registered in 56% of patients. ESPB was performed in 17 TLIF and in 4 TLIF+ALIF patients. ESPB significantly reduced pain intensity at rest in both surgical approaches 48 h after surgery (p < 0.05). The need for postoperative fentanyl infusion was significantly lower in the group treated with GA + ESPB in both surgical approaches than in those who only received GA (29% vs. 77% in TLIF and 0% vs. 80% in TLIF+ALIF); p = 0.01 and p = 0.004. Additionally, we observed that ESPB provides a good analgesic effect for up to 6.8 ± 3.2 h in the TLIF and 8.9 ± 7.6 h in the TLIF+ALIF approaches. Consequently, ESPB reduced the initiation of the fentanyl compared to GA alone, with a mean difference of 3.2 ± 4.2 h in the TLIF subgroup (p = 0.045) and 6.7 ± 5.3 h in TLIF +ALIF (p = 0.028). Only in the TLIF+ALIF approach, ESPB reduced the total fentanyl consumption compared to those with GA (1.43 ± 0.45 mg/24 h vs. 0.93 ± 0.68 mg/24 h; p = 0.015). Conclusion ESPB significantly reduced pain at rest after surgery, the number of patients requiring immediate postoperative fentanyl analgesia, and total fentanyl consumption in both surgical approaches, particularly in TLIF+ALIF. However, the application of ESPB does not always provide completely sufficient analgesia.
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Affiliation(s)
| | - Agnese Ozoliņa
- Riga Stradins University, Riga, Latvia
- Riga East University Hospital, Riga, Latvia
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13
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Xin L, Wang L, Feng Y. Efficacy of ultrasound-guided erector spinae plane block on analgesia and quality of recovery after minimally invasive direct coronary artery bypass surgery: protocol for a randomized controlled trial. Trials 2024; 25:65. [PMID: 38243276 PMCID: PMC10797856 DOI: 10.1186/s13063-024-07925-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 01/12/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Minimally invasive direct coronary artery bypass (MIDCAB) surgery offers an effective option for coronary artery disease (CAD) patients with the avoidance of median sternotomy and fast postoperative recovery. However, MIDCAB is still associated with significant postoperative pain which may lead to delayed recovery. The erector spinae plane block (ESPB) is a superficial fascial plane block. There have not been randomized controlled trials evaluating the effects of ESPB on analgesia and patient recovery following MIDCAB surgery. We therefore designed a double-blind prospective randomized placebo-controlled trial, aiming to prove the hypothesis that ESPB reduces postoperative pain scores in patients undergoing MIDCAB surgery. METHODS The study protocol has been reviewed and approved by the Ethical Review Committee of Peking University People's Hospital. Sixty adult patients of either sex scheduled for MIDCAB surgery under general anesthesia (GA) will be included. Patients will be randomly allocated to receive either a preoperative single-shot ESPB with 30 mL of ropivacaine 0.5% (ESPB group) or normal saline 0.9% (control group). The primary outcomes are the difference between the two groups in numeric rating scale (NRS) scores at rest at different time points (6, 12, 18, 24, 48 h) after surgery. The secondary outcomes include NRS scores on deep inspiration within 48 h, postoperative hydromorphone consumption, and quality of patient recovery at 24 h and 48 h, using the Quality of Recovery-15 (QoR-15) scale. The other outcomes include intraoperative fentanyl requirements, the need for additional postoperative rescue analgesics, time to tracheal extubation and chest tube removal after surgery, incidence of postoperative nausea and vomiting (PONV) and postoperative cognitive dysfunction (POCD), intensive care unit (ICU) length of stay (LOS), hospital discharge time, and 30-day mortality. Adverse events will be also evaluated. DISCUSSION This is a novel randomized controlled study evaluating a preoperative ultrasound-guided single-shot unilateral ESPB on analgesia and quality of patient recovery in MIDCAB surgery. The results of this study will characterize the degree of acute postoperative pain and clinical outcomes following MIDCAB. Our study may help optimizing analgesia regimen selection and improving patient comfort in this specific population. TRIAL REGISTRATION The study was prospectively registered with the Chinese Clinical Trial Registry (trial identifier: ChiCTR2100052810). Date of registration: November 5, 2021.
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Affiliation(s)
- Ling Xin
- Department of Anesthesiology, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, China.
| | - Lu Wang
- Department of Anesthesiology, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, China
| | - Yi Feng
- Department of Anesthesiology, Peking University People's Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, China
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14
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Dou D, Jia Y, Yuan S, Wang Y, Li Y, Wang H, Ding J, Wu X, Bie D, Liu Q, An R, Yan H, Yan F. The protocol of Enhanced Recovery After Cardiac Surgery (ERACS) in congenital heart disease: a stepped wedge cluster randomized trial. BMC Pediatr 2024; 24:22. [PMID: 38183047 PMCID: PMC10768436 DOI: 10.1186/s12887-023-04422-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/14/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND The Enhanced Recovery After Cardiac Surgery (ERACS) programs are comprehensive multidisciplinary interventions to improve patients' recovery. The application of the ERAS principle in pediatric patients has not been identified completely. METHODS This study is a multicenter, stepwise design, cluster randomized controlled trial. 3030 patients presenting during control and intervention periods are eligible if they are aged from 28 days to 6 years old and awaiting elective correction surgery of congenital heart disease with cardiopulmonary bypass. 5 centers are randomly assigned to staggered start dates for one-way crossover from the control phase to the intervention phase. In the intervention periods, patients will receive a bundle strategy including preoperative, intraoperative, and postoperative approaches. During the control phase, patients receive the usual care. The primary outcome consists of major adverse cardiac and cerebrovascular events (MACCEs), postoperative pulmonary complications (PPCs), and acute kidney injury (AKI). DISCUSSION This study aims to explore whether the bundle of ERAS measurements could improve patients' recovery in congenital heart surgery. TRIAL REGISTRATION http://www. CLINICALTRIALS gov . (NCT05914103).
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Affiliation(s)
- Dou Dou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Yuan Jia
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Yang Wang
- Department of Medical Research & Biometrics Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Yinan Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Hongbai Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Jie Ding
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Xie Wu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Dongyun Bie
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Qiao Liu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Ran An
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Haoqi Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China
| | - Fuxia Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 167 BeilishiRd, Xicheng District, Beijing, 100037, China.
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15
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Ocker A, Muafa H, Baratta JL. Regional anesthesia in cardiac surgery and electrophysiology procedures. Int Anesthesiol Clin 2024; 62:21-27. [PMID: 38063034 DOI: 10.1097/aia.0000000000000423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Aaron Ocker
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
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16
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Grant MC, Chappell D, Gan TJ, Manning MW, Miller TE, Brodt JL. Pain management and opioid stewardship in adult cardiac surgery: Joint consensus report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society. J Thorac Cardiovasc Surg 2023; 166:1695-1706.e2. [PMID: 36868931 DOI: 10.1016/j.jtcvs.2023.01.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/07/2023] [Accepted: 01/19/2023] [Indexed: 01/30/2023]
Abstract
BACKGROUND Opioid-based anesthesia and analgesia is a traditional component of perioperative care for the cardiac surgery patient. Growing enthusiasm for Enhanced Recovery Programs (ERPs) coupled with evidence of potential harm associated with high-dose opioids suggests that we reconsider the role of opioids in cardiac surgery. METHODS An interdisciplinary North American panel of experts, using a structured appraisal of the literature and a modified Delphi method, derived consensus recommendations for optimal pain management and opioid stewardship for cardiac surgery patients. Individual recommendations are graded based on the strength and level of evidence. RESULTS The panel addressed 4 main topics: the harms associated with historical opioid use, the benefits of more targeted opioid administration, the use of nonopioid medications and techniques, and patient and provider education. A key principle that emerged is that opioid stewardship should apply to all cardiac surgery patients, entailing judicious and targeted use of opioids to achieve optimal analgesia with the fewest potential side effects. The process resulted in the promulgation of 6 recommendations regarding pain management and opioid stewardship in cardiac surgery, focused on avoiding the use of high-dose opioids, as well as encouraging more widespread application of foundational aspects of ERPs, such as the use of multimodal nonopioid medications and regional anesthesia techniques, formal patient and provider education, and structured system-level opioid prescription practices. CONCLUSIONS Based on the available literature and expert consensus, there is an opportunity to optimize anesthesia and analgesia for cardiac surgery patients. Although additional research is needed to establish specific strategies, core principles of pain management and opioid stewardship apply to the cardiac surgery population.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
| | - Michael W Manning
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Timothy E Miller
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Jessica L Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, Calif.
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17
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Li J, Li Z, Dong P, Liu P, Xu Y, Fan Z. Effects of parasternal intercostal block on surgical site wound infection and pain in patients undergoing cardiac surgery: A meta-analysis. Int Wound J 2023; 21:e14433. [PMID: 37846438 PMCID: PMC10828712 DOI: 10.1111/iwj.14433] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023] Open
Abstract
This study aimed to assess the effect of parasternal intercostal block on postoperative wound infection, pain, and length of hospital stay in patients undergoing cardiac surgery. PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, VIP, and Wanfang databases were extensively queried using a computer, and randomised controlled studies (RCTs) from the inception of each database to July 2023 were sought using keywords in English and Chinese language. Literature quality was assessed using Cochrane-recommended tools, and the included data were collated and analysed using Stata 17.0 software for meta-analysis. Ultimately, eight RCTs were included. Meta-analysis revealed that utilising parasternal intercostal block during cardiac surgery significantly reduced postoperative wound pain (standardised mean difference [SMD] = -1.01, 95% confidence intervals [CI]: -1.70 to -0.31, p = 0.005) and significantly shortened hospital stay (SMD = -0.40, 95% CI: -0.77 to -0.04, p = 0.029), though it may increase the risk of wound infection (OR = 5.03, 95% CI:0.58-44.02, p = 0.144); however, the difference was not statistically significant. The application of parasternal intercostal block during cardiac surgery can significantly reduce postoperative pain and shorten hospital stay. This approach is worth considering for clinical implementation. Decisions regarding its adoption should be made in conjunction with the relevant clinical indices and surgeon's experience.
