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Zengin EN, Yiğit H, Çobas M, Salman N, Aslı Demir Z. The analgesic effects of combined bilateral parasternal block and serratus anterior plane block for coronary artery bypass grafting surgery. BMC Anesthesiol 2024; 24:274. [PMID: 39103782 DOI: 10.1186/s12871-024-02659-7] [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: 04/30/2024] [Accepted: 07/25/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Severe pain occurs after cardiac surgery in the sternum and chest tubes sites. Although analgesia targeting the sternum is often prioritized, the analgesia of the drain site is sometimes overlooked. This study of patients undergoing coronary artery bypass grafting (CABG) aimed to provide optimized analgesia for both the sternum and the chest tubes area by combining parasternal block (PSB) and serratus anterior plane block (SAPB). METHODS Ethics committee approval (E.Kurul-E2-24-6176, 07/02/2024) was received for the study. Then, the trial was registered on www. CLINICALTRIALS gov ( https://clinicaltrials.gov/ ) under the identifier NCT05427955 on 17/03/2024. Twenty patients between the ages of 18-80, with ASA physical status classification II-III, undergoing coronary artery bypass grafting CABG with sternotomy, were included. While the patients were under general anesthesia, PSB was performed through the second and fourth intercostal spaces, and SAPB was performed over the sixth rib. The primary outcome was VAS (Visual Analog Scale) during the first 12 h after extubation. The secondary outcomes were intraoperative remifentanil consumption and block-related side effects. RESULTS The average age of the patients was 64 years. Five patients were female, and 15 were male. For the sternum area, only one patient had resting VAS scores of 4, while the VAS scores for resting for the other patients were below 4. For chest tubes area, only two patients had resting VAS scores of 4 or above, while the resting VAS scores for the other patients were below 4. The patients' intraoperative remifentanil consumption averaged 2.05 mg. No side effects related to analgesic protocol were observed in any of the patients. CONCLUSIONS In this preliminary study where PSB and SAPB were combined in patients undergoing CABG, effective analgesia was achieved for the sternum and chest tubes area.
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Affiliation(s)
- Emine Nilgün Zengin
- Ankara Bilkent City Hospital, Anesthesiology and Reanimation Clinic, University of Health Sciences, Ankara, Turkey.
- Ministry of Health Ankara City Hospital, Anesthesiology and Reanimation Clinic, Ankara, Turkey.
| | - Hülya Yiğit
- Ankara Bilkent City Hospital, Anesthesiology and Reanimation Clinic, University of Health Sciences, Ankara, Turkey
| | - Muhammed Çobas
- Ankara Bilkent City Hospital, Anesthesiology and Reanimation Clinic, University of Health Sciences, Ankara, Turkey
| | - Nevriye Salman
- Ankara Bilkent City Hospital, Anesthesiology and Reanimation Clinic, University of Health Sciences, Ankara, Turkey
| | - Zeliha Aslı Demir
- Ankara Bilkent City Hospital, Anesthesiology and Reanimation Clinic, University of Health Sciences, Ankara, Turkey
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Li Q, Liao Y, Wang X, Zhan M, Xiao L, Chen Y. Efficacy of bilateral catheter superficial parasternal intercostal plane blocks using programmed intermittent bolus for opioid-sparing postoperative analgesia in cardiac surgery with sternotomy: A randomized, double-blind, placebo-controlled trial. J Clin Anesth 2024; 95:111430. [PMID: 38537393 DOI: 10.1016/j.jclinane.2024.111430] [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: 09/13/2023] [Revised: 01/20/2024] [Accepted: 03/01/2024] [Indexed: 04/29/2024]
Abstract
STUDY OBJECTIVE This study investigated whether catheter superficial parasternal intercostal plane (SPIP) blocks, using a programmed intermittent bolus (PIB) with ropivacaine, could reduce opioid consumption while delivering enhanced analgesia for a period exceeding 48 h following cardiac surgery involving sternotomy. DESIGN A double-blind, prospective, randomized, placebo-controlled trial. SETTING University-affiliated tertiary care hospital. PATIENTS 60 patients aged 18 or older, scheduled for cardiac surgery via sternotomy. INTERVENTIONS The patients were randomly assigned in a 1:1 ratio to either the ropivacaine or saline group. After surgery, patients received bilateral SPIP blocks for 48 h with 0.4% ropivacaine (20 mL per side) for induction, followed by bilateral SPIP catheters using PIB with 0.2% ropivacaine (8 mL/side, interspersed with a 2-h interval) or 0.9% normal saline following the same administration schedule. All patients were administered patient-controlled analgesia with hydromorphone. MEASUREMENTS The primary outcome was the cumulative morphine equivalent consumption during the initial 48 h after the surgery. Secondary outcomes included postoperative pain assessment using the Numeric Rating Scale (NRS) at rest and during coughing at designated intervals for three days post-extubation. Furthermore, recovery indicators and ropivacaine plasma levels were diligently documented. MAIN RESULTS Cumulative morphine consumption within 48 h in ropivacaine group decreased significantly compared to saline group (25.34 ± 31.1 mg vs 76.28 ± 77.2 mg, respectively; 95% CI, -81.9 to -20.0, P = 0.002). The ropivacaine group also reported lower NRS scores at all recorded time points (P < 0.05) and a lower incidence of nausea and vomiting than the saline group (3/29 vs 12/29, respectively; P = 0.007). Additionally, the ropivacaine group showed significant improvements in ambulation (P = 0.018), respiratory exercises (P = 0.006), and self-reported analgesia satisfaction compared to the saline group (P = 0.016). CONCLUSIONS Bilateral catheter SPIP blocks using PIB with ropivacaine reduced opioid consumption over 48 h, concurrently delivering superior postoperative analgesia in adult cardiac surgery with sternotomy.
