Parasternal Block and Local Anesthetic Infiltration with Levobupivacaine After Cardiac Surgery with Desflurane: The Effect on Postoperative Pain, Pulmonary Function, and Tracheal Extubation Times

The analgesic effects of combined bilateral parasternal block and serratus anterior plane block for coronary artery bypass grafting surgery

BACKGROUND

Severe pain occurs after cardiac surgery in the sternum and chest tubes sites. Although analgesia targeting the sternum is often prioritized, the analgesia of the drain site is sometimes overlooked. This study of patients undergoing coronary artery bypass grafting (CABG) aimed to provide optimized analgesia for both the sternum and the chest tubes area by combining parasternal block (PSB) and serratus anterior plane block (SAPB).

METHODS

Ethics committee approval (E.Kurul-E2-24-6176, 07/02/2024) was received for the study. Then, the trial was registered on www.

CLINICALTRIALS

gov ( https://clinicaltrials.gov/ ) under the identifier NCT05427955 on 17/03/2024. Twenty patients between the ages of 18-80, with ASA physical status classification II-III, undergoing coronary artery bypass grafting CABG with sternotomy, were included. While the patients were under general anesthesia, PSB was performed through the second and fourth intercostal spaces, and SAPB was performed over the sixth rib. The primary outcome was VAS (Visual Analog Scale) during the first 12 h after extubation. The secondary outcomes were intraoperative remifentanil consumption and block-related side effects.

RESULTS

The average age of the patients was 64 years. Five patients were female, and 15 were male. For the sternum area, only one patient had resting VAS scores of 4, while the VAS scores for resting for the other patients were below 4. For chest tubes area, only two patients had resting VAS scores of 4 or above, while the resting VAS scores for the other patients were below 4. The patients' intraoperative remifentanil consumption averaged 2.05 mg. No side effects related to analgesic protocol were observed in any of the patients.

CONCLUSIONS

In this preliminary study where PSB and SAPB were combined in patients undergoing CABG, effective analgesia was achieved for the sternum and chest tubes area.

The impact of magnesium on shivering incidence in cardiac surgery patients: A systematic review

Background and objective

This scientific review involves a sequential analysis of randomized trial research focused on the incidence of shivering in patients undergoing cardiac surgery. The study conducted a comprehensive search of different databases, up to the end of 2020. Only randomized trials comparing magnesium administration with either placebo or no treatment in patients expected to experience shivering were included. The primary objective was to evaluate shivering occurrence, distinguishing between patients receiving general anesthesia and those not. Secondary outcomes included serum magnesium concentrations, intubation time, post-anesthesia care unit stay, hospitalization duration, and side effects. Data collection included patient demographics and various factors related to magnesium administration.

Material and methods

This scientific review analyzed 64 clinical trials meeting inclusion criteria, encompassing a total of 4303 patients. Magnesium was administered via different routes, primarily intravenous, epidural, and intraperitoneal, and compared against placebo or control. Data included demographics, magnesium dosage, administration method, and outcomes. Heterogeneity was assessed using the I2 statistic. Some studies were excluded due to unavailability of data or non-responsiveness from authors.

Result

and discussion: Out of 2546 initially identified articles, 64 trials were selected for analysis. IV magnesium effectively reduced shivering, with epidural and intraperitoneal routes showing even greater efficacy. IV magnesium demonstrated cost-effectiveness and a favorable safety profile, not increasing adverse effects. The exact dose-response relationship of magnesium remains unclear. The results also indicated no significant impact on sedation, extubation time, or gastrointestinal distress. However, further research is needed to determine the optimal magnesium dose and to explore its potential effects on blood pressure and heart rate, particularly regarding pruritus prevention.

Conclusion

This study highlights the efficacy of intravenous (IV) magnesium in preventing shivering after cardiac surgery. Both epidural and intraperitoneal routes have shown promising results. The safety profile of magnesium administration appears favorable, as it reduces the incidence of shivering without significantly increasing costs. However, further investigation is required to establish the ideal magnesium dosage and explore its potential effects on blood pressure, heart rate, and pruritus prevention, especially in various patient groups.

The Medipol Combination: Novel Rectointercostal Fascial Plane Block and Pectointercostal Fascial Plane Block for Postoperative Analgesia Management After Cardiac Surgery: A Report of 15 Cases

The parasternal blocks cannot cover the T7 and lower anterior and lateral branches of the thoracoabdominal nerves. In the open heart surgeries, chest drainage tubes are generally outside the target of the parasternal blocks. Recently, Tulgar et al described a novel interfascial plane block technique named "recto-intercostal fascial plane block" (RIFPB). RIFPB is performed between the rectus abdominis muscle and the sixth to seventh costal cartilages. RIFPB targets the anterior and lateral cutaneous branches of the T6-T9 thoracoabdominal nerves. In this clinical report, we want to share our experiences about pectointercostal plane block and RIFPB combination (Medipol Combination) after cardiac surgery.

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.

Peripheral Regional Anesthetic Techniques in Cardiac Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this systematic review was to investigate postoperative pain outcomes and adverse events after peripheral regional anesthesia (PRA) compared to no regional anesthesia (RA), placebo, or neuraxial anesthesia in children and adults undergoing cardiac surgery.

DESIGN

A systematic review and meta-analysis with an assessment of the risk of bias (Cochrane RoB 1) and certainty of evidence (Grading of Recommendations, Assessment, Development, and Evaluation).

SETTING

Randomized controlled trials (RCTs).

PARTICIPANTS

Adults and children undergoing heart surgery.

INTERVENTIONS

Any kind of PRA compared to no RA or placebo or neuraxial anesthesia.