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Affiliation(s)
- Jian‐Qiang Li
- Department of Cardiac SurgeryYantai Yuhuangding HospitalYantaiChina
| | - Zhen‐Hui Li
- Department of AnesthesiologyQingdao Fuwai HospitalQingdaoChina
| | - Ping Dong
- Department of HematologyYantai Yuhuangding HospitalYantaiChina
| | - Peng Liu
- Department of Cardiac Surgery ICUYantai Yuhuangding HospitalYantaiChina
| | - Ying‐Zhen Xu
- Department of AnesthesiologyQingdao Fuwai HospitalQingdaoChina
| | - Zhi‐Jun Fan
- Department of Cardiac SurgeryQingdao Fuwai HospitalQingdaoChina
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18
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Chen LJ, Chen SH, Hsieh YL, Yu PC. Continuous nerve block versus thoracic epidural analgesia for post-operative pain of pectus excavatum repair: a systematic review and meta-analysis. BMC Anesthesiol 2023; 23:266. [PMID: 37559029 PMCID: PMC10410789 DOI: 10.1186/s12871-023-02221-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Abstract
Surgery to repair pectus excavatum (PE) is often associated with severe postoperative pain, which can impact the length of hospital stay (LOS). While thoracic epidural analgesia (TEA) has traditionally been used for pain management in PE, its placement can sometimes result in severe neurological complications. Recently, paravertebral block (PVB) and erector spinae plane block (ESPB) have been recommended for many other chest and abdominal surgeries. However, due to the more severe and prolonged pain associated with PE repair, it is still unclear whether continuous administration of these blocks is as effective as TEA. Therefore, we conducted this systematic review and meta-analysis to demonstrate the equivalence of continuous PVB and ESPB to TEA.
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Affiliation(s)
- Li-Jung Chen
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan
| | - Shih-Hong Chen
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan
| | - Yung-Lin Hsieh
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan
| | - Po-Chuan Yu
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.289, Jianguo Rd., Xindian Dist, 231405, New Taipei City, Taiwan.
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19
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Oravec N, Arora RC, Bjorklund B, Gregora A, Monnin C, Dave MG, Duhamel TA, Kent DE, Schultz ASH, Chudyk AM. Patient and caregiver preferences and prioritized outcomes for cardiac surgery: A scoping review and consultation workshop. J Thorac Cardiovasc Surg 2023; 166:598-609.e7. [PMID: 34924192 DOI: 10.1016/j.jtcvs.2021.11.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/10/2021] [Accepted: 11/19/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE(S) In light of the absence of patient and caregiver input in Enhanced Recovery After Surgery Cardiac Surgery guideline development, we conducted a scoping review to identify patient and caregiver preferences and prioritized outcomes related to perioperative care in cardiac surgery and its lifelong impact. METHODS Five electronic databases were searched to retrieve studies investigating patient or caregiver preferences and prioritized outcomes. Information was charted in duplicate and analyzed using descriptive statistics or thematic analysis. A patient and caregiver consultation workshop validated scoping review findings and solicited novel preferences and outcomes. RESULTS Of the 5292 articles retrieved, 43 met inclusion criteria. Most were from Europe (n = 19, 44%) or North America (n = 15, 35%) and qualitative and quantitative designs were represented in equal proportions. Fifty-two methods were used to obtain stakeholder preferences and prioritized outcomes, the majority being qualitative in nature (n = 32, 61%). Based on the collective preferences of 3772 patients and caregivers from the review and 17 from the consultation workshop, a total of 108 patient preferences, 32 caregiver preferences, and 19 prioritized outcomes were identified. The most commonly identified theme was "information and education." Improved quality of life was the most common patient-prioritized outcome, and all caregiver-prioritized outcomes were derived from the consultation workshop. CONCLUSIONS Patient and caregiver preferences overlap with Enhanced Recovery After Surgery Cardiac Surgery recommendations targeting preoperative risk reduction strategies, prehabilitation, patient engagement technology, and intra- and postoperative strategies to reduce discomfort. To support clinical practice, future research should investigate associations with key surgical outcomes.
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Affiliation(s)
- Nebojša Oravec
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Cardiac Sciences, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | - Brian Bjorklund
- Enhanced Recovery Protocols for Cardiac Surgery Patient Researcher Group, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | - April Gregora
- Enhanced Recovery Protocols for Cardiac Surgery Patient Researcher Group, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | - Caroline Monnin
- Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mudra G Dave
- Department of Cardiac Sciences, St Boniface General Hospital, Winnipeg, Manitoba, Canada; Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Todd A Duhamel
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada; Institute of Cardiovascular Sciences, St Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - David E Kent
- Department of Cardiac Sciences, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | - Annette S H Schultz
- Rady Faculty of Health Sciences, College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada; Health Services & Structural Determinants of Health Research Group, St Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - Anna M Chudyk
- Rady Faculty of Health Sciences, College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada; Health Services & Structural Determinants of Health Research Group, St Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada.
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20
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Bajpai S, Kumar KS, Patibandla S, Giridhar CM. Ultrasound-guided continuous erector spinae plane block for perioperative opioid sparing analgesia in breast cancer surgery: A randomized controlled trial. Saudi J Anaesth 2023; 17:327-333. [PMID: 37601522 PMCID: PMC10435801 DOI: 10.4103/sja.sja_760_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/07/2022] [Accepted: 11/19/2022] [Indexed: 08/22/2023] Open
Abstract
Background Erector spinae plane (ESP) block provides postoperative analgesia in breast surgeries but has limited duration of action that restricts its efficacy to early postoperative period. This study aims to evaluate the analgesic efficacy and opioid sparing effect of ultrasound (US)-guided continuous erector spinae plane (CESP) block in perioperative period in breast cancer surgery. Methods Fifty ASA I/II patients aged more than 18 years, scheduled for elective breast cancer surgery were randomized to either Group B (Block group) or Group C (Control group). Patients in group B received US-guided CESP block, whereas patients in group C did not receive the block prior to general anesthesia. The primary outcome of this study was to measure total tramadol consumption in 24 h postsurgery. Intraoperative fentanyl consumption, pain scores, postoperative nausea/vomiting, and patient satisfaction score at discharge were also recorded. Results Total tramadol consumption was 94.6% lower in the block group as compared to the control group (5.4 ± 18.7 mg in CESP block group as compared to 99.7 ± 49.6 mg in control group). Intraoperative fentanyl requirement and pain scores were significantly lower in CESP group. Postoperative incidence of nausea/vomiting was similar, but satisfaction score was significantly better in block group. Conclusion US-guided CESP block provides effective and prolonged peri operative analgesia and opioid sparing in breast cancer surgeries.
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Affiliation(s)
- Shalini Bajpai
- Department of Anesthesia, Critical Care and Pain, Homi Bhabha Cancer Hospital and Research Centre (A Unit of Tata Memorial Centre, Mumbai), Visakhapatnam, Andhra Pradesh, India
| | - K. Shiv Kumar
- Department of Anesthesia, Critical Care and Pain, Homi Bhabha Cancer Hospital and Research Centre (A Unit of Tata Memorial Centre, Mumbai), Visakhapatnam, Andhra Pradesh, India
| | - Swetha Patibandla
- Department of Anesthesia, Critical Care and Pain, Homi Bhabha Cancer Hospital and Research Centre (A Unit of Tata Memorial Centre, Mumbai), Visakhapatnam, Andhra Pradesh, India
| | - C. M. Giridhar
- Department of Surgical Oncology, Homi Bhabha Cancer Hospital and Research Centre (A Unit of Tata Memorial Centre, Mumbai), Visakhapatnam, Andhra Pradesh, India
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Makkad B, Heinke TL, Sheriffdeen R, Khatib D, Brodt JL, Meng ML, Grant MC, Kachulis B, Popescu WM, Wu CL, Bollen BA. Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2. Anesth Analg 2023; 137:26-47. [PMID: 37326862 DOI: 10.1213/ane.0000000000006506] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.