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Affiliation(s)
- Qi Li
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Yi Liao
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Xiaoe Wang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Mingying Zhan
- Department of Anesthesiology, Guangdong Provincial People's Hospital, Guangzhou, China.
| | - Li Xiao
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Yu Chen
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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Samerchua A, Leurcharusmee P, Supphapipat K, Unchiti K, Lapisatepun P, Maikong N, Kantakam P, Navic P, Mahakkanukrauh P. Optimal techniques of ultrasound-guided superficial and deep parasternal intercostal plane blocks: a cadaveric study. Reg Anesth Pain Med 2024; 49:320-325. [PMID: 37460213 DOI: 10.1136/rapm-2023-104595] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/04/2023] [Indexed: 05/10/2024]
Abstract
INTRODUCTION The optimal techniques of a parasternal intercostal plane (PIP) block to cover the T2-T6 intercostal nerves have not been elucidated. This pilot cadaveric study aims to determine the optimal injection techniques that achieve a consistent dye spread over the second to sixth intercostal spaces after both ultrasound-guided superficial and deep PIP blocks. We also investigated the presence of the transversus thoracis muscle at the first to sixth intercostal spaces and its sonographic identification agreement, as well as the location of the internal thoracic artery in relation to the lateral border of the sternum. METHODS Ultrasound-guided superficial or deep PIP blocks with single, double, or triple injections were applied in 24 hemithoraces (three hemithoraces per technique). A total volume of dye for all techniques was 20 mL. On dissection, dye distribution over the first to sixth intercostal spaces, the presence of the transversus thoracis muscle at each intercostal space and the distance of the internal thoracic artery from the lateral sternal border were recorded. RESULTS The transversus thoracis muscles were consistently found at the second to sixth intercostal spaces, and the agreement between sonographic identification and the presence of the transversus thoracis muscles was >80% at the second to fifth intercostal spaces. The internal thoracic artery is located medial to the halfway between the sternal border and costochondral junction along the second to sixth intercostal spaces. Dye spread following the superficial PIP block was more localized than the deep PIP block. For both approaches, the more numbers of injections rendered a wider dye distribution. The numbers of stained intercostal spaces after superficial block at the second, fourth, and fifth intercostal spaces, and deep block at the third and fifth intercostal spaces were 5.3±1.2 and 5.7±0.6 levels, respectively. CONCLUSION Triple injections at the second, fourth, and fifth intercostal spaces for the superficial approach and double injections at the third and fifth intercostal spaces for the deep approach were optimal techniques of the PIP blocks.
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Affiliation(s)
- Artid Samerchua
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Prangmalee Leurcharusmee
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Excellence in Osteology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kittitorn Supphapipat
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kantarakorn Unchiti
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Panuwat Lapisatepun
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Naraporn Maikong
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Perada Kantakam
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pagorn Navic
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pasuk Mahakkanukrauh
- Excellence in Osteology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Douglas RN, Kattil P, Lachman N, Johnson RL, Niesen AD, Martin DP, Ritter MJ. Superficial versus deep parasternal intercostal plane blocks: cadaveric evaluation of injectate spread. Br J Anaesth 2024; 132:1153-1159. [PMID: 37741722 DOI: 10.1016/j.bja.2023.08.014] [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] [Received: 05/04/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND Deep and superficial parasternal intercostal plane blocks provide anterior chest wall analgesia for both breast and cardiac surgery. Our primary objective of this cadaveric study was to describe the parasternal spread of deep and superficial parasternal intercostal plane blocks. Our secondary objectives were to describe needle proximity to the internal mammary artery when performing deep parasternal intercostal plane blocks, and compare lateral injectate spread and extension into the rectus sheath. METHODS We performed ultrasound-guided deep and superficial parasternal intercostal plane blocks 2 cm from the sternum at the T3-4 interspace in four fresh frozen cadavers as described in clinical studies. RESULTS Parasternal spread of injectate was greater with the deep parasternal intercostal plane injection than with the superficial parasternal intercostal plane injection. The internal mammary artery was ∼3 mm away from the needle trajectory in cadaver #1 and ∼5 mm from the internal mammary artery in cadaver #2. Lateral spread extended to the midclavicular line for all deep parasternal intercostal plane blocks and beyond the midclavicular line for all superficial parasternal intercostal plane blocks. Neither block extended to the rectus sheath. CONCLUSIONS A greater number of parasternal interspaces were covered with the deep parasternal intercostal plane block than with the superficial parasternal intercostal plane block when one injection was performed at the T3-4 interspace. However, considering proximity to the internal mammary artery, and potential devastating consequences of an arterial injury, we propose that the deep parasternal intercostal plane block be classified as an advanced block and that future studies focus on optimising superficial parasternal intercostal plane parasternal spread.
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Affiliation(s)
- Rachel N Douglas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Punnose Kattil
- Department of Clinical Anatomy, Mayo Clinic, Rochester, MN, USA
| | - Nirusha Lachman
- Department of Clinical Anatomy, Mayo Clinic, Rochester, MN, USA
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Adam D Niesen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Matthew J Ritter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
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Cui YY, Xu ZQ, Hou HJ, Zhang J, Xue JJ. Transversus Thoracic Muscle Plane Block For Postoperative Pain in Pediatric Cardiac Surgery: A Systematic Review And Meta-Analysis of Randomized And Observational Studies. J Cardiothorac Vasc Anesth 2024; 38:1228-1238. [PMID: 38453555 DOI: 10.1053/j.jvca.2024.02.016] [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: 01/05/2024] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVES Pediatric patients undergoing cardiac surgery usually experience significant surgical pain. Additionally, the effect of poor surgical analgesia creates a pain continuum that extends to the postoperative period. Transversus thoracic muscle plane block (TTMPB) is a novel plane block technique that can provide analgesia to the anterior chest wall. The analgesic role of TTMPB in pediatric cardiac surgery is still uncertain. A meta-analysis was conducted to determine the analgesic efficacy of this procedure. DESIGN AND SETTING Systematic review and meta-analysis. PubMed, Embase, Web of Science, CENTRAL, WanFang Data, and the China National Knowledge Infrastructure were searched to November 2023, and the Grading of Recommendations Assessment, Development, and Evaluation approach was followed to evaluate the certainty of evidence. PARTICIPANTS Eligible studies enrolled pediatric patients from 2 months to 12 years old scheduled to undergo cardiac surgery, and randomized them to receive a TTMPB or no block/sham block. MEASUREMENTS AND MAIN RESULTS Six studies that enrolled 601 pediatric patients were included. Low-certainty evidence from randomized trials showed that, compared with no block or sham block, TTMPB in pediatric patients undergoing cardiac surgery may reduce postoperative modified objective pain score at 12 hours (weighted mean difference [WMD] -2.20, 95% CI -2.73 to -1.68) and 24 hours (WMD -1.76, 95% CI -2.09 to -1.42), intraoperative opioid consumption (WMD -3.83, 95% CI -5.90 to -1.76 μg/kg), postoperative opioid consumption (WMD -2.51, 95% CI -2.84 to -2.18 μg/kg), length of intensive care unit (ICU) stay (WMD -5.56, 95% CI -8.30 to -2.83 hours), and extubation time (WMD -2.13, 95% CI -4.21 to -0.05 hours). Retrospective studies provided very low certainty that the results were consistent with the randomized trials. CONCLUSION Very low- to low-certainty evidence showed that TTMPB in pediatric patients undergoing cardiac surgery may reduce postoperative pain, opioid consumption, ICU length of stay, and extubation time.
