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

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.

Effect of Low-dose Ketamine Infusion on Opioid Consumption in Children Undergoing Open Cardiac Surgery: A Randomized Controlled Double-Blind Study

OBJECTIVE

This study was designed to evaluate the effect of low-dose ketamine infusion on the perioperative consumption of opioids in pediatric open cardiac surgery.

DESIGN

A randomized, controlled, double-blinded single-center study was conducted.

SETTING

The study took place in a tertiary care children's hospital.

PARTICIPANTS

Patients of both sexes aged 2-12 years who underwent cardiac surgery were included.

INTERVENTIONS

Patients in the ketamine group received a bolus of 0.3 mg/kg of ketamine before skin incision followed by continuous intraoperative infusion of 0.25 mg/kg/h and postoperative infusion of 0.1 mg/kg/h for 24 h. Patients in the control groups received volumes of normal saline either bolus or continuous infusion like that of the ketamine group.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the total dose of fentanyl consumed over the first 24 hours postoperatively. Secondary outcomes were intraoperative fentanyl consumption, time to extubation, modified objective pain score, and incidence of vomiting, pruritus, diplopia, or hallucinations. A total of 80 patients were recruited but the final analysis was done on 35 patients in the ketamine group and 34 in the control group. Fentanyl consumption during surgery and in the first 24 hours postoperatively was significantly lower in the ketamine than the control group. Patients in both the ketamine and control groups had similar times to extubation. Modified objective pain scores were significantly lower in the ketamine group than the control group. None of the patients in either group had diplopia or hallucinations.

CONCLUSIONS

Low-dose ketamine infusion in children undergoing open cardiac surgery reduced intra- and postoperative opioid consumption and postoperative pain scores. Moreover, ketamine did not cause diplopia or hallucinations.

Regional analgesia using ultrasound-guided intermediate cervical plexus block versus cervical erector spinae block for anterior cervical spine surgery: a randomized trial

BACKGROUND

Regional analgesia techniques are crucial for pain management after cervical spine surgeries. Anesthesiologists strive to select the most effective and least hazardous regional analgesia technique for the cervical region. Our hypothesis is that an intermediate cervical plexus (IC) block can provide adequate postoperative analgesia compared to a cervical erector spinae (ES) block in patients undergoing anterior cervical spine surgery.

METHODS

In this double-blind prospective trial, 58 patients were randomly assigned into two equal groups prior to the administration of general anesthesia. Patients in the IC group (n = 29) underwent ultrasound-guided bilateral intermediate cervical plexus block with 15 ml of bupivacaine 0.25% administered to each side. The ES group (n = 29) underwent ultrasound-guided bilateral cervical erector spinae plane blocks with 15 ml of 0.25% bupivacaine administered to each side at the C6 level. The primary outcome was to record the time to the first call for rescue analgesia (nalbuphine), and the secondary outcomes were to measure the performance time, the onset of the sensory block, the intraoperative fentanyl consumption, postoperative pain intensity using VAS, the postoperative total nalbuphine consumption, and postoperative complications such as nausea, vomiting, hypotension, and bradycardia.

RESULTS

The performance and onset of sensory block times were significantly shorter in the IC group compared to the ES group. The time to first call for nalbuphine was significantly shorter in the IC group (7.31 ± 1.34 h) compared to the ES group (11.10 ± 1.82 h). The mean postoperative VAS scores were comparable between the two groups at the measured time points, except at 8 h, where it was significantly higher in the IC group, and at 12 h, where it was significantly higher in the ES group. The total nalbuphine consumption was significantly higher in the IC group (33.1 ± 10.13 mg) compared to the ES group (22.76 ± 8.62 mg).

CONCLUSIONS

For patients undergoing anterior cervical spine surgery, the intermediate cervical plexus block does not provide better postoperative regional analgesia compared to the cervical erector spinae block. Performance time and onset time were shorter in the IC group, whereas nalbuphine consumption was lower in the ES group.