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Affiliation(s)
- Benu Makkad
- From the Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Timothy Lee Heinke
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Raiyah Sheriffdeen
- Department of Anesthesiology, Medstar Washington Hospital Center, Washington, DC
| | - Diana Khatib
- Department of Anesthesiology, Weil Cornell Medical College, New York, New York
| | - Jessica Louise Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bessie Kachulis
- Department of Anesthesiology, Columbia University, New York, New York
| | - Wanda Maria Popescu
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher L Wu
- Department of Anesthesiology, Hospital of Special Surgery, Weill Cornell Medical College, New York, New York
| | - Bruce Allen Bollen
- Missoula Anesthesiology, Missoula, Montana
- The International Heart Institute of Montana, Missoula, Montana
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22
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Nair A, Saxena P, Borkar N, Rangaiah M, Arora N, Mohanty PK. Erector spinae plane block for postoperative analgesia in cardiac surgeries- A systematic review and meta-analysis. Ann Card Anaesth 2023; 26:247-259. [PMID: 37470522 PMCID: PMC10451138 DOI: 10.4103/aca.aca_148_22] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/14/2022] [Accepted: 09/26/2022] [Indexed: 07/21/2023] Open
Abstract
Ultrasound-guided erector spinae plane block (ESPB) has been used in many studies for providing opioid-sparing analgesia after various cardiac surgeries. We performed a systematic review and meta-analysis of randomized controlled trials to assess the efficacy of ESPB in cardiac surgeries. We searched PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar to identify the studies in which ESPB was compared with the control group/sham block in patients undergoing cardiac surgeries. The primary outcomes were postoperative opioid consumption and postoperative pain scores. The secondary outcomes were intraoperative opioid consumption, ventilation time, time to the first mobilization, length of ICU and hospital stay, and adverse events. Out of 607 studies identified, 16 studies (n = 1110 patients) fulfilled inclusion criteria and were used for qualitative and quantitative analysis. Although, 24-hr opioid consumption were comparable in both groups group (MD, -18.74; 95% CI, -46.85 to 9.36, P = 0.16), the 48-hr opioid consumption was significantly less in ESPB group than control ((MD, -11.01; 95% CI, -19.98 to --2.04, P = 0.02). The pain scores at various time intervals and intraoperative opioid consumption were significantly less in ESPB group. Moreover, duration of ventilation, time to the first mobilization, and length of ICU and hospital were also less in ESPB group (P < 0.00001, P < 0.00001, P < 0.00001, and P < 0.0001, respectively). This systematic review and meta-analysis demonstrated that ESPB provides opioid-sparing perioperative analgesia, facilitates early extubation and mobilization, leads to early discharge from ICU and hospital, and has lesser pruritus when compared to control in patients undergoing cardiac surgeries.
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Affiliation(s)
- Abhijit Nair
- Department of Anaesthesiology, Ibra Hospital, Ministry of Health-Oman, Ibra-414, Sultanate of Oman, Oman
| | - Praveen Saxena
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
| | - Nitin Borkar
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Manamohan Rangaiah
- Department of Anaesthetics and Pain Management, Walsall Manor Hospital, Moat Rd, Walsall WS2 9PS, United Kingdom
| | - Nishant Arora
- Department of Anaesthesiology, Kings College Hospital, NHS Foundation Trust, London, United Kingdom
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23
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Wu S, Wu J, Zhang X. Application of an ultrasound-guided bilateral erector spinae plane block after the Nuss procedure for pectus excavatum in children: a retrospective cohort study with propensity score matching. Front Pediatr 2023; 11:1201604. [PMID: 37449266 PMCID: PMC10336535 DOI: 10.3389/fped.2023.1201604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Objective To retrospectively analyze the effect of applying an ultrasound-guided bilateral erector spine plane block (ESPB) after the Nuss procedure for surgical repair of pectus excavatum (PE) in children. Methods The subjects of the study were patients with severe PE who received the Nuss procedure in our hospital between 1 January 2019 and 30 November 2021. According to different methods for postoperative pain management, the enrolled patients were divided into two groups, the ultrasound-guided ESPB group and the thoracic epidural analgesia (TEA) group. The primary outcome of this study was analgesic drug dosage and the secondary outcome was numerical rating scales (NRSs) between the two groups. Results There was no significant difference between the two groups in terms of demographic, preoperative clinical evaluation, or surgical characteristics (P > 0.05). The catheter duration in the TEA group was significantly shorter than that in the ESPB group (P < 0.05), while the hospitalization time in the ESPB group was significantly shorter than that in the TEA group (P < 0.05). In terms of oral morphine equivalent comparison, the required dose of the TEA group was lower than that of the ESPB group on the 1st and 2nd day after the operation (P < 0.05), and there was no statistical difference between the two groups on the 3rd and 4th day after the operation (P > 0.05). The number of patients with an S-NRS ≥ 7 and D-NRS ≥ 7 in the TEA group at day 1 was lower than that in the ESPB group (P < 0.05). There was no significant difference between the two groups at other time points (P > 0.05). Conclusion An ultrasound-guided ESPB used in Nuss surgery for children with funnel chest can provide good analgesia for surgery and shorten the postoperative rehabilitation and hospitalization time of patients. It is a safe and effective alternative to TEA.
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Guinot PG, Andrei S, Durand B, Martin A, Duclos V, Spitz A, Berthoud V, Constandache T, Grosjean S, Radhouani M, Anciaux JB, Nguyen M, Bouhemad B. Balanced Nonopioid General Anesthesia With Lidocaine Is Associated With Lower Postoperative Complications Compared With Balanced Opioid General Anesthesia With Sufentanil for Cardiac Surgery With Cardiopulmonary Bypass: A Propensity Matched Cohort Study. Anesth Analg 2023; 136:965-974. [PMID: 36763521 DOI: 10.1213/ane.0000000000006383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
BACKGROUND There are no data on the effect of balanced nonopioid general anesthesia with lidocaine in cardiac surgery with cardiopulmonary bypass. The main study objective was to evaluate the association between nonopioid general balanced anesthesia and the postoperative complications in relation to opioid side effects. METHODS Patients undergoing cardiac surgery with cardiopulmonary bypass between 2019 and 2021 were identified. After exclusion of patients for heart transplantation, left ventricular assistance device, and off-pump surgery, we classified patients according to an opioid general balanced anesthesia or a nonopioid balanced anesthesia with lidocaine. The primary outcome was a collapsed composite of postoperative complications that comprise respiratory failure and confusion, whereas secondary outcomes were acute renal injury, pneumoniae, death, intensive care unit (ICU), and hospital length of stay. RESULTS We identified 859 patients exposed to opioid-balanced general anesthesia with lidocaine and 913 patients exposed to nonopioid-balanced general anesthesia. Propensity score matching yielded 772 individuals in each group with balanced baseline covariates. Two hundred thirty-six patients (30.5%) of the nonopioid-balanced general anesthesia versus 186 patients (24.1%) presented postoperative composite complications. The balanced lidocaine nonopioid general anesthesia group was associated with a lower proportion with the postoperative complication composite outcome OR, 0.72 (95% CI, 0.58-0.92; P = .027). The number of patients with acute renal injury, death, and hospital length of stay did not differ between the 2 groups. CONCLUSIONS A balanced nonopioid general anesthesia protocol with lidocaine was associated with lower odds of postoperative complication composite outcome based on respiratory failure and confusion.
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Affiliation(s)
- Pierre-Grégoire Guinot
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
- Department of Anaesthesiology and Intensive Care Medicine, University of Burgundy and Franche-Comté, Dijon, France
| | - Stefan Andrei
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Bastien Durand
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Audrey Martin
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Valerian Duclos
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Alexandra Spitz
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Vivien Berthoud
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Tiberiu Constandache
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Sandrine Grosjean
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Mohamed Radhouani
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Jean-Baptiste Anciaux
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Maxime Nguyen
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
- Department of Anaesthesiology and Intensive Care Medicine, University of Burgundy and Franche-Comté, Dijon, France
| | - Belaid Bouhemad
- From the Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
- Department of Anaesthesiology and Intensive Care Medicine, University of Burgundy and Franche-Comté, Dijon, France
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25
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Darçın K, Çetin S, Karakaya MA, Yenigün Y, Ateş MŞ, Gürkan Y. The effect of erector spinae plane block on arterial grafts in coronary artery bypass grafting. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2023; 31:186-191. [PMID: 37484629 PMCID: PMC10357865 DOI: 10.5606/tgkdc.dergisi.2023.24089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/08/2022] [Indexed: 07/25/2023]
Abstract
Background This study aims to evaluate the sympathectomy effects of erector spinae plane block on the diameters and cross-sectional areas of the left and right internal mammary arteries and of the radial arteries. Methods This prospective study included a total of 25 patients (14 males, 11 females; median age: 67 years; range, 23 to 75 years) who underwent erector spinae plane block categorized as the American Society of Anesthesiologists Class III and underwent off-pump coronary artery bypass grafting between June 01, 2020 and March 01, 2021. The effects of erector spinae plane block on the diameters and cross-sectional areas of the left and right internal mammary arteries and radial arteries were assessed using ultrasonography images taken both before and 45 min after the procedure, from the third, fourth, and fifth intercostal spaces for the left and right internal mammary arteries and from 3 cm proximal to the wrist for the radial arteries. Results The diameters and cross-sectional areas of the left and right internal mammary arteries and radial arteries significantly increased compared to baseline values after the erector spinae plane block (p<0.05). There was no significant difference in the pre- and post-procedural heart rate and mean arterial pressure values (p>0.05). Conclusion The bilateral erector spinae plane block, which was performed at the T5 level, provided vasodilatation of the left and right internal mammary arteries and radial arteries without causing any significant difference in the heart rate and mean arterial pressure. These findings indicate that the sympathetic block produced by the erector spinae plane block may facilitate better surgical conditions by preventing arterial spasms. Thus, bilateral erector spinae plane block may be a promising technique to achieve regional anesthesia for off-pump coronary artery bypass grafting.
