Perspectives on the Role of Thoracic Fascial Blocks in Cardiac Anaesthesia: Will They Represent a New Era?

Cardiac surgery is continuously evolving, with increasing skills required by the cardiac anaesthesiologist. Following the advent of intraoperative echocardiography, we are witnessing a potential new revolution for the cardiac anaesthesiologist. A new era has indeed started with the implementation of thoracic fascial blocks (TFBs) in the field of cardiac surgery. TFBs provide several advantages in the context of multimodal analgesia, with improved pain control and reduction of the side effects related to large doses of opioids. We envisage that implementation of TFBs is likely to become a pivotal concept in the field of enhanced recovery after cardiac surgery. We describe the main TFBs for the anterior and/or antero-lateral chest wall, and their peculiar use in cardiac surgery. In particular, we discuss indications and tips and tricks to enhance clinical results for the following blocks: (1) Pecto-Intercostal Plane (superficial and deep); (2) Rectus Sheath; (3) Interpectoral Plane and Pectoserratus Plane; (4) Serratus Anterior Plane; (5) Erector Spinae Plane. Nonetheless, the scientific evidence for the use of TFBs in the field of cardiac anaesthesia is not robust yet, mostly based on small-sized single-centre studies, making it difficult to achieve a high quality of evidence. Further, it remains unclear which cardiac surgery patients may benefit the most from these techniques.

Fascial plane blocks for cardiothoracic surgery: a narrative review

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

Sensory Assessment and Block Duration of Deep Parasternal Intercostal Plane Block in Patients Undergoing Cardiac Surgery: A Prospective Observational Study

INTRODUCTION

There has been increasing interest in using deep parasternal intercostal plane (PIP) block as a supplement to multimodal analgesia regimens in cardiac surgery. The aim of this study was to observe cutaneous sensory block distribution and its duration for deep PIP blocks in patients undergoing open cardiac surgery.

METHODS

This observational, prospective clinical study consisted of 113 participants. All patients received bilateral ultrasound-guided deep PIP block with 40 ml 0.33% ropivacaine. The primary study outcome was cutaneous sensory block distribution of deep PIP blocks in patients undergoing open cardiac surgery. Secondary outcome included block duration in all participants. The area of cutaneous sensory block was tested by using a cold stimulus (ice cube) 30 min after the end of deep PIP block administration. Cutaneous sensory testing was performed once every hour after extubation until the return of normal sensation.

RESULTS

Thirty minutes after bilateral deep PIP block administration, the successful block rate of dermatomes T4 to T6 was almost 100%. However, T2 (percentage of left T2 block: 64.6%; percentage of right T2 block: 42.5%) and T3 (percentage of left T3 block: 88.5%; percentage of right T3 block: 87.6%) had a lower percentage of success. A few patients had blocked dermatomes at T1 or T7 (percentage of left T1 block: 7.08%; percentage of right T1 block: 2.65%; percentage of left T7 block: 6.19%; percentage of right T7 block: 10.6%). The mean effective duration of the deep PIP block was 17 h.

CONCLUSION

Bilateral deep PIP blocks can produce a widespread cutaneous sensory blockade with variable dermatomal distribution in the mid-sternum for a considerable effective duration.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100047755).

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.