Regional Anesthesia in Cardiac Surgery: An Overview of Fascial Plane Chest Wall Blocks

The Role of Regional Anesthesia in ICU Pain Management

PURPOSE OF REVIEW

The purpose of this review is to provide the most recent update and summary on the consideration, benefits and application of regional anesthesia in the ICU setting, as it pertains to the management of perioperative pain.

RECENT FINDINGS

Regional anesthesia and analgesia have become ubiquitous in the perioperative setting, with numerous indications and benefits. As integral part of the multimodal analgesia approach, various regional blocks have been increasingly utilized in critically ill patients. We focus this review on various regional techniques employed for critically ill patients after cardiac, thoracic, and major abdominal surgery, including neuraxial and novel truncal blocks. Effective pain management in critically ill patients poses many challenges and is extremely important. Regional anesthesia, in combination with other analgesia modalities, while still under-utilized, can help reduce acute perioperative pain, stress response, opioid use and related side effects and expedite recovery and improve clinical outcomes.

Advances in Anesthesia Techniques for Postoperative Pain Management in Minimally Invasive Cardiac Surgery: An Expert Opinion

Minimally invasive cardiac surgery (MICS) often leads to severe postoperative pain. At present, multimodal analgesia schemes for MICS have attracted much attention, and the application of various chest wall analgesia techniques is becoming increasingly widespread. However, research on anesthesia techniques for postoperative pain management in MICS remains relatively limited at present. We searched for relevant literature and summarized recent related research in eight MICS techniques, including thoracic epidural anesthesia, spinal anesthesia, thoracic paravertebral plane block, erector spinae plane block, serratus anterior plane block, pectoral nerve block, intercostal nerve block, and parasternal block. This article provides an overview of the anatomy and procedures involved in these analgesic techniques, their mechanisms of action, and the latest clinical trial evidence. It also evaluates their progress in MICS, compares their advantages and disadvantages, and discusses practical challenges.

Efficacy of Transversus Thoracic Plane Block for Pain Management in Cardiac Surgeries

PURPOSE OF REVIEW

Effective pain management in cardiac surgery presents as a continuous challenge related to the intensity of postoperative pain and reliance on opioid therapy. The dependance of opioid-based therapies is concerning, as these therapies carry risk future addiction and potential severe side effects. The transversus thoracic plane block (TTPB) has emerged as a promising regional anesthesia technique that blocks the anterior branches of the intercostal nerves in the chest wall, potentially providing improved analgesia for cardiac surgery patients. The present investigation evaluates the efficacy of TTPB in reducing opioid consumption, decreasing postoperative pain scores, and enhancing recovery outcomes in patients undergoing cardiac surgeries.

RECENT FINDINGS

Data from randomized controlled trials revealed that TTPB significantly reduced 24-hour opioid consumption, increased the time to first rescue analgesic, and lowered Visual Analog Scale (VAS) pain scores both at rest and with movement, particularly in the first 12 h post-surgery. Additional benefits include fewer opioid-related side effects, such as nausea and pruritus, and reductions in intensive care unit (ICU) length of stay. Studies also suggested that TTPB can support earlier extubation and accelerated recovery, contributing to higher patient satisfaction and overall improved postoperative outcomes.

CONCLUSION

Despite these promising results, challenges in technique standardization and limited long-term data are still obstacles that prevent widespread adoption. Achieving consistent TTPB efficacy requires technical precision in ultrasound guidance, and there is little research on its effectiveness across diverse populations, such as pediatric and high-risk cardiac patients. Addressing these gaps through multi-center, long-term studies could help establish TTPB as a prominent pain management strategy in cardiac surgery to minimize opioid dependence and enhance patient comfort and recovery.

The Impact of Preoperative Combined Pectoserratus and/or Interpectoral Plane (Pectoralis Type II) Blocks on Opioid Consumption, Pain, and Overall Benefit of Analgesia in Patients Undergoing Minimally Invasive Cardiac Surgery: A Prospective, Randomized, Controlled, and Triple-blinded Trial

OBJECTIVE

Acute postoperative pain remains a major obstacle in minimally invasive cardiac surgery (MICS). Evidence of the analgesic benefit of chest wall blocks is limited. This study was designed to assess the influence of combined pectoserratus plane block plus interpectoral plane block (PSPB + IPPB) on postoperative pain and the overall benefit of analgesia compared with placebo.

DESIGN

A prospective, randomized, triple-blinded study was conducted.

SETTING

The setting was the operating room and intensive care unit of a university hospital.

PARTICIPANTS

A total of 60 patients undergoing elective right-lateral MICS were enrolled.

INTERVENTIONS

Patients were randomly assigned to preoperative PSPB + IPPB with 30 mL of ropivacaine 0.5% or saline.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was total intravenous morphine milligram equivalents administered in the first 24 hours after extubation. Secondary endpoints included the Overall Benefit of Analgesia Score (OBAS) at 24 hours after extubation and repeated Visual Analogue Scale (VAS). Values for intravenous morphine milligram equivalents administered in the first 24 hours after extubation were significantly lower (median [interquartile range]: 4.2 mg [2.1 - 7.9] v 8.3 mg [4.2 - 15.7], p = 0.025; mean difference: 6.7 mg [0.94 - 12 mg], p = 0.024, Cohen's d: 0.64 [0.09 - 1.2]). Moreover, OBAS at 24 hours and VAS after extubation were significantly lower (4.0 [3.0 - 6.0] v 7.0 [3.0 - 9.0], p = 0.043; 0.0 cm [0.0 - 2.0] v 1.5 cm [0.3 - 3.0], p = 0.030). VAS did not differ between groups at later points.

CONCLUSIONS

Preoperative PSPB + IPPB reduced 24-hour postextubation opioid consumption, pain at extubation, and OBAS. Given its low risk and expedient placement, it could be a helpful addition to MICS protocols. Future studies should evaluate these findings in multicenter settings and further elucidate the optimal timing of block placement.

Efficacy of Erector Spinae Plane Block (ESPB) in pediatric cardiac surgeries: a systematic review and meta-analysis

BACKGROUND

Erector Spinae Plane Block (ESPB) effectively reduces pain scores for sternotomy in adults. However, evidence is insufficient to assert that the same result occurs in children. The aim of this systematic review and meta-analysis was to evaluate the efficacy of ESPB in pediatric cardiac surgeries.