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Affiliation(s)
- Kamil Darçın
- Department of Anaesthesiology and Reanimation, Koç University Faculty of Medicine, Istanbul, Türkiye
| | - Seçil Çetin
- Department of Anaesthesiology and Reanimation, Koç University Faculty of Medicine, Istanbul, Türkiye
| | - Muhammet Ahmet Karakaya
- Department of Anaesthesiology and Reanimation, Acıbadem Ataşehir Hospital, Istanbul, Türkiye
| | - Yılmaz Yenigün
- Department of Anaesthesiology and Reanimation, Liv Hospital Vadistanbul, Istanbul, Türkiye
| | - Mehmet Şanser Ateş
- Department of Cardiovascular Surgery, Koç University Faculty of Medicine, Istanbul, Türkiye
| | - Yavuz Gürkan
- Department of Anaesthesiology and Reanimation, Koç University Faculty of Medicine, Istanbul, Türkiye
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Walter CM, Lee CS, Moore DL, Abbasian N, Clay SJ, Mecoli MD, Olbrecht VA, Batra M, Ding L, Yang F, Nair M, Huq A, Simpson BE, Brown RL, Garcia VF, Chidambaran V. Retrospective study comparing outcomes of multimodal epidural and erector spinae catheter pain protocols after pectus surgery. J Pediatr Surg 2023; 58:397-404. [PMID: 35907711 DOI: 10.1016/j.jpedsurg.2022.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/10/2022] [Accepted: 06/28/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There are no optimal postoperative analgesia regimens for Nuss procedures. We compared the effectiveness of thoracic epidurals (EPI) and novel ambulatory erector spinae plane (ESP) catheters as part of multimodal pain protocols after Nuss surgery. METHODS Data on demographics, comorbidities, perioperative details, length of stay (LOS), in hospital and post discharge pain/opioid use, side effects, and emergency department (ED) visits were collected retrospectively in children who underwent Nuss repair with EPI (N = 114) and ESP protocols (N = 97). Association of the group with length of stay (LOS), in hospital opioid use (intravenous morphine equivalents (MEq)/kg over postoperative day (POD) 0-2), and oral opioid use beyond POD7 was analyzed using inverse probability of treatment weighting (IPTW) with propensity scores, followed by multivariable regression. RESULTS Groups had similar demographics. Compared to EPI, ESP had longer block time and higher rate of ketamine and dexmedetomidine use. LOS for ESP was 2 days IQR (2, 2) compared to 3 days IQR (3, 4) for EPI (p < 0.01). Compared to EPI, ESP group had higher opioid use (in MEq/kg) intraoperatively (0.32 (IQR 0.27, 0.36) vs. 0.28 (0.24, 0.32); p < 0.01) but lower opioid use on POD 0 (0.09 (IQR 0.04, 0.17) vs. 0.11 (0.08, 0.17); p = 0.03) and POD2 (0.00 (IQR 0.00, 0.00) vs. 0.04 (0.00, 0.06) ; p < 0.01). ESP group also had lower total in hospital opioid use (0.57 (IQR 0.42, 0.73) vs.0.82 (0.71, 0.91); p < 0.01), and shorter duration of post discharge opioid use (6 days (IQR 5,8) vs. 9 days (IQR 7,12) (p < 0.01). After IPTW adjustment, ESP continued to be associated with shorter LOS (difference -1.20, 95% CI: -1.38, -1.01, p < 0.01) and decreased odds for opioid use beyond POD7 (OR 0.11, 95% CI: 0.05, 0.24); p < 0.01). However, total in hospital opioid use in MEq/kg (POD0-2) was now similar between groups (difference -0.02 (95% CI: -0.09, -0.04); p = 0.50). The EPI group had higher incidence of emesis (29% v 4%, p < 0.01), while ESP had higher catheter malfunction rates (23% v 0%; p < 0.01) but both groups had comparable ED visits/readmissions. DISCUSSION/CONCLUSION Compared to EPI, multimodal ambulatory ESP protocol decreased LOS and postoperative opioid use, with comparable ED visits/readmissions. Disadvantages included higher postoperative pain scores, longer block times and higher catheter leakage/malfunction. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Charlotte M Walter
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Christopher S Lee
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - David L Moore
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Niekoo Abbasian
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Smokey J Clay
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
| | - Marc D Mecoli
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Vanessa A Olbrecht
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Meenu Batra
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Lili Ding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, MLC 5041, 3333 Burnet Ave, Cincinnati, OH 45229, United States; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Fang Yang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, MLC 5041, 3333 Burnet Ave, Cincinnati, OH 45229, United States; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Manu Nair
- Summer Undergraduate Research Fellow, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - Abraar Huq
- Summer Undergraduate Research Fellow, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - Blair E Simpson
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, MLC 3024, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Rebeccah L Brown
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric, General and Thoracic Surgery Department, Cincinnati Children's Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Victor F Garcia
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, United States; Division of Pediatric, General and Thoracic Surgery Department, Cincinnati Children's Hospital Medical Center, MLC 2023, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Vidya Chidambaran
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, MLC 2001, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
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Morkos M, DeLeon A, Koeckert M, Gray Z, Liao K, Pan W, Tolpin DA. The Use of Unilateral Erector Spinae Plane Block in Minimally Invasive Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:432-436. [PMID: 36599778 DOI: 10.1053/j.jvca.2022.11.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/05/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To examine the efficacy of continuous unilateral erector spinae plane (ESP) blocks in minimally invasive cardiac surgery patients. DESIGN A retrospective nonrandomized study. SETTING At a single-center, tertiary academic institution. PARTICIPANTS The study comprised 129 adult patients undergoing minimally invasive cardiac surgery with cardiopulmonary bypass or extracorporeal membrane oxygenation. INTERVENTIONS Patient data were retrospectively collected and compared. Group 1 patients received ultrasound-guided ESP blocks, and group 2 patients underwent conventional intraoperative management without ESP blocks. After intubation in the group 1 cohort, 20-to- 25 mL of 0.25% ropivacaine were deposited beneath the erector spinae plane, along with catheter placement for continuous postoperative infusion. MEASUREMENTS AND MAIN RESULTS Patient characteristics (ie, age, sex, and comorbidities) were well-matched between both cohorts. The total 48-hour opioid consumption, as measured in morphine equivalents (mg), was significantly decreased in patients receiving erector spinae plane blocks compared to patients receiving conventional therapy (30.24 mg ± 23.8 v 47.82 mg ± 53.6, p = 0.04). The length of stay in the intensive care unit (ICU) also was reduced in the treatment group in comparison to the control group (1.99 days ± 1.7 v 2.65 days ± 2.4, p = 0.03). Lastly, patients receiving the blocks benefitted from a decrease in overall hospital length of stay when compared to the control group (5.93 days ± 2.4 v 7.35 days ± 5.8, p = 0.04). CONCLUSION Erector spinae plane catheter use may safely improve postoperative measures, including decreased opioid consumption and improved pain relief, as well as reductions in ICU and hospital lengths of stay in patients undergoing minimally invasive cardiac surgery.
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Affiliation(s)
- Michael Morkos
- Department of Cardiovascular Anesthesiology, Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Aidan DeLeon
- Department of Cardiovascular Anesthesiology, Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Michael Koeckert
- Division of Cardiothoracic Transplantation & Circulatory Support, Baylor College of Medicine, Houston, TX
| | - Zachary Gray
- Division of Cardiothoracic Transplantation & Circulatory Support, Baylor College of Medicine, Houston, TX
| | - Kenneth Liao
- Division of Cardiothoracic Transplantation & Circulatory Support, Baylor College of Medicine, Houston, TX
| | - Wei Pan
- Department of Cardiovascular Anesthesiology, Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Daniel A Tolpin
- Department of Cardiovascular Anesthesiology, Texas Heart Institute, Baylor College of Medicine, Houston, TX.
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Bellini R, Salandini MC, Granieri S, Chierici A, Passaretta R, Cotsoglou C. Erector spine plane block as single loco-regional anesthesia in non-intubated video-assisted thoracic surgery for unfit patients: a case-match study. Updates Surg 2023:10.1007/s13304-023-01464-0. [PMID: 36820964 DOI: 10.1007/s13304-023-01464-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Abstract
In the present study, we analyzed the safety and efficacy of non-intubated video-assisted thoracoscopy (NI-VATS) for the diagnosis and palliation of malignant pleural effusion in the elderly population using erector-spinae plane block (ESPB) as single loco-regional anesthesia. From January 2016 to December 2020 a consecutive series of 158 patients who underwent surgery for malignant pleural effusion was analyzed. Of these, 20 patients were operated using ESPB NI-VATS, while 138 were operated under general anesthesia (GA). After propensity score matching, the NI-VATS population was older (81 vs. 76 years p 0.006), and had more severe pre-existing comorbidities, evaluated using Charlson Comorbidity Index (p = 0.029) and ASA score (p < 0.001). GA and NI-VATS patients did not differ in terms of postoperative opioid consumption, complication rate and postoperative hospitalization. Both short- and long-term efficacy of talc poudrage was equal in the two populations. The overall length of stay in the operative room was significantly shorter for the NI-VATS than for the GA-VATS group (67.5 vs. 105 min, p < 0.001), and operative time significantly differed in the two groups (35 vs. 47.5 min, respectively, p < 0.001). ESPB NI-VATS can be a safe and effective option for the diagnosis and palliation of malignant pleural effusion for elderly and frail patients.
