Effects of bilateral Pecto-intercostal Fascial Block for perioperative pain management in patients undergoing open cardiac surgery: a prospective randomized study

The Effect of Perineural Adjuvants on Superficial Parasternal Intercostal Plane Blocks in Cardiac Surgery: A Triple-Blinded Randomized Controlled Feasibility Trial

Background and aim The study aimed to investigate the effect of adding perineural adjuvants, clonidine and dexamethasone, to local anesthetic in Superficial Parasternal Intercostal Plane (SPIP) blocks. It was designed as a prospective, randomized, triple-blinded, feasibility trial, conducted at a single-center university hospital. The participants included adult patients who were undergoing cardiac surgery via median sternotomy. Methodology Following skin closure, patients were randomized to receive either SPIP with 0.25% bupivacaine and 2.5 mcg/mL epinephrine (control group, n = 12) or SPIP with 0.25% bupivacaine, 2.5 mcg/mL epinephrine, 1.67 mcg/mL clonidine, and 0.1 mg/mL preservative-free dexamethasone (adjuvant group, n = 8). Results No significant difference was found between the adjuvant and control groups for the primary outcome of the area under the curve of longitudinal pain scores with incentive spirometry use measured at four timepoints during the first 24 hours following surgery (96.5 ± 58.4 vs. 94.3 ± 39.6, P = 0.93, respectively). Additionally, no difference was found for secondary outcomes, including opioid consumption in morphine milligram equivalents (120, interquartile range [IQR] 93-150 vs. 120, IQR 82-158; P = 0.88), time to extubation (232.02 ± 68.69 vs. 276.82 ± 78.61 min, P = 0.25), intensive care unit length of stay (31.4 vs. 38.2 hours, P = 0.64), or pain satisfaction scores between the adjuvant and control groups (P = 0.46), respectively. The adjuvant group demonstrated higher incentive spirometry volumes at the six-hour postoperative timepoint (1333.33 ± 857.97 mL vs. 525.00 ± 338.56 mL, P = 0.003), with a trend toward a difference at 12 and 18 hours (P = 0.24 and P = 0.10, respectively). Conclusions The addition of perineural adjuvants to SPIP was not associated with any difference in pain scores within the first 24 hours after cardiac surgery. Given the small nature of this feasibility study, further investigation is warranted.

Recommendations for fast-track extubation in adult cardiac surgery patients: a consensus statement

INTRODUCTION

Enhanced recovery after cardiac surgery in selected low-risk patients, has the potential to improve outcomes and reduce the burden of healthcare costs. Anesthesia-related challenges play a major role in the successful implementation of Enhanced Recovery After Surgery (ERAS) protocols, with particular emphasis placed on fast-track extubation. Acknowledging the importance of this practice, the Italian Association of Cardiac Anesthesiologists and Intensive Care (ITACTAIC) has advocated for an initiative to establish a consensus offering practical recommendations for fast-track extubation after adult cardiac surgery.

EVIDENCE ACQUISITION

After conducting a systematic review, all randomised control trials (RCTs) published between 2013 and 2023 were meticulously selected and analysed during a consensus meeting that involved statement voting.

EVIDENCE SYNTHESIS

Out of the 2268 publications identified using the search string, 60 RCTs were selected and classified into six groups, each evaluating specific interventions associated with extubation within 6 hours post-surgery. The authors examined 20 RCTs pertaining to loco-regional anesthesia, 19 analysing elements of general anesthesia, 12 focused on surgery-related aspects and techniques, three examining ventilation, two exploring anesthesia depth monitoring, and four addressing miscellaneous aspects. The expert panel approved 16 statements with 15 achieving high agreement and one obtaining moderate agreement. Finally a total of eight interventions were considered associated with fast-track extubation: parasternal block, erector spinae plane block, alpha agonist in the operating room (OR), opioids in the OR, dexmedetomidine in the intensive care unit (ICU), minimal invasive surgical access, anesthesia depth monitoring, adaptative support ventilation.

CONCLUSIONS

In the first consensus document ever published by a scientific society addressing practical recommendations for fast-track extubation post-cardiac surgery, the authors identified sixteen interventions commonly associated with fast-track extubation in selected adult cardiac surgery patients.

Nociception level index-directed superficial parasternal intercostal plane block vs erector spinae plane block in open-heart surgery: a propensity matched non-inferiority clinical trial

This single-center study explored the efficacy of superficial parasternal intercostal plane block (SPIPB) versus erector spinae plane block (ESPB) in opioid-sparing within Nociception Level (NOL) index-directed anesthesia for elective open-heart surgery. After targeted propensity matching, 19 adult patients given general anesthesia with preincisional SPIPB were compared to 33 with preincisional ESPB. We hypothesized that SPIPB is non-inferior to ESPB in reducing total intraoperative fentanyl consumption, with a non-inferiority margin (δ) set at 0.1 mg. Intraoperative fentanyl dosing targeted a NOL index ≤ 25. Postoperatively, paracetamol 1 g 6-hourly and morphine for numeric rating scale (NRS) ≥ 4 were administered. This study could not demonstrate that SPIPB was inferior to ESPB for total intraoperative fentanyl consumption, as the confidence interval for the median difference of 0.1 mg (95% CI 0.05-0.15) crossed the predefined δ, with the lower bound falling below and the upper bound exceeding δ, p = 0.558. SPIPB led to higher postoperative morphine use at 24 and 48 h: 0 (0-40.6) vs. 59.5 (28.5-96.1) µg kg-1, p < 0.001 and 22.2 (0-42.6) vs. 63.5 (28.5-96.1) µg kg-1, p = 0.001. Four times fewer SPIPB patients remained morphine-free at 48 h, p < 0.001, and their time to first morphine dose was three times shorter compared to ESPB patients, p = 0.001. SPIPB led to higher time-weighted average NRS scores at rest, 1 (0-1) vs. 1 (1-2), p = 0.004, and with movement, 2 (1-2) vs. 3 (2-3), p = 0.002, calculated over the 48-h period post-extubation. The SPIPB group had a significantly higher average NOL index, p = 0.003, and greater NOL index variability, p = 0.027. This study could not demonstrate that SPIPB was inferior to ESPB for intraoperative fentanyl consumption. Significant differences were observed in secondary outcomes, with SPIPB leading to higher postoperative morphine use, higher pain scores, and reduced nociception control.