MEASUREMENTS AND MAIN RESULTS

In total, 33 RCTs (2,044 patients) were included-24 of these had a high risk of bias, and 28 were performed in adults. Compared to no RA, PRA may reduce pain intensity at rest 24 hours after surgery (mean difference [MD] -0.81 points, 95% CI -1.51 to -0.10; I2 = 92%; very low certainty evidence). Peripheral regional anesthesia, compared to placebo, may reduce pain intensity at rest (MD -1.36 points, 95% CI -1.59 to -1.13; I2 = 54%; very low certainty evidence) and during movement (MD -1.00 points, 95% CI -1.34 to -0.67; I² = 72%; very low certainty evidence) 24 hours after surgery. No data after pediatric cardiac surgery could be meta-analyzed due to the low number of included trials.

CONCLUSIONS

Compared to no RA or placebo, PRA may reduce pain intensity at rest and during movement. However, these results should be interpreted cautiously because the certainty of evidence is only very low.

Effects of parasternal intercostal block on surgical site wound infection and pain in patients undergoing cardiac surgery: A meta-analysis

This study aimed to assess the effect of parasternal intercostal block on postoperative wound infection, pain, and length of hospital stay in patients undergoing cardiac surgery. PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, VIP, and Wanfang databases were extensively queried using a computer, and randomised controlled studies (RCTs) from the inception of each database to July 2023 were sought using keywords in English and Chinese language. Literature quality was assessed using Cochrane-recommended tools, and the included data were collated and analysed using Stata 17.0 software for meta-analysis. Ultimately, eight RCTs were included. Meta-analysis revealed that utilising parasternal intercostal block during cardiac surgery significantly reduced postoperative wound pain (standardised mean difference [SMD] = -1.01, 95% confidence intervals [CI]: -1.70 to -0.31, p = 0.005) and significantly shortened hospital stay (SMD = -0.40, 95% CI: -0.77 to -0.04, p = 0.029), though it may increase the risk of wound infection (OR = 5.03, 95% CI:0.58-44.02, p = 0.144); however, the difference was not statistically significant. The application of parasternal intercostal block during cardiac surgery can significantly reduce postoperative pain and shorten hospital stay. This approach is worth considering for clinical implementation. Decisions regarding its adoption should be made in conjunction with the relevant clinical indices and surgeon's experience.

Pain management after cardiac surgery via median sternotomy: A systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations

BACKGROUND

Pain after cardiac surgery via median sternotomy can be difficult to treat, and if inadequately managed can lead to respiratory complications, prolonged hospital stays and chronic pain.

OBJECTIVES

To evaluate available literature and develop recommendations for optimal pain management after cardiac surgery via median sternotomy.

DESIGN

A systematic review using PROcedure-SPECific Pain Management (PROSPECT) methodology.

ELIGIBILITY CRITERIA

Randomised controlled trials and systematic reviews published in the English language until November 2020 assessing postoperative pain after cardiac surgery via median sternotomy using analgesic, anaesthetic or surgical interventions.

DATA SOURCES

PubMed, Embase and Cochrane Databases.

RESULTS

Of 319 eligible studies, 209 randomised controlled trials and three systematic reviews were included in the final analysis. Pre-operative, intra-operative and postoperative interventions that reduced postoperative pain included paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), intravenous magnesium, intravenous dexmedetomidine and parasternal block/infiltration.

CONCLUSIONS

The analgesic regimen for cardiac surgery via sternotomy should include paracetamol and NSAIDs, unless contraindicated, administered intra-operatively and continued postoperatively. Intra-operative magnesium and dexmedetomidine infusions may be considered as adjuncts particularly when basic analgesics are not administered. It is not clear if combining dexmedetomidine and magnesium would provide superior pain relief compared with either drug alone. Parasternal block/surgical site infiltration is also recommended. However, no basic analgesics were used in the studies assessing these interventions. Opioids should be reserved for rescue analgesia. Other interventions, including cyclo-oxygenase-2 specific inhibitors, are not recommended because there was insufficient, inconsistent or no evidence to support their use and/or due to safety concerns.

Regional analgesia for lung transplantation: A narrative review

Lung transplantation (LTx) is the definitive treatment for end-stage pulmonary disease. About 4500 LTxs are performed annually worldwide. It is considered challenging and complex surgery regarding anaesthesia and pain management. While providing adequate analgesia is crucial for patient comfort, early mobilisation and prevention of postoperative pulmonary complications, standardising an analgesic protocol is challenging due to the diversity of aetiologies, surgical approaches and the potential use of extracorporeal life support (ECLS). Although thoracic epidural analgesia is commonly considered the gold standard, concerns regarding procedural safety and its potential for devastating consequences have led physicians to seek safer analgesic modalities such as thoracic nerve blocks. The advantages of thoracic nerve blocks for general thoracic surgery are well established. However, their utility in LTx remains unclear. Considering paucity of relevant literature, this review aims to raise awareness about the literature gap in the field and highlight the need for further high-quality studies determining the effectiveness of available techniques.

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.

Preemptive parasternal intercostal nerve block for patients undergoing off-pump coronary artery bypass grafting: a double-blind, randomized, controlled trial

Background

Parasternal intercostal nerve block has been increasingly used for postoperative analgesia and has shown that this technique can provide effective postoperative analgesia. This study aimed to investigate the effect of preemptive parasternal intercostal nerve block on the opioid and vasoactive drug dose required for intraoperative hemodynamic stability and postoperative analgesia in patients undergoing off-pump coronary artery bypass grafting.

Methods

In this prospective, randomized controlled study, 64 participants aged 45-75 years scheduled for off-pump coronary artery bypass grafting at The Second Xiangya Hospital of Central South University. Patients were randomized into two groups and preoperatively administered ropivacaine (group R) and saline (group S), in the parasternal intercostal spaces with ultrasound-guided bilateral nerve block.