METHODS

Systematic Medline, Embase and Cochrane searches were conducted for studies that compared ESPB versus no block or sham block for pediatric cardiac surgery under sternotomy. The primary outcome was cumulative opioid consumption for up to 48 hours. Statistical analyses were carried out with the use of RStudio version 1.2.1335. Heterogeneity was assessed by Cochran's Q test and I2 statistics. Quality assessment and risk of bias assessment complied with Cochrane recommendations.

RESULTS

Five studies, involving 328 patients (3 Randomized Controlled Trials [RCT], and 2 cohorts) were included. Of the 328 patients, 160 (48.7%) underwent ESPB. There were significant reductions in cumulative opioid consumption up to 48 hours after ESPB (SMD -0.68; 95% CI -1.13 - -0.23; p < 0.01). In the following outcomes ESPB failed to show superiority: postoperative nausea and vomiting (OR = 0.56; 95% CI 0.25-1.23; p = 0.54), fever (OR = 0.75; 95% CI 0.24-2.31; p = 0.58), length of intensive care unit stay in hours (MD -2.42; 95% CI -5.47-0.64; p < 0.01] and length of hospital stay in days (MD -0.87; 95% CI -2.69-0.96; p = 0.02). Only one cohort study had a high risk of bias.

CONCLUSION

ESPB potentially reduces postoperative pain by significant reductions in cumulative opioid consumption up to 48 hours in pediatric cardiac surgery patients.

Clinical Benefits of Parasternal Block with Multihole Catheters when Inserted before Sternotomy

BACKGROUND

The aim of this study was to assess whether parasternal block with multihole catheters inserted before surgical incision enables to alleviate postoperative analgesia and opioid reduction in cardiac surgery patients with sternotomy.

METHODS

Twenty-six adult patients scheduled for cardiac surgery with sternotomy aged between 18 and 84 olds were included in this prospective, monocentric, open, single-group trial. Two parasternal multihole catheters were inserted on each side of the sternum before the surgical skin incision for cardiac surgery and 10 mL of ropivacaine 7.5 mg mL-1 was initially administered in each catheter. Local anesthetic administration followed by continued infusion at 3 mL hr-1 of ropivacaine 2 mg mL-1 per catheter for 48 h postoperatively upon patient arrival in the intensive care unit. The efficacy of the parasternal block was assessed according to a composite endpoint including pain score at rest, pain score during movements (dynamic pain), and morphine consumption over 48 hours.

RESULTS

The treatment failed in 11 patients and was considered effective in 15 patients. Sixteen patients out of 26 had a sternal pain score ≤3/10 on more than 75% of observations, and the treatment was considered successful. In 23/26 patients (88%), the mean pain score at cough was ≤3.5/10 and the treatment was considered successful. Morphine consumption over 48 h was significantly lower in the intervention group compared to the control group 7 mg [6; 21] versus 142 mg [116; 176] (P < 0.001).

CONCLUSIONS

Parasternal block with multihole catheters inserted before the surgical incision is an effective technique for postoperative analgesia and opioid reduction.

Nerve Blocks for Post-Surgical Pain Management: A Narrative Review of Current Research

Opioids remain the mainstay of post-surgical pain management; however, concerns regarding addiction and side effects necessitate the exploration of alternatives. This narrative review highlights the potential of nerve blocks as a safe and effective strategy for post-surgical pain control. This review explores the use of various nerve block techniques tailored to specific surgical procedures. These include nerve blocks for abdominal surgeries; fascial plane blocks for chest surgeries; nerve blocks for arm surgeries; and nerve blocks for lower limb surgery including; femoral, hip, and knee surgeries. By targeting specific nerves, these blocks can provide targeted pain relief without the negative side effects associated with opioids. Emerging evidence suggests that nerve blocks can be as effective as opioids in managing pain, while potentially offering additional benefits such as faster recovery, improved patient satisfaction, and reduced reliance on opioids. However, the effectiveness of nerve blocks varies depending on type of surgery, and in individual patients. Rebound pain, which temporary increase in pain after a block wears off, can occur. In addition, some techniques require specialized guidance for accurate placement. In conclusion, nerve blocks show great promise as effective alternatives for managing post-surgical pain. They can reduce the need for opioids and their side effects, leading to better patient outcomes and satisfaction. Future studies should assess the long-term impacts of specific nerve blocks on mortality rates, cost-effectiveness, and their incorporation into multimodal pain management approaches to further enhance post-surgical care.

Postoperative pain management after thoracic transplantations

PURPOSE OF REVIEW

Heart and lung transplantation evolution marked significant milestones. Pioneering efforts of Dr Christiaan Barnard with the first successful heart transplant in 1967, followed by advancements in heart-lung and single-lung transplants by Drs Bruce Reitz, Norman Shumway, and Joel Cooper laid the groundwork for contemporary organ transplantation, offering hope for patients with end-stage heart and pulmonary diseases.

RECENT FINDINGS

Pretransplant opioid use in heart transplant recipients is linked to higher mortality and opioid dependence posttransplant. Effective pain control is crucial to reduce opioid-related adverse effects and enhance recovery. However, research on specific pain management protocols for heart transplant recipients is limited. In lung transplantation effective pain management is crucial. Studies emphasize the benefits of multimodal strategies, including thoracic epidural analgesia and thoracic paravertebral blocks, to enhance recovery and reduce opioid use. Perioperative pain control challenges in lung transplantation are unique and necessitate careful consideration to prevent complications and improve outcomes.

SUMMARY

This review emphasizes the importance of tailored pain management in heart and lung transplant recipients. It advocates for extended follow-up and alternative analgesics to minimize opioid dependency and enhance quality of life. Further high-quality research is needed to optimize postoperative analgesia and improve patient outcomes.

Randomized Controlled Trial of Ultrasound-Guided Parasternal Intercostal Nerve Block and Transversus Thoracis Muscle Plane Block for Postoperative Analgesia of Cardiac Surgical Patients

BACKGROUND

Transversus thoracis muscle plane block (TTPB) and parasternal intercostal nerve block (PICNB) inhibit the anterior branches of intercostal nerves and potentially provide adequate analgesia after cardiac surgery. This study aimed to compare these two blocks for a reduction in postoperative opioid consumption after cardiac surgery.