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Affiliation(s)
- Roberto Bellini
- General Surgery Unit, ASST-Brianza, Vimercate Hospital, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy
| | - Maria Chiara Salandini
- General Surgery Unit, ASST-Brianza, Vimercate Hospital, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy.
| | - Stefano Granieri
- General Surgery Unit, ASST-Brianza, Vimercate Hospital, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy
| | - Andrea Chierici
- Service de Chirurgie Digestive, Centre Hospitalier d'Antibes Juan-Les-Pins, 107, av. de Nice, 06600, Antibes, France
| | - Rita Passaretta
- Anesthesia and Resuscitation Unit, ASST-Brianza, Vimercate Hospital, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy
| | - Christian Cotsoglou
- General Surgery Unit, ASST-Brianza, Vimercate Hospital, Via Santi Cosma e Damiano, 10, 20871, Vimercate, Italy
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Post-operative vomiting and enhanced recovery after congenital cardiac surgery. Cardiol Young 2023; 33:260-265. [PMID: 35322768 DOI: 10.1017/s1047951122000592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Post-operative nausea and vomiting is frequent after congenital cardiac surgery. AIMS We sought to determine factors associated to severe post-operative vomiting after congenital cardiac surgery and the effect on post-operative outcomes. METHODS Patients > 30 days of age who underwent elective cardiac surgical repair as part of an enhanced recovery after congenital cardiac surgery programme were retrospectively reviewed. Patient characteristics and perioperative factors were compared by univariate analysis for patients with severe post-operative vomiting, defined as three events or more, and for patients with no-or-mild post-operative vomiting. All variables with a p-value < 0.1 were included in a multivariable model, and major post-operative outcomes were compared using regression analysis. RESULTS From 1 October, 2018 to 30 September, 2019, 430 consecutive patients were included. The median age was 4.8 years (interquartile range 1.2-12.6). Twenty-one per cent of patients (91/430) experienced severe post-operative vomiting. Total intraoperative opioids > 5.0 mg/kg of oral morphine equivalent (adjusted odds ratio 1.72) and post-operative inotropes infusion(s) (adjusted odds ratio 1.64) were identified as independent predictors of severe post-operative vomiting after surgery. Patients suffering from severe post-operative vomiting had increased pulmonary complications (adjusted odds ratio 5.18) and longer post-operative hospitalisation (adjusted coefficient, 0.89). CONCLUSIONS Greater cumulative intraoperative opioids are associated with severe post-operative vomiting after congenital cardiac surgery. Multimodal pain strategies targeting the reduction of intraoperative opioids should be considered during congenital cardiac surgery to enhance recovery after surgery.
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Nociception Control of Bilateral Single-Shot Erector Spinae Plane Block Compared to No Block in Open Heart Surgery-A Post Hoc Analysis of the NESP Randomized Controlled Clinical Trial. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020265. [PMID: 36837467 PMCID: PMC9965417 DOI: 10.3390/medicina59020265] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023]
Abstract
Background and Objectives: The erector spinae plane block (ESPB) is an analgesic adjunct demonstrated to reduce intraoperative opioid consumption within a Nociception Level (NOL) index-directed anesthetic protocol. We aimed to examine the ESPB effect on the quality of intraoperative nociception control evaluated with the NOL index. Materials and Methods: This is a post hoc analysis of the NESP (Nociception Level Index-Directed Erector Spinae Plane Block in Open Heart Surgery) randomized controlled trial. Eighty-five adult patients undergoing on-pump cardiac surgery were allocated to group 1 (Control, n = 43) and group 2 (ESPB, n = 42). Both groups received general anesthesia. Preoperatively, group 2 received bilateral single-shot ESPB (1.5 mg/kg/side 0.5% ropivacaine mixed with dexamethasone 8 mg/20 mL). Until cardiopulmonary bypass (CPB) was initiated, fentanyl administration was individualized using the NOL index. The NOL index was compared at five time points: pre-incision (T1), post-incision (T2), pre-sternotomy (T3), post-sternotomy (T4), and pre-CPB (T5). On a scale from 0 (no nociception) to 100 (extreme nociception), a NOL index > 25 was considered an inadequate response to noxious stimuli. Results: The average NOL index across the five time points in group 2 to group 1 was 12.78 ± 0.8 vs. 24.18 ± 0.79 (p < 0.001). The NOL index was significantly lower in the ESPB-to-Control group at T2 (12.95 ± 1.49 vs. 35.97 ± 1.47), T3 (13.28 ± 1.49 vs. 24.44 ± 1.47), and T4 (15.52 ± 1.49 vs. 34.39 ± 1.47) (p < 0.001) but not at T1 and T5. Compared to controls, significantly fewer ESPB patients reached a NOL index > 25 at T2 (4.7% vs. 79%), T3 (0% vs. 37.2%), and T4 (7.1% vs. 79%) (p < 0.001). Conclusions: The addition of bilateral single-shot ESPB to general anesthesia during cardiac surgery improved the quality of intraoperative nociception control according to a NOL index-based evaluation.
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Rubio G, Ibekwe SO, Anton J, Tolpin D. Pro: Regional Anesthesia for Cardiac Surgery With Sternotomy. J Cardiothorac Vasc Anesth 2023; 37:1042-1045. [PMID: 36775746 DOI: 10.1053/j.jvca.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/07/2023] [Accepted: 01/10/2023] [Indexed: 01/18/2023]
Affiliation(s)
- Gabriel Rubio
- Division of Cardiovascular Anesthesiology at the Texas Heart Institute, Baylor St. Luke's Medical Center, Baylor College of Medicine, Houston, TX.
| | - Stephanie Opusunju Ibekwe
- Division of Cardiovascular Anesthesiology at Ben Taub Hospital, Baylor College of Medicine, Houston, TX
| | - James Anton
- Baylor College of Medicine Department of Anesthesiology, Texas Heart Institute, Houston, TX
| | - Daniel Tolpin
- Division of Cardiovascular Anesthesiology at the Texas Heart Institute, Baylor St. Luke's Medical Center, Baylor College of Medicine, Houston, TX
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Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline. Cardiol Young 2022; 32:1881-1893. [PMID: 36382361 DOI: 10.1017/s1047951122003559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline. METHODS A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus. RESULTS 60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations. CONCLUSIONS Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.
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Thalji NK, Patel SJ, Augoustides JG, Schiller RJ, Dalia AA, Low Y, Hamzi RI, Fernando RJ. Opioid-Free Cardiac Surgery: A Multimodal Pain Management Strategy With a Focus on Bilateral Erector Spinae Plane Block Catheters. J Cardiothorac Vasc Anesth 2022; 36:4523-4533. [PMID: 36184473 PMCID: PMC9745636 DOI: 10.1053/j.jvca.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Nabil K Thalji
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Jayant Patel
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robin J Schiller
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Adam A Dalia
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Yinghui Low
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA
| | - Rawad I Hamzi
- Department of Anesthesiology, Regional Anesthesia and Acute Pain Management, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC.
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Kodali VRK, Shree S, Prasad M, Sambandam KKG, Karthekeyan RB, Vakamudi M. A Comparative Study of Bilateral Erector Spinae Block Versus Intravenous Dexmedetomidine for Perioperative Pain Management in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting - A Single-Blind Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2022; 36:4085-4092. [PMID: 35970671 DOI: 10.1053/j.jvca.2022.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/10/2022] [Accepted: 07/12/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Regional analgesia, along with general anesthesia, reduce postoperative pain. In this study, the authors compared the erector spinae plane (ESP) block having dexmedetomidine as an adjuvant with conventional pain management along with intravenous dexmedetomidine. DESIGN Prospective randomized single-blinded trial. SETTING Tertiary care teaching hospital. PARTICIPANTS All of the patients scheduled for elective off-pump coronary artery bypass grafting with an ejection fraction of >45%. INTERVENTIONS After obtaining institutional ethical committee approval, 130 patients were randomized into Group E and Group D. Group E patients received ESP block bilaterally with 25 mL of bupivacaine plus 0.5 μg/kg of dexmedetomidine. The patients in Group D received conventional intravenous analgesia, as well as a 0.7 μg/kg of dexmedetomidine bolus, followed by a 0.3 μg/kg dexmedetomidine infusion during surgery and continued postoperatively for 24 hours. Group E patients received 8 mL/h of bupivacaine infusion bilaterally for 24 hours. MEASUREMENTS The primary outcome assessed was pain scores in the postoperative period. The secondary outcomes assessed were postoperative rescue analgesic consumption, time to first rescue analgesia, intraoperative fentanyl consumption, duration of mechanical ventilation, and duration of intensive care unit (ICU) stay. RESULTS Both groups were comparable in demographic characteristics. The postoperative pain scores from 4 hours to 12 hours were lower in Group E compared with Group D. The pain scores at 24 hours were not significantly different between groups. Postoperative fentanyl consumption in Group E (99.23 ± 50.19 μg) was significantly lower than in Group D (181.15 ± 82.92 μg), with a p value of 0.001. Time to first rescue analgesia was significantly longer in Group E, with a median score of 8 hours when compared with that of 4 hours in Group D, with a p value of 0.01. Intraoperative fentanyl consumption was significantly lower in Group E (392.15 ± 55.36 μg) compared with Group D (604.00 ± 131.87 μg; p = 0.001). There were no significant differences in the duration of mechanical ventilation in both groups. Duration of ICU stay was significantly lower in Group E (51.95 ± 8.54 hours) when compared with Group D (59.06 ± 8.68 hours) (p = 0.001). CONCLUSIONS Erector spinae fascial plane blocks appeared to reduce postoperative pain scores in off-pump coronary artery bypass graft patients. Furthermore, ESP block was beneficial in terms of less intraoperative and postoperative opioid consumption, longer time to first rescue analgesia, and shorter ICU stay.