Superficial parasternal intercostal plane blocks in cardiac surgery: a systematic review and meta-analysis

PURPOSE

Traditional multimodal analgesic strategies have several contraindications in cardiac surgery patients, forcing clinicians to use alternative options. Superficial parasternal intercostal plane blocks, anesthetizing the anterior cutaneous branches of the thoracic intercostal nerves, are being explored as a straightforward method to treat pain after sternotomy. We sought to evaluate the literature on the effects of superficial parasternal blocks on pain control after cardiac surgery.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). We searched MEDLINE, Embase, CENTRAL, and Web of Science databases for RCTs evaluating superficial parasternal intercostal plane blocks in adult patients undergoing cardiac surgery via midline sternotomy published from inception to 11 March 2022. The prespecified primary outcome was opioid consumption at 12 hr. The risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool, and the quality of evidence was evaluated using the grading of recommendations, assessments, development, and evaluations. Outcomes were analyzed with a random-effects model. All subgroups were prespecified.

RESULTS

We reviewed 1,275 citations. Eleven RCTs, comprising 756 patients, fulfilled the inclusion criteria. Only one study reported the prespecified primary outcome, precluding the possibility of meta-analysis. This study reported a reduction in opioid consumption (-11.2 mg iv morphine equivalents; 95% confidence interval [CI], -8.2 to -14.1) There was a reduction in opioid consumption at 24 hr (-7.2 mg iv morphine equivalents; 95% CI,  -5.6 to -8.7; five trials; 436 participants; moderate certainty evidence). All five studies measuring complications reported that none were detected, which included a sample of 196 blocks.

CONCLUSION

The literature suggests a potential benefit of using superficial parasternal blocks to improve acute postoperative pain control after cardiac surgery via midline sternotomy. Future studies specifying dosing regimens and adjuncts are required.

STUDY REGISTRATION

PROSPERO (CRD42022306914); first submitted 22 March 2022.

Superficial versus deep parasternal intercostal plane blocks: cadaveric evaluation of injectate spread

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.

Pecto-intercostal Fascial Plane Block: A Novel Technique for Analgesia in Patients with Sternal Dehiscence

ABSTRACT

Sternal wound complications following sternotomy need a multidisciplinary approach in high-risk postoperative cardiac surgical patients. Poorly controlled pain during surgical management of such wounds increases cardiovascular stress and respiratory complications. Multimodal analgesia including intravenous opioids, non-opioid analgesics, and regional anesthesia techniques, like central neuraxial blocks and fascial plane blocks, have been described. Pecto-intercostal fascial plane block (PIFB), a novel technique, has been effectively used in patients undergoing cardiac surgery. Under ultrasound (US) guidance PIFB is performed with the aim of depositing local anesthetic between two superficial muscles, namely the pectoralis major muscle and the external intercostal muscle. The authors report a series of five cases where US-guided bilateral PIFB was used in patients undergoing sternal wound debridement. Patients had excellent analgesia intraoperatively as well as postoperatively for 24 hours with minimal requirement of supplemental analgesia. None of the patients experienced complications due to PIFB administration. The authors concluded that bilateral PIFB can be effectively used as an adjunct to multimodal analgesia with general anesthesia and as a sole anesthesia technique in selected cases of sternal wound debridement.

Fascial plane blocks for cardiothoracic surgery: a narrative review

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

Comparison of Erector Spinae Plane Block and Pectointercostal Facial Plane Block for Enhanced Recovery After Sternotomy in Adult Cardiac Surgery

OBJECTIVES

This study aimed to investigate and compare the effects of the pectointercostal fascial plane block (PIFPB) and the erector spinae plane block (ESPB) on enhancing the recovery of patients who undergo cardiac surgery.

DESIGN

A randomized, controlled, double-blinded study.

SETTING

The operating rooms and intensive care units of university hospitals.

PARTICIPANTS

One hundred patients who were American Society of Anesthesiologists class II to III aged 18-to-70 years scheduled for elective cardiac surgery.

INTERVENTIONS

Patients were randomly assigned to undergo either ultrasound-guided bilateral PIFPB or ESPB.

MEASUREMENTS AND MAIN RESULTS

Patients shared comparable baseline characteristics. Time to extubation, the primary outcome, did not demonstrate a statistically significant difference between the groups, with median (95% confidence interval) values of 115 (90-120) minutes and 110 (100-120) minutes, respectively (p = 0.875). The ESPB group had a statistically significant reduced pain score postoperatively. The median (IQR) values of postoperative fentanyl consumption were statistically significantly lower in the ESPB group than in the PIFPB group (p < 0.001): 4 (4-5) versus 9 (9-11) µg/kg, respectively. In the ESPB group, the first analgesia request was given 4 hours later than in the PIFPB group (p < 0.001). Additionally, 12 (24%) patients in the PIFPB group reported nonsternal wound chest pain, compared with none in the ESPB group. The median intensive care unit length of stay for both groups was 3 days (p = 0.428).