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Affiliation(s)
- Yi-Yang Cui
- First School of Clinical Medicine, Gansu University of Chinese Medicine, Chengguan District, Lanzhou, China
| | - Zi-Qing Xu
- Department of Anesthesiology, Gansu Province Hospital of Traditional Chinese Medicine, Lanzhou, China; Gansu Clinical Research Center of Integrative Anesthesiology, Lanzhou, China
| | - Huai-Jing Hou
- Department of Anesthesiology, Gansu Province Hospital of Traditional Chinese Medicine, Lanzhou, China; Gansu Clinical Research Center of Integrative Anesthesiology, Lanzhou, China
| | - Jie Zhang
- Department of Anesthesiology, Gansu Province Hospital of Traditional Chinese Medicine, Lanzhou, China; Gansu Clinical Research Center of Integrative Anesthesiology, Lanzhou, China
| | - Jian-Jun Xue
- Department of Anesthesiology, Gansu Province Hospital of Traditional Chinese Medicine, Lanzhou, China; Gansu Clinical Research Center of Integrative Anesthesiology, Lanzhou, China; Evidence-based Medicine Center, School of Basic Medical Science, Lanzhou University, Gansu, Lanzhou, China.
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Laferrière-Langlois P, Jeffries S, Harutyunyan R, Hemmerling TM. Epidural Catheterization in Cardiac Surgery: A Systematic Review and Risk Assessment of Epidural Hematoma. Ann Card Anaesth 2024; 27:111-120. [PMID: 38607874 PMCID: PMC11095789 DOI: 10.4103/aca.aca_160_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: 10/16/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 04/14/2024] Open
Abstract
ABSTRACT The potential benefits of epidural anesthesia on mortality, atrial fibrillation, and pulmonary complications must be weighed against the risk of epidural hematoma associated with intraoperative heparinization. This study aims to provide an updated assessment of the clinical risks of epidural anesthesia in cardiac surgery, focusing on the occurrence of epidural hematomas and subsequent paralysis. A systematic search of Embase, Medline, Ovid Central, Web of Science, and PubMed was conducted to identify relevant publications between 1966 and 2022. Two independent reviewers assessed the eligibility of the retrieved manuscripts. Studies reporting adult patients undergoing cardiac surgery with epidural catheterization were included. The incidence of hematomas was calculated by dividing the number of hematomas by the total number of patients in the included studies. Risk calculations utilized various denominators based on the rigor of trial designs, and the risks of hematoma and paralysis were compared to other commonly encountered risks. The analysis included a total of 33,089 patients who underwent cardiac surgery with epidural catheterization. No epidural hematomas were reported across all published RCTs, prospective, and retrospective trials. Four case reports associated epidural hematoma with epidural catheterization and perioperative heparinization. The risks of epidural hematoma and subsequent paralysis were estimated at 1:7643 (95% CI 1:3860 to 380,916) and 1:10,190 (95% CI 1:4781 to 0:1), respectively. The risk of hematoma is similar to the non-obstetric population (1:5405; 95% CI 1:4784 to 6134). The risk of hematoma in cardiac surgery patients receiving epidural anesthesia is therefore similar to that observed in some other surgical non-obstetric populations commonly exposed to epidural catheterization.
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Affiliation(s)
- Pascal Laferrière-Langlois
- Department of Anaesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l’Est de L’Ile de Montréal, Montréal, Québec, Canada
| | - Sean Jeffries
- Department of Experimental Surgery, McGill University Health Centre, Montréal, Canada
- Intelligent Technology Anaesthesia Group (ITAG) Laboratory, McGill University, Montréal, Canada
| | - Robert Harutyunyan
- Department of Experimental Surgery, McGill University Health Centre, Montréal, Canada
- Intelligent Technology Anaesthesia Group (ITAG) Laboratory, McGill University, Montréal, Canada
| | - Thomas M. Hemmerling
- Department of Experimental Surgery, McGill University Health Centre, Montréal, Canada
- Intelligent Technology Anaesthesia Group (ITAG) Laboratory, McGill University, Montréal, Canada
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Chen Y, Li Q, Liao Y, Wang X, Zhan MY, Li YY, Liu GJ, Xiao L. Preemptive deep parasternal intercostal plane block for perioperative analgesia in coronary artery bypass grafting with sternotomy: a randomized, observer-blind, controlled study. Ann Med 2024; 55:2302983. [PMID: 38375661 PMCID: PMC10880567 DOI: 10.1080/07853890.2024.2302983] [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: 10/13/2023] [Accepted: 01/03/2024] [Indexed: 02/21/2024] Open
Abstract
OBJECTIVE The precise characteristics of deep parasternal intercostal plane block (DPIP), which is useful for providing analgesia during open heart surgery, have not yet been thoroughly elucidated. In this study, we aimed to establish the efficacy, define the cutaneous sensory block area, and determine the duration of preemptive DPIP block at the T3-4 or T4-5 intercostal spaces in patients undergoing coronary artery bypass grafting (CABG) via sternotomy. DESIGN A prospective, single-blind, randomized controlled trial. SETTING Patients were randomly divided into three cohorts, each containing thirty patients. PARTICIPANTS Ninety patients who underwent elective CABG via sternotomy were included in this study. INTERVENTIONS The T3-4 and T4-5 groups received a preoperative single-shot DPIP block at the respective intercostal spaces. The principal objective of the study was to ascertain the optimal dosage of sufentanil administered during surgical procedures involving either a DPIP block or its absence, and to conduct a comparative analysis thereof across distinct injection sites, specifically T3-4 and T4-5. Secondary factors considered were the dosage of postoperative analgesics, the extent of sensory block on the skin, pain levels after extubation, time of recovery from anesthesia (time to extubation), duration of the block, and the occurrence of nausea and vomiting. MEASUREMENTS & MAIN RESULTS Preemptive DPIP block significantly reduced intraoperative sufentanil requirement compared to the control group (T3-4:0.38 ± 0.1, T4-5:0.32 ± 0.10, vs. Control:0.88 ± 0.3 μg/kg/h, p < 0.001). It also resulted in decreased analgesic consumption and numeric rating scale scores on the day of surgery (p < 0.01 compared to the control group). The DPIP block provided accurate anesthetic coverage of the dermatomes in the sternal region and reduced the time to extubation and postoperative nausea. However, the injection point (either via the T3-4 intercostal or the T4-5 intercostal) did not affect the efficacy. Preoperative DPIP block failed to provide adequate analgesia beyond 24 h post-surgery. CONCLUSION Preemptive bilateral DPIP block provided effective analgesia in patients undergoing CABG during surgery and in the early postoperative period. The analgesic effects of the DPIP block in the T3-4 and T4-5 intercostal spaces were comparable.