Results

The primary outcome was intraoperative sufentanil and vasopressor dosage. The secondary outcomes were intraoperative hemodynamics, postoperative pain scores, and anesthesia recovery, postoperative use of rescue dezocine, stay in intensive care unit, and length of hospital stay. The consumption of intraoperative sufentanil and vasopressor was significantly lower in group R than in group S. The visual analog score in group R was significantly lower than that in group S up to 12 h postoperatively. The time to anesthesia recovery was significantly less in group R than in group S. Most patients in group S required rescue dezocine, whereas most patients in group R did not. The hemodynamic variables were stable in all patients.

Conclusions

A preemptive parasternal intercostal nerve block effectively reduced the required intraoperative sufentanil and norepinephrine dose and provided adequate analgesia for the first 12 h after surgery. Therefore, a preemptive parasternal intercostal nerve block is a good option for patients undergoing off-pump coronary artery bypass grafting.

Clinical trial registration

chictr.org.cn, identifier ChiCTR1800017210.

Ultrasound Guided Parasternal Block for Perioperative Analgesia in Cardiac Surgery: A Prospective Study

Ultrasound guided parasternal block is a regional anaesthesia technique targeting the anterior branches of intercostal nerves, which supply the anterior thoracic wall. The aim of this prospective study is to assess the efficacy of parasternal block to manage postoperative analgesia and reduce opioid consumption in patients undergoing cardiac surgery throughout sternotomy. A total of 126 consecutive patients were allocated to two different groups, receiving (Parasternal group) or not (Control group) preoperative ultrasound guided bilateral parasternal block with 20 mL of 0.5% ropivacaine per side. The following data were recorded: postoperative pain expressed by a 0-10 numeric rating scale (NRS), intraoperative fentanyl consumption, postoperative morphine consumption, time to extubation and perioperative pulmonary performance at incentive spirometry. Postoperative NRS was not significantly different between Parasternal and Control groups with a median (IQR) of 2 (0-4.5) vs. 3 (0-6) upon awakening (p = 0.07); 0 (0-3) vs. 2 (0-4) at 6 h (p = 0.46); 0 (0-2) vs. 0 (0-2) at 12 h (p = 0.57). Postoperative morphine consumption was similar among groups. However, intraoperative fentanyl consumption was significantly lower in the Parasternal group [406.3 ± 81.6 mcg vs. 864.3 ± 154.4, (p < 0.001)]. Parasternal group showed shorter times to extubation [(191 ± 58 min vs. 305 ± 72 min, (p)] and better performance at incentive spirometer with a median (IQR) of 2 raised balls (1-2) vs. 1 (1-2) after awakening (p = 0.04). Ultrasound guided parasternal block provided an optimal perioperative analgesia with a significant reduction in intraoperative opioid consumption, time to extubation and a better postoperative performance at spirometry when compared to the Control group.

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.

Median sternotomy pain after cardiac surgery: To block, or not? A systematic review and meta-analysis

BACKGROUND

Inadequate pain control after median sternotomy leads to reduced mobilization, increased respiratory complications, and longer hospital stays. Typically, postoperative pain is controlled by opioid analgesics that may have several adverse effects. Parasternal intercostal block (PSB) has emerged as part of a multimodal strategy to control pain after median sternotomy. However, the effectiveness of this intervention on postoperative pain control and analgesic use has not been fully established.

METHODS AND RESULTS

We conducted a meta-analysis to assess the effect of PSB on postoperative pain and analgesic use in adult cardiac surgery patients undergoing median sternotomy. PubMed, Embase, Google Scholar, and the Cochrane database were searched with the following search strategy: ([postoperative pain] or [pain relief] OR [analgesics] or [analgesia] or [nerve block] or [regional block] or [local block] or [regional anesthesia] or [local anesthetic] or [parasternal block] and [sternotomy]) and (humans [filter]). Inclusion criteria were: patients who underwent cardiac surgery via median sternotomy, age >18 and parasternal block (continuous and single dose). Exclusion criteria were: noncardiac surgery, nonparasternal nerve blocks, and the use of NSAIDS in parasternal block. Quality assessment was performed by three independent reviewers via the Cochrane risk of bias assessment tool. Of 1165 total citations, 18 were found to be relevant. Of these 18 citations, 7 citations (N = 2223 patients) reported postoperative pain scores in an extractable format and 11 citations (N = 2155 patients) reported postoperative opioid use in an extractable format. For postoperative opioid use, morphine equivalent doses were calculated for all studies and postoperative pain scores were standardized to a 10-point visual analog scale for comparison between studies; both these were reported as total opioid use or cumulative score ranging from 24 to 72 h postoperative. All data analyses were run using a random effects model, using a restricted maximum likelihood estimator, to obtain summary standardized mean differences with 95% confidence interval (CI's). For studies which only reported median and interquatile range (IQR), the median was standard deviation was estimated by IQR/1.35. Following median sternotomy both postoperative pain (SMD [95% CI] -0.49 [-0.92 to -0.06]) and postoperative morphine equivalent use (SMD [95% CI] -1.68 [-3.11 to -0.25]) were significantly less in the PSB group.

CONCLUSION

Our meta-analysis suggests that parasternal nerve block significantly reduces postoperative pain and opioid use.

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 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.

Peak plasma concentration of total and free bupivacaine after erector spinae plane and pectointercostal fascial plane blocks

PURPOSE

Erector spinae plane blocks (ESPB) and pectointercostal fascial (PIFB) plane blocks are novel interfascial blocks for which local anesthetic (LA) doses and concentrations necessary to achieve safe and effective analgesia are unknown. The goal of this prospective observational study was to provide the timing (Tmax) and concentration (Cmax) of maximum total and free plasma bupivacaine after ESPB in breast surgery and after PIFB in cardiac surgery patients.