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Affiliation(s)
- V Rajesh Kumar Kodali
- Department of Anaesthesiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India.
| | - Shruthi Shree
- Department of Cardiac Anaesthesiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
| | - Mahender Prasad
- Department of Cardiac Anaesthesiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
| | - Kamala Kannan G Sambandam
- Department of Cardiac Anaesthesiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
| | - Ranjith B Karthekeyan
- Department of Cardiac Anaesthesiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
| | - Mahesh Vakamudi
- Department of Anaesthesiology, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
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Nociception Level Index-Directed Erector Spinae Plane Block in Open Heart Surgery: A Randomized Controlled Clinical Trial. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58101462. [PMID: 36295622 PMCID: PMC9611455 DOI: 10.3390/medicina58101462] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/07/2022] [Accepted: 10/12/2022] [Indexed: 11/11/2022]
Abstract
Background and Objectives: The erector spinae plane block (ESPB) is a multimodal opioid-sparing component, providing chest-wall analgesia of variable extent, duration, and intensity. The objective was to examine the ESPB effect on perioperative opioid usage and postoperative rehabilitation when used within a Nociception Level (NOL) index-directed anesthetic protocol. Materials and Methods: This prospective, randomized, controlled, open-label study was performed in adult patients undergoing on-pump cardiac surgery in a single tertiary hospital. Eighty-three adult patients who met eligibility criteria were randomly allocated to group 1 (Control, n = 43) and group 2 (ESPB, n = 40) and received general anesthesia with NOL index-directed fentanyl dosing. Preoperatively, group 2 also received bilateral single-shot ultrasound-guided ESPB (1.5 mg/kg/side 0.5% ropivacaine mixed with dexamethasone 8 mg/20 mL). Postoperatively, both groups received intravenous paracetamol (1 g every 6 h). Morphine (0.03 mg/kg) was administered for numeric rating scale (NRS) scores ≥4. Results: The median (IQR, 25th−75th percentiles) intraoperative fentanyl and 48 h morphine dose in group 2-to-group 1 were 1.2 (1.1−1.5) vs. 4.5 (3.8−5.5) µg·kg−1·h−1 (p < 0.001) and 22.1 (0−40.4) vs. 60.6 (40−95.7) µg/kg (p < 0.001). The median (IQR) time to extubation in group 2-to-group 1 was 90 (60−105) vs. 360 (285−510) min (p < 0.001). Two hours after ICU admission, 87.5% of ESPB patients were extubated compared to 0% of controls (p < 0.001), and 87.5% were weaned off norepinephrine compared to 46.5% of controls (p < 0.001). The median NRS scores at 0, 6, 12, 24, and 48 h after extubation were significantly decreased in group 2. There was no difference in opioid-related adverse events and length of stay. Conclusions: NOL index-directed ESPB reduced intraoperative fentanyl by 73.3% and 48 h morphine by 63.5%. It also hastened the extubation and liberation from vasopressor support and improved postoperative analgesia.
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Wiech M, Żurek S, Kurowicki A, Horeczy B, Czuczwar M, Piwowarczyk P, Widenka K, Borys M. Erector Spinae Plane Block Decreases Chronic Postoperative Pain Severity in Patients Undergoing Coronary Artery Bypass Grafting. J Clin Med 2022; 11:5949. [PMID: 36233819 PMCID: PMC9571025 DOI: 10.3390/jcm11195949] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/30/2022] [Accepted: 10/02/2022] [Indexed: 12/02/2022] Open
Abstract
Up to 56% of patients develop chronic postsurgical pain (CPSP) after coronary artery bypass grafting (CABG). CPSP can affect patients’ moods and decrease daily activities. The primary aim of this study was to investigate CPSP severity in patients following off-pump (OP) CABG using the Neuropathic Pain Symptom Inventory (NPSI). This was a prospective cohort study conducted in a cardiac surgery department of a teaching hospital. Patients undergoing OP-CABG were enrolled in an erector spinae plane block (ESPB) group (n = 27) or a control (CON) group (n = 24). Before the induction of general anesthesia, ESPB was performed on both sides under ultrasound guidance using 0.375% ropivacaine. The secondary outcomes included cumulative oxycodone consumption, acute pain intensity, mechanical ventilation time, hospital length of stay, and postoperative complications. CPSP intensity was lower in the ESPB group than in the CON group 1, 3, and 6 months post-surgery (p < 0.001). Significant between-group differences were also observed in other outcomes, including postoperative pain severity, opioid consumption, mechanical ventilation time, and hospital length of stay, in favor of the ESPB group. Preemptive ESPB appears to decrease the risk of CPSP development in patients undergoing OP-CABG. Reduced acute pain severity and shorter mechanical ventilation times and hospital stays should improve patients’ satisfaction and reduce perioperative complications.
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Affiliation(s)
- Marcin Wiech
- Second Department of Anesthesia and Intensive Therapy, Medical University of Lublin, Staszica 16, 20-081 Lublin, Poland
| | - Sławomir Żurek
- Department of Cardiac Surgery, Medical Faculty, University of Rzeszow, Lwowska 60, 35-301 Rzeszow, Poland
| | - Arkadiusz Kurowicki
- Department of Cardiac Surgery, Medical Faculty, University of Rzeszow, Lwowska 60, 35-301 Rzeszow, Poland
| | - Beata Horeczy
- Pro-Familia Hospital, Medical College of Rzeszow University, Witolda 6B, 35-302 Rzeszow, Poland
| | - Mirosław Czuczwar
- Second Department of Anesthesia and Intensive Therapy, Medical University of Lublin, Staszica 16, 20-081 Lublin, Poland
| | - Paweł Piwowarczyk
- Second Department of Anesthesia and Intensive Therapy, Medical University of Lublin, Staszica 16, 20-081 Lublin, Poland
| | - Kazimierz Widenka
- Department of Cardiac Surgery, Medical Faculty, University of Rzeszow, Lwowska 60, 35-301 Rzeszow, Poland
| | - Michał Borys
- Second Department of Anesthesia and Intensive Therapy, Medical University of Lublin, Staszica 16, 20-081 Lublin, Poland
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The influence of preoperative anxiety on postoperative pain in patients undergoing cardiac surgery. Sci Rep 2022; 12:16464. [PMID: 36183003 PMCID: PMC9526739 DOI: 10.1038/s41598-022-20870-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Patients undergoing cardiac surgery represent a challenge in terms of pain management due to multiple factors relating to the patients and to the procedure itself. Our aim was to identify the influence of levels of preoperative anxiety on postoperative pain in patients undergoing cardiac surgery and explore associations between preoperative anxiety, postoperative pain, analgesic requirements, and sex. We present a prospective cohort study of 116 patients undergoing cardiac surgery between January and April 2020. Preoperative anxiety was evaluated using the State-Trait Anxiety Inventory and the amount of morphine needed to keep pain intensity below 4 on the verbal numerical rating scale was recorded for 48 h post-surgery. Given the extracorporeal circulation time, type of surgery and body surface, it was observed that every percentile increase in preoperative state anxiety led to an extra 0.068 mg of morphine being administered. For each extra year of age, the amount of morphine needed decreased by 0.26 mg, no difference was observed between men and women in terms of preoperative anxiety or postoperative analgesics requirements. It may be concluded that in cardiac surgery, postoperative analgesic requirements increased with higher levels of preoperative state anxiety and decreased for every extra year of age.
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Dost B, Kaya C, Turunc E, Dokmeci H, Yucel SM, Karakaya D. Erector spinae plane block versus its combination with superficial parasternal intercostal plane block for postoperative pain after cardiac surgery: a prospective, randomized, double-blind study. BMC Anesthesiol 2022; 22:295. [PMID: 36114466 PMCID: PMC9479438 DOI: 10.1186/s12871-022-01832-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to compare the effectiveness of bilateral erector spinae plane (ESP) block and superficial parasternal intercostal plane (S-PIP) + ESP block in acute post-sternotomy pain following cardiac surgery. METHODS Forty-seven patients aged between 18 and 80 years of age with American Society of Anesthesiologists class II-III due to undergo median sternotomy for cardiac surgery were included in this prospective, randomized, double-blinded study. Following randomization into two groups, one group received bilateral ultrasound-guided ESP and the other S-PIP plus ESP block. Morphine consumption within the first 24 h after surgery was the primary outcome of the study while NRS scores at rest, NRS scores when coughing, time taken until extubation, use of rescue analgesic, presence of nausea/vomiting, length of hospital and intensive care unit (ICU) stay, and patient satisfaction were secondary outcome measures. RESULTS Morphine use up to 24 h following surgery was statistically significantly different between the ESP block and ESP + S-PIP block groups (18.63 ± 6.60 [15.84-21.41] mg/24 h vs 14.41 ± 5.38 [12.08-16.74] mg/24 h, p = 0.021). The ESP + S-PIP block group had considerably reduced pain scores compared to the ESP block group across all time points. Rescue analgesics were required in 21 (87.5%) patients in the ESP block group and seven (30.4%) in the ESP + S-PIP group (p < 0.001). PONV, length of stay in the ICU and hospital, and time to extubation were similar between groups. CONCLUSIONS In open cardiac surgery, the combination of ESP and S-PIP blocks lowers pain scores and postoperative morphine requirement of patients. TRIAL REGISTRATION Clinicaltrials Registration No: NCT05191953, Registration Date: 14/01/2022.