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Affiliation(s)
- Yu Chen
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Qi Li
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yi Liao
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiaoe Wang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ming-ying Zhan
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ying-yuan Li
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Gai-jiao Liu
- Department of Anesthesiology, Shenzhen Second People’s Hospital, Shenzhen, China
| | - Li Xiao
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Toscano A, Capuano P, Perrucci C, Giunta M, Orsello A, Pierani T, Costamagna A, Tedesco M, Arcadipane A, Sepolvere G, Buono G, Brazzi L. Which ultrasound-guided parasternal intercostal nerve block for post-sternotomy pain? Results from a prospective observational study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:48. [PMID: 37974241 PMCID: PMC10652511 DOI: 10.1186/s44158-023-00134-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Parasternal intercostal blocks (PSB) have been proposed for postoperative analgesia in patients undergoing median sternotomy. PSB can be achieved using two different approaches, the superficial parasternal intercostal plane block (SPIP) and deep parasternal intercostal plane block (DPIP) respectively. METHODS We designed the present prospective, observational cohort study to compare the analgesic efficacy of the two approaches. Cardiac surgical patients who underwent full sternotomy from January to September 2022 were enrolled and divided into three groups, according to pain control strategy: morphine, SPIP, and DPIP group. Primary outcomes were was postoperative pain evaluated as absolute value of NRS at 12 h. Secondary outcomes were the NRS at 24 and 48 h, the need for salvage analgesia (both opioids and NSAIDs), incidence of postoperative nausea and vomiting, time to extubation, mechanical ventilation duration, and bowel disfunction. RESULTS Ninety-six were enrolled. There was no significant difference in terms of median Numeric Pain Rating Scale at 24 h and at 48 h between the study groups. Total postoperative morphine consumption was 1.00 (0.00-3.00), 2.00 (0.00-5.50), and 15.60 mg (9.60-30.00) in the SPIP, DPIP, and morphine group, respectively (SPIP and DPIP vs morphine: p < 0.001). Metoclopramide consumption was lower in SPIP and DPIP group compared with morphine group (p = 0.01). There was no difference in terms of duration of mechanical ventilation and of bowel activity between the study groups. Two pneumothorax occurred in the DPIP group. CONCLUSIONS Both SPIP and DPIP seem able to guarantee an effective pain management in the postoperative phase of cardiac surgeries via full median sternotomy while ensuring a reduced consumption of opioids and antiemetic drugs.
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Affiliation(s)
- Antonio Toscano
- Department of Anesthesia, Critical Care and Emergency, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Paolo Capuano
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, UPMC, 90127, Palermo, Italy.
| | - Chiara Perrucci
- Division of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| | - Matteo Giunta
- Department of Anesthesia, Critical Care and Emergency, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Alberto Orsello
- Department of Anesthesia, Critical Care and Emergency, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Tommaso Pierani
- Department of Anesthesia, Critical Care and Emergency, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Andrea Costamagna
- Department of Anesthesia, Critical Care and Emergency, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Mario Tedesco
- Department of Anesthesia and Intensive Care Unit and Pain Therapy, Mater Dei Hospital, Bari, Italy
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, UPMC, 90127, Palermo, Italy
| | - Giuseppe Sepolvere
- Department of Anesthesia and Cardiac Surgery Intensive Care Unit, Casa di Cura San Michele, Maddaloni, Caserta, Italy
| | - Gabriella Buono
- Division of Cardiovascular Anesthesia and Intensive Care, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| | - Luca Brazzi
- Department of Anesthesia, Critical Care and Emergency, 'Città della Salute e della Scienza' Hospital, Turin, Italy
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Tulgar S, Ciftci B, Ahiskalioglu A, Bilal B, Alver S, Sakul BU, Ansen G, Pence KB, Alici HA. Recto-intercostal fascial plane block: Another novel fascial plane block. J Clin Anesth 2023; 89:111163. [PMID: 37295124 DOI: 10.1016/j.jclinane.2023.111163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/02/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Serkan Tulgar
- Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Department of Anesthesiology and Reanimation, Samsun, Turkey
| | - Bahadir Ciftci
- Istanbul Medipol University, Department of Anesthesiology and Reanimation, Istanbul, Turkey.
| | - Ali Ahiskalioglu
- Ataturk University School of Medicine, Department of Anesthesiology and Reanimation, Development and Design Application and Research Center, Erzurum, Turkey
| | - Bora Bilal
- Kahramanmaras Sutcu Imam University Faculty of Medicine, Department of Anesthesiology and Reanimation, Kahramanmaras, Turkey
| | - Selcuk Alver
- Istanbul Medipol University, Department of Anesthesiology and Reanimation, Istanbul, Turkey
| | - Bayram Ufuk Sakul
- Istanbul Medipol University, Department of Anatomy, Istanbul, Turkey
| | - Gamze Ansen
- Istanbul Medipol University, Department of Anatomy, Istanbul, Turkey
| | | | - Hacı Ahmet Alici
- Istanbul Medipol University, Department of Algology, Istanbul, Turkey
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Kumar A, Sinha C, Kumar A, Krishna K, Prakash A, Surabhi. Ultrasound-guided bilateral continuous pecto-intercostal fascial block for post-sternotomy pain management. J Anaesthesiol Clin Pharmacol 2023; 39:656-657. [PMID: 38269152 PMCID: PMC10805193 DOI: 10.4103/joacp.joacp_38_22] [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: 01/27/2022] [Revised: 04/07/2022] [Accepted: 04/10/2022] [Indexed: 01/26/2024] Open
Affiliation(s)
- Amarjeet Kumar
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Chandni Sinha
- Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Ajeet Kumar
- Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Kunal Krishna
- Department of CTVS, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Abhinav Prakash
- Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Surabhi
- Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
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Xue JJ, Cui YY, Busse JW, Ge L, Zhou T, Huang WH, Ding SS, Zhang J, Yang KH. Transversus thoracic muscle plane block for pain during cardiac surgery: a systematic review and meta-analysis. Int J Surg 2023; 109:2500-2508. [PMID: 37246971 PMCID: PMC10442103 DOI: 10.1097/js9.0000000000000470] [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: 01/09/2023] [Accepted: 05/08/2023] [Indexed: 05/30/2023]
Abstract
STUDY OBJECTIVE The role of transversus thoracic muscle plane blocks (TTMPBs) during cardiac surgery is controversial. We conducted a systematic review to establish the effectiveness of this procedure. DESIGN Systematic review. We searched PubMed, Embase, Web of Science, CENTRAL, WanFang Data, and the China National Knowledge Infrastructure to June 2022, and followed the GRADE approach to evaluate the certainty of evidence. STUDY ELIGIBILITY CRITERIA Eligible studies enrolled adult patients scheduled to undergo cardiac surgery and randomized them to receive a TTMPB or no block/sham block. MAIN RESULTS Nine trials that enrolled 454 participants were included. Compared to no block/sham block, moderate certainty evidence found that TTMPB probably reduces postoperative pain at rest at 12 h [weighted mean difference (WMD) -1.51 cm on a 10 cm visual analogue scale for pain, 95% CI -2.02 to -1.00; risk difference (RD) for achieving mild pain or less (≤3 cm), 41%, 95% CI 17-65) and 24 h (WMD -1.07 cm, 95% CI -1.83 to -0.32; RD 26%, 95% CI 9-37). Moderate certainty evidence also supported that TTMPB probably reduces pain during movement at 12 h (WMD -3.42 cm, 95% CI -4.47 to -2.37; RD 46%, 95% CI 12-80) and at 24 h (WMD -1.73 cm, 95% CI -3.24 to -0.21; RD 32%, 95% CI 5-59), intraoperative opioid use [WMD -28 milligram morphine equivalent (MME), 95% CI -42 to -15], postoperative opioid consumption (WMD -17 MME, 95% CI -29 to -5), postoperative nausea and vomiting (absolute risk difference 255 less per 1000 persons, 95% CI 140-314), and intensive care unit (ICU) length of stay (WMD -13 h, 95% CI -21 to -6). CONCLUSION Moderate certainty evidence showed TTMPB during cardiac surgery probably reduces postoperative pain at rest and with movement, opioid consumption, ICU length of stay, and the incidence of nausea and vomiting.