CONCLUSIONS

Erector spinae plane block and PIFPB were found to equally affect recovery after cardiac surgery, with comparable extubation times and intensive care unit length of stay.

Non-Neuraxial Chest and Abdominal Wall Regional Anesthesia for Intensive Care Physicians-A Narrative Review

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.

Comparison of the effects of transversus thoracic muscle plane block and pecto-intercostal fascial block on postoperative opioid consumption in patients undergoing open cardiac surgery: a prospective randomized study

BACKGROUND

There is an association exists between cardiac surgery, performed through median sternotomy, and a considerable postoperative pain.

OBJECTIVES

The aim of the current study is to compare the effects of transversus thoracic muscle plane block (TTMPB) and pecto-intercostal fascial plane block (PIFB) upon postoperative opioid consumption among the patients who underwent open cardiac surgery.

METHODS

The present prospective, randomized, comparative study was conducted among 80 patients who underwent elective on-pump cardiac surgery with sternotomy. The subjects were randomly assigned to two groups with each group containing 40 individuals. For the TTMPB group, bilateral ultrasound-guided TTMPB was adopted in which 20 ml of 0.25% bupivacaine was used on each side. In case of PIFB group, bilateral ultrasound-guided PIFB was adopted with the application of 20 ml of 0.25% bupivacaine on each side. The researchers recorded the first time for rescue analgesia, the overall dosage of rescue analgesia administered in the first 24 h after the operation and the postoperative complications.

RESULTS

The PIFB group took significantly longer time to raise the first request for rescue analgesia (7.8 ± 1.7 h) than the TTMPB group (6.7 ± 1.4 h). Likewise, the PIFB group subjects had a remarkably lower 'overall morphine usage' in the first 24 h after the operation (4.8 ± 1.0 mg) than TTMPB group (7.8 ± 2.0 mg).

CONCLUSION

Bilateral ultrasound-guided PIFB provided a longer time for the first analgesic demand than bilateral ultrasound-guided TTMPB in patients undergoing open cardiac surgery. In addition to this, the PIFB reported less postoperative morphine usage than the TTMPB and increases satisfaction in these patients.

TRIAL REGISTRATION

This study was registered at Clinical Trials.gov on 28/11/2022 (registration number: NCT05627869).

Deep Parasternal Intercostal Plane Block for Postoperative Analgesia After Sternotomy for Cardiac Surgery-A Retrospective Cohort Study

OBJECTIVE

To examine the analgesic efficacy of postoperative deep parasternal intercostal plane (DPIP) blocks for patients having cardiac surgery via median sternotomy.

DESIGN

This single-center retrospective study compared patients receiving bilateral DPIP blocks with a matched cohort of patients not receiving DPIP blocks.

SETTING

Large quaternary referral center.

PARTICIPANTS

Adult patients admitted to the authors' institution from January 1, 2016, to August 14, 2020, for elective cardiac surgery via median sternotomy.

INTERVENTIONS

Patients received ultrasound-guided bilateral DPIP blocks.

MEASUREMENTS AND MAIN RESULTS

A total of 113 patients received a DPIP block; 3,461 patients did not. The estimated multiplicative change in cumulative opioid consumption through 24 hours was 0.42 (95% CI 0.32-0.56; p < 0.001), indicating that patients receiving DPIP blocks required 60% fewer opioids than patients who did not. Proportional odds ratios for the average pain score on postoperative day (POD) 0 was 0.46 (95% CI 0.32-0.65; p < 0.001), and POD 1 was 0.67 (95% CI 0.47-0.94; p = 0.021), indicating lower pain scores for patients receiving blocks. The exploratory analysis identified an inverse correlation between DPIP blocks and atrial fibrillation incidence (2% v 15%; inverse probability of treatment weighting odds ratio 0.088, 95% CI 0.02-0.41; p = 0.002).

CONCLUSIONS

The use of DPIP blocks in patients undergoing cardiac surgery via median sternotomy was associated with less opioid use and improved pain scores in the early postoperative period compared with patients not receiving blocks. Prospective randomized controlled studies should further elucidate the efficacy and risks of DPIP blocks in cardiac surgery.

The effect of pectointercostal fascial block on stress response in open heart surgery

Background

Activation of the hypothalamus-pituitary-adrenal (HPA) axis and inflammatory processes are common forms of stress response. The increased stress response is associated with a higher chance of complications. Open hearth surgery is one of the procedures with a high-stress response. Pectointercostal fascial block (PIFB), as a new pain management option in sternotomy, has the potential to modulate the stress response.

Objective

To determine the effect of PIFB on stress response in open heart surgery.

Methods

This study was a Randomized Controlled Trial on 40 open heart surgery. Patients were divided into two groups, control (20 patients) and PIFB (20 patients). Primary parameters included basal and postoperative TNF-α, basal and post sternotomy ACTH, and basal, 0, and 24 hours postoperative NLR. Secondary parameters include the amount of opioid use, length of the post-operative ventilator, length of ICU stay, and Numeric Rating Scale (NRS) 6, 12, 24, and 48 hours postoperative.