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Affiliation(s)
- Burhan Dost
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey.
| | - Cengiz Kaya
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Esra Turunc
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Hilal Dokmeci
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Semih Murat Yucel
- Department of Cardiovascular Surgery, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Deniz Karakaya
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Rong LQ, Shen L, Bartels K. Cardiac surgery's long opioid dependency: time to recalibrate pain therapy? Br J Anaesth 2022; 129:655-658. [PMID: 36115713 DOI: 10.1016/j.bja.2022.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/18/2022] [Accepted: 08/12/2022] [Indexed: 11/28/2022] Open
Abstract
Opioid analgesia is the cornerstone of anaesthetic management during cardiac surgery. However, a subset of patients use opioids persistently after 3 months of surgery. We discuss a recent meta-analysis and systematic review by Liu and colleagues describing both patient and peri-procedural risk factors that contribute to this phenomenon in the context of chronic pain after cardiac surgery. Anaesthetists for cardiac surgery should consider opioid alternatives and individual patient risk factors to optimise recovery and pain control.
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Affiliation(s)
- Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
| | - Liang Shen
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Karsten Bartels
- Department of Anesthesia, University of Nebraska Medical Center, Omaha, NE, USA
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Maximos S, Vaillancourt-Jean É, Mouksassi S, De Cassai A, Ayoub S, Ruel M, Desroches J, Hétu PO, Moore A, Williams S. Peak plasma concentration of total and free bupivacaine after erector spinae plane and pectointercostal fascial plane blocks. Can J Anaesth 2022; 69:1151-1159. [PMID: 35513684 DOI: 10.1007/s12630-022-02260-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 12/13/2021] [Accepted: 02/04/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Erector spinae plane blocks (ESPB) and pectointercostal fascial (PIFB) plane blocks are novel interfascial blocks for which local anesthetic (LA) doses and concentrations necessary to achieve safe and effective analgesia are unknown. The goal of this prospective observational study was to provide the timing (Tmax) and concentration (Cmax) of maximum total and free plasma bupivacaine after ESPB in breast surgery and after PIFB in cardiac surgery patients. METHODS Erector spinae plane blocks or PIFBs (18 patients per block; total, 36 patients) were performed with 2 mg⋅kg-1 of bupivacaine with epinephrine 5 μg⋅mL-1. Our principal outcomes were the mean or median Cmax of total and free plasma bupivacaine measured 10, 20, 30, 45, 60, 90, 180, and 240 min after LA injection using liquid chromatography with tandem mass spectrometry. RESULTS For ESPB, the mean (standard deviation [SD]) total bupivacaine Cmax was 0.37 (0.12) μg⋅mL-1 (range, 0.19 to 0.64), and the median [interquartile range (IQR)] Tmax was 30 [50] min (range, 10-180). For ESPB, the mean (SD) free bupivacaine Cmax was 0.015 (0.017) μg⋅mL-1 (range, 0.003-0.067), and the median [IQR] Tmax was 30 [20] min (range, 10-120). After PIFB, mean plasma concentrations plateaued at 60-240 min. For PIFB, the mean (SD) total bupivacaine Cmax was 0.32 (0.21) μg⋅mL-1 (range, 0.14-0.95), with a median [IQR] Tmax of 120 [150] min (range, 30-240). For PIFB, the mean (SD) free bupivacaine Cmax was 0.019 (0.010) μg⋅mL-1 (range, 0.005-0.048), and the median [IQR] Tmax was 180 [120] min (range, 30-240). For both ESPB and PIFB, we observed no correlations between pharmacokinetic and demographic parameters. CONCLUSION Total and free bupivacaine Cmax observed after ESPB and PIFB with 2 mg⋅kg-1 of bupivacaine with epinephrine 5 μg⋅mL-1 were five to twenty times lower than levels considered toxic in the literature.
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Affiliation(s)
- Sarah Maximos
- Département d'Anesthésiologie, Centre hospitalier de l'Université de Montréal, Montreal, QC, H2L 4M1, Canada
| | - Éric Vaillancourt-Jean
- Département de Biochimie, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Samer Mouksassi
- Faculté de Pharmacie, Université de Montréal, Montreal, QC, Canada
| | - Alessandro De Cassai
- UOC Anesthesia and Intensiva Care Unit, Padua University Hospital, Padua, Veneto, Italy
| | - Sophie Ayoub
- Département d'Anesthésiologie, Centre hospitalier de l'Université de Montréal, Montreal, QC, H2L 4M1, Canada
| | - Monique Ruel
- Département d'Anesthésiologie, Centre hospitalier de l'Université de Montréal, Montreal, QC, H2L 4M1, Canada
| | - Julie Desroches
- Département d'Anesthésiologie, Centre hospitalier de l'Université de Montréal, Montreal, QC, H2L 4M1, Canada
| | - Pierre-Oliver Hétu
- Département de Biochimie, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Alex Moore
- Département d'Anesthésiologie, Centre hospitalier de l'Université de Montréal, Montreal, QC, H2L 4M1, Canada.
| | - Stephan Williams
- Département d'Anesthésiologie, Centre hospitalier de l'Université de Montréal, Montreal, QC, H2L 4M1, Canada
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Kim RS, Gonzalez-Ciccarelli LF, Brovman EY. Regional anesthesia techniques for cardiac surgery: where are we? Curr Opin Anaesthesiol 2022; 35:485-492. [PMID: 35788542 DOI: 10.1097/aco.0000000000001161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE OF REVIEW Inadequate pain relief after cardiac surgery results in decreased patient experience and satisfaction, increased opioid consumption with its associated adverse consequences, and reduced efficiency metrics. To mitigate this, regional analgesic techniques are an increasingly important part of the perioperative cardiac anesthesia care plan. The purpose of this review is to compare current regional anesthesia techniques, and the relative evidence supporting their efficacy and safety in cardiac surgery. RECENT FINDINGS Numerous novel plane blocks have been developed in recent years, with evidence of improved pain control after cardiac surgery. SUMMARY The current data supports the use of a variety of different regional anesthesia techniques to reduce acute pain after cardiac surgery. However, future randomized trials are needed to quantify and compare the efficacy and safety of different regional techniques for pain control after cardiac surgery.
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Affiliation(s)
- Rosa S Kim
- Department of Anesthesiology, Tufts Medical Center, 800 Washington St., Boston, Massachusetts, USA
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Jian C, Shen Y, Fu H, Yu L. Effects of ultrasound-guided erector spinae plane block with dexmedetomidine combined with ropivacaine of the same dose and different concentrations on analgesic effect and rehabilitation quality of patients undergoing thoracoscopic wedge resection of the lung: a prospective, randomized, controlled trial. BMC Anesthesiol 2022; 22:225. [PMID: 35842610 PMCID: PMC9288034 DOI: 10.1186/s12871-022-01768-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/07/2022] [Indexed: 11/12/2022] Open
Abstract
Objective To investigate the analgesic effect and rehabilitation quality of patients undergoing thoracoscopic wedge resection of the lung under erector spinae plane (ESP) block with dexmedetomidine combined with the same dose and different concentrations of ropivacaine. Methods Seventy patients undergoing thoracoscopic wedge resection were randomly divided into groups A (n = 35) and B (n = 35). To perform ESP block, the groups were administered dexmedetomidine (0.5 μg/kg) combined with 30 mL of 0.33% ropivacaine or 20 mL of 0.5% ropivacaine, respectively, half an hour before general anesthesia induction. We compared the onset time of anesthesia, the block level, and the duration of the block between the two groups. The number of compressions of the analgesic pump within 24 h and 48 h postoperatively and the time of the first compression were noted. The visual analog scale (VAS) scores of static and cough at 0.5 h, 6 h, 12 h, 24 h, and 48 h postoperatively were noted. Furthermore, the 40-item quality of recovery questionnaire (QoR-40) score was recorded at 24 h postoperatively. In addition, we noted the time taken to get out of the bed for the first time, the length of hospital stay, analgesia satisfaction, and the occurrence of related adverse reactions and complications within 48 h postoperatively. Results The range of ESP block was wider in Group A than in Group B (P < 0.05). Group B had a significantly shorter onset time (P < 0.05) and lower static and cough VAS scores at 6 h and 12 h postoperatively (P < 0.05); this was associated with significantly fewer compressions of the analgesic pump within 24 h and 48 h postoperatively and significantly more time until the first compression of the analgesic pump was required (P < 0.05). Group B was associated with significantly superior QoR-40 scores 24 h postoperatively and significantly shorter time to get out of the bed for the first time than Group A (P < 0.05). Conclusion Dexmedetomidine combined with 0.5% ropivacaine for ESP block is better than 0.33% ropivacaine for overall analgesia and postoperative rehabilitation of patients undergoing thoracoscopic wedge resection. Trial registration ChiCTR2200058114, Date of registration: 30/03/2022.
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Affiliation(s)
- Chunfang Jian
- Department of Anesthesiology, Longyan First Affiliated Hospital of Fujian Medical University, Jiuyi North Road, Xinluo District, Longyan, 364000, Fujian, China
| | - Yi Shen
- Department of Anesthesiology, Longyan First Affiliated Hospital of Fujian Medical University, Jiuyi North Road, Xinluo District, Longyan, 364000, Fujian, China
| | - Hangxiang Fu
- Department of Anesthesiology, Longyan First Affiliated Hospital of Fujian Medical University, Jiuyi North Road, Xinluo District, Longyan, 364000, Fujian, China
| | - Lizhen Yu
- Department of Anesthesiology, Longyan First Affiliated Hospital of Fujian Medical University, Jiuyi North Road, Xinluo District, Longyan, 364000, Fujian, China.