METHODS

This randomized, single-blind trial included 60 adult cardiac surgical patients divided into three groups to receive ultrasound-guided TTPB (group T), PICNB (group P), or no block (group C) before surgery. All patients received standard anesthesia with intravenous etomidate, fentanyl, midazolam, and vecuronium. Postoperative fentanyl consumption in the first 24 hours was the primary outcome variable. Secondary outcomes were pain fentanyl consumption in 48 hours, intensity, analgesia duration, heart rate, mean arterial pressure, and complications.

RESULTS

The groups had similar baseline characteristics. The duration of analgesia was longer, while the intensity of pain and opioid consumption were statistically lower (p<0.01) in groups P and T compared to group C. The differences between groups P and T were not statistically significant. Fentanyl consumption in the first 24 hours was 284.00±37.61 µg, 293.00±35.11 µg, and 383.40±57.21 µg in groups P, T, and C, respectively. Other outcome variables were statistically similar among the groups.

CONCLUSION

Both TTPB and PICNB produce equivalent and satisfactory postoperative analgesia, reducing the postoperative fentanyl use in 24 hours for patients undergoing elective cardiac surgery.

Image-guided peripheral nerve interventions- applications and techniques

Interventional radiology continues to be at the forefront of acute and chronic pain management. Our unique imaging expertise and ability to target difficult to reach structures allows for the continuous development of new ways to treat a variety of pain generators. In addition, the advent of thermal ablation techniques and technologies has provided a unique opportunity to offer patients more durable and predictable options to treat their pain. This is particularly important during the opioid epidemic, as multiple local and international governmental bodies push for physicians to create ways to manage pain while reducing the need for long-term opioid dependence. This article aims to review various image-guided techniques and tools for the treatment of pain related to peripheral pain generators, with a focus on the extremities, lumbosacral and pelvic region, and the chest wall. For each target and pathology, we will discuss general etiology, anatomy, procedural approach, and briefly evaluate the supporting literature in each clinical situation.

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.

Efficacy of bilateral catheter superficial parasternal intercostal plane blocks using programmed intermittent bolus for opioid-sparing postoperative analgesia in cardiac surgery with sternotomy: A randomized, double-blind, placebo-controlled trial

STUDY OBJECTIVE

This study investigated whether catheter superficial parasternal intercostal plane (SPIP) blocks, using a programmed intermittent bolus (PIB) with ropivacaine, could reduce opioid consumption while delivering enhanced analgesia for a period exceeding 48 h following cardiac surgery involving sternotomy.

DESIGN

A double-blind, prospective, randomized, placebo-controlled trial.

SETTING

University-affiliated tertiary care hospital.

PATIENTS

60 patients aged 18 or older, scheduled for cardiac surgery via sternotomy.

INTERVENTIONS

The patients were randomly assigned in a 1:1 ratio to either the ropivacaine or saline group. After surgery, patients received bilateral SPIP blocks for 48 h with 0.4% ropivacaine (20 mL per side) for induction, followed by bilateral SPIP catheters using PIB with 0.2% ropivacaine (8 mL/side, interspersed with a 2-h interval) or 0.9% normal saline following the same administration schedule. All patients were administered patient-controlled analgesia with hydromorphone.

MEASUREMENTS

The primary outcome was the cumulative morphine equivalent consumption during the initial 48 h after the surgery. Secondary outcomes included postoperative pain assessment using the Numeric Rating Scale (NRS) at rest and during coughing at designated intervals for three days post-extubation. Furthermore, recovery indicators and ropivacaine plasma levels were diligently documented.

MAIN RESULTS

Cumulative morphine consumption within 48 h in ropivacaine group decreased significantly compared to saline group (25.34 ± 31.1 mg vs 76.28 ± 77.2 mg, respectively; 95% CI, -81.9 to -20.0, P = 0.002). The ropivacaine group also reported lower NRS scores at all recorded time points (P < 0.05) and a lower incidence of nausea and vomiting than the saline group (3/29 vs 12/29, respectively; P = 0.007). Additionally, the ropivacaine group showed significant improvements in ambulation (P = 0.018), respiratory exercises (P = 0.006), and self-reported analgesia satisfaction compared to the saline group (P = 0.016).

CONCLUSIONS

Bilateral catheter SPIP blocks using PIB with ropivacaine reduced opioid consumption over 48 h, concurrently delivering superior postoperative analgesia in adult cardiac surgery with sternotomy.

Comparison of Continuous Thoracic Epidural Analgesia Versus Bilateral Erector Spinae Plane Block for Pain Management in Coronary Bypass Surgery

Background Effective pain control is vital for patients undergoing heart surgery. Utilizing a multimodal approach to analgesia is essential, as poor pain management can result in hemodynamic and systemic complications. This study aimed to compare perioperative pain management techniques in patients undergoing coronary artery bypass grafting (CABG), specifically evaluating continuous thoracic epidural analgesia and ultrasound-guided bilateral erector spinae block. Methods This randomized comparative study was conducted at a tertiary care centre over a period of six months, with approval from the institute's ethics committee. A total of 24 patients undergoing CABG under general anesthesia participated in the study. They were randomly assigned to either the continuous thoracic epidural analgesia (TEA) group (Group A) or the ultrasound-guided bilateral erector spinae plane (ESP) block group (Group B) using a simple randomization method. The study assessed intraoperative intravenous opioid requirements for maintaining stable hemodynamics, as well as postoperative resting and coughing Visual Analog Scale (VAS) scores and peak inspiratory spirometry. Results Twelve patients from each group completed the study, with comparable demographics (age, gender). Both groups exhibited similar resting and coughing VAS scores at 0, 3, 6, and 12 hours postoperatively (p > 0.05). However, at 24, 36, and 48 hours, Group A had significantly higher VAS scores compared to Group B (p < 0.05). Group A maintained an overall mean VAS score of 4 or less during rest and coughing. Peak inspiratory spirometry results were consistent between both groups (p > 0.05). Conclusion The ultrasound-guided bilateral erector spinae block provided pain control comparable to thoracic epidural analgesia, making it a viable alternative for perioperative pain management. This is particularly beneficial for CABG patients where early postoperative anticoagulant therapy is crucial for graft patency. Effective pain management also contributes to faster recovery in coronary artery bypass grafting.

Blood bupivacaine concentrations after pecto-serratus and serratus anterior plane injections of plain and liposomal bupivacaine in robotically-assisted mitral valve surgery: Sub-study of a randomized trial

STUDY OBJECTIVE

To investigate the timing of peak blood concentrations and potential toxicity when using a combination of plain and liposomal bupivacaine for thoracic fascial plane blocks.