Results

The PIFB group had a decrease in ACTH levels with an average change that was not significantly different from the control group (-57.71 ± 68.03 vs. -129.78 ± 140.98). The PIFB group had an average change in TNFα levels and an average increase in NLR 0 hours postoperative that was not significantly lower than the control group (TNFα: -0.52 ± 1.31 vs. 0.54 ± 1.76; NLR: 12.80 ± 3.51 vs. 14.82 ± 4.23). PIFB significantly reduced the amount of opioid use during surgery, NRS at 6, 12, and 24 hours, and the length of post-operative ventilator use (P < 0.05, CI: 95%).

Conclusion

PIFB has a good role in reducing the stress response of open heart surgery and producing good clinical outcomes.

Which ultrasound-guided parasternal intercostal nerve block for post-sternotomy pain? Results from a prospective observational study

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.

Regional anesthesia for transplantation surgery - A white paper part 1: Thoracic transplantation surgery

Transplantation surgery continues to evolve and improve through advancements in transplant technique and technology. With the increased availability of ultrasound machines as well as the continued development of enhanced recovery after surgery (ERAS) protocols, regional anesthesia has become an essential component of providing analgesia and minimizing opioid use perioperatively. Many centers currently utilize peripheral and neuraxial blocks during transplantation surgery, but these techniques are far from standardized practices. The utilization of these procedures is often dependent on transplantation centers' historical methods and perioperative cultures. To date, no formal guidelines or recommendations exist which address the use of regional anesthesia in transplantation surgery. In response, the Society for the Advancement of Transplant Anesthesia (SATA) identified experts in both transplantation surgery and regional anesthesia to review available literature concerning these topics. The goal of this task force was to provide an overview of these publications to help guide transplantation anesthesiologists in utilizing regional anesthesia. The literature search encompassed most transplantation surgeries currently performed and the multitude of associated regional anesthetic techniques. Outcomes analyzed included analgesic effectiveness of the blocks, reduction in other analgesic modalities-particularly opioid use, improvement in patient hemodynamics, as well as associated complications. The findings summarized in this systemic review support the use of regional anesthesia for postoperative pain control after transplantation surgeries. Part 1 of the manuscript focuses on regional anesthesia performed in thoracic transplantation surgeries, and part 2 in abdominal transplantations.

Effect of superficial and deep parasternal blocks on recovery after cardiac surgery: study protocol for a randomized controlled trial

BACKGROUND

Pain is frequent after cardiac surgery and source of multiple complications that can impair postoperative recovery. Regional anesthesia seems to be an interesting technique to reduce the pain in this context, but its effectiveness in improving recovery has been poorly studied so far. The objective of this study is to compare the effectiveness of two of the most studied chest wall blocks in cardiac surgery, i.e., the superficial and the deep parasternal intercostal plane blocks (SPIP and DPIP respectively), in addition to standard care, versus the standard care without regional anesthesia, on the quality of postoperative recovery (QoR) after cardiac surgery with sternotomy.

METHODS

This is a single-center, single-blind, controlled, randomized trial with a 1:1:1 ratio. Patients (n = 254) undergoing cardiac surgery with sternotomy will be randomized into three groups: a control group with standard care and no regional anesthesia, a SPIP group with standard care and a SPIP, and a DPIP with standard care and a DPIP. All groups will receive the usual analgesic protocol. The primary endpoint is the value of the QoR evaluated by the QoR-15 at 24 h after the surgery.

DISCUSSION

This study will be the first powered trial to compare the SPIP and the DPIP on global postoperative recovery after cardiac surgery with sternotomy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05345639. Registered on April 26, 2022.

Parasternal intercostal plane block catheters for cardiac surgery: a retrospective, propensity weighted, cohort study

Aim: Anesthesia for cardiac surgery has evolved toward fast-track recovery strategies incorporating non opioid analgesics and regional anesthesia. Materials & methods: This retrospective cohort study compared opioid consumption, pain scores and length of stay in patients who underwent cardiac surgery via median sternotomy and did or did not receive preoperative parasternal intercostal plane block catheters with postoperative ropivacaine infusions. Results: Postoperative opioid consumption and postoperative pain scores did not differ. Blocks were associated with decreased intraoperative opioids and reduced length of stay in the intensive care unit and hospital. Conclusion: Parasternal intercostal plane block catheters were not associated with decreased postoperative opioid consumption or pain scores, but were associated with reduced intraoperative opioids and length of stay.

Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2

Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.

Regional anesthesia as part of enhanced recovery strategies in pediatric cardiac surgery

PURPOSE OF REVIEW

The purpose of this review article was to highlight the enhanced recovery protocols in pediatric cardiac surgery, including early extubation, rapid mobilization and recovery, reduction of opioid-related side effects, and length of pediatric ICU and hospital stay, resulting in decreased costs and perioperative morbidity, by introducing recent trends in perioperative anesthesia management combined with peripheral nerve blocks.

RECENT FINDINGS

Efficient postoperative pain relief is essential for realizing enhanced recovery strategies, especially in pediatric patients. It has been reported that approaches to perioperative pain management using additional peripheral nerve blocks ensure early extubation and a shorter duration of ICU and hospital stay. This article provides an overview of several feasible musculofascial plane blocks to achieve fast-track anesthesia management for pediatric cardiac surgery.

SUMMARY

Recent remarkable advances in combined ultrasound techniques have made it possible to perform various peripheral nerve blocks. The major strategy underlying fast-track anesthesia management is to achieve good analgesia while reducing perioperative opioid use. Furthermore, it is important to consider early extubation not only as a competition for time to extubation but also as the culmination of a qualitative improvement in the outcome of treatment for each patient.