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Cosarcan SK, Sezer ÖA, Gürkahraman S, Erçelen Ö. Regional analgesia techniques for effective recovery from coronary artery bypass surgeries: a retrospective study involving the experience of a single center. J Cardiothorac Surg 2022; 17:170. [PMID: 35794614 PMCID: PMC9261027 DOI: 10.1186/s13019-022-01923-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain after cardiac surgery is both multifocal and multifactorial. Sternotomy, sternal retraction, internal mammary dissection, posterior rib dislocation or fracture, potential brachial plexus injury, and mediastinal and pleural drains all contribute to pain experienced in the immediate postoperative period. Ineffective pain management can result in systemic and pulmonary complications and significant cardiac consequences. METHODS This study compared the effectiveness of regional anesthesia techniques for perioperative pain management in cardiac surgery patients at our clinic. The effects of different analgesic methods, in terms of contributing to recovery, were examined. RESULTS The records of 221 patients who had undergone coronary bypass surgery were evaluated retrospectively. The extubation rate in the operating room was 91%. No patient received balloon pump support, and 20 patients were transferred to the cardiovascular intensive care unit while intubated. Regional anesthesia was performed on two of these 20 patients, but not on the remaining 18. Examination of intraoperative and postoperative opioid consumption revealed significantly lower levels among patients receiving regional anesthesia. The most effective results among the regional anesthesia techniques applied were achieved with double injection erector spinae plane block. CONCLUSION Regional anesthesia techniques severely limit opioid consumption during cardiac surgery. Their importance will gradually increase in terms of rapid recovery criteria. Based on our study results, double injection of the erector spinae plane block seems to be the most effective technique in cardiac surgery. We therefore favor the use of fascial plane blocks during such procedures. Trial Numbers The study is registered with ClinicalTrials (NCT05282303). Ethics committee registration and approval were Granted under Number 2021.464.IRB1.131.
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Affiliation(s)
- Sami Kaan Cosarcan
- Department of Anesthesiology, VKV American Hospital, Istanbul, Turkey. .,Department of Anesthesiology and Pain Clinic, VKV American Hospital, Istanbul, Turkey.
| | - Özer Ali Sezer
- Department of Anesthesiology, VKV American Hospital, Istanbul, Turkey
| | - Sami Gürkahraman
- Department of Cardiovascular Surgery, VKV American Hospital, Istanbul, Turkey
| | - Ömür Erçelen
- Department of Anesthesiology and Pain Clinic, VKV American Hospital, Istanbul, Turkey
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Quintero-Cifuentes IF, Camilo Clement J, Cruz-Suárez GA, Chaparro-Mendoza K, Holguín-Noreña A, Vélez-Esquivia MA. Bilateral continuous erector spinae plane block for cardiac surgery: case series. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2022. [DOI: 10.5554/22562087.e1042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Multimodal analgesia in cardiac surgery sternotomy includes bilateral continuous erector spinae plane block (BC-ESPB). However, the effectiveness of the local anesthetic regimens is still uncertain.
The purpose of this study was to assess pain control achieved with a multimodal analgesia regimen including BC-ESPB at the level of T5 with PCA with a 0.125 % bupivacaine infusion and rescue boluses.
This is a descriptive case series study which recruited 11 adult patients undergoing cardiac surgery through sternotomy in whom multimodal analgesia including BC-ESPB was used, between February and April 2021, at a fourth level institution.
All patients reported pain according to the numeric rating scale (NRS) ≤ 3 both at rest and in motion, at extubation and then 4 and 12 hours after surgery. After 24 hours the pain was NRS ≤ 3 in 100 % of the patients at rest and in 63.6 % in motion. At 48 h 81 % of the patients reported pain NRS ≤ 3 at rest and in motion. At 72h all patients reported pain NRS ≤ 3 at rest and 82 % in motion. The average intraoperative use of fentanyl was 2.35 µg/kg and postoperative hydromorphone was 5.3, 4.1 and 3.3 mg at 24, 48 and 72 hours, respectively.
Hence, bilateral ESP block in continuous infusion plus rescue boluses allows for proper control of acute intra and post-operative pain.
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Hsu M, Kinthala S, Huang J, Philip J, Saththasivam P, Porter B. Successful Management of a Patient With a History of Postoperative Delirium Undergoing Cardiac Surgery With an Erector Spinae Plane Block and Multimodal Analgesia: A Case Report. Cureus 2022; 14:e25504. [PMID: 35800818 PMCID: PMC9243216 DOI: 10.7759/cureus.25504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/05/2022] Open
Abstract
Perioperative delirium is an acute confusional state with fluctuating levels of consciousness, which can be precipitated by opioid-based anesthetics and inadequate pain control, especially in patients undergoing cardiac surgery. We seek to minimize opioid usage to avoid postoperative delirium in a patient with multiple risk factors undergoing aortic valve replacement. We used cardiac enhanced recovery after surgery protocols (ERAS-C), which include multimodal analgesia and regional anesthesia via bilateral erector spinae plane (ESP) blocks. Our observations suggest that bilateral ESP blocks and cardiac ERAS protocols offer a potential option to manage pain and control risk factors in patients at high risk of postoperative delirium undergoing cardiac surgery.
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Orhon Ergün M, Güvenç Y. Comparison of the Effectiveness of Anesthesia Methods on Percutaneous Kyphoplasty: Erector Spinae Plane Block Versus Local Anesthesia. ISTANBUL MEDICAL JOURNAL 2022. [DOI: 10.4274/imj.galenos.2022.13911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Unilateral erector spinae plane block versus intravenous morphine for postoperative analgesia after Percutaneous nephrolithotomy. A randomized controlled trial. Int J Health Sci (Qassim) 2022. [DOI: 10.53730/ijhs.v6ns4.6282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Pain is an everyday challenge during all surgeries and it is a chief postoperative complication, so pain management is a corner stone in anesthetic practice. Percutaneous nephrolithotomy PCNL surgeries are usually associated with acute postoperative pain. Ultrasound guided nerve block is considered a recent technique for pain management. it provides better visualization of the nerves and reduces the risk for complications e.g. unintended injury to adjacent structures. Erector spinae plane (ESP) block is a novel method of delivering postoperative analgesia after PCNL surgery, technique involves injecting local anaesthetic into the interfascial plane between the erector spinae muscle and the transverse processes.and is therefore devoid of major adverse effects like pneumothorax, spinal cord trauma, and hypotension that can occur with other types of blocks like thoracic paravertebral block (TPVB). The goal of this research was to determine the analgesic efficacy and safety of ultrasound-guided ESP. block done at T8 transverse process level in patients undergoing PCNL surgeries for intraoperative and postoperative analgesia.
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Hoan DT, Hung DD, Dat PQ, Tu NH. Continuous Unilateral Erector Spinae Plane Block versus Intravenous Analgesia in Minimally Invasive Cardiac Surgery: A Randomized Controlled Trial. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives: the study was conducted to assess the safety and efficacy of anesthesia under the erector spinae plane block (ESPB) in minimally invasive cardiac surgery (MICS). Methods: a prospective, randomized controlled trial was carried out in 56 adult patients who underwent MICS via a right thoracic incision at Vietnam National Heart Institute, Bach Mai hospital, Vietnam. Patients were randomly allocated into two groups: ESPB and conventional analgesia (intravenousmorphine patient-controlled analgesia, PCA). Patients in ESPB group received ultrasound-guided unilateral ESPB at the T4/T5 transverse process level, and the tip of the catheter was advanced 5cm beyond the tip of the needle; injected with 20 ml ropivacaine 0.5%. At the cardiac ICU, patients received paracetamol (1g every 6 hours), continuous infusion ropivacaine 0.1% 0.2ml/kg/hour. Patients in the PCA group received paracetamol (1g every 6 hours) and intravenous morphine PCA. All patients were followed for 72 hours after being extubated. Results: the resting VAS score was significantly lower in ESPB group at the time H4, H8, H12, H16, H36, H42, H48, H54, H60, H66 after extubated compared to that of the PCA group (p< 0.05). The dynamic VAS score at was also significantly lower in the ESPB group at all measured time points (p<0.05). Only 4 patients in the ESPB group required intravenous morphine PCA with the mean amount morphine were statistically lower in the ESPB group compared to the PCA group at 24 hours, 48 hours, 72 hours postoperative. No serious adverse events such as neurological complications, bleeding or infection were observed in both groups. Conclusion: ESPB is an effective analgesic for MICS via thoracic incision in reducing the VAS score and the morphine required. It is also a safe method with no severe ESPB-related complications.
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Tempe DK. Opioid stewardship in cardiac anesthesia practice. J Cardiothorac Vasc Anesth 2022; 36:2262-2264. [DOI: 10.1053/j.jvca.2022.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 11/11/2022]
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Kussman BD. Commentary: Thoracic epidural anesthesia for pediatric cardiac surgery and enhanced recovery: Still lessons yet to be learned. JTCVS Tech 2022; 11:69-70. [PMID: 35169742 PMCID: PMC8828791 DOI: 10.1016/j.xjtc.2021.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/13/2021] [Accepted: 10/22/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Barry D. Kussman
- Address for reprints: Barry D. Kussman, MBBCh, FFA(SA), Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115.
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