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

Prachi Kar, Gopinath Ramachandran, Prachi Kar, Gopinath Ramachandran

Abstract

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

Keywords: Analgesia; cardiac surgery; fascial blocks; pain relief; regional nerve blocks; sternotomy.

Conflict of interest statement

None

Figures

Figure 1
Figure 1
(a) Diagram illustrating the paravertebral space and its boundaries. (b) Sagittal section through paravertebral space showing needle walking over the transverse process and reaching paravertebral space after piercing superior costotransverse ligament (landmark technique)
Figure 2
Figure 2
Diagram showing sites of injection in parasternal intercostal block. Blue circles denote injection in the parasternal region of 2nd to 6th intercostal space. Green x denote periosteal infiltration over sternum and red x denote infiltration around chest tubes
Figure 3
Figure 3
Illustration showing muscles and nerves relevant for pectoral nerve block. The blue and red arrows show the plane for deposition of local anaesthetic in pecs 1 and pecs 2 block, respectively
Figure 4
Figure 4
Diagram illustrating the intercostal nerve and its branches. Blue arrow shows the plane for local anesthetic injection in erector spinae block. EIM, external intercostal muscle; IIM, internal intercostal muscle; INIM, innermost intercostal muscle
Figure 5
Figure 5
(a) Figure illustrating intercostal nerve anatomy in the parasternal region relevant for PIFB. PM, pectoralis major; IIM, internal intercostal muscle; TTM, transverse thoracic muscle. (b) Illustration showing deposition of drug between pectoralis major (PM) and internal intercostal muscle (IIM) during administration of Pecto-intercosto fascial block (PIFB)
Figure 6
Figure 6
Illustration showing relevant nerve and muscle anatomy for TTP block. EIM, external intercostal muscle; IIM, Internal intercostal muscle; INIM, innermost intercostal muscle; TTM, transverse thoracic muscle; EIA, external intercostal aponeurosis

