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Capuano P, Sepolvere G, Toscano A, Scimia P, Silvetti S, Tedesco M, Gentili L, Martucci G, Burgio G. Fascial plane blocks for cardiothoracic surgery: a narrative review. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:20. [PMID: 38468350 PMCID: PMC10926596 DOI: 10.1186/s44158-024-00155-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/23/2024] [Indexed: 03/13/2024]
Abstract
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.
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Affiliation(s)
- Paolo Capuano
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), UPMCI (University of Pittsburgh Medical Center Italy), Palermo, Italy.
| | - Giuseppe Sepolvere
- Department of Anesthesia and Cardiac Surgery Intensive Care Unit, Casa Di Cura San Michele, Maddaloni, Caserta, Italy
| | - Antonio Toscano
- Department of Anesthesia, Critical Care and Emergency, "Città Della Salute E Della Scienza" Hospital, Turin, Italy
| | - Paolo Scimia
- Intensive Care Unit, Department of Anesthesia, G. Mazzini Hospital, Teramo, Italy
| | - Simona Silvetti
- Department of Cardioanesthesia and Intensive Care, Policlinico San Martino IRCCS Hospital - IRCCS Cardiovascular Network, Genoa, Italy
| | - Mario Tedesco
- Department of Anesthesia and Intensive Care Unit and Pain Therapy, Mater Dei Hospital, Bari, Italy
| | - Luca Gentili
- Intensive Care Unit, Department of Anesthesia, S. Maria Goretti Hospital, Latina, Italy
| | - Gennaro Martucci
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), UPMCI (University of Pittsburgh Medical Center Italy), Palermo, Italy
| | - Gaetano Burgio
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), UPMCI (University of Pittsburgh Medical Center Italy), Palermo, Italy
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Ott S, Müller-Wirtz LM, Sertcakacilar G, Tire Y, Turan A. Non-Neuraxial Chest and Abdominal Wall Regional Anesthesia for Intensive Care Physicians-A Narrative Review. J Clin Med 2024; 13:1104. [PMID: 38398416 PMCID: PMC10889232 DOI: 10.3390/jcm13041104] [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: 12/17/2023] [Revised: 01/29/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
Multi-modal analgesic strategies, including regional anesthesia techniques, have been shown to contribute to a reduction in the use of opioids and associated side effects in the perioperative setting. Consequently, those so-called multi-modal approaches are recommended and have become the state of the art in perioperative medicine. In the majority of intensive care units (ICUs), however, mono-modal opioid-based analgesic strategies are still the standard of care. The evidence guiding the application of regional anesthesia in the ICU is scarce because possible complications, especially associated with neuraxial regional anesthesia techniques, are often feared in critically ill patients. However, chest and abdominal wall analgesia in particular is often insufficiently treated by opioid-based analgesic regimes. This review summarizes the available evidence and gives recommendations for peripheral regional analgesia approaches as valuable complements in the repertoire of intensive care physicians' analgesic portfolios.
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Affiliation(s)
- Sascha Ott
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Deutsches Herzzentrum der Charité-Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiac Anesthesiology and Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Lukas M Müller-Wirtz
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center, Saarland University Faculty of Medicine, 66424 Homburg, Germany
| | - Gokhan Sertcakacilar
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Anesthesiology and Reanimation, Bakırköy Dr. Sadi Konuk Training and Research Hospital, 34147 Istanbul, Turkey
| | - Yasin Tire
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of Anesthesiology and Reanimation, Konya City Hospital, University of Health Science, 42020 Konya, Turkey
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Hoogma DF, Van den Eynde R, Al Tmimi L, Verbrugghe P, Tournoy J, Fieuws S, Coppens S, Rex S. Efficacy of erector spinae plane block for minimally invasive mitral valve surgery: Results of a double-blind, prospective randomized placebo-controlled trial. J Clin Anesth 2023; 86:111072. [PMID: 36807995 DOI: 10.1016/j.jclinane.2023.111072] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/04/2023] [Accepted: 02/02/2023] [Indexed: 02/19/2023]
Abstract
STUDY OBJECTIVE To investigate if an erector spinae plane (ESP) block decreases postoperative opioid consumption, pain and postoperative nausea and vomiting in patients undergoing minimally invasive mitral valve surgery (MIMVS). DESIGN A single-center, double-blind, prospective, randomized, placebo-controlled trial. SETTING Postoperative period; operating room, post-anesthesia care unit (PACU) and hospital ward in a university hospital. PATIENTS Seventy-two patients undergoing video-assisted thoracoscopic MIMVS via right-sided mini-thoracotomy and enrolled in the institutional enhanced recovery after cardiac surgery program. INTERVENTIONS At the end of surgery, all patients received an ESP catheter at vertebra T5 under ultrasound guidance and were randomized to the administration of either ropivacaine 0.5% (loading of dose 30 ml and three additional doses of 20 ml with a 6 h interval) or normal saline 0.9% (with an identical administration scheme). In addition, patients received multimodal postoperative analgesia including dexamethasone, acetaminophen and patient-controlled intravenous analgesia with morphine. Following the final ESP bolus and before catheter removal, the position of the catheter was re-evaluated by ultrasound. Patients, investigators and medical personnel were blinded for the group allocation during the entire trial. MEASUREMENTS Primary outcome was cumulative morphine consumption during the first 24 h after extubation. Secondary outcomes included severity of pain, presence/extent of sensory block, duration of postoperative ventilation and hospital length of stay. Safety outcomes comprised the incidence of adverse events. MAIN RESULTS Median (IQR) 24-h morphine consumption was not different between the intervention- and control-group, 41 mg (30-55) versus 37 mg (29-50) (p = 0.70), respectively. Likewise, no differences were detected for secondary and safety endpoints. CONCLUSIONS Following MIMVS, adding an ESP block to a standard multimodal analgesia regimen did not reduce opioid consumption and pain scores.
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Affiliation(s)
- Danny Feike Hoogma
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium.
| | - Raf Van den Eynde
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium.
| | - Layth Al Tmimi
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium.
| | - Peter Verbrugghe
- Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium; Department of Cardiac Surgery, University Hospitals of Leuven, Leuven, Belgium.
| | - Jos Tournoy
- Department of Public Health and Primary Care, Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Steffen Fieuws
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), Biomedical Sciences Group, University of Leuven, Leuven, Belgium.
| | - Steve Coppens
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium.
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Biomedical Sciences Group, University of Leuven, Leuven, Belgium.
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Prin M, Clendenen N, Lum H, Kertai MD, Abrams BA. Challenging Paradigms and Trusting Evidence: New Approaches to Perioperative Care. Semin Cardiothorac Vasc Anesth 2022; 26:257-259. [PMID: 36314083 DOI: 10.1177/10892532221138170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Meghan Prin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nathan Clendenen
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hillary Lum
- Department of Medicine-Geriatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Miklos D Kertai
- Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin A Abrams
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
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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: 3.5] [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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