TRIAL REGISTRATION

The trial was registered at clinicaltrials.gov. (NCT05577559, and the date of registration: 13-10-2022).

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

OBJECTIVES

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

DESIGN

A randomized, controlled, double-blinded study.

SETTING

The operating rooms and intensive care units of university hospitals.

PARTICIPANTS

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

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

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

Multi-modal analgesic strategies, including regional anesthesia techniques, have been shown to contribute to a reduction in the use of opioids and associated side effects in the perioperative setting. Consequently, those so-called multi-modal approaches are recommended and have become the state of the art in perioperative medicine. In the majority of intensive care units (ICUs), however, mono-modal opioid-based analgesic strategies are still the standard of care. The evidence guiding the application of regional anesthesia in the ICU is scarce because possible complications, especially associated with neuraxial regional anesthesia techniques, are often feared in critically ill patients. However, chest and abdominal wall analgesia in particular is often insufficiently treated by opioid-based analgesic regimes. This review summarizes the available evidence and gives recommendations for peripheral regional analgesia approaches as valuable complements in the repertoire of intensive care physicians' analgesic portfolios.

Erector spinae plane block as an anesthesia technique for an emergent thoracotomy; a case report

BACKGROUND

The erector spinae plane block (ESPB) is a novel regional block technique for pain management following thoracic surgeries. However, there are minimal cases in which the technique was used as the main anesthesia technique during surgery.

CASE PRESENTATION

Here, we report the successful use of ESBP for applying anesthesia in a case during an emergent thoracotomy for performing pericardiotomy and loculated tamponade evacuation.

CONCLUSIONS

Using ESPB with a higher concentration of local anesthetics, in this case, prepared appropriate anesthesia for performing an emergent thoracotomy while avoiding multiple needle insertions and the risk of further hemodynamic instability.

Impact of Chronic Kidney Disease on Clinical Outcomes during Hospitalization and Five-Year Follow-Up after Coronary Artery Bypass Grafting

Background

Chronic kidney disease (CKD) is often associated with multiple comorbidities including diabetes mellitus, and each has its own complications and impact after cardiac surgery including coronary revascularization. The objective of this work was to study the impact of CKD on clinical outcomes after coronary artery bypass grafting (CABG) and to compare outcomes in patients with different grades of renal functions. We retrospectively reviewed all patients who underwent CABG from January 2016 to August 2020 at our tertiary care hospital using electronic medical records.

Results

The study included 410 patients with a median age of 60 years, and 28.6% of them had CKD and hospital mortality of 2.7%. About 71.4% of the patients had GFR > 60 mL/min per 1.73 m2, 18.1% had early CKD (GFR 30-60), 2.7% had late CKD (GFR < 30), and 7.8% of them had end-stage renal disease (ESRD) requiring dialysis. The CKD group had significantly more frequent hospital mortality (p = 0.04), acute cerebrovascular stroke (p = 0.03), acute kidney injury (AKI) (p < 0.001), longer ICU stay (p = 0.002), post-ICU stay (p = 0.001), and sternotomy wound debridement (p = 0.03) compared to the non-CKD group. The frequencies of new need for dialysis were 2.4% vs. 14.9% vs. 45.5% (p < 0.001) in the patients with GFR > 60 mL/min per 1.73 m2, early CKD, and late CKD, respectively. Acute cerebral stroke (OR: 10.29, 95% CI: 1.82-58.08, and p = 0.008), new need for dialysis (OR: 25.617, 95% CI: 13.78-85.47, and p < 0.001), and emergency surgery (OR: 3.1, 95% CI: 1.82-12.37, and p = 0.036) were the independent predictors of hospital mortality after CABG. The patients with CKD had an increased risk of strokes (HR: 2.14, 95% CI: 1.20-3.81, and p = 0.01) but insignificant mortality increase (HR: 1.44, 95% CI: 0.42-4.92, and p = 0.56) during follow-up.

