Pectoralis-Intercostal-Rectus Sheath (PIRS) Plane Block With Catheters. A New Technique to Provide Analgesia in Cardiac Surgery

Rectus sheath block added to parasternal block may improve postoperative pain control and respiratory performance after cardiac surgery: a superiority single-blinded randomized controlled clinical trial

BACKGROUND

The population undergoing cardiac surgery confronts challenges from uncontrolled post-sternotomy pain, with possible adverse effects on outcome. While the parasternal block can improve analgesia, its coverage may be insufficient to cover epigastric area. In this non-blinded randomized controlled study, we evaluated the analgesic and respiratory effect of adding a rectus sheath block to a parasternal block.

METHODS

58 patients undergoing cardiac surgery via median sternotomy were randomly assigned to receive parasternal block with rectus sheath block (experimental) or parasternal block with epigastric exit sites of chest drains receiving surgical infiltration of local anesthetic (control). The primary outcome of this study was pain at rest at extubation. We also assessed pain scores at rest and during respiratory exercises, opiate consumption and respiratory performance during the first 24 hours after extubation.

RESULTS

The median (IQR) maximum pain scores (on a 0-10 Numeric Rate Scale (NRS)) at extubation were 4 (4, 4) in the rectus sheath group and 5 (4, 5) in the control group (difference 1, p value=0.03). Rectus sheath block reduced opioid utilization by 2 mg over 24 hours (IC 95% 0.0 to 2.0; p<0.01), reduced NRS scores at other time points, and improved respiratory performance at 6, 12, and 24 hours after extubation.

CONCLUSION

The addition of a rectus sheath block with a parasternal block improves analgesia for cardiac surgery requiring chest drains emerging in the epigastric area.

TRIAL REGISTRATION NUMBER

NCT05764616.

Fascial plane blocks for cardiothoracic surgery: a narrative review

In recent years, there has been a growing awareness of the limitations and risks associated with the overreliance on opioids in various surgical procedures, including cardiothoracic surgery.This shift on pain management toward reducing reliance on opioids, together with need to improve patient outcomes, alleviate suffering, gain early mobilization after surgery, reduce hospital stay, and improve patient satisfaction and functional recovery, has led to the development and widespread implementation of enhanced recovery after surgery (ERAS) protocols.In this context, fascial plane blocks are emerging as part of a multimodal analgesic in cardiac surgery and as alternatives to conventional neuraxial blocks for thoracic surgery, and there is a growing body of evidence suggesting their effectiveness and safety in providing pain relief for these procedures. In this review, we discuss the most common fascial plane block techniques used in the field of cardiothoracic surgery, offering a comprehensive overview of regional anesthesia techniques and presenting the latest evidence on the use of chest wall plane blocks specifically in this surgical setting.

Effects of pecto-intercostal fascial block combined with rectus sheath block for postoperative pain management after cardiac surgery: a randomized controlled trial

Background

Pecto-intercostal fascial block (PIFB) provides analgesia for cardiac median sternotomy, but many patients complain of severe drainage pain that cannot be covered by PIFB. Rectus sheath block (RSB) has been attempted to solve this problem, but whether PIFB combined with RSB can achieve better analgesia is uncertain.

Methods

This was a single-center randomized controlled trial at Peking University People’s Hospital from September 22, 2022 to December 21, 2022. Patients undergoing elective cardiac surgery with a median sternotomy were randomized at a 1:1 ratio to receive either bilateral PIFB and RSB (PIFB + RSB group) or PIFB (PIFB group). The primary outcome was intravenous opioid consumption within 24 h after surgery. Secondary outcomes included opioid consumption within 48 h, postoperative pain scores, time to extubation, and length of stay in the hospital. Interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α before and the first 24 h after surgery were measured.

Results

A total of 54 patients were analyzed (27 in each group). Intravenous opioid consumption within 24 h after surgery was 2.33 ± 1.77 mg in the PIFB + RSB group vs 3.81 ± 2.24 mg in the PIFB group (p = 0.010). Opioid consumption within 48 h after surgery was also reduced in the PIFB + RSB group (4.71 ± 2.71 mg vs 7.25 ± 3.76 mg, p = 0.006). There was no significant difference in pain scores, time to extubation, length of stay in hospital, or the levels of IL-6, IL-10 and TNF-α between the two groups.

Conclusions

The combination of PIFB and RSB reduced postoperative intravenous opioid consumption until 48 h after cardiac surgery.

Trial registration

This trial is registered at the Chinese Clinical Trial Registry (www.chictr.org.cn, ChiCTR2200062017) on 19/07/2022.

Implementation of Bilateral Rectus Sheath Blocks in Conjunction With Transversus Thoracis Plane and Pectointercostal Fascial Blocks for Immediate Postoperative Analgesia After Cardiac Surgery

Pain continues to be a well-known complication of cardiac surgery in the postoperative period and intravenous opioid analgesia has traditionally been employed to manage cardiac surgical pain. However, both components have contributed to a multitude of undesirable adverse effects which can further exacerbate delays in recovery. Often overlooked in the analgesic plan, chest tube pain contributes significantly to the overall postoperative pain from cardiac surgery. Novel regional anesthetic blocks have shown great promise as analgesic adjuncts for cardiothoracic anesthesia but preliminary investigations focus primarily on management of sternotomy pain. Reduction of chest tube pain should be considered while implementing regional blocks to control surgical pain. This study presents a case where the rectus sheath block minimized chest tube pain after aortic valve replacement in conjunction with intercostal nerve blocks and a multimodal analgesic plan.

Awake cardiac surgery using the novel pectoralis-intercostal-rectus sheath (PIRS) plane block and subxiphoid approach

BACKGROUND

Postoperative pain after cardiac surgery is a very important issue and affects recovery, risk of postoperative complications and quality of life. The pain management has been traditionally based on intravenous opioids with growing evidence suggesting the use of opioid-free and opioid-sparing techniques to reduce its adverse effects.

CASE PRESENTATION

We report the case of a 75-year-old frail patient underwent awake mediastinal revision with subxiphoid access due to deep sternal wound infection using a pectoralis-intercostal rectus sheath (PIRS) plane block. During the procedure the patient never reported pain receiving acetaminophen 1 g every 8 h for postoperative pain management without others pain relievers.

CONCLUSION

Ultrasound guided PIRS block could be an effective and safe analgesic technique to manage sternal and subxiphoid drainage pain in patients undergoing cardiac surgery via subxiphoid approach.