Outcomes After Paravertebral Blocks

Pain relief following sternotomy in conventional cardiac surgery: A review of non neuraxial regional nerve blocks

Acute post-operative pain following sternotomy in cardiac surgery should be adequately managed so as to avoid adverse hemodynamic consequences and pulmonary complications. In the era of fast tracking, adequate and efficient technique of post-operative analgesia enables early extubation, mobilization and discharge from intensive care unit. Due to increasing expertise in ultrasound guided blocks there is a recent surge in trial of bilateral nerve blocks for pain relief following sternotomy. The aim of this article was to review non-neuraxial regional blocks for analgesia following sternotomy in cardiac surgery. Due to the paucity of similar studies and heterogeneity, the assessment of bias, systematic review or pooled analysis/meta-analysis was not feasible. A total of 17 articles were found to be directly related to the performance of non-neuraxial regional nerve blocks across all study designs. Due to scarcity of literature, comments cannot be made on the superiority of these blocks over each other. However, most of the reviewed techniques were found to be equally efficacious or better than conventional and established techniques.

Anesthesia management with single injection paravertebral block for aorta coarctation in infant

BACKGROUND

Thoracotomy causes severe pain in the postoperative period. Perioperative thoracic paravertebral block reduces pain score and may improve outcome after pediatric cardiac surgery. This prospective study was designed for the efficacy and duration of a single level, single injection ultrasound-guided thoracic paravertebral block (TPVB) for fifteen infants undergoing aortic coarctation repair.

METHODS

After approval of the ethical committee and the relatives of the patients, 15 infants who had undergone thoracotomy were enrolled in the study. The patients received 0.5 ml·kg(-1) a bolus 0.25% bupivacaine with epinephrine 1 : 200 000 at T5-6 level after standard general anesthesia induction. Anesthesia depth with Index of Consciousness (IOC) and tissue oxygen saturation with cerebral (rSO2-C) and somatic thoracodorsal (rSO2-S) were monitored. Intraoperative hemodynamic and postoperative hemodynamic and pain scores were evaluated for 24 h after surgery. Face, Legs, Activity, Cry, Consolability (FLACC) score was utilized to measure postoperative pain in the intensive care unit. Rescue 0.05 mg·kg(-1) IV morphine was applied to patients in whom FLACC was >3.

RESULTS

The median age of the patients was 4.5 (1-11) months, and the median intraoperative endtidal isoflurane concentration was 0.6% (0.3-0.8). The amount of remifentanil used intraoperatively was 4.5 (2.5-14) μg·kg(-) (1) ·h(-1). Intraoperative heart rate and blood pressure values significantly decreased compared with values detected at 5th, 10th, and 15th min after TPVB application, after incision prior and after cross-clamp (P < 0.01). The median time of first dose of morphine application after block was 320 (185-430) min. The median morphine consumption in 24 h was 0.16 (0.09-0.4) mg·kg(-1). The median length of postoperative intensive care unit and in-hospital stay times was 23 (1-67) h and 4 (1-10) days, respectively.

CONCLUSION

We believe that TPVB, as part of a balanced anesthetic and analgesic regime, provides effective pain relief in patients undergoing aortic coarctation repair.

Paravertebral blocks

Paravertebral blocks have been demonstrated to represent an interesting alternative to epidural, especially for the management of perioperative and trauma pain. Initially performed mostly as single-shot blocks for breast surgery, thoracotomy, and hernia repairs in adults and children, presently these blocks are also used for placement of a paravertebral catheter, either unilateral or bilateral. Although complications associated with the performance of these blocks are infrequent, the use of ultrasound-guided approaches, which allow performing the block under direct vision, is becoming the standard in most groups performing these blocks routinely.

A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks

Regional analgesia has entered cardiac anesthesia in the form of spinal or epidural analgesia. However, the risk of spinal or epidural hematoma is a constant worry. Alternative regional techniques might be applicable in cardiac surgery. The purpose of this study is to present a novel technique of bilateral single-shot paravertebral blocks (BSS-PVB) for cardiac surgery via median sternotomy and compare its efficacy versus high thoracic epidural analgesia (TEA). Fifty-two patients were compared in this prospective cohort audit. In 26 patients, cardiac surgery was performed using low-dose fentanyl/BSS-PVB (bilateral blocks of 3 mL bupivacaine 0.5% each, T1-7) and general anesthesia; in another 26 patients, TEA (bupivacaine 0.125% at 10 mL/hour) and general anesthesia were used. Patients were assigned to cohorts according to their preoperative data and types of surgery. All patient data are shown as mean +/- SD; pain scores were compared between groups using the t test immediately, 6 hours, and 24 hours after surgery (P < .05). In the BSS-PVB-group (19 men, 7 women), mean age was 65 +/- 11 years, weight 74 +/- 16 kg, ejection fraction 59% +/- 12%, and duration of surgery 130 +/- 27 minutes; in the TEA-group (17 men, 9 women), mean age was 63 +/- 10 years, weight 75 +/- 16 kg, ejection fraction 58% +/- 12%, and duration of surgery 113 +/- 27 minutes. These data and preoperative comorbidity variables were not significantly different between the two groups. In each group, 18 patients underwent off-pump coronary artery bypass grafting, 3 on-pump and 5 mitral valve replacements. All patients were successfully immediately extubated. Postoperative pain scores were at any point significantly lower with TEA, immediately at 2.4 +/- 2.2 versus 3.7 +/- 2.6, at 6 hours at 1.1 +/- 1.5 versus 2.4 +/- 1.8, and at 24 hours at 1.0 +/- 1.4 versus 2.3 +/- 1.6 (0 = no pain, 10 = maximum pain). There was no complications related to epidural catheter placement or BSS-PVB. Using both techniques, immediate extubation after cardiac surgery is feasible; TEA provides better pain relief after cardiac surgery than BSS-PVB.