METHODS

Erector spinae plane blocks or PIFBs (18 patients per block; total, 36 patients) were performed with 2 mg⋅kg-1 of bupivacaine with epinephrine 5 μg⋅mL-1. Our principal outcomes were the mean or median Cmax of total and free plasma bupivacaine measured 10, 20, 30, 45, 60, 90, 180, and 240 min after LA injection using liquid chromatography with tandem mass spectrometry.

RESULTS

For ESPB, the mean (standard deviation [SD]) total bupivacaine Cmax was 0.37 (0.12) μg⋅mL-1 (range, 0.19 to 0.64), and the median [interquartile range (IQR)] Tmax was 30 [50] min (range, 10-180). For ESPB, the mean (SD) free bupivacaine Cmax was 0.015 (0.017) μg⋅mL-1 (range, 0.003-0.067), and the median [IQR] Tmax was 30 [20] min (range, 10-120). After PIFB, mean plasma concentrations plateaued at 60-240 min. For PIFB, the mean (SD) total bupivacaine Cmax was 0.32 (0.21) μg⋅mL-1 (range, 0.14-0.95), with a median [IQR] Tmax of 120 [150] min (range, 30-240). For PIFB, the mean (SD) free bupivacaine Cmax was 0.019 (0.010) μg⋅mL-1 (range, 0.005-0.048), and the median [IQR] Tmax was 180 [120] min (range, 30-240). For both ESPB and PIFB, we observed no correlations between pharmacokinetic and demographic parameters.

CONCLUSION

Total and free bupivacaine Cmax observed after ESPB and PIFB with 2 mg⋅kg-1 of bupivacaine with epinephrine 5 μg⋅mL-1 were five to twenty times lower than levels considered toxic in the literature.

Use of Ultrasound-Guided Interfascial Plane Blocks in Anterior and Lateral Thoracic Wall Region as Safe Method for Patient Anesthesia and Analgesia: Review of Techniques and Approaches during COVID-19 Pandemic

Ultrasound-guided interfascial plane blocks performed on the anterior and lateral thoracic wall have become an important adjuvant method to general anesthesia and an independent method of local anesthesia and pain management. These procedures diminish the harmful effects of anesthesia on respiratory function and reduce the risk of phrenic nerve paralysis or iatrogenic pneumothorax. In postoperative pain management, interfascial plane blocks decrease the dosage of intravenous drugs, including opioids. They can also eliminate the complications associated with general anesthesia when used as the sole method of anesthesia for surgical procedures. The following procedures are classified as interfascial plane blocks of the anterior and lateral thoracic wall: pectoral nerve plane block (PECS), serratus anterior plane block (SAP), transversus thoracic muscle plane block (TTP), pectoral interfascial plane block (PIF), and intercostal nerve block (ICNB). These blocks are widely used in emergency medicine, oncologic surgery, general surgery, thoracic surgery, cardiac surgery, orthopedics, cardiology, nephrology, oncology, palliative medicine, and pain medicine. Regional blocks are effective for analgesic treatment, both as an anesthesia procedure for surgery on the anterior and lateral thoracic wall and as an analgesic therapy after trauma or other conditions that induce pain in this area. In the era of the COVID-19 pandemic, ultrasound-guided interfascial plane blocks are safe alternatives for anesthesia in patients with symptoms of respiratory distress related to SARS-CoV-2 and appear to reduce the risk of COVID-19 infection among medical personnel.

Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump

OBJECTIVE

To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.

METHODS

Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions.

CONCLUSIONS

Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

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 Different Pain-Control Procedures for Post-cardiac Surgery: A Systematic Review and Network Meta-Analysis

Objective

To identify superior pain-control procedures for postoperative patients who undergo cardiac surgeries.

Methods

Literature searches were conducted in globally recognized databases, including MEDLINE, EMBASE and Cochrane Central, to identify randomized controlled trials (RCTs) investigating pain-control procedures after cardiac surgeries. The parameters evaluating analgesic efficacy and postoperative recovery, namely, the pain score and ICU stay, were quantitatively pooled and estimated using Bayesian methods. The values of the surface under the cumulative ranking (SUCRA) probabilities regarding each parameter were calculated to enable the ranking of various pain-control procedures. Node-splitting analysis was performed to test the inconsistency of the main results, and the publication bias was assessed by examining the funnel-plot symmetry.

Results

After a detailed review, 13 RCTs containing 7 different procedures were included in the network meta-analysis. After pooling the results together, an erector spinae plane block (ESPB) and a local parasternal block (LPB) plus target-controlled infusion (TCI) presented the best analgesic effects for reducing pain at rest (SUCRA, .47) and during movement (SUCRA, .52), respectively, while the former also achieved the shortest ICU stay (SUCRA, .48). Moreover, the funnel-plot symmetries showed no inconsistencies or obvious publication bias in the current study.

Conclusions

The current evidence indicates that ESPB is a potential superior analgesic strategy for post-cardiac surgery patients. To verify this conclusion further, it is imperative to obtain more high-quality evidence and conduct relevant investigations in the future.

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.