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Affiliation(s)
- Jian-jun Xue
- Evidence-based Medicine Center, School of Basic Medical Science, Lanzhou University, Gansu Lanzhou
- Department of Anesthesiology, Gansu Province Hospital of Traditional Chinese Medicine
- Gansu Clinical Research Center of Integrative Anesthesiology
| | - Yi-yang Cui
- First School of Clinical Medicine, Gansu University of Chinese Medicine, Chengguan District
| | - Jason W. Busse
- Department of Anesthesia
- The Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, Ontario, Canada
| | - Long Ge
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, People’s Republic of China
| | - Ting Zhou
- First School of Clinical Medicine, Gansu University of Chinese Medicine, Chengguan District
| | - Wei-hua Huang
- First School of Clinical Medicine, Gansu University of Chinese Medicine, Chengguan District
| | - Sheng-shuang Ding
- First School of Clinical Medicine, Gansu University of Chinese Medicine, Chengguan District
| | - Jie Zhang
- First School of Clinical Medicine, Gansu University of Chinese Medicine, Chengguan District
| | - Ke-hu Yang
- Evidence-based Medicine Center, School of Basic Medical Science, Lanzhou University, Gansu Lanzhou
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, People’s Republic of China
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12
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Elbardan IM, Ahmed Sayed Shehab AS, Mabrouk IM. Comparison of transversus thoracis muscle plane block and pecto-intercostal fascial plane block for enhanced recovery after pediatric open-heart surgery. Anaesth Crit Care Pain Med 2023; 42:101230. [PMID: 37031816 DOI: 10.1016/j.accpm.2023.101230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 03/18/2023] [Accepted: 03/19/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Effective analgesia after cardiac surgery contributes to enhanced recovery. AIM To compare the perioperative analgesic effectiveness of Transversus Thoracis Muscle Plane Block (TTPB) and Pecto-Intercostal-Fascial Plane Block (PIFB) for controlling post-sternotomy pain in the pediatric population for ultrafast track cardiac surgery. METHODS Double-blind randomized study of 60 children, 2-12 years old, undergoing cardiac surgery via median sternotomy in whom a bilateral ultrasound-guided TTPB or TIBP block was performed preemptively. RESULTS Epidemiologic data of both groups were comparable. TTPB group had a lower median Modified Objective Pain Score (MOPS) all over the time postoperatively. Fentanyl consumption was significantly lower in TTBP group compared with PIFB group, only 4/30 received supplemental fentanyl during surgery in the TTPB group vs. 11/30 in the PIFB group (p = 0.033). The median [interquartile] values of postoperative fentanyl consumption were significantly lower in the TTBP compared with PIFB group: 12.0 [10.0-12.0] vs. 15.0 [15.0-16.0] µg/kg (p < 0.001), respectively. First rescue analgesia was later in the TTPB group compared to the PIFB group with median times of 7.25 and 5.0 hours, respectively (p < 0.001). Both groups had a comparable ICU length of stay (p = 0.919), with a median of 3 days. Furthermore, in the PIFB group, the incidence of non-sternal wound chest pain (53.3%) was significantly higher than in the TTPB group (3.3%) (p < 0.05). CONCLUSION TTPB and PIFB are safe regional blocks that could enhance recovery after pediatric cardiac surgery. In our series, TTPB provided better and longer-lasting postoperative analgesia with less incidence of non-sternal wound pain than PIFB.
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Affiliation(s)
- I M Elbardan
- Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, Alexandria University, Champollion Street, 21521 Azaritta, Alexandria, Egypt.
| | - A S Ahmed Sayed Shehab
- Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, Alexandria University, Champollion Street, 21521 Azaritta, Alexandria, Egypt.
| | - I M Mabrouk
- Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, Alexandria University, Champollion Street, 21521 Azaritta, Alexandria, Egypt.
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Ultrasound Guided Parasternal Block for Perioperative Analgesia in Cardiac Surgery: A Prospective Study. J Clin Med 2023; 12:jcm12052060. [PMID: 36902846 PMCID: PMC10003888 DOI: 10.3390/jcm12052060] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/03/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
Ultrasound guided parasternal block is a regional anaesthesia technique targeting the anterior branches of intercostal nerves, which supply the anterior thoracic wall. The aim of this prospective study is to assess the efficacy of parasternal block to manage postoperative analgesia and reduce opioid consumption in patients undergoing cardiac surgery throughout sternotomy. A total of 126 consecutive patients were allocated to two different groups, receiving (Parasternal group) or not (Control group) preoperative ultrasound guided bilateral parasternal block with 20 mL of 0.5% ropivacaine per side. The following data were recorded: postoperative pain expressed by a 0-10 numeric rating scale (NRS), intraoperative fentanyl consumption, postoperative morphine consumption, time to extubation and perioperative pulmonary performance at incentive spirometry. Postoperative NRS was not significantly different between Parasternal and Control groups with a median (IQR) of 2 (0-4.5) vs. 3 (0-6) upon awakening (p = 0.07); 0 (0-3) vs. 2 (0-4) at 6 h (p = 0.46); 0 (0-2) vs. 0 (0-2) at 12 h (p = 0.57). Postoperative morphine consumption was similar among groups. However, intraoperative fentanyl consumption was significantly lower in the Parasternal group [406.3 ± 81.6 mcg vs. 864.3 ± 154.4, (p < 0.001)]. Parasternal group showed shorter times to extubation [(191 ± 58 min vs. 305 ± 72 min, (p)] and better performance at incentive spirometer with a median (IQR) of 2 raised balls (1-2) vs. 1 (1-2) after awakening (p = 0.04). Ultrasound guided parasternal block provided an optimal perioperative analgesia with a significant reduction in intraoperative opioid consumption, time to extubation and a better postoperative performance at spirometry when compared to the Control group.