DESIGN

Pharmacokinetic analysis.

SETTING

Operating room.

PATIENTS

Eighteen adult patients undergoing robotically-assisted mitral valve surgery.

INTERVENTIONS

Ultrasound-guided pecto-serratus and serratus anterior plane blocks using a mixture of 0.5% bupivacaine HCl up to 2.5 mg/kg and liposomal bupivacaine up to 266 mg.

MEASUREMENTS

Arterial plasma bupivacaine concentration.

MAIN RESULTS

Samples from 13 participants were analyzed. There was substantial inter-patient variability in plasma concentrations. A geometric mean maximum bupivacaine concentration was 1492 ng/ml (range 660 to 4650 ng/ml) at median time of 30 min after injection. In 4/13 (31%) patients, plasma bupivacaine concentrations exceeded our predefined 2000 ng/ml toxic threshold. A second much smaller peak was observed about 32 h after the injection. No obvious signs of local anesthetic toxicity were observed.

CONCLUSIONS

Combined injection of plain and liposomal bupivacaine for pecto-serratus/serratus anterior plane blocks produced a biphasic pattern, with the highest arterial plasma concentrations observed within 30 min. Maximum concentrations exceeded the potential toxic threshold in nearly a third of patients, but without clinical evidence of toxicity. Clinicians should not assume that routine combinations of plain and liposomal bupivacaine for thoracic fascial plane blocks are inherently safe.

Start Strong, Finish Strong: A Review of Prehabilitation in Cardiac Surgery

Cardiac surgery constitutes a significant surgical insult in a patient population that is often marred by significant comorbidities, including frailty and reduced physiological reserve. Prehabilitation programs seek to improve patient outcomes and recovery from surgery by implementing a number of preoperative optimization initiatives. Since the initial trial of cardiac prehabilitation twenty-four years ago, new data have emerged on how to best utilize this tool for the perioperative care of patients undergoing cardiac surgery. This review will explore recent cardiac prehabilitation investigations, provide clinical considerations for an effective cardiac prehabilitation program, and create a framework for future research studies.

Rectus sheath block added to parasternal block may improve postoperative pain control and respiratory performance after cardiac surgery: a superiority single-blinded randomized controlled clinical trial

BACKGROUND

The population undergoing cardiac surgery confronts challenges from uncontrolled post-sternotomy pain, with possible adverse effects on outcome. While the parasternal block can improve analgesia, its coverage may be insufficient to cover epigastric area. In this non-blinded randomized controlled study, we evaluated the analgesic and respiratory effect of adding a rectus sheath block to a parasternal block.

METHODS

58 patients undergoing cardiac surgery via median sternotomy were randomly assigned to receive parasternal block with rectus sheath block (experimental) or parasternal block with epigastric exit sites of chest drains receiving surgical infiltration of local anesthetic (control). The primary outcome of this study was pain at rest at extubation. We also assessed pain scores at rest and during respiratory exercises, opiate consumption and respiratory performance during the first 24 hours after extubation.

RESULTS

The median (IQR) maximum pain scores (on a 0-10 Numeric Rate Scale (NRS)) at extubation were 4 (4, 4) in the rectus sheath group and 5 (4, 5) in the control group (difference 1, p value=0.03). Rectus sheath block reduced opioid utilization by 2 mg over 24 hours (IC 95% 0.0 to 2.0; p<0.01), reduced NRS scores at other time points, and improved respiratory performance at 6, 12, and 24 hours after extubation.

CONCLUSION

The addition of a rectus sheath block with a parasternal block improves analgesia for cardiac surgery requiring chest drains emerging in the epigastric area.

TRIAL REGISTRATION NUMBER

NCT05764616.

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.

Ultrasound-guided erector spinae plane block for postoperative analgesia in patients undergoing minimally invasive direct coronary artery bypass surgery: a double-blinded randomized controlled trial

PURPOSE

Minimally invasive direct coronary artery bypass (MIDCAB) surgery is associated with significant postoperative pain. We aimed to investigate the efficacy of ultrasound-guided erector spinae plane block (ESPB) for analgesia after MIDCAB.

METHODS

We conducted randomized controlled trial in 60 patients undergoing MIDCAB who received either a single-shot ESPB with 30 mL of ropivacaine 0.5% (ESPB group, n = 30) or normal saline 0.9% (control group, n = 30). The primary outcome was numerical rating scale (NRS) pain scores at rest within 48 hr postoperatively. The secondary outcomes included postoperative NRS pain scores on deep inspiration within 48 hr, hydromorphone consumption, and quality of recovery-15 (QoR-15) score at 24 and 48 hr.

RESULTS

Compared with the control group, the ESPB group had lower NRS pain scores at rest at 6 hr (estimated mean difference, -2.1; 99% confidence interval [CI], -2.7 to -1.5; P < 0.001), 12 hr (-1.9; 99% CI, -2.6 to -1.2; P < 0.001), and 18 hr (-1.2; 99% CI, -1.8 to -0.6; P < 0.001) after surgery. The ESPB group also showed lower pain scores on deep inspiration at 6 hr (-2.9; 99% CI, -3.6 to -2.1; P < 0.001), 12 hr (-2.3; 99% CI, -3.1 to -1.5; P < 0.001), and 18 hr (-1.0; 99% CI, -1.8 to -0.2; P = 0.01) postoperatively. Patients in the ESPB group had lower total intraoperative fentanyl use, lower 24-hr hydromorphone consumption, a shorter time to extubation, and a shorter time to intensive care unit (ICU) discharge.

CONCLUSION

Erector spinae plane block provided early effective postoperative analgesia and reduced opioid consumption, time to extubation, and ICU discharge in patients undergoing MIDCAB.

TRIAL REGISTRATION

www.chictr.org.cn (ChiCTR2100052810); registered 5 November 2021.

Battle of the Blocks: Which Pain Management Technique Triumphs in Gender-Affirming Bilateral Mastectomies?

Background

Gender-affirming mastectomy, performed on transgender men and non-binary individuals, frequently leads to considerable postoperative pain. This pain can significantly affect both patient satisfaction and the overall recovery process. The study examines the efficacy of four analgesic techniques pectoral nerve (PECS) 2 block, erector spinae plane (ESP) block, thoracic wall local anesthesia infiltration (TWI), and systemic multimodal analgesia (SMA) in managing perioperative pain, with special consideration for the effects of chronic testosterone therapy on pain thresholds.