Conclusion

The patients with CKD, especially the late grade, had worse postoperative early and late outcomes compared to non-CKD patients after CABG. Patients with dialysis-independent CKD had increased risks of needing dialysis, hospital mortality, and permanent dialysis after CABG.

The Impact of Left Ventricular Diastolic Dysfunction on Respiratory Adverse Events in Cardiac Surgery Patients-An Observational Prospective Single-Center Study

BACKGROUND

Left ventricular diastolic dysfunction (LV DD) is the most dominant cause of heart failure with preserved ejection fraction (HFpEF) worldwide. This pathological condition may contribute to postcapillary pulmonary hypertension (pcPH) development. Hypoxemia, often observed in pcPH, may significantly negatively impact the course of hospitalization in patients after cardiac surgery. The aim of our study was to investigate the impact of LV DD on the frequency of postoperative respiratory adverse events (RAE) in patients undergoing Coronary Artery Bypass Grafting (CABG).

METHODS

The left ventricular (LV) diastolic function was assessed in 56 consecutive patients admitted for CABG. We investigated the relationship between LV DD and postoperative respiratory adverse events (RAE) in groups with normal LV diastolic function and LV DD stage I, II, and III.

RESULTS

Left ventricular diastolic dysfunction stage I was observed in 11 patients (19.6%) and LV DD stage II or III in 19 patients (33.9%). Arterial blood partial pressure of oxygen (PaO2) to the fraction of inspired oxygen (FiO2) index during postoperative mechanical ventilation was significantly lower in LV DD stage II or III than in the group with normal LV diastolic function. Patients with DD stage II or III had a higher occurrence of postoperative pneumonia than the group with normal LV diastolic function.

CONCLUSIONS

Left ventricular diastolic dysfunction is widespread in cardiac surgery patients and is an independent risk factor for lower minimal PaO2/FiO2 index during mechanical ventilation and higher occurrence of pneumonia.

Prevalence and risk factors of significant persistent pain symptoms after critical care illness: a prospective multicentric study

BACKGROUND

Prevalence, risk factors and medical management of persistent pain symptoms after critical care illness have not been thoroughly investigated.

METHODS

We performed a prospective multicentric study in patients with an intensive care unit (ICU) length of stay ≥ 48 h. The primary outcome was the prevalence of significant persistent pain, defined as a numeric rating scale (NRS) ≥ 3, 3 months after admission. Secondary outcomes were the prevalence of symptoms compatible with neuropathic pain (ID-pain score > 3) and the risk factors of persistent pain.

RESULTS

Eight hundred fourteen patients were included over a 10-month period in 26 centers. Patients had a mean age of 57 (± 17) years with a SAPS 2 score of 32 (± 16) (mean ± SD). The median ICU length of stay was 6 [4-12] days (median [interquartile]). At 3 months, the median intensity of pain symptoms was 2 [1-5] in the entire population, and 388 (47.7%) patients had significant pain. In this group, 34 (8.7%) patients had symptoms compatible with neuropathic pain. Female (Odds Ratio 1.5 95% CI [1.1-2.1]), prior use of anti-depressive agents (OR 2.2 95% CI [1.3-4]), prone positioning (OR 3 95% CI [1.4-6.4]) and the presence of pain symptoms on ICU discharge (NRS ≥ 3) (OR 2.4 95% CI [1.7-3.4]) were risk factors of persistent pain. Compared with sepsis, patients admitted for trauma (non neuro) (OR 3.5 95% CI [2.1-6]) were particularly at risk of persistent pain. Only 35 (11.3%) patients had specialist pain management by 3 months.

CONCLUSIONS

Persistent pain symptoms were frequent in critical illness survivors and specialized management remained infrequent. Innovative approaches must be developed in the ICU to minimize the consequences of pain.

TRIAL REGISTRATION

NCT04817696. Registered March 26, 2021.

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.