A case series of continuous paravertebral block in minimally invasive cardiac surgery

Local anesthetic dosing and toxicity of adult truncal catheters: a narrative review of published practice

BACKGROUND/IMPORTANCE

Anesthesiologists frequently use truncal catheters for postoperative pain control but with limited characterization of dosing and toxicity.

OBJECTIVE

We reviewed the published literature to characterize local anesthetic dosing and toxicity of paravertebral and transversus abdominis plane catheters in adults.

EVIDENCE REVIEW

We searched the literature for bupivacaine or ropivacaine infusions in the paravertebral or transversus abdominis space in humans dosed for 24 hours. We evaluated bolus dosing, infusion dosing and cumulative 24-hour dosing in adults. We also identified cases of local anesthetic systemic toxicity and toxic blood levels.

FINDINGS

Following screening, we extracted data from 121 and 108 papers for ropivacaine and bupivacaine respectively with a total of 6802 patients. For ropivacaine and bupivacaine, respectively, bolus dose was 1.4 mg/kg (95% CI 0.4 to 3.0, n=2978) and 1.0 mg/kg (95% CI 0.18 to 2.1, n=2724); infusion dose was 0.26 mg/kg/hour (95% CI 0.06 to 0.63, n=3579) and 0.2 mg/kg/hour (95% CI 0.06 to 0.5, n=3199); 24-hour dose was 7.75 mg/kg (95% CI 2.1 to 15.7, n=3579) and 6.0 mg/kg (95% CI 2.1 to 13.6, n=3223). Twenty-four hour doses exceeded the package insert recommended upper limit in 28% (range: 17%-40% based on maximum and minimum patient weights) of ropivacaine infusions and 51% (range: 45%-71%) of bupivacaine infusions. Toxicity occurred in 30 patients and was associated with high 24-hour dose, bilateral catheters, cardiac surgery, cytochrome P-450 inhibitors and hypoalbuminemia.

CONCLUSION

Practitioners frequently administer ropivacaine and bupivacaine above the package insert limits, at doses associated with toxicity. Patient safety would benefit from more specific recommendations to limit excessive dose and risk of toxicity.

The safety of thoracic paravertebral block and erector spinae plane block in patients treated with anticoagulant or antiplatelet therapy. A narrative review of the evidence

INTRODUCTION

The management of thoracic paravertebral block (TPVB) and erector spine plane block (ESPB) in patients treated with anticoagulant or antiplatelet therapy is based on limited clinical data, mostly from single case reports. Scientific societies and organizations do not provide strong detailed indications about the limitations of these regional anesthesia techniques in patients receiving antithrombotic therapy. This review summarizes evidence regarding TPVB and ESPB in patients under antithrombotic therapy.

EVIDENCE ACQUSITION

A literature review from PubMed/MEDLINE, EMBASE, Cochrane, Google Scholar and Web of Science databases was conducted from 1999 to 2022 to identify articles concerning TPVB and ESPB for cardio-thoracic surgery or thoracic procedures in patients under anticoagulant or antiplatelet therapy.

EVIDENCE SYNTHESIS

A total of 1704 articles were identified from the initial search. After removing duplicates and not-pertinent articles, 15 articles were analyzed. The results demonstrated a low risk of bleeding for TPVB and minimal or absent risk for ESPB. Ultrasound guidance was extensively used to perform ESPB, but not for TPVB.

CONCLUSIONS

Although the low level of evidence available, TPVB and ESPB are reasonably safe options in patients ineligible for epidural anesthesia due to antithrombotic therapy. The few published studies suggest that ESPB offers a risk profile safer than TPVB and the use of ultrasound guidance minimizes any complication. Since the literature available does not allow us to draw definitive conclusions, future adequately-powered trials are warranted to determine the indications and the safety of TPVB and ESPB in patients receiving anticoagulant or antiplatelet therapy.

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 techniques for cardiac surgery: where are we?

PURPOSE OF REVIEW

Inadequate pain relief after cardiac surgery results in decreased patient experience and satisfaction, increased opioid consumption with its associated adverse consequences, and reduced efficiency metrics. To mitigate this, regional analgesic techniques are an increasingly important part of the perioperative cardiac anesthesia care plan. The purpose of this review is to compare current regional anesthesia techniques, and the relative evidence supporting their efficacy and safety in cardiac surgery.

RECENT FINDINGS

Numerous novel plane blocks have been developed in recent years, with evidence of improved pain control after cardiac surgery.

SUMMARY

The current data supports the use of a variety of different regional anesthesia techniques to reduce acute pain after cardiac surgery. However, future randomized trials are needed to quantify and compare the efficacy and safety of different regional techniques for pain control after cardiac surgery.

Optimal Management of Patients Treated With Minimally Invasive Cardiac Surgery in the Era of Enhanced Recovery After Surgery and Fast-Track Protocols: A Narrative Review

OBJECTIVES

Use of minimally invasive cardiac surgery (MICS) is increasing, but to exert its maximum effect on patient outcomes, MICS must be coupled with improved perioperative management, including the Enhanced Recovery after Surgery (ERAS) and fast-track protocols. This study aimed to evaluate the impact of ERAS and fast track in this context.

DESIGN

NARRATIVE REVIEW: The authors performed a narrative review that included patients treated with MICS and patients treated with the ERAS/fast-track protocols in the MEDLINE/PubMed database. The keywords ERAS and fast-track were combined with the following key words: minimally invasive cardiac surgery OR robotic cardiac surgery OR minimally invasive mitral surgery OR minimally invasive aortic surgery.