Methods

A retrospective analysis was conducted on patients aged 18 - 45 who underwent gender-affirming bilateral mastectomies at a New York City community hospital. The study compared intraoperative and post-anesthesia care unit (PACU) opioid consumption, postoperative pain scores, the interval to first rescue analgesia, and total PACU duration among the four analgesic techniques.

Results

The study found significant differences in intraoperative and PACU opioid consumption across the groups, with the PECS 2 block group showing the least opioid requirement. The PACU morphine milligram equivalent (MME) consumption was highest in the SMA group. Postoperative pain scores were significantly lower in the PECS and ESP groups at earlier time points post-surgery. However, by postoperative day 2, pain scores did not significantly differ among the groups. Chronic testosterone therapy did not significantly impact intraoperative opioid requirements.

Conclusion

The PECS 2 block is superior in reducing overall opioid consumption and providing effective postoperative pain control in gender-affirming mastectomies. The study underscores the importance of tailoring pain management strategies to the unique physiological responses of the transgender and non-binary community. Future research should focus on prospective designs, standardized block techniques, and the complex relationship between hormonal therapy and pain perception.

Efficacy of opioid-sparing analgesia after median sternotomy with continuous bilateral parasternal subpectoral plane blocks

OBJECTIVES

Regional anesthetic techniques, traditionally underutilized in cardiac surgery, may play a role in multimodal analgesia, effectively improving pain control and reducing opioid consumption. We investigated the efficacy of continuous bilateral ultrasound-guided parasternal subpectoral plane blocks following sternotomy.

METHODS

We reviewed all opioid-naïve patients who underwent cardiac surgery via median sternotomy under our enhanced recovery after surgery protocol between May 2018 and March 2020. Patients were grouped based on postoperative pain management strategy-those who received standard Enhanced Recovery After Surgery (ERAS) multimodal analgesia alone (no nerve block group) versus those receiving ERAS multimodal analgesia plus continuous bilateral parasternal subpectoral plane blocks (block group). In the block group, parasternal subpectoral plane catheters were placed under ultrasound-guidance on each side of the sternum with initial 0.25% ropivacaine bolus, followed by continuous 0.125% bupivacaine infusions. Postoperative patient-reported numerical rating scale pain scores and opioid consumption in morphine milligram equivalents were compared through postoperative day 4.

RESULTS

Of 281 patients included in the study, the block group comprised 125 (44%) patients. Although baseline characteristics, type of surgery, and length of stay were similar between groups, average numerical rating scale pain scores and opioid consumption were significantly lower in the block group through postoperative day 4 (all P values < .05). We also observed a 44% reduction in total opioid consumption after surgery in the block group (75.1 vs 133.1 MME; P = .001) and 1 less hospital day requiring opioids (4.2 vs 3 days; P = .001).

CONCLUSIONS

Continuous bilateral parasternal subpectoral plane blocks may further reduce poststernotomy pain and opioid consumption within the context ERAS multimodal analgesia.

Preemptive deep parasternal intercostal plane block for perioperative analgesia in coronary artery bypass grafting with sternotomy: a randomized, observer-blind, controlled study

OBJECTIVE

The precise characteristics of deep parasternal intercostal plane block (DPIP), which is useful for providing analgesia during open heart surgery, have not yet been thoroughly elucidated. In this study, we aimed to establish the efficacy, define the cutaneous sensory block area, and determine the duration of preemptive DPIP block at the T3-4 or T4-5 intercostal spaces in patients undergoing coronary artery bypass grafting (CABG) via sternotomy.

DESIGN

A prospective, single-blind, randomized controlled trial.

SETTING

Patients were randomly divided into three cohorts, each containing thirty patients.

PARTICIPANTS

Ninety patients who underwent elective CABG via sternotomy were included in this study.

INTERVENTIONS

The T3-4 and T4-5 groups received a preoperative single-shot DPIP block at the respective intercostal spaces. The principal objective of the study was to ascertain the optimal dosage of sufentanil administered during surgical procedures involving either a DPIP block or its absence, and to conduct a comparative analysis thereof across distinct injection sites, specifically T3-4 and T4-5. Secondary factors considered were the dosage of postoperative analgesics, the extent of sensory block on the skin, pain levels after extubation, time of recovery from anesthesia (time to extubation), duration of the block, and the occurrence of nausea and vomiting.

MEASUREMENTS & MAIN RESULTS

Preemptive DPIP block significantly reduced intraoperative sufentanil requirement compared to the control group (T3-4:0.38 ± 0.1, T4-5:0.32 ± 0.10, vs. Control:0.88 ± 0.3 μg/kg/h, p < 0.001). It also resulted in decreased analgesic consumption and numeric rating scale scores on the day of surgery (p < 0.01 compared to the control group). The DPIP block provided accurate anesthetic coverage of the dermatomes in the sternal region and reduced the time to extubation and postoperative nausea. However, the injection point (either via the T3-4 intercostal or the T4-5 intercostal) did not affect the efficacy. Preoperative DPIP block failed to provide adequate analgesia beyond 24 h post-surgery.

CONCLUSION

Preemptive bilateral DPIP block provided effective analgesia in patients undergoing CABG during surgery and in the early postoperative period. The analgesic effects of the DPIP block in the T3-4 and T4-5 intercostal spaces were comparable.

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.

Additive value of superficial parasternal intercostal plane block and serratus anterior plane block in lung transplantation surgery: a retrospective exploratory study

BACKGROUND

Adequate pain control following lung transplantation (LTx) surgery is paramount. Thoracic epidural analgesia (TEA) is the gold standard; however, the potential use of extracorporeal membrane oxygenation (ECMO) and consequent anticoagulation therapy raises safety concerns, prompting clinicians to seek safer alternatives. The utility of thoracic wall blocks in general thoracic surgery is well established; however, their role in the context of LTx has been poorly investigated.

METHODS

In this retrospective exploratory study, we assessed the effect of adding a superficial parasternal intercostal plane (sPIP) block and serratus anterior plane (SAP) block to standard anesthetic and analgesic care on tracheal extubation rates, pain scores and opioid consumption until 72 hours postoperatively in LTx.