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14
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Schiavoni L, Nenna A, Cardetta F, Pascarella G, Costa F, Chello M, Agrò FE, Mattei A. Parasternal Intercostal Nerve Blocks in Patients Undergoing Cardiac Surgery: Evidence Update and Technical Considerations. J Cardiothorac Vasc Anesth 2022; 36:4173-4182. [PMID: 35995636 DOI: 10.1053/j.jvca.2022.07.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/16/2022] [Accepted: 07/20/2022] [Indexed: 11/11/2022]
Abstract
In the Enhanced Recovery After Surgery era, parasternal intercostal nerve block has been proposed to improve pain control and reduce opioid use in patients undergoing cardiac surgery. However current literature has reported conflicting evidence about the effect of this multimodal pain management, as procedural variations might pose a significant bias on outcomes evaluation. In this setting, the infiltration of the parasternal plane into 2 intercostal spaces, second and fifth, with a local anesthetic spread under or above the costal plane with ultrasound guidance, seem to be standardized in theory, but significant differences might be observed in clinical practice. This narrative review summarizes and defines the optimal techniques for parasternal plane blocks in patients undergoing cardiac surgery with full median sternotomy, considering both pectointercostal fascial block and transversus thoracic plane block. A total of 10 randomized trials have been published, in adjunct to observational studies, which are heterogeneous in terms of techniques, methods, and outcomes. Parasternal block has been shown to reduce perioperative opioid consumption and provide a more favorable analgesic profile, with reduced postoperative opioid-related side effects. A trend toward reduced intensive care unit stay or duration of mechanical ventilation should be confirmed by adequately powered randomized trials or registry studies. Differences in operative technique might impact outcomes and, therefore, standardization of the procedure plays a pivotal role before reporting specific outcomes. Parasternal plane blocks might significantly improve outcomes of cardiac surgery with full median sternotomy, and should be introduced comprehensively in Enhanced Recovery After Surgery protocols.
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Affiliation(s)
- Lorenzo Schiavoni
- Anesthesia, Intensive Care and Pain Management, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Antonio Nenna
- Cardiac Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.
| | | | - Giuseppe Pascarella
- Anesthesia, Intensive Care and Pain Management, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Fabio Costa
- Anesthesia, Intensive Care and Pain Management, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Massimo Chello
- Cardiac Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Felice E Agrò
- Anesthesia, Intensive Care and Pain Management, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Alessia Mattei
- Anesthesia, Intensive Care and Pain Management, Università Campus Bio-Medico di Roma, Rome, Italy
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15
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Zhang Y, Min J, Chen S. Sensory Assessment and Block Duration of Deep Parasternal Intercostal Plane Block in Patients Undergoing Cardiac Surgery: A Prospective Observational Study. Pain Ther 2022; 11:951-958. [PMID: 35751781 PMCID: PMC9314528 DOI: 10.1007/s40122-022-00403-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/07/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION There has been increasing interest in using deep parasternal intercostal plane (PIP) block as a supplement to multimodal analgesia regimens in cardiac surgery. The aim of this study was to observe cutaneous sensory block distribution and its duration for deep PIP blocks in patients undergoing open cardiac surgery. METHODS This observational, prospective clinical study consisted of 113 participants. All patients received bilateral ultrasound-guided deep PIP block with 40 ml 0.33% ropivacaine. The primary study outcome was cutaneous sensory block distribution of deep PIP blocks in patients undergoing open cardiac surgery. Secondary outcome included block duration in all participants. The area of cutaneous sensory block was tested by using a cold stimulus (ice cube) 30 min after the end of deep PIP block administration. Cutaneous sensory testing was performed once every hour after extubation until the return of normal sensation. RESULTS Thirty minutes after bilateral deep PIP block administration, the successful block rate of dermatomes T4 to T6 was almost 100%. However, T2 (percentage of left T2 block: 64.6%; percentage of right T2 block: 42.5%) and T3 (percentage of left T3 block: 88.5%; percentage of right T3 block: 87.6%) had a lower percentage of success. A few patients had blocked dermatomes at T1 or T7 (percentage of left T1 block: 7.08%; percentage of right T1 block: 2.65%; percentage of left T7 block: 6.19%; percentage of right T7 block: 10.6%). The mean effective duration of the deep PIP block was 17 h. CONCLUSION Bilateral deep PIP blocks can produce a widespread cutaneous sensory blockade with variable dermatomal distribution in the mid-sternum for a considerable effective duration. TRIAL REGISTRATION This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100047755).
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Affiliation(s)
- Yang Zhang
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006 Jiangxi China
| | - Jia Min
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006 Jiangxi China
| | - Shibiao Chen
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006 Jiangxi China
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16
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Li J, Lin L, Peng J, He S, Wen Y, Zhang M. Efficacy of ultrasound-guided parasternal block in adult cardiac surgery: a meta-analysis of randomized controlled trials. Minerva Anestesiol 2022; 88:719-728. [PMID: 35381838 DOI: 10.23736/s0375-9393.22.16272-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Pain after cardiac surgery is a common and severe postoperative complication. As a new regional nerve block method, ultrasound-guided parasternal block (PSB) has been increasingly used to supplement the analgesic effects of opioids in order to eliminate opioid-related adverse drug events, but its efficacy still remains controversial. In the present meta-analysis, we aim to screen all eligible randomized controlled trials (RCTs) and give a comprehensive summary of the clinical value of PSB after adult cardiac surgery. EVIDENCE ACQUISITION We searched all RCTs about PSB after cardiac surgery in the database of Pubmed, Embase, Cochrane, CNKI and Wanfang with no limitation of language from inception to September 2021. Two reviewers were independently involved in the process of data extraction. Meta-analysis was performed by using Review Manager software. The quality of included RCTs were assessed by using Cochrane's risk of bias assessment tool, and funnel plots were drawn to assess publication bias. EVIDENCE SYNTHESIS A total of 12 RCTs with 366 patients in PSB group and 364 patients in control group were included in the present meta-analysis. Pooled analysis revealed that intraoperative and postoperative consumption of sufentanil were significantly decreased with the addition of PSB (P<0.05). Numerical rating scale (NRS) scores in PSB group were found to be significantly lower than that of control group at extubation, postoperative 4h and 8h (P<0.05) instead of postoperative 24h or longer. PSB could reduce the incidence of postoperative nausea and vomiting (PONV) (P<0.05). In addition, we demonstrated that PSB was significantly related to decreased mechanical ventilation time, total length of ICU stay and hospital days (P<0.05). CONCLUSIONS Through decreasing the consumption of opioids, ultrasound-guided PSB could relieve pain and limit opioid-related complications. Clinical outcomes, such as mechanical ventilation time, total length of ICU stay and hospital days, will also be improved. Our findings prove that ultrasound-guided PSB is an effective regional analgesic method after adult cardiac surgery.