Comparison of regional anesthetic techniques for postoperative analgesia after adult cardiac surgery: bayesian network meta-analysis

Background

Patients usually suffer acute pain after cardiac surgery. Numerous regional anesthetic techniques have been used for those patients under general anesthesia. The most effective regional anesthetic technique was still unclear.

Methods

Five databases were searched, including PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library. The efficiency outcomes were pain scores, cumulative morphine consumption, and the need for rescue analgesia in this Bayesian analysis. Postoperative nausea, vomiting and pruritus were safety outcomes. Functional outcomes included the time to tracheal extubation, ICU stay, hospital stay, and mortality.

Results

This meta-analysis included 65 randomized controlled trials involving 5,013 patients. Eight regional anesthetic techniques were involved, including thoracic epidural analgesia (TEA), erector spinae plane block, and transversus thoracic muscle plane block. Compared to controls (who have not received regional anesthetic techniques), TEA reduced the pain scores at 6, 12, 24 and 48 h both at rest and cough, decreased the rate of need for rescue analgesia (OR = 0.10, 95% CI: 0.016-0.55), shortened the time to tracheal extubation (MD = -181.55, 95% CI: -243.05 to -121.33) and the duration of hospital stay (MD = -0.73, 95% CI: -1.22 to -0.24). Erector spinae plane block reduced the pain score 6 h at rest and the risk of pruritus, shortened the duration of ICU stay compared to controls. Transversus thoracic muscle plane block reduced the pain scores 6 and 12 h at rest compared to controls. The cumulative morphine consumption of each technique was similar at 24, 48 h. Other outcomes were also similar among these regional anesthetic techniques.

Conclusions

TEA seems the most effective regional postoperative anesthesia for patients after cardiac surgery by reducing the pain scores and decreasing the rate of need for rescue analgesia.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, ID: CRD42021276645.

Comparison of transversus thoracis muscle plane block and pecto-intercostal fascial plane block for enhanced recovery after pediatric open-heart surgery

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.

Effect of transverse thoracic muscle plane block on postoperative cognitive dysfunction after open cardiac surgery: A randomized clinical trial

The transversus thoracis muscle plane (TTMP) block provides effective analgesia in cardiac surgery patients. The aim of this study was to assess whether bilateral TTMP blocks can reduce the incidence of postoperative cognitive dysfunction (POCD) in patients undergoing cardiac valve replacement. A group of 103 patients were randomly divided into the TTM group (n = 52) and the PLA (placebo) group (n = 51). The primary endpoint was the incidence of POCD at 1 week after surgery. Secondary outcome measures included a reduction of intraoperative mean arterial pressure (MAP) >20% from baseline, intraoperative and postoperative sufentanil consumption, length of stay in the ICU, incidence of postoperative nausea and vomiting (PONV), time to first faeces, postoperative pain at 24 h after surgery, time to extubation and the length of hospital stay. Interleukin (IL)-6, TNF-α, S-100β, insulin, glucose and insulin resistance were measured at before induction of anaesthesia, 1, 3and 7 days after surgery. The MoCA scores were significantly lower and the incidence of POCD decreased significantly in TTM group compared with PLA group at 7 days after surgery. Perioperative sufentanil consumption, the incidence of PONV and intraoperative MAP reduction >20% from baseline, length of stay in the ICU, postoperative pain at 24 h after surgery, time to extubation and the length of hospital stay were significantly decreased in the TTM group. Postoperatively, IL-6, TNF-α, S-100β, HOMA-IR, insulin, glucose levels increased and the TTM group had a lower degree than the PLA group at 1, 3 and 7 days after surgery. In summary, bilateral TTMP blocks could improve postoperative cognitive function in patients undergoing cardiac valve replacement.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Retrospective Evaluation of Fascial Plane Blocks in Cardiac Surgery With Median Sternotomy in a Tertiary Hospital

BACKGROUND AND AIM

Cardiac surgery typically causes moderate to severe postoperative pain and discomfort. Inadequate pain management in the early postoperative period leads to pulmonary complications. The length of intensive care unit (ICU) stay and the hospital is typically prolonged. As a component of multimodal analgesia regimens, fascial plane blocks have become more popular. In our clinic, serratus anterior plane blocks (SAPB), pectoral nerve blocks (PECS I-II), and pectointercostal nerve fascial plane blocks (PIFB) are performed by ultrasonography. We wished to evaluate the postoperative visual pain scale, initial additional analgesic agent requirement time, extubation time, morbidity and mortality in patients who underwent open heart surgery with fascial plane blocks.

MATERIALS AND METHODS

Forty-eight patients over 18 years who underwent open heart surgery with sternotomy between 01 September 2021 and 15 June 2022 were evaluated retrospectively. Only patients with chest wall blocks placed at the end of surgery were included in the study. In Group 1, the PECS II block was placed on the chest tube side and bilateral PIFBs were placed at the end of surgery in the operating room. In Group 2, SAPB was placed on the chest tube side and bilateral PIFBs were placed at the end of surgery. Data regarding patient demographics, anesthesia method applied, amount of opioid used intraoperatively, cardiopulmonary bypass time, anesthesia and surgery time, postoperative extubation time, mechanical ventilation time, Visual Analogue Scale (VAS) of patients at rest and movement at 6th, 12th, 18th, 24th, 48th hours post-extubation, time to and type of first postoperative analgesic, postoperative complications, length of cardiac intensive care unit (CICU) stay and hospital length of stay were recorded from hospital records.