RESULTS

Sixty patients were included in the analysis; 35 received the standard anesthetic and analgesic care (control group), and 25 received sPIP and SAP blocks in addition to the standard anesthetic and analgesic care (intervention group). We observed higher tracheal extubation rates in the intervention group at 8 hours postoperatively (16.0% vs 0.0%, p=0.03). This was also shown after adjusting for known prognostic factors (OR 1.18; 95% CI 1.04 to 1.33, p=0.02). Furthermore, we noted a lower opioid consumption measured by morphine milligram equivalents at 24 hours in the intervention group (median 405 (IQR 300-490) vs 266 (IQR 168-366), p=0.02). This was also found after adjusting for known prognostic factors (β -118; 95% CI -221 to 14, p=0.03).

CONCLUSION

sPIP and SAP blocks are safe regional analgesic techniques in LTx involving ECMO and clamshell incision. They are associated with faster tracheal extubation and lower opioid consumption. These techniques should be considered when TEA is not appropriate. Further high-quality studies are warranted to confirm these findings.

Efficacy of ultrasound-guided erector spinae plane block on analgesia and quality of recovery after minimally invasive direct coronary artery bypass surgery: protocol for a randomized controlled trial

BACKGROUND

Minimally invasive direct coronary artery bypass (MIDCAB) surgery offers an effective option for coronary artery disease (CAD) patients with the avoidance of median sternotomy and fast postoperative recovery. However, MIDCAB is still associated with significant postoperative pain which may lead to delayed recovery. The erector spinae plane block (ESPB) is a superficial fascial plane block. There have not been randomized controlled trials evaluating the effects of ESPB on analgesia and patient recovery following MIDCAB surgery. We therefore designed a double-blind prospective randomized placebo-controlled trial, aiming to prove the hypothesis that ESPB reduces postoperative pain scores in patients undergoing MIDCAB surgery.

METHODS

The study protocol has been reviewed and approved by the Ethical Review Committee of Peking University People's Hospital. Sixty adult patients of either sex scheduled for MIDCAB surgery under general anesthesia (GA) will be included. Patients will be randomly allocated to receive either a preoperative single-shot ESPB with 30 mL of ropivacaine 0.5% (ESPB group) or normal saline 0.9% (control group). The primary outcomes are the difference between the two groups in numeric rating scale (NRS) scores at rest at different time points (6, 12, 18, 24, 48 h) after surgery. The secondary outcomes include NRS scores on deep inspiration within 48 h, postoperative hydromorphone consumption, and quality of patient recovery at 24 h and 48 h, using the Quality of Recovery-15 (QoR-15) scale. The other outcomes include intraoperative fentanyl requirements, the need for additional postoperative rescue analgesics, time to tracheal extubation and chest tube removal after surgery, incidence of postoperative nausea and vomiting (PONV) and postoperative cognitive dysfunction (POCD), intensive care unit (ICU) length of stay (LOS), hospital discharge time, and 30-day mortality. Adverse events will be also evaluated.

DISCUSSION

This is a novel randomized controlled study evaluating a preoperative ultrasound-guided single-shot unilateral ESPB on analgesia and quality of patient recovery in MIDCAB surgery. The results of this study will characterize the degree of acute postoperative pain and clinical outcomes following MIDCAB. Our study may help optimizing analgesia regimen selection and improving patient comfort in this specific population.

TRIAL REGISTRATION

The study was prospectively registered with the Chinese Clinical Trial Registry (trial identifier: ChiCTR2100052810). Date of registration: November 5, 2021.

Inadvertent Puncture of Dilated Right Ventricle During Transversus Thoracic Muscle Plane Block: Lessons Learnt

ABSTRACT

The transversus thoracic muscle plane (TTP) block is gaining widespread recognition in cardiac surgery, particularly in facilitating fast-tracking. Here, we report a case of inadvertent puncture of the right ventricle (RV) during the administration of ultra sound-guided (USG) TTP block in a 3-year-old child posted for atrial septal defect (ASD) closure and mitral valve repair. We also discuss the care that should be taken to avoid such complications and such cases require extra caution during TTP block.

Safety and feasibility of ultrasound-guided serratus anterior plane block and intercostal nerve block for management of post-sternotomy pain in pediatric cardiac patients: A prospective, randomized trial

BACKGROUND

Postoperative analgesia in the cardiothoracic ICU has traditionally relied on intravenous opioids. Thoracic nerve blocks are attractive alternatives for analgesia that reduce the requirement for opioids, but their safety and feasibility remain unclear.

METHODS

Sixty children were allocated randomly to three groups: group C received intravenous opioids alone, while group SAPB (deep serratus anterior plane block) and group ICNB (intercostal nerve block) received opioids combined with ultrasound-guided regional nerve blocks (0.2% ropivacaine 2.5 mg.kg-1) after patients were transferred to the ICU. The primary outcome was opioid requirement in the first 24 h after surgery. Other outcomes included the postoperative FLACC scale value, tracheal extubation time, and plasma ropivacaine concentrations after the block.

RESULTS

The mean [sd] cumulative dose of opioids administered postoperatively within 24 h in the SAPB (168.6 [76.9] μg.kg-1) and ICNB groups (170.0 [86.8] μg.kg-1) were significantly lower by nearly 53% than those in group C (359.3 [125.3] μg.kg-1, p = 0.000). The tracheal extubation time was shorter in the regional block groups than that in the control group, but the difference was not statistically significant (p = 0.177). The FLACC scale values at 0, 1, 3, 6, 12, and 24 h post-extubation were similar in the three groups. The mean peak plasma ropivacaine concentrations in the SAP and ICNB groups were 2.1 [0.8] and 1.8 [0.7] mg.L-1, respectively, 10 min post-block and then slowly decreased. No noticeable complications associated with regional anesthesia were observed.

CONCLUSIONS

Ultrasound-guided SAPB and ICNB provided safe and satisfactory early postoperative analgesia while reducing opioid consumption following sternotomy in pediatric patients.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiChiCTR2100046754.

Pain management and opioid stewardship in adult cardiac surgery: Joint consensus report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society

BACKGROUND

Opioid-based anesthesia and analgesia is a traditional component of perioperative care for the cardiac surgery patient. Growing enthusiasm for Enhanced Recovery Programs (ERPs) coupled with evidence of potential harm associated with high-dose opioids suggests that we reconsider the role of opioids in cardiac surgery.

METHODS

An interdisciplinary North American panel of experts, using a structured appraisal of the literature and a modified Delphi method, derived consensus recommendations for optimal pain management and opioid stewardship for cardiac surgery patients. Individual recommendations are graded based on the strength and level of evidence.