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Affiliation(s)
- Jing Li
- Department of Anesthesiology, People's Hospital of Yilong County, Nanchong, China
| | - Lu Lin
- Department of Anesthesiology, The General Hospital of Western Theater Command Hospital, Chengdu, China
| | - Jian Peng
- Department of Anesthesiology, People's Hospital of Yilong County, Nanchong, China
| | - Shushao He
- Department of Anesthesiology, People's Hospital of Yilong County, Nanchong, China
| | - Yan Wen
- Department of Anesthesiology, Traditional Chinese Medicine Hospital of Nanchong, Nanchong, China
| | - Ming Zhang
- Department of Neurology, People's Hospital of Yilong County, Nanchong, China -
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17
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Sepolvere G, Coppolino F, Tedesco M, Cristiano L. Ultrasound-guided parasternal blocks: techniques, clinical indications and future prospects: a narrative review. Minerva Anestesiol 2021; 87:1338-1346. [PMID: 34633167 DOI: 10.23736/s0375-9393.21.15599-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fascial plane blocks represent anesthetic procedures performed to manage perioperative and chronic pain. Recently, many fascial blocks techniques have been described increasing their field of applications. They offer anesthetic and analgesic efficacy, easy of execution and low risk of complications. The newest techniques recently described are the ultrasound parasternal blocks (USPSB) which provide analgesia to the antero-medial chest wall. In particular, the antero-medial chest wall blocks are performed to provide analgesia and anesthesia in several and different surgeries such as median sternotomy, breast surgery, implantable cardioverter-defibrillator implantation and in the management of acute and chronic pain. The nervous target for these blocks is represented by the anterior branches of the intercostal nerves which enter the intercostal (ICM) and pectoralis major (PMM) muscles innervating the antero-medial region of chest wall, the main cause of poststernotomy pain. Local anesthetic is injected deep to PMM and superficial to the ICM or between the internal thoracic muscle (IIM) and transversus thoracis muscle (TTM). So, essentially these blocks may be described as superficial or deep parasternal-intercostal plane blocks, based on where the target nerves are hunted. Even if they all provide analgesia to the antero-medial chest wall, the anatomical injection site represents the main peculiarity that differentiates these techniques. To date, a common nomenclature for antero-medial chest wall blocks or parasternal-intercostal plane blocks is not yet well defined and a standardized nomenclature is needed to ensure an adequate communication among anesthesiologists.
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Affiliation(s)
- Giuseppe Sepolvere
- Intensive Care Unit, Department of Anesthesia and Cardiac Surgery, San Michele Hospital, Maddaloni, Caserta, Italy -
| | - Francesco Coppolino
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Mario Tedesco
- Department of Anesthesia and Intensive Care Unit and Pain Therapy, Mater Dei Hospital, Bari, Italy
| | - Loredana Cristiano
- Intensive Care Unit, Department of Anesthesia and Cardiac Surgery, San Michele Hospital, Maddaloni, Caserta, Italy
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18
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Zhang J, Luo F, Zhang X, Xue Y. Ultrasound-Guided Continuous Parasternal Intercostal Block Relieves Postoperative Pain After Open Cardiac Surgery: A Case Series. J Cardiothorac Vasc Anesth 2021; 36:2051-2054. [PMID: 34183252 DOI: 10.1053/j.jvca.2021.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 11/11/2022]
Abstract
Pain after open cardiac surgery can be severe and may persist for several days, potentially developing into chronic postsurgical pain. Herein the authors describe three patients who underwent open cardiac surgery via traditional median sternotomy approach. Postoperative pain was relieved in these patients via a novel, straightforward, ultrasound-guided parasternal intercostal block, peripheral regional anesthetic technique. This plane block, thus, may represent an effective regional anesthetic strategy and a valuable component of a multimodal analgesic approach for patients who have undergone open cardiac surgery with median sternotomy.
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Affiliation(s)
- Junhua Zhang
- Department of Anesthesiology, Central Hospital of Fuling, Chongqing, China
| | - Fuchao Luo
- Department of Thoracic and Cardiovascular Surgery, Central Hospital of Fuling, Chongqing, China
| | - Xiaoliang Zhang
- Department of Anesthesiology, Central Hospital of Fuling, Chongqing, China
| | - Yun Xue
- Department of Anesthesiology, Central Hospital of Fuling, Chongqing, China.
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19
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Sepolvere G, Di Zazzo F, Merola L, Tedesco M, Cristiano L. The correct internal mammary artery anatomy: A topic for ultrasound parasternal block. Saudi J Anaesth 2021; 15:233-234. [PMID: 34188654 PMCID: PMC8191278 DOI: 10.4103/sja.sja_1028_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Giuseppe Sepolvere
- Department of Anesthesia and Cardiac Surgery Intensive Care Unit, San Michele Hospital, Maddaloni, Caserta, Italy
| | - Fabrizio Di Zazzo
- Department of Anesthesia and Cardiac Surgery Intensive Care Unit, San Michele Hospital, Maddaloni, Caserta, Italy
| | - Luigi Merola
- Department of Anesthesia and Cardiac Surgery Intensive Care Unit, San Michele Hospital, Maddaloni, Caserta, Italy
| | - Mario Tedesco
- Department of Anesthesia and Intensive Care Unit and Pain Therapy, Mater Dei Hospital, Bari, Italy
| | - Loredana Cristiano
- Department of Anesthesia and Cardiac Surgery Intensive Care Unit, San Michele Hospital, Maddaloni, Caserta, Italy
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20
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Balan C, Bubenek-Turconi SI, Tomescu DR, Valeanu L. Ultrasound-Guided Regional Anesthesia-Current Strategies for Enhanced Recovery after Cardiac Surgery. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:312. [PMID: 33806175 PMCID: PMC8065933 DOI: 10.3390/medicina57040312] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/09/2021] [Accepted: 03/22/2021] [Indexed: 11/25/2022]
Abstract
With the advent of fast-track pathways after cardiac surgery, there has been a renewed interest in regional anesthesia due to its opioid-sparing effect. This paradigm shift, looking to improve resource allocation efficiency and hasten postoperative extubation and mobilization, has been pursued by nearly every specialty area in surgery. Safety concerns regarding the use of classical neuraxial techniques in anticoagulated patients have tempered the application of regional anesthesia in cardiac surgery. Recently described ultrasound-guided thoracic wall blocks have emerged as valuable alternatives to epidurals and landmark-driven paravertebral and intercostal blocks. These novel procedures enable safe, effective, opioid-free pain control. Although experience within this field is still at an early stage, available evidence indicates that their use is poised to grow and may become integral to enhanced recovery pathways for cardiac surgery patients.