RESULTS

 The data of a total of 46 patients (Group 1: PECS II block + PIFB, n=20; Group 2: SAPB+ PIFB, n=26) were analyzed retrospectively. There was no difference in demographic variables between the groups. Intraoperative opioid usage, operation time, Cardiopulmonary bypass time, postoperative mechanical ventilation time, extubation time, ICU discharge time, and length of hospital stay were not statistically different between the groups. The first rescue analgesic requirement time was longer in group 2 than in group 1 but not statistically significant (18.76±15.36 h vs 12.62±10.61 h, p=0.162). The post-extubation VAS scores at rest and movement at the 6th hour were significantly lower in group 2 than in group 1 (1.73±1.28 vs 3.15±2.10, respectively, p=0.02).

CONCLUSION

In our study, the VAS scores at the 6th hour were lower in SAPB + PIFB group than in PECS II + PIFB group. As these blocks can be easy to apply, we thought these combinations could be an alternative for pain relief in cardiac surgery. Prospective randomized studies are needed with a large number of patients.

An Expert Review of Chest Wall Fascial Plane Blocks for Cardiac Surgery

The recent integration of regional anesthesia techniques into the cardiac surgical patient population has become a component of enhanced recovery after cardiac surgery pathways. Fascial planes of the chest wall enable single-injection or catheter-based infusions to spread local anesthetic over multiple levels of innervation. Although median sternotomy remains a common approach to cardiac surgery, minimally invasive techniques have integrated additional methods of performing cardiac surgery. Understanding the surgical approach and chest wall innervation is crucial to success in choosing the appropriate chest wall block. Parasternal intercostal plane techniques (previously termed "pectointercostal fascial plane" and "transversus thoracic muscle plane") provide anterior chest and ipsilateral sternal coverage. Anterolateral chest wall coverage is feasible with the interpectoral plane and pectoserratus plane blocks (previously termed "pectoralis") and superficial and deep serratus anterior plane blocks. The erector spinae plane block provides extensive coverage of the ipsilateral chest wall. Any of these techniques has the potential to provide bilateral chest wall analgesia. The relative novelty of these techniques requires ongoing research to be strategic, thoughtful, and focused on clinically meaningful outcomes to enable widespread evidence-based implementation. This review article discusses the key perspectives for performing and assessing chest wall blocks in a cardiac surgical population.

Effect of pecto-intercostal fascial block on extubation time in patients undergoing cardiac surgery: A randomized controlled trial

Objectives

Epidural and paravertebral block reduce the extubation time in patients undergoing surgery under general anesthesia but are relatively contraindicated in heparinized patients due to the potential risk of hematoma. The Pecto-intercostal fascial block (PIFB) is an alternative in such patients.

Methods

This is a single-center randomized controlled trial. Patients scheduled for elective open cardiac surgery were randomized at a 1:1 ratio to receive PIFB (30 ml 0.3% ropivacaine plus 2.5 mg dexamethasone on each side) or saline (30 ml normal saline on each side) after induction of general anesthesia. The primary outcome was extubation time after surgery. Secondary outcomes included opioid consumption during surgery, postoperative pain scores, adverse events related to opioids, and length of stay in the hospital.

Results

A total of 50 patients (mean age: 61.8 years; 34 men) were randomized (25 in each group). The surgeries included sole coronary artery bypass grafting in 38 patients, sole valve surgery in three patients, and both procedures in the remaining nine patients. Cardiopulmonary bypass was used in 20 (40%) patients. The time to extubation was 9.4 ± 4.1 h in the PIFB group vs. 12.1 ± 4.6 h in the control group (p = 0.031). Opioid (sufentanil) consumption during surgery was 153.2 ± 48.3 and 199.4 ± 51.7 μg, respectively (p = 0.002). In comparison to the control group, the PIFB group had a lower pain score while coughing (1.45 ± 1.43 vs. 3.00 ± 1.71, p = 0.021) and a similar pain score at rest at 12 h after surgery. The two groups did not differ in the rate of adverse events.

Conclusions

PIFB decreased the time to extubation in patients undergoing cardiac surgery.

Trial Registration

This trial is registered at the Chinese Clinical Trial Registry (ChiCTR2100052743) on November 4, 2021.

Effects of ultrasound-guided regional anesthesia in cardiac surgery: a systematic review and network meta-analysis

BACKGROUND

The objective of this systematic review and network meta-analysis was to compare the effects of single-shot ultrasound-guided regional anesthesia techniques on postoperative opioid consumption in patients undergoing open cardiac surgery.

METHODS

This systematic review and network meta-analysis involved cardiac surgical patients (age > 18 y) requiring median sternotomy. We searched PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science. The effects of the single-shot ultrasound-guided regional anesthesia technique were compared with those of placebo and no intervention. We conducted a risk assessment of bias for eligible studies and assessed the overall quality of evidence for each outcome.

RESULTS

The primary outcome was opioid consumption during the first 24 h after surgery. The secondary outcomes were pain after extubation at 12 and 24 h, postoperative nausea and vomiting, extubation time, intensive care unit discharge time, and length of hospital stay. Fifteen studies with 849 patients were included. The regional anesthesia techniques included pecto-intercostal fascial block, transversus thoracis muscle plane block, erector spinae plane (ESP) block, and pectoralis nerve block I. All the regional anesthesia techniques included significantly reduced postoperative opioid consumption at 24 h, expressed as morphine milligram equivalents (MME). The ESP block was the most effective treatment (-22.93 MME [-34.29;-11.56]).