Ultrasound-guided parasternal blocks: techniques, clinical indications and future prospects: a narrative review

Fascial plane blocks represent anesthetic procedures performed to manage perioperative and chronic pain. Recently, many fascial blocks techniques have been described increasing their field of applications. They offer anesthetic and analgesic efficacy, easy of execution and low risk of complications. The newest techniques recently described are the ultrasound parasternal blocks (USPSB) which provide analgesia to the antero-medial chest wall. In particular, the antero-medial chest wall blocks are performed to provide analgesia and anesthesia in several and different surgeries such as median sternotomy, breast surgery, implantable cardioverter-defibrillator implantation and in the management of acute and chronic pain. The nervous target for these blocks is represented by the anterior branches of the intercostal nerves which enter the intercostal (ICM) and pectoralis major (PMM) muscles innervating the antero-medial region of chest wall, the main cause of poststernotomy pain. Local anesthetic is injected deep to PMM and superficial to the ICM or between the internal thoracic muscle (IIM) and transversus thoracis muscle (TTM). So, essentially these blocks may be described as superficial or deep parasternal-intercostal plane blocks, based on where the target nerves are hunted. Even if they all provide analgesia to the antero-medial chest wall, the anatomical injection site represents the main peculiarity that differentiates these techniques. To date, a common nomenclature for antero-medial chest wall blocks or parasternal-intercostal plane blocks is not yet well defined and a standardized nomenclature is needed to ensure an adequate communication among anesthesiologists.

Description of an Ultrasound-Guided Transverse Approach to the Transversus Thoracis Plane Block and Evaluation of Injectate Spread in Canine Cadavers

Simple Summary

In humans, the aim of the transversus thoracis plane block is to desensitise the intercostal nerves running through this plane, providing analgesia to the anterior chest wall. Our objective was twofold: describing an ultrasound-guided transverse approach to the transversus thoracis plane and evaluating the spread of two injectable volumes in canine cadavers. Gross anatomy of the ventral thoracic area and sonoanatomy between the fifth and sixth costal cartilages were described in two dog cadavers. Eight cadavers were used to describe this approach and were subsequently dissected to evaluate the injectate spread and the intercostal nerves staining after low volume (0.5 mL kg⁻¹) and high volume (1 mL kg⁻¹) dye-lidocaine injection. After all injections, the injectable solution was distributed along the transversus thoracis plane, staining a median number (range) of 3 (2–4) and 4 (3–5) nerves with low and high volume, respectively (p = 0.014). The transverse approach to the transversus thoracis plane is a feasible, single injection point technique that provides the staining of several intercostal nerves. The injection of high versus low volume increases the number of stained nerves.

Abstract

Transversus thoracis plane (TTP) block has demonstrated to produce analgesia in humans undergoing median sternotomy. The objectives of the study were to describe an ultrasound-guided transverse approach to the transversus thoracis plane (t-TTP) and to evaluate the spread of two injectable volumes in canine cadavers. Two cadavers were used to describe relevant gross anatomy of the ventral thoracic area and sonoanatomy between the fifth and sixth costal cartilages. Then, eight cadavers were used to describe the ultrasound-guided injection into the TTP and were dissected to evaluate the injectate spread and the intercostal nerves staining with two different dye-lidocaine volumes: low volume (LV) 0.5 mL kg⁻¹ and high volume (HV) 1 mL kg⁻¹. To compare the spread between both volumes the Fisher’s exact test and Wilcoxon signed-rank test were used. The solution spread along the TTP after all injections, staining a median number (range) of 3 (2–4) and 4 (3–5) nerves with LV and HV, respectively (p = 0.014). The injection of HV versus LV increases the number of stained nerves. Ultrasound-guided t-TTP is a feasible technique that provides staining of several intercostal nerves with a single injection site, so it could be useful to provide analgesia to the ventral chest wall.

Efficacy of parasternal block to decrease intraoperative opioid use in coronary artery bypass surgery via sternotomy: a randomized controlled trial

OBJECTIVE

This study aims to assess the effect of a preoperative parasternal plane block (PSB) on opioid consumption required to maintain hemodynamic stability during sternotomy for coronary artery bypass graft surgery.

METHODS

This double-blind, randomized, placebo-controlled trial prospectively enrolled 35 patients scheduled for coronary artery bypass graft surgery under general anesthesia with propofol and remifentanil. Patients were randomized to receive preoperative PSB using either ropivacaine (PSB group) or saline solution (placebo group) (1:1 ratio). The primary endpoint was the maximal effect-site concentration of remifentanil required to maintain heart rate and blood pressure within the recommended ranges during sternotomy.

RESULTS

Median maximum concentration of remifentanil necessary to maintain adequate hemodynamic status during sternotomy was significantly reduced in PSB group (4.2 (2.5-6.0) ng/mL) compared with placebo group (7.0 (5.2-8.0) ng/mL) (p=0.02). Mean maximum concentration of propofol used to control depth of anesthesia was also reduced (3.9±1.1 µg/mL vs 5.0±1.5 µg/mL, PSB vs placebo, respectively; p=0.02). This reduction in propofol consumption during sternotomy enabled a more adequate level of sedation to be maintained in patients (minimum patient state index was 11.7±8.7 in placebo group and 18.3±6.8 in PSB group; p=0.02). PSB reduced postoperative inflammatory response by limiting concentrations of proinflammatory cytokines IL-8, IL-18, IL-23, IL-33 and MCP-1 measured in the first 7-day after surgery (p<0.05).

CONCLUSIONS

Preoperative PSB reduced the maximum concentrations of remifentanil and propofol required to maintain hemodynamic stability and depth of anesthesia during sternotomy.

TRIAL REGISTRATION NUMBER

NCT03734159.Sébastien Bloc, M.D.^1,2; Brieuc P. Pérot, Ph.D.³; Hadrien Gibert, M.D.¹; Jean-Dominique Law Koune, M.D.¹; Yannick Burg, M.D.¹; Didier Leclerc, M.D.¹; Anne-Sophie Vuitton, M.D.¹; Christophe De La Jonquière, M.D.¹; Marine Luka, L.S.³; Thierry Waldmann, M.D.⁴; Nicolas Vistarini, M.D.⁴; Stéphane Aubert, M.D.⁴; Mickaël M. Ménager, Ph.D.³; Messaouda Merzoug, Ph.D.²; Cécile Naudin, Ph.D.²; Pierre Squara, M.D.^2,5.