RESULTS

The panel addressed 4 main topics: the harms associated with historical opioid use, the benefits of more targeted opioid administration, the use of nonopioid medications and techniques, and patient and provider education. A key principle that emerged is that opioid stewardship should apply to all cardiac surgery patients, entailing judicious and targeted use of opioids to achieve optimal analgesia with the fewest potential side effects. The process resulted in the promulgation of 6 recommendations regarding pain management and opioid stewardship in cardiac surgery, focused on avoiding the use of high-dose opioids, as well as encouraging more widespread application of foundational aspects of ERPs, such as the use of multimodal nonopioid medications and regional anesthesia techniques, formal patient and provider education, and structured system-level opioid prescription practices.

CONCLUSIONS

Based on the available literature and expert consensus, there is an opportunity to optimize anesthesia and analgesia for cardiac surgery patients. Although additional research is needed to establish specific strategies, core principles of pain management and opioid stewardship apply to the cardiac surgery population.

Role of Cardiac Anesthesiologists in Intraoperative Enhanced Recovery After Cardiac Surgery (ERACS) Protocol: A Retrospective Single-Center Study Analyzing Preliminary Results of a Yearlong ERACS Protocol Implementation

INTRODUCTION

Enhanced recovery after cardiac surgery (ERACS) has been gaining rapid acceptance after multiple studies have demonstrated promising results in improved outcomes of enhanced recovery after surgery in other surgical fields (eg, colorectal, orthopedic, thoracic, etc). Cardiac surgery has several unique challenges, including sternotomy, cardiopulmonary bypass and associated coagulopathy, blood transfusion, and postoperative intensive care requirement. Nonetheless, selective cardiac surgical patients can still benefit from ERACS. Guidelines for perioperative care in cardiac surgery, previously published by the ERACS Society, are weighted heavily in preoperative and postoperative management without much focus on intraoperative care provided by anesthesiologists. To address this gap and to explore anesthesiology's contribution in achieving ERACS, the study authors' cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol in their institution in February 2020.

METHODS

The cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol consisting of multimodal opioid-sparing analgesia, including the introduction of regional blocks, hemostasis management protocol, reversal of neuromuscular blockade, and administration of antiemetics in the authors' institution in February 2020. They have conducted a retrospective chart review study comparing patients who have received ERACS measures with a similar historic cohort who underwent cardiac surgery prior to initiation of an ERACS protocol. The primary outcomes of the study were to determine patients' time to extubation, postoperative opioid consumption, intensive care unit (ICU) length of stay (LOS), and incidence of postoperative complications (eg, postoperative nausea vomiting [PONV], bleeding, ICU readmission, delirium.

RESULTS

The ERACS patients showed reduced opioid consumption (intraoperative fentanyl; postoperative fentanyl, as well as oxycodone, in the first 6 hours postoperatively), lesser mechanical ventilation (2.5 hours less), shorter ICU stays (5 hours less), shorter hospital LOS (1 day), and lesser incidence of PONV. None of the ERACS patients required blood transfusion. The study authors performed an anonymous survey among the anesthesiologists and ICU providers to assess providers' satisfaction, which showed 92% of survey takers agreed that the ERACS protocol should be continued for future cardiac patients, and 61% of survey takers reported superior pain control in ERACS group of patients while managing those patients.

DISCUSSION

The ERACS is achievable after the careful implementation of a series of measures. It does not signify only fast-track extubation and opioid-sparing analgesia, and must be implemented in the entire perioperative period beginning from preoperative clinic to postoperative rehabilitation. Cardiac anesthesiologists play a vital role in execution of intraoperative ERACS measures. Both providers and patients themselves are key stakeholders. A larger randomized prospective trial is warranted to solidify the inference.

Chest Wall and Abdominal Blocks for Thoracic and Abdominal Surgeries: A Review

PURPOSE OF REVIEW

The purpose of this review is to provide an up-to-date description and overview of the rapidly growing literature pertaining to techniques and clinical applications of chest wall and abdominal fascial plane blocks in managing perioperative pain.

RECENT FINDINGS

Clinical evidence suggests that regional anesthesia blocks, including fascial plane blocks, such as pectoralis, serratus, erector spinae, transversus abdominis, and quadratus lumborum blocks, are effective in providing analgesia for various surgical procedures and have more desirable side effect profile when compared to traditional neuraxial techniques. They offer advantages such as reduced opioid consumption, improved pain control, and decreased opioid-related side effects. Further research is needed to establish optimal techniques and indications for these blocks. Presently, they are a vital instrument in a gamut of multimodal analgesia options, especially when there are contraindications to neuraxial or para-neuraxial procedures. Ultimately, clinical judgment and provider skill set determine which blocks-alone or in combination-should be offered to any patient.

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.

The impact of PECS II blockade in patients undergoing minimally invasive cardiac surgery-a prospective, randomized, controlled, and triple-blinded trial

BACKGROUND

Classic neuraxial techniques, such as thoracic epidural anesthesia, or alternative approaches like the paravertebral block, are not indicated in cardiac surgery due to increased bleeding risk. To provide satisfactory analgesia without the need for excessive opioid use, novel ultrasound techniques gained popularity and are of growing interest. The pectoralis nerve block II (PECS II) has been shown to provide good postoperative analgesia in modified radical mastectomy and might also be suitable for minimally invasive cardiac surgery.

METHODS

In a single center, prospective, triple-blinded, two-group randomized trial, 60 patients undergoing elective, unilateral minimal invasive cardiac surgery will be randomized to receive a PECS II with 30 ml of ropivacaine 0.5% (intervention group) or sodium chloride 0.9% (placebo group). The primary outcome parameter is the overall opioid demand given as intravenous morphine milligram equivalents (MME) during the first 24 h after extubation. Secondary endpoints are the visual analog scale (VAS) 2, 4, 6, 8, 12, and 24 h after extubation, the Overall Benefit of Analgesia Score (OBAS) after 24 h, the interval until extubation, and intensive care unit (ICU) discharge within 24 h, as well as the length of hospital stay (LOS).

DISCUSSION

This prospective randomized, controlled, and triple-blinded trial aims to assess if a PECS II with ropivacaine 0.5% helps to decrease the opioid demand in the first 24 h and increases postoperative pain control after minimally invasive cardiac surgery.

TRIAL REGISTRATION

www.clinicaltrialsregister.eu ; EudraCT Nr: 2021-005452-11; Lukas Gasteiger MD, November 18, 2021.