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Affiliation(s)
- Cosmin Balan
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (S.-I.B.-T.); (L.V.)
| | - Serban-Ion Bubenek-Turconi
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (S.-I.B.-T.); (L.V.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Dana Rodica Tomescu
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
- 3rd Department of Anesthesiology and Intensive Care, Fundeni Clinical Institute, 258 Fundeni Road, 022328 Bucharest, Romania;
| | - Liana Valeanu
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (S.-I.B.-T.); (L.V.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
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21
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Sepolvere G, Tognù A, Tedesco M, Coppolino F, Cristiano L. Avoiding the Internal Mammary Artery During Parasternal Blocks: Ultrasound Identification and Technique Considerations. J Cardiothorac Vasc Anesth 2020; 35:1594-1602. [PMID: 33293216 DOI: 10.1053/j.jvca.2020.11.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 11/11/2022]
Abstract
Fascial plane chest wall blocks are an integral component to optimal multimodal postoperative analgesia in breast and cardiothoracic surgery, facilitating faster functional recovery and earlier discharge. Pectoral nerves block and serratus plane block have been used to treat postsurgical pain after breast and cardiothoracic surgeries; however, they cannot be used to anesthetize the anterior chest wall. Ultrasound parasternal block, or pectointercostal fascial block and transversus thoracis muscle plane block are two novel ultrasound-guided anesthetic and analgesic techniques that block the anterior cutaneous branches T2 to T6 intercostal nerves, providing anesthesia and analgesia to the anterior chest wall. Ultrasound parasternal block/pectointercostal fascial block and transversus thoracis muscle plane block are performed in the region of the internal mammary artery and could be considered to treat post-thoracotomy pain. This anatomic region is innervated by the anterior cutaneous branches T2-to-T6 intercostal nerves, which are obliterated during cardiac surgery artery harvesting. At the level of the fourth parasternal rib interspace, the internal mammary artery can be identified between the internal intercostal muscle and transversus thoracis muscle as a longitudinal pulsatile structure approximately 1.5 cm from the lateral border of the sternum. The transversus thoracis muscle is variable in many people and, thus, is an unreliable target and is difficult to visualize with ultrasound. Moreover, patients with a history of coronary artery bypass grafting could have tissue disruption in the transversus thoracis plane because of the internal mammary artery harvest, making transversus thoracis muscle identification more difficult. Despite ultrasound parasternal block and transversus thoracis muscle plane block having good safety profiles and reduced risk of complications, pneumothorax, local anesthetic systemic toxicity, and internal mammary artery injury or hematoma should be considered. If the block is performed before cardiac surgery, both the right and left internal mammary arteries could be damaged. The injury could render the internal mammary artery unusable for bypass grafting. If the block is performed after left internal mammary artery harvesting at the end of coronary artery bypass grafting, only the right internal mammary artery could be damaged. In patients in whom the internal mammary artery has been surgically used and the transversus thoracis muscle is difficult to visualize, ultrasound parasternal block should be considered. In patients in whom the internal mammary artery could be difficult to visualize or considering that it is in the vicinity of the transversus thoracis muscle plane block target and that the transversus thoracis muscle is difficult to visualize with ultrasound after internal mammary artery harvesting, then ultrasound parasternal block should be considered. The authors believe that ultrasound parasternal block is the safer regional technique for protecting the internal mammary artery and the pleura because it is more superficial. For this reason, ultrasound parasternal block also could be performed by inexperienced anesthesiologists. Although ultrasound parasternal block is more superficial, its superiority in terms of safety is yet to be proven. Additional studies are warranted to validate the authors' hypothesis.
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Affiliation(s)
- Giuseppe Sepolvere
- Department of Anesthesia and Cardiac Surgery Intensive Care Unit, San Michele Hospital, Maddaloni, Caserta, Italy.
| | - Andrea Tognù
- Department of Intensive Care Unit and Pain Therapy, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Mario Tedesco
- Department of Anesthesia and Intensive Care Unit and Pain Therapy, Mater Dei Hospital, Bari, Italy
| | - Francesco Coppolino
- Department of Woman, Child, and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Napoli, Italy
| | - Loredana Cristiano
- Department of Anesthesia and Cardiac Surgery Intensive Care Unit, San Michele Hospital, Maddaloni, Caserta, Italy
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22
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Grocott HP. Rational choices for chest wall interfascial plane blocks in cardiac surgery: where should we focus our research efforts? Anaesthesia 2020; 76:423-424. [PMID: 33170510 DOI: 10.1111/anae.15307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 12/27/2022]
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23
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Sepolvere G, Tedesco M, Cristiano L. Ultrasound Parasternal Block as a Novel Approach for Cardiac Sternal Surgery: Could it Be the Safest Strategy? J Cardiothorac Vasc Anesth 2020; 34:2284-2286. [DOI: 10.1053/j.jvca.2020.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/05/2020] [Accepted: 03/09/2020] [Indexed: 11/11/2022]
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24
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Sepolvere G, Tedesco M, Fusco P, Scimia P, Donatiello V, Cristiano L. Subxiphoid cardiac drainage pain management: could ultrasound rectus sheath block be the answer? Minerva Anestesiol 2020; 86:994-996. [PMID: 32420716 DOI: 10.23736/s0375-9393.20.14576-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Giuseppe Sepolvere
- Department of Anesthesia and Cardiac Surgery, Intensive Care Unit, San Michele Hospital, Maddaloni, Caserta, Italy -
| | - Mario Tedesco
- Department of Anesthesia and Intensive Care Unit and Pain Therapy, Mater Dei Hospital, Bari, Italy
| | - Pierfrancesco Fusco
- Department of Anesthesia and Intensive Care Unit, San Salvatore Academic Hospital, L'Aquila, Italy
| | - Paolo Scimia
- Department of Anesthesia and Intensive Care Unit, G. Mazzini Hospital, Teramo, Italy
| | - Valerio Donatiello
- Department of Anesthesia and Cardiac Surgery, Intensive Care Unit, San Michele Hospital, Maddaloni, Caserta, Italy
| | - Loredana Cristiano
- Department of Anesthesia and Cardiac Surgery, Intensive Care Unit, San Michele Hospital, Maddaloni, Caserta, Italy
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25
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Fujii S. Transversus thoracis muscle plane block and parasternal block. Reg Anesth Pain Med 2020; 45:317. [DOI: 10.1136/rapm-2019-101036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/18/2019] [Accepted: 11/20/2019] [Indexed: 11/03/2022]
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