Ultrasound-guided parasternal injection in dogs: a cadaver study

OBJECTIVES

To describe the technique of performing an ultrasound-guided distal parasternal intercostal block and to determine the distribution of two volumes of methylene blue dye solution injected in canine cadavers.

STUDY DESIGN

Prospective cadaver study.

ANIMALS

A group of seven canine cadavers weighing 12-34 kg.

METHODS

The space between the transversus thoracic and the internal intercostal muscles is a virtual cavity. Ultrasound-guided injections in the distal (parasternal) intercostal space were performed using dye solution at 0.05 mL kg^-1 in each intercostal space from the second to seventh (LV, low volume, six injections per dog) in one hemithorax, and 0.1 mL kg^-1 in the third, fifth and seventh intercostal spaces (HV, high volume, three injections in each dog) on the contralateral side. Anatomical dissection was carried out to describe dye spread characteristics and staining of intercostal nerves.

RESULTS

The ultrasonographic landmarks for injection were identified in each cadaver. In the LV group the solution was found in every intercostal space (36/36), whereas the HV injection stained six intercostal spaces in two dogs, five in two, and in two dogs the solution was found in four and three spaces, respectively, demonstrating multisegmental distribution. Intrapleural staining was observed after two injections.

CONCLUSIONS AND CLINICAL RELEVANCE

Ultrasound-guided injection of 0.05 mL kg^-1 at the distal intercostal space resulted in staining of the intercostal nerve in all dogs when performed in every space and may be an appropriate alternative to previously reported techniques. A single injection of 0.1 mL kg^-1 may anaesthetize more than one intercostal nerve, but not consistently. Clinical investigations are warranted to better characterize and to refine this locoregional technique.

Ultrasound-guided parasternal intercostal nerve block for postoperative analgesia in mediastinal mass resection by median sternotomy: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Ultrasound-guided parasternal intercostal nerve block is rarely used for postoperative analgesia, and its value remains unclear. This study aimed to evaluate the effectiveness of ultrasound-guided parasternal intercostal nerve block for postoperative analgesia in patients undergoing median sternotomy for mediastinal mass resection.

METHODS

This randomized, double-blind, placebo-controlled trial performed in Renmin Hospital, Wuhan University, enrolled 41 participants aged 18-65 years. The patients scheduled for mediastinal mass resection by median sternotomy were randomly assigned were randomized into 2 groups, and preoperatively administered 2 injections of ropivacaine (PSI) and saline (control) groups, respectively, in the 3rd and 5th parasternal intercostal spaces with ultrasound-guided (USG) bilateral parasternal intercostal nerve block. Sufentanil via patient-controlled intravenous analgesia (PCIA) was administered to all participants postoperatively. Pain score, total sufentanil consumption, and postoperative adverse events were recorded within the first 24 h.

RESULTS

There were 20 and 21 patients in the PSI and control group, respectively. The PSI group required 20% less PCIA-sufentanil compared with the control group (54.05 ± 11.14 μg vs. 67.67 ± 8.92 μg, P < 0.001). In addition, pain numerical rating scale (NRS) scores were significantly lower in the PSI group compared with control patients, both at rest and upon coughing within 24 postoperative hours. Postoperative adverse events were generally reduced in the PSI group compared with controls.

CONCLUSIONS

USG bilateral parasternal intercostal nerve block effectively reduces postoperative pain and adjuvant analgesic requirement, with good patient satisfaction, therefore constituting a good option for mediastinal mass resection by median sternotomy.

Pain relief following sternotomy in conventional cardiac surgery: A review of non neuraxial regional nerve blocks

Acute post-operative pain following sternotomy in cardiac surgery should be adequately managed so as to avoid adverse hemodynamic consequences and pulmonary complications. In the era of fast tracking, adequate and efficient technique of post-operative analgesia enables early extubation, mobilization and discharge from intensive care unit. Due to increasing expertise in ultrasound guided blocks there is a recent surge in trial of bilateral nerve blocks for pain relief following sternotomy. The aim of this article was to review non-neuraxial regional blocks for analgesia following sternotomy in cardiac surgery. Due to the paucity of similar studies and heterogeneity, the assessment of bias, systematic review or pooled analysis/meta-analysis was not feasible. A total of 17 articles were found to be directly related to the performance of non-neuraxial regional nerve blocks across all study designs. Due to scarcity of literature, comments cannot be made on the superiority of these blocks over each other. However, most of the reviewed techniques were found to be equally efficacious or better than conventional and established techniques.

Bupivacaine infiltration for acute postoperative pain management after cardiac surgery

BACKGROUND

Despite increased attention, acute and persistent post-operative pain are not treated efficiently and interventions against acute pain are therefore of clinical importance and should be welcomed.

AIMS AND OBJECTIVES

To evaluate the effectiveness of wound infiltration with 0.5% bupivacaine for pain management in the immediate post-operative period in patients that underwent cardiac surgery with sternotomy.

DESIGN

The study was performed employing a single-centre nonrandomized experimental design to evaluate a prospective cohort of patients recruited from June to December of 2017.

METHODS

A single-centre study with a non-randomized experimental design compared the pain perceived by 137 patients undergoing to cardiac surgery within which 68 patients who received infiltration of bupivacaine and 69 patients received infiltration with saline solution. Pain measures were made with the numeric rating scale (NRS) at 2, 12, 24, and 48 hours. Socio-demographic and clinical variables were included too and descriptive, bivariate, and multivariate logistic regression analyses were performed.