CONCLUSIONS

In this meta-analysis, we concluded that fascial plane blocks were better than placebo when evaluating 24 h MMEs. However, it is still challenging to determine which is better, given the paucity of studies available in the literature. More randomized controlled trials are required to determine which regional anesthesia technique is better.

TRIAL REGISTRATION

PROSPERO; CRD42022315497.

Analgesic Effects of a Novel Combination of Regional Anesthesia After Pediatric Cardiac Surgery: A Retrospective Cohort Study

OBJECTIVE

The objective of this study was to determine whether the use of regional anesthesia in children undergoing congenital heart surgery was associated with differences in outcomes when compared to surgeon-delivered local anesthetic wound infiltration.

DESIGN

A retrospective cohort study.

SETTING

At a single pediatric tertiary care center.

PARTICIPANTS

Pediatric patients who underwent primary repair of septal defects between January 1, 2018, and March 31, 2022.

INTERVENTIONS

The patients were grouped by whether they received surgeon-delivered local anesthetic wound infiltration or bilateral pectointercostal fascial blocks (PIFBs) and a unilateral rectus sheath block (RSB) on the side ipsilateral to the chest tube.

MEASUREMENTS AND MAIN RESULTS

Using overlap propensity score-weighted models, the authors examined postoperative opioid requirements (morphine milliequivalents per kilogram), pain scores, length of stay, and time under general anesthesia (GA). Eighty-nine patients were eligible for inclusion and underwent analysis. In the first 12 hours postoperatively, the block group used fewer morphine equivalents per kilogram versus the infiltration group, 0.27 ± 0.2 v 0.64 ± 0.42, with a weighted estimated decrease of 0.39 morphine equivalents per kilogram (95% CI -0.52 to -0.25; p < 0.001), and had lower pain scores, 3.2 v 1.6, with a weighted estimated decrease of 1.7 (95% CI -2.3 to -1.1; p < 0.001). The length of stay and time under GA also were shorter in the block group with weighted estimated decreases of 22 hours (95% CI -33 to -11; p = 0.001) and 18 minutes (95% CI -34 to -2; p = 0.03), respectively.

CONCLUSIONS

Bilateral PIFBs and a unilateral RSB on the side ipsilateral to the chest tube is a novel analgesic technique for sternotomy in pediatric patients. In this retrospective study, these interventions were associated with decreases in postoperative opioid use, pain scores, and hospital length of stay without prolonging time under GA.

Parasternal Intercostal Nerve Blocks in Patients Undergoing Cardiac Surgery: Evidence Update and Technical Considerations

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.

Regional Pain Blocks and Perioperative Pain Control in Patients Undergoing Breast Implant Removal With Capsulectomy

Background

Demand for breast implant removal is on the rise, with more than 36,000 explants performed in 2020, an increase of 7.5% from previous years. Postoperative (PO) analgesia is an important consideration in this patient group due to scar tissue surrounding the implant and the potential for extensive dissection during capsulectomy.

Objectives

The authors sought to compare perioperative pain control between three different types of ultrasound (US)-guided regional anesthetic techniques in patients undergoing implant removal with capsulectomy.

Methods

The authors reviewed all patients who received an US-guided block and underwent breast implant removal with capsulectomy at their outpatient surgical center over a 2-year period. They compared intraoperative (IO), PO opioid requirement, and patient-reported pain on the first postoperative day (POD1) between 3 different block techniques using chi-square analysis. A P-value of <.05 was considered statistically significant.

Results

A total of 352 patients were included. Twenty-six patients (7.4%) underwent a serratus plane (SP) block, 13 (3.7%) underwent an erector spinae combined with pectointercostal fascial plane (ES + PIFP) block, and 313 (88.9%) underwent an erector spinae combined with pectoral nerve (ES + PECS1) block. ES + PECS1 was associated with less IO and PO opioid use compared with SP and ES + PIFP (1.9% vs 19.2% vs 61.5%, P < .001 for IO, 26.8% vs 34.6% vs 38.5% PO, P < .001). The ES + PECS1 block was associated with mild pain on POD1 compared with the other 2 regional block techniques (P = .001).

Conclusions

Regional pain blocks, and specifically the ES block, offer effective pain control for patients undergoing breast implant removal with capsulectomy, demonstrating high patient satisfaction in the PO period with low opioid requirements.

Level of Evidence 3

Regional analgesia for cardiac surgery

PURPOSE OF REVIEW

Regional anesthesia is gaining attention as a valuable component of multimodal, opioid-sparing analgesia in cardiac surgery, where improving the patient's quality of recovery while minimizing the harms of opioid administration are key points of emphasis in perioperative care. This review serves as an outline of recent advancements in a variety of applications of regional analgesia for cardiac surgery.

RECENT FINDINGS

Growing interest in regional analgesia, particularly the use of newer "chest wall blocks", has led to accumulating evidence for the efficacy of multiple regional techniques in cardiac surgery. These include a variety of technical approaches, with results consistently demonstrating optimized pain control and reduced opioid requirements. Regional and pain management experts have worked to derive consensus around nerve block nomenclature, which will be foundational to establish best practice, design and report future research consistently, improve medical education, and generally advance our knowledge in this vital area of perioperative patient care.

SUMMARY

The field of regional analgesia for cardiac surgery has matured over the last several years. A variety of regional techniques have been described and shown to be efficacious as part of the multimodal, opioid-sparing approach to pain management in the cardiac surgical setting.

Efficacy of ultrasound-guided parasternal block in adult cardiac surgery: a meta-analysis of randomized controlled trials

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.