Serratus anterior fascia plane block for pain control in patients with multiple rib fractures

[Purpose] Respiratory physiotherapy plays an important role in the management of acute respiratory disturbance; however, chest pain often impedes patients from performing respiratory physiotherapy. In this study, we investigated whether pain due to multiple rib fractures can be managed with intermittent serratus anterior fascia plane (SAP) block. [Participants and Methods] We performed intermittent SAP blocks in three consecutive patients with pain due to multiple rib fractures based on the level of pain. The level of pain and differences in expiratory/inspiratory chest expansion were evaluated before and after performing the SAP block. [Results] All three patients reported an improvement in the severity of pain and increase in the thoracic range of motion after receiving the SAP block. No adverse events associated with intermittent SAP blocks were observed in any of the patients. [Conclusion] We report the cases of three patients who completed respiratory physiotherapy after receiving intermittent SAP blocks for the management of pain due to multiple rib fractures. SAP blocks are associated with a low risk of complications as the ribs are not punctured while performing SAP blocks.

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 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.

Serratus anterior and pectoralis plane blocks for robotically assisted mitral valve repair: a randomised clinical trial

BACKGROUND

Minimally invasive cardiac surgery provokes substantial pain and therefore analgesic consumption. The effect of fascial plane blocks on analgesic efficacy and overall patient satisfaction remains unclear. We therefore tested the primary hypothesis that fascial plane blocks improve overall benefit analgesia score (OBAS) during the initial 3 days after robotically assisted mitral valve repair. Secondarily, we tested the hypotheses that blocks reduce opioid consumption and improve respiratory mechanics.

METHODS

Adults scheduled for robotically assisted mitral valve repairs were randomised to combined pectoralis II and serratus anterior plane blocks or to routine analgesia. The blocks were ultrasound-guided and used a mixture of plain and liposomal bupivacaine. OBAS was measured daily on postoperative Days 1-3 and were analysed with linear mixed effects modelling. Opioid consumption was assessed with a simple linear regression model and respiratory mechanics with a linear mixed model.

RESULTS

As planned, we enrolled 194 patients, with 98 assigned to blocks and 96 to routine analgesic management. There was neither time-by-treatment interaction (P=0.67) nor treatment effect on total OBAS over postoperative Days 1-3 with a median difference of 0.08 (95% confidence interval [CI]: -0.50 to 0.67; P=0.69) and an estimated ratio of geometric means of 0.98 (95% CI: 0.85-1.13; P=0.75). There was no evidence of a treatment effect on cumulative opioid consumption or respiratory mechanics. Average pain scores on each postoperative day were similarly low in both groups.

CONCLUSIONS

Serratus anterior and pectoralis plane blocks did not improve postoperative analgesia, cumulative opioid consumption, or respiratory mechanics during the initial 3 days after robotically assisted mitral valve repair.

CLINICAL TRIAL REGISTRATION

NCT03743194.

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.

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.

Thoracic Interfascial Plane Blocks and Outcomes After Minithoracotomy for Valve Surgery

Introduction. Thoracic interfascial plane blocks are increasingly used for pain management after minimally invasive thoracotomy for valve repair and replacement procedures. We hypothesized that the addition of these blocks to the intercostal nerve block injected by the surgeon would further reduce pain scores and opioid utilization. Methods. In this retrospective cohort study, 400 consecutive patients who underwent minimally invasive thoracotomy for mitral or aortic valve replacement and were extubated within 2 hours of surgery were enrolled. The maximum pain score and opioid utilization on the day of surgery and other outcome variables were compared between patients who received interfascial plane blocks and those who did not. Results.193 (48%) received at least one interfascial plane block while 207 (52%) received no interfascial plane block. Patients who received a thoracic interfascial plane block had a maximum VAS score on the day of surgery (mean 7.4 ± 2.5) after the block was administered which was significantly lower than patients in the control group who did not receive the block (mean 7.9 ± 2.2) (P = .02). Opioid consumption in the interfascial plane block group on the day of surgery was not significantly different from the control group. Conclusion. Compared to intercostal blocks alone, the addition of thoracic interfascial plane blocks was associated with a modest reduction in maximum VAS score on the day of surgery. However, no difference in opioid consumption was noted. Patients who received interfascial plane blocks also had decreased blood transfusion requirements and a shorter hospital length of stay.

Issues in patients' experiences of enhanced recovery after surgery (ERAS) : a systematic review of qualitative evidence

OBJECTIVE

To explore patients' experiences of enhanced recovery after surgery (ERAS) and to identify issues in the implementation of ERAS from the patient's perspective.

DESIGN

The systematic review and qualitative analysis were based on the Joanna Briggs Institute's methodology for conducting synthesis.

DATA SOURCES

Relevant studies published in four databases, that is, Web of Science, PubMed, Ovid Embase and the Cochrane Library, were systematically searched, and some studies were supplemented by key authors and reference lists.

STUDY SELECTION

Thirty-one studies were identified, involving 1069 surgical patients enrolled in the ERAS programme. The inclusion and exclusion criteria were formulated based on the Population, Interest of phenomena, Context, Study design criteria recommended by the Joanna Briggs Institute to determine the scope of article retrieval. The inclusion criteria were as follows: ERAS patients' experiences; qualitative data; English language and published from January 1990 to August 2021.

DATA EXTRACTION

Data were extracted from relevant studies using the standardised data extraction tool from Joanna Briggs Institute Qualitative Assessment and Review Instrument for qualitative research.

DATA SYNTHESIS

The themes in the structure dimension are as follows: (1) patients cared about the timeliness of healthcare professionals' help; (2) patients cared about the professionalism of family care; and (3) patients misunderstood and worried about the safety of ERAS. The themes in the process dimension are as follows: (1) patients needed adequate and accurate information from healthcare professionals; (2) patients needed to communicate adequately with healthcare professionals; (3) patients hoped to develop a personalised treatment plan and (4) patients required ongoing follow-up services. The theme in the outcome dimension is as follows: patients wanted to effectively improve severe postoperative symptoms.

CONCLUSIONS

Evaluating ERAS from the patient's perspective can reveal the omissions and deficiencies of healthcare professionals in clinical care so that problems in patients' recovery process can be solved in a timely manner, reducing potential barriers to the implementation of ERAS.

PROSPERO REGISTRATION NUMBER

CRD42021278631.

Perioperative Optimization of the Cardiac Surgical Patient

Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.

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.