RESULTS

A statistically significant difference was found between the means of the NRS scores in favour of the intervention group. Cohen's d showed a significant effect size. NRS scores were grouped into NRS ≥4 or NRS <4 and similar results were found. Multivariate logistic regression analyses showed the absence of confounding factors that could call results into question.

CONCLUSION

Subcutaneous infiltration of 0.5% bupivacaine in the surgical site of patients who have undergone cardiac surgery showed clinically and statistically significant pain relief compared with patients who received saline infiltration throughout the first 12 hours after surgery. This intervention provides promising preliminary results that, alone or in conjunction with other nursing interventions, could constitute an important therapeutic tool for this area of nursing clinical practice.

Ultrasound-guided Modified Parasternal Intercostal Nerve Block: Role of Preemptive Analgesic Adjunct for Mitigating Poststernotomy Pain

Background and Aim

To assess the quality and effectiveness of postoperative pain relief after fast-tracking tracheal extubation in cardiac surgery intensive care unit, effected by a single-shot modified parasternal intercostal nerve block compared with routine in-hospital analgesic protocol, when administered before sternotomy.

Design

A prospective, randomized, double-blinded interventional study.

Setting

Single-center tertiary teaching hospital.

Participants

Ninety adult patients undergoing elective coronary artery bypass grafting surgery under cardiopulmonary bypass.

Materials and Methods

Patients were randomized into two groups. Patients in the parasternal intercostal block group (PIB) (n = 45) received ultrasound-guided modified parasternal intercostal nerve block with 0.5% levobupivacaine after anesthesia induction at 2^nd-6^th intercostal space along postinduction using standardized anesthesia drugs with routine postoperative hospital analgesic protocol with intravenous morphine. Patients in the group following routine hospital analgesia protocol (HAP) (n = 45) served as controls, with standardized anesthesia drugs and routine hospital postoperative analgesic protocol with intravenous morphine. The primary study outcome aimed to evaluate pain at rest and when doing deep breathing exercises with spirometry, coughing expectorations using a 11-point numerical rating scale.

Results

The postoperative pain score at rest and during breathing exercises was compared between the two groups at different time durations (15 min after extubation and every 4^th hourly for 24 h). Patients in the PIB group had significantly lower pain scores and better quality of analgesia during the entire study period at rest and during breathing exercise (P < 0.0001). Furthermore, the side effect profile and need of rescue analgesics were better in the PIB group than the HAP group at different time intervals.

Conclusion

PIB is safe for presternotomy administration and provided significant quality of pain relief postoperatively, as seen after tracheal extubation for a period of 24 h, on rest as well as with deep breathing, coughing, and chest physiotherapy exercises when compared to intravenous morphine alone after sternotomy. This study further emphasizes the role of preemptive analgesia in mitigating postoperative sternotomy pain and it's role as a plausible safe analgesic adjunct facilitating fast tracking with sternotomies on systemic heparinization.

Comparison of preincisional and postincisional parasternal intercostal block on postoperative pain in cardiac surgery

BACKGROUND

The optimum cardiac surgical pain management has known to maintain hemodynamic stability and, reduces respiratory and cardiovascular complications. Postoperative parasternal intercostal block has shown to reduce postoperative analgesic consumption after cardiac surgery. Therefore, this study sought to investigate the effectiveness of the preoperative ultrasound guided parasternal block in reducing postoperative pain after cardiac surgery.

METHODS

This was a randomized, prospective, interventional, single blind study comprised of 90 adult patients scheduled for cardiac surgery involving sternotomy. Preoperatively and postoperatively, 0.25% bupivacaine administered in 4 mL aliquots into the anterior (2nd-6th) intercostal spaces on each side about 2 cm lateral to the sternal edge with a total volume of 40 mL under ultrasound guidance and direct vision, respectively. Postoperative pain was rated according to visual analogue scale. Secondary outcomes included intraoperative and postoperative fentanyl consumptions, dosages of rescue medications, and time to extubation.

MAIN RESULTS

There was no significant differences in visual analogue score visual analogue score at all time points till 24 hours postoperatively. Intraoperative fentanyl requirements (microgram/kg) before cardiopulmonary bypass was significantly lower in pre-incisional group than the post-incisional group (0.16 ± 0.43 vs 0.68 ± 0.72; P = .0001). Furthermore, there were no significant difference in total fentanyl requirement (7.20 ± 2.66 vs 8.37 ± 3.13; P = .06) and tramadol requirement (0.02 ± 0.15 vs 0.07 ± 0.26; P = .28) within first 24 hours. However, time to extubation was significantly higher in the preoperative group (P = .02).

CONCLUSIONS

Preoperative and postoperative parasternal intercostal block provide comparable pain relief during the postoperative period.

Atrial septal defect closure via mini-thoracotomy in pediatric patients: Postoperative analgesic effect of intercostal nerve block

Background

In this study, we evaluated the efficacy of intercostal nerve block for postoperative pain management in pediatric patients undergoing atrial septal defect closure through a right lateral mini-thoracotomy.

Methods

Between January 2016 and January 2019, a total of 63 pediatric patients (37 males, 26 females; mean age 34.8±26.8 months; range, 2 to 96 months) who underwent corrective congenital heart surgery for atrial septal defect closure through a right lateral mini-thoracotomy were retrospectively reviewed. The patients were divided into two groups as those (Group 1, n=33) receiving intercostal nerve block and general anesthesia and those (Group 2, n=30) receiving general anesthesia alone. Intravenous morphine at a dose of 0.03 mg/kg was applied as rescue analgesia to the patients with a Ramsay Sedation Scale score of >4 and Children"s Hospital of Eastern Ontario Pain Scale score of >7. The total analgesic requirement, adverse effects, duration of mechanical ventilation and length of stay in the intensive care unit were recorded.

