Thoracic Paravertebral Block for Perioperative Analgesia in the Surgical Management of Left Ventricular Assist Device Infections

Combined General and Regional Anesthesia for a Patient With Duchenne Muscle Dystrophy With an Implanted Left Ventricular Assisted Device Undergoing Orthopedic Surgery

Duchenne muscular dystrophy (DMD) is an X-linked inherited dystrophinopathy, with an incidence of 1 in 3,600 - 5,000 male live-born infants. The leading cause of death is often cardiomyopathy-related heart failure. Given the progressive nature of the disorder with involvement of skeletal muscle, respiratory and cardiac function, perioperative care remains challenging with an increased incidence of perioperative morbidity and mortality. Perioperative care can be challenging due to life-threatening perioperative adverse events related to associated end-organ effects, as well as sensitivity to various anesthetic agents, rhabdomyolysis, hyperkalemia, hyperthermia, and cardiac arrest. We present a 22-year-old DMD patient with left ventricular assisted device (LVAD), who presented for repair of both left distal femur and tibial diaphysis fractures. Anesthetic care included the unique combination of total intravenous anesthesia with dexmedetomidine and remimazolam combined with regional anesthesia including a supra-inguinal fascia iliaca block, saphenous nerve block, and popliteal nerve block. The basics of dystrophinopathies are presented, perioperative concerns discussed, and previous reports of the use of regional anesthesia as an adjunct to general anesthesia in adult and pediatric patients with DMD are reviewed.

Transversus thoracic plane block and rectus sheath block for left ventricular assist device implantation via full median sternotomy: A case report

BACKGROUND

Traditionally, pain management after left ventricular assist device (LVAD) implantation via median sternotomy have been based on intravenous opioids but, in the era of enhanced recovery after surgery, a multimodal opioid-sparing analgesia could represent a valid alternative reducing opioids related side effects.

CASE REPORT

We described the successfully use of an opioid-sparing regimen for pain management after LVAD implantation via median sternotomy based on two ultrasound-guided fascial plane wall blocks. Bilateral ultrasound-guided transversus thoracic plane block was performed to manage sternotomy pain; additionally, unilateral left ultrasound-guided rectus sheath block was performed to provide somatic pain relief for left abdominal wall structures superficial to the peritoneum within which the LVAD driveline was inserted. The patient was extubated on Day 1 and good quality analgesia (numerical rating scale <3) was obtained, without using nonsteroidal antiinflammatory drugs or opioids. The patient was discharged from Intensive Care Unit on Day 3 and during hospitalization (lasted 24 days) there was no need for rescue analgesia administration.