RESULTS

Overall, the authors selected six studies in which either the ERAS or fast-track protocol was applied. The reported adherence to ERAS protocols was high, and neither protocol-related complications nor in-hospital mortality occurred. Patients managed based on ERAS had significantly lower postoperative pain scores, fewer rates of blood transfusions, and shorter hospital and intensive care unit stays compared with those who received standard management. All ERAS patients were managed safely, with early extubation. Similarly, fast-track cardiac surgery, with immediate postprocedure extubation and early transfer to the ward, was shown to be safe, with no increased morbidity or mortality.

CONCLUSION

Use of standardized ERAS and fast-track protocols seems to be feasible and safe in the context of MICS, with improved outcomes. Both ERAS and fast track allow for a faster return to full functional status while minimizing perioperative complications.

Efficacy of paravertebral block in "Fast-tracking" pediatric cardiac surgery - Experiences from a tertiary care center

Introduction:

Fast tracking plays a crucial role in reducing perioperative morbidity and financial burden by facilitating early extubation and discharge from hospital. Paravertebral block (PVB) is becoming more popular in paediatric surgeries as an alternative to epidural and caudal analgesia. There is scarcity of data regarding the efficacy and safety of PVB in paediatric cardiac surgery.

Methods:

We performed a review of records of paediatric cardiac patients who underwent cardiac surgery under general anaesthesia with single shot PVB and compared the analgesia and postoperative outcomes with matched historical controls who underwent cardiac surgery with same anaesthesia protocol without PVB.

Results:

The data from 200 children were analysed. 100 children who received paravertebral block were compared with a matched historical controls. The median time to extubation was shorter in the PVB group (0 hr, IQR 0-3 hrs) compared to the control group (16 hrs, IQR 4-20 hrs) (P value 0.017*). Intraoperative and postoperative fentanyl requirement was much lower in the PVB group (3.49 (0.91)) compared to the control group (9.86 (1.37)) P value <0.01*. Time to first rescue dose of analgesic was longer (7 hrs vs 5 hrs, P 0.01*), while time to extubation and duration of ICU stay were significantly less in PVB group . Mean postoperative pain scores were significantly lower in the PVB group at the time of ICU admission (0.85 vs 3.12, P 0.001*) till 4 hours (2.11 vs 3.32, P 0.001*).

Conclusion:

PVB provides an effective and safe anaesthetic approach which can form an important component of “fast-track” care in paediatric cardiac surgery.

Postoperative pain treatment with erector spinae plane block and pectoralis nerve blocks in patients undergoing mitral/tricuspid valve repair - a randomized controlled trial

BACKGROUND

Effective postoperative pain control remains a challenge for patients undergoing cardiac surgery. Novel regional blocks may improve pain management for such patients and can shorten their length of stay in the hospital. To compare postoperative pain intensity in patients undergoing cardiac surgery with either erector spinae plane (ESP) block or combined ESP and pectoralis nerve (PECS) blocks.

METHODS

This was a prospective, randomized, controlled, double-blinded study done in a tertiary hospital. Thirty patients undergoing mitral/tricuspid valve repair via mini-thoracotomy were included. Patients were randomly allocated to one of two groups: ESP or PECS + ESP group (1:1 randomization). Patients in both groups received a single-shot, ultrasound-guided ESP block. Participants in PECS + ESP group received additional PECS blocks. Each patient had to be extubated within 2 h from the end of the surgery. Pain was treated via a patient-controlled analgesia (PCA) pump. The primary outcome was the total oxycodone consumption via PCA during the first postoperative day. The secondary outcomes included pain intensity measured on the visual analog scale (VAS), patient satisfaction, Prince Henry Hospital Pain Score (PHHPS), and spirometry.

RESULTS

Patients in the PECS + ESP group used significantly less oxycodone than those in the ESP group: median 12 [interquartile range (IQR): 6-16] mg vs. 20 [IQR: 18-29] mg (p = 0.0004). Moreover, pain intensity was significantly lower in the PECS + ESP group at each of the five measurements during the first postoperative day. Patients in the PECS + ESP group were more satisfied with pain management. No difference was noticed between both groups in PHHPS and spirometry.

CONCLUSIONS

The addition of PECS blocks to ESP reduced consumption of oxycodone via PCA, reduced pain intensity on the VAS, and increased patient satisfaction with pain management in patients undergoing mitral/tricuspid valve repair via mini-thoracotomy.

TRIAL REGISTRATION

The study was registered on the 19th July 2018 (first posted) on the ClinicalTrials.gov identifier: NCT03592485.

Regional anesthesia for cardiac surgery

PURPOSE OF REVIEW

Anesthesia for cardiac surgery has traditionally utilized high-dose opioids to blunt the sympathetic response to surgery. However, recent data suggest that opioids prolong postoperative intubation, leading to increased morbidity. Given the increased risk of opioid dependency after in-hospital exposure to opioids, coupled with an increase in morbidity, regional techniques offer an adjunct for perioperative analgesia. The aim of this review is to describe conventional and emerging regional techniques for cardiac surgery.

RECENT FINDINGS

Well-studied techniques such as thoracic epidurals and paravertebral blocks are relatively low risk despite lack of widespread adoption. Benefits include reduced opioid exposure after paravertebral blocks and reduced risk of perioperative myocardial infarction after epidurals. To further lower the risk of epidural hematoma and pneumothorax, new regional techniques have been studied, including parasternal, pectoral, and erector spinae plane blocks. Because these are superficial compared with paravertebral and epidural blocks, they may have even lower risks of hematoma formation, whereas patients are anticoagulated on cardiopulmonary bypass. Efficacy data have been promising, although large and generalizable studies are lacking.

SUMMARY

New regional techniques for cardiac surgery may be potent perioperative analgesic adjuncts, but well-designed studies are needed to quantify the effectiveness and safety of these blocks.