Results

The mean duration of mechanical ventilation and intensive care unit stay was shorter in Group 1 compared to Group 2 (3.6±1.3 vs. 9.4±2.1 h; 23±2.6 vs. 30±7.2 h, respectively) (p<0.0001). The need for postoperative rescue analgesia was statistically significantly lower in Group 1 compared to Group 2 (0.3±0.5 mg vs. 1.1±0.9 mg, respectively) (p=0.003). The mean total morphine consumption was also lower in Group 1 compared to Group 2 (4.0±2.2 mg vs. 9.0±3.4 mg, respectively) (p<0.0001).

Conclusion

Intercostal nerve block before thoracotomy closure in pediatric patients undergoing atrial septal defect repair under mini-thoracotomy provides early extubation, shorter mechanical ventilation duration and intensive care unit stay, and reduced analgesic requirements.

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.

A single dose of tramadol in continuous wound analgesia with levobupivacaine does not reduce post-sternotomy pain: a randomized controlled trial

Background

Medial sternotomy is commonly used in cardiac surgery, although it results in intense post-operative pain. The placement of a sternal wound catheter for the administration of local anesthetic represents an effective technique. An initial bolus of tramadol in the sternal wound catheter could potentiate the effect of the local anesthetic and decrease both the post-operative pain and the morphine consumption.

Patients and methods

We conducted a prospective, randomized, double-blind study at the University Hospital Center, Dijon, France. Patients requiring scheduled or non-extreme emergency surgery for valve disease, aorta disease, atrial myxoma, or coronary artery bypass graft via sternotomy were included. A sternal wound catheter was inserted at the end of the surgery. The patients were randomized to receive either a 2 mg/kg bolus of tramadol (n=80) or a placebo (n=80) in the wound catheter. The bolus administration was followed by a continuous infusion of 1.25% levobupivacaine for the first 48 hrs following surgery. The patients’ morphine consumption during the first 48 hrs after extubation was recorded. The other investigated variables were the patients’ rescue analgesia, arterial blood gasses, and length of stay in the intensive care unit and in hospital, as well as the incidence of chronic pain at the four-month follow-up point.

Results

The morphine consumption was found to be comparable in the two groups (38 mg vs 32 mg, p=0.102). No effect was found in terms of the arterial blood gasses, lengths of stay, or incidence of chronic pain.

Conclusion

The addition of tramadol to the local anesthetic delivered via a wound catheter following sternotomy did not reduce the patients’ post-operative morphine consumption.

Trial registration

Clinicaltrials.gov identifier: NCT02851394.

Regional anesthesia for sternotomy and bypass-Beyond the epidural

Systemic opioids have been the main stay for the management of perioperative pain in children undergoing cardiac surgery with sternotomy. The location, distribution, and duration of pain in these children have not been studied as extensively as in adults. Currently, there is no consensus to the dose of opioids required to provide optimum analgesia and attenuate the stress response while minimizing their unwanted side effects. At present there is a tendency to use lower dose aiming for early extubation and minimize opioid-related side effects, but this may not obtund the stress response in all children. The development of chronic pain although rare when compared to adults is still a risk that needs further investigation. Regional anesthetic techniques, by blocking the afferent impulses, have been shown to be advantageous in reducing the stress response to surgery as well as pain and opioid requirements in children up to 24 hours after cardiac surgery. Central neuraxial blockades have not gained wide spread acceptance in these procedures due to the worry of hematoma, although rare, leading to catastrophic neurological outcomes. This review focuses on blocks outside the vertebral column, ie, peripheral nerve blocks, performed either in the front or the back of the chest wall to target the thoracic intercostal nerves. Techniques of ultrasound-guided bilateral single shot paravertebral block and erector spinae block posteriorly and transversus thoracic plane block anteriorly are discussed. In addition, parasternal block and wound infiltration by surgeon as well as continuous local anesthetic infusion via catheters placed at end of procedures are summarized. Current evidence available for use of these techniques in children undergoing cardiac surgery are reviewed. These are based on small studies and case series and further studies are required to evaluate the risks and benefits of local anesthetic blocks in children undergoing cardiac surgery.

The efficacy of different modes of analgesia in postoperative pain management and early mobilization in postoperative cardiac surgical patients: A systematic review

Cardiac surgery induces severe postoperative pain and impairment of pulmonary function, increases the length of stay (LOS) in hospital, and increases mortality and morbidity; therefore, evaluation of the evidence is needed to assess the comparative benefits of different techniques of pain management, to guide clinical practice, and to identify areas of further research. A systematic search of the Cochrane Central Register of Controlled Trials, DARE database, Joanna Briggs Institute, Google scholar, PUBMED, MEDLINE, EMBASE, Academic OneFile, SCOPUS, and Academic search premier was conducted retrieving 1875 articles. This was for pain management postcardiac surgery in intensive care. Four hundred and seventy-one article titles and 266 abstracts screened, 52 full text articles retrieved for critical appraisal, and ten studies were included including 511 patients. Postoperative pain (patient reported), complications, and LOS in intensive care and the hospital were evaluated. Anesthetic infiltrations and intercostal or parasternal blocks are recommended the immediate postoperative period (4-6 h), and patient-controlled analgesia (PCA) and local subcutaneous anesthetic infusions are recommended immediate postoperative and 24-72 h postcardiac surgery. However, the use of mixed techniques, that is, PCA with opioids and local anesthetic subcutaneous infusions might be the way to go in pain management postcardiac surgery to avoid oversedation and severe nausea and vomiting from the narcotics. Adequate studies in the use of ketamine for pain management postcardiac surgery need to be done and it should be used cautiously.