Evaluation of ultrasound-guided pecto-intercostal block in canine cadavers

OBJECTIVE

To describe the technique for performing an ultrasound-guided pecto-intercostal fascial (PIF) block and compare two volumes of injectate in canine cadavers.

STUDY DESIGN

Prospective experimental cadaveric study.

ANIMALS

A total of 11 canine cadavers (11.8 ± 1.9 kg).

METHODS

Parasternal ultrasound-guided injections were performed within the PIF plane, between the deep pectoral and external intercostal muscles, at the intercostal space between ribs four and five. Each hemithorax was injected with 0.25 mL kg-1 (treatment low volume, LV) or 0.5 mL kg-1 (treatment high volume, HV) of 1% methylene blue dye. Treatments were randomly assigned to either right or left hemithorax, with each cadaver injected with both treatments, for a total of 22 injections. Anatomical dissections were performed to determine staining of ventral cutaneous branches of intercostal nerves, surrounding nerves and musculature and spread of injectate. The presence or absence of intrathoracic puncture was also noted.

RESULTS

The PIF plane was identified and injected in each hemithorax. No significant differences between treatments LV and HV were found for number of ventral cutaneous nerve branches stained or any other analyzed variable. The ventral cutaneous branches of intercostal nerves (T3-T8) were variably stained, and the most commonly stained nerves were T5 (6 and 10), T6 (8 and 9) and T7 (2 and 7) in treatments LV and HV, respectively. Staining outside the immediate parasternal region was noted in both treatments, with greater spread away from the parasternal region in treatment HV. No intrathoracic staining was found.

CONCLUSIONS AND CLINICAL RELEVANCE

Ultrasound-guided PIF injections resulted in staining of ventral cutaneous branches and parasternal musculature; however, the spread observed was inadequate to provide effective analgesia to the sternum. In vivo studies are warranted to investigate this regional anesthetic technique in veterinary patients.

The Analgesic Effect of Ultrasound-guided Bilateral Pectointercostal Fascial Plane Block on Sternal Wound Pain After Open Heart Surgeries: A Randomized Controlled Study

OBJECTIVES

We aimed to evaluate the analgesic efficacy of ultrasound-guided bilateral pectointercostal fascial plane block after open heart surgeries.

METHODS

Seventy patients aged above 18 years and scheduled for on-pump coronary artery bypass grafting or valve replacement or both through median sternotomy were enrolled in this study. Patients were randomly allocated into 2 groups of 35 (block group or control group). The block group had the block performed through 20 ml of a solution of 0.25% bupivacaine plus epinephrine (5 mcg/mL), and the control group received dry needling. The primary outcome was the 24-hour cumulative morphine consumption. The secondary outcomes were time to the first analgesic request, pain score, quality of oxygenation, intensive care unit stays, and hospital stay.

RESULTS

The cumulative morphine consumption in the first 24 hours was significantly lower in the block group, with a mean difference of -3.54 (95% confidence interval=-6.55 to -0.53; P=0.015). In addition, the median estimate time to the first analgesic request was significantly longer in the block group than in the control group. Finally, during the postoperative period (4 to 24 h), mean sternal wound objective pain scores were, on average, 0.58 units higher in the block group.

CONCLUSION

pectointercostal fascial block is an effective technique in reducing morphine consumption and controlling poststernotomy pain after cardiac surgeries. Also, it may have a role in better postoperative respiratory outcomes.

Comparison of Ultrasound-Guided Pectointercostal Fascial Block and Transversus Thoracic Muscle Plane Block for Acute Poststernotomy Pain Management After Cardiac Surgery: A Prospective, Randomized, Double-Blind Pilot Study

OBJECTIVE

The objective of the present study was to evaluate morphine consumption and pain scores 24 hours postoperatively to compare the effects of a bilateral pectointercostal fascial block (PIFB) with those of a transversus thoracic muscle plane block (TTMPB) on acute poststernotomy pain in cardiac surgery patients who have undergone median sternotomy.

DESIGN

Prospective, randomized, double-blinded.

SETTING

The operating room, intensive care unit, and patient ward at a university hospital.

PARTICIPANTS

Thirty-nine American Society of Anesthesiologists II-to-III patients aged 18- to-80 years, scheduled for elective cardiac surgery via median sternotomy.

INTERVENTIONS

Patients randomly were allocated to groups scheduled to receive bilateral ultrasound-guided PIFB or TTMPB.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was postoperative morphine use within the first 24 hours. Secondary outcomes were the numerical pain rating scale (NRS) scores at rest and during coughing, time of first analgesic demand from the patient-controlled analgesia (PCA) device, and rescue analgesia use. The nausea/vomiting scores, time to extubation, length of stays in intensive care and the hospital, patient satisfaction scores, and complications were also recorded. The first 24-hour morphine use did not significantly differ between the PIFB and TTMPB groups (mean ± standard deviation [95% CI], 13.89 ± 6.80 [10.83-16.95] mg/24 h and 15.08 ± 7.42 [11.83-18.33] mg/24 h, respectively, p = 0.608). No significant difference between the two groups in the NRS scores at rest and during coughing was observed; the groups had similar requirements for rescue analgesia in the first 24 hours (n [%], three [15.8] and seven [35], p = 0.273, respectively). The time from PCA to the first analgesia request was longer in the PIFB than in the TTMPB group (median [interquartile range], 660 [540-900] minutes, and 240 [161-525] minutes, respectively, p = 0.002).

CONCLUSIONS

PIFB and TTMPB showed similar effectiveness for morphine consumption within 24 hours postoperatively and in pain scores in cardiac surgery patients.