References

    1. Davies F, Gladstone RJ, Stibbe EP. The anatomy of the intercostal nerves. J Anat. 1932;66:323–33.
    1. Karmakar MK. Thoracic paravertebral block. Anesthesiology. 2001;95:771–80.
    1. Kittredge RD. Computed tomographic evaluation of the thoracic prevertebral and paravertebral spaces. J Comput Tomogr. 1983;7:239–50.
    1. Eason MJ, Wyatt R. Paravertebral thoracic block—A reappraisal. Anaesthesia. 1979;34:638–42.
    1. Nunn JF, Slavin G. Posterior intercostal nerve block for pain relief after cholecystectomy. Anatomical basis and efficacy. Br J Anaesth. 1980;52:253–60.
    1. Pusch F, Freitag H, Weinstabl C, Obwegeser R, Huber E, Wildling E, et al. Single-injection paravertebral block compared to general anaesthesia in breast surgery. Acta Anaesthesiol Scand. 1999;43:770–4.
    1. Cheema SP, Ilsley D, Richardson J, Sabanathan S. A thermographic study of paravertebral analgesia. Anaesthesia. 1995;50:118–21.
    1. SC OR, Donnell BO, Cuffe T, Harmon DC, Fraher JP, Shorten G. Thoracic paravertebral block using real-time ultrasound guidance. Anesth Analg. 2010;110:248–51.
    1. Bouzinac A, Delbos A, Mazieres M, Rontes O. Interest of ultrasound in the realization of thoracic paravertebral block in breast surgery. Ann Fr Anesth Reanim. 2011;30:453–5.
    1. Abdallah FW, Brull R. Off side! A simple modification to the parasagittal in-plane approach for paravertebral block. Reg Anesth Pain Med. 2014;39:240–2.
    1. Ganapathy S, Nielsen KC, Steele SM. Outcomes after paravertebral blocks. Int Anesthesiol Clin. 2005;43:185–93.
    1. Canto M, Sanchez MJ, Casas MA, Bataller ML. Bilateral paravertebral blockade for conventional cardiac surgery. Anaesthesia. 2003;58:365–70.
    1. El Shora HA, El Beleehy AA, Abdelwahab AA, Ali GA, Omran TE, Hassan EA, et al. Bilateral paravertebral block versus thoracic epidural analgesia for pain control post-cardiac surgery: A randomized controlled trial. Thorac Cardiovasc Surg. 2018 doi: 101055/s-0038-1668496.
    1. Olivier JF, Bracco D, Nguyen P, Le N, Noiseux N, Hemmerling T. A novel approach for pain management in cardiac surgery via median sternotomy: Bilateral single-shot paravertebral blocks. Heart Surg Forum. 2007;10:E357–62.
    1. Lockwood GG, Cabreros L, Banach D, Punjabi PP. Continuous bilateral thoracic paravertebral blockade for analgesia after cardiac surgery: A randomised, controlled trial. Perfusion. 2017;32:591–7.
    1. McDonald SB, Jacobsohn E, Kopacz DJ, Desphande S, Helman JD, Salinas F, et al. Parasternal block and local anesthetic infiltration with levobupivacaine after cardiac surgery with desflurane: The effect on postoperative pain, pulmonary function, and tracheal extubation times. Anesth Analg. 2005;100:25–32.
    1. Dogan Baki E, Kavrut Ozturk N, Ayoglu RU, Emmiler M, Karsli B, Uzel H. Effects of parasternal block on acute and chronic pain in patients undergoing coronary artery surgery. Semin Cardiothorac Vasc Anesth. 2016;20:205–12.
    1. Ozturk NK, Baki ED, Kavakli AS, Sahin AS, Ayoglu RU, Karaveli A, et al. Comparison of transcutaneous electrical nerve stimulation and parasternal block for postoperative pain management after cardiac surgery. Pain Res Manag. 2016;2016:4261949.
    1. Barr AM, Tutungi E, Almeida AA. Parasternal intercostal block with ropivacaine for pain management after cardiac surgery: A double-blind, randomized, controlled trial. J Cardiothorac Vasc Anesth. 2007;21:547–53.
    1. Lee CY, Robinson DA, Johnson CA, Jr, Zhang Y, Wong J, Joshi DJ, et al. A randomized controlled trial of liposomal bupivacaine parasternal intercostal block for sternotomy. Ann Thorac Surg. 2019;107:128–34.
    1. Blanco R. The ‘pecs block’: A novel technique for providing analgesia after breast surgery. Anaesthesia. 2011;66:847–8.
    1. Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): A novel approach to breast surgery. Rev Esp Anestesiol Reanim. 2012;59:470–5.
    1. Kumar KN, Kalyane RN, Singh NG, Nagaraja PS, Krishna M, Babu B, et al. Efficacy of bilateral pectoralis nerve block for ultrafast tracking and postoperative pain management in cardiac surgery. Ann Card Anaesth. 2018;21:333–8.
    1. Chin KJ, Adhikary S, Sarwani N, Forero M. The analgesic efficacy of pre-operative bilateral erector spinae plane (ESP) blocks in patients having ventral hernia repair. Anaesthesia. 2017;72:452–60.
    1. Ivanusic J, Konishi Y, Barrington MJ. A Cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med. 2018;43:567–71.
    1. Leyva FM, Mendiola WE, Bonilla AJ, Cubillos J, Moreno DA, Chin KJ. Continuous erector spinae plane (ESP) block for postoperative analgesia after minimally invasive mitral valve surgery. J Cardiothorac Vasc Anesth. 2018;32:2271–74.
    1. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: A novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41:621–7.
    1. Tsui BCH, Navaratnam M, Boltz G, Maeda K, Caruso TJ. Bilateral automatized intermittent bolus erector spinae plane analgesic blocks for sternotomy in a cardiac patient who underwent cardiopulmonary bypass: A new era of cardiac regional anesthesia. J Clin Anesth. 2018;48:9–10.
    1. Krishna SN, Chauhan S, Bhoi D, Kaushal B, Hasija S, Sangdup T, et al. Bilateral erector spinae plane block for acute post-surgical pain in adult cardiac surgical patients: A randomized controlled trial. J Cardiothorac Vasc Anesth. 2019;33:368–75.
    1. Nagaraja PS, Ragavendran S, Singh NG, Asai O, Bhavya G, Manjunath N, et al. Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Ann Card Anaesth. 2018;21:323–77.
    1. de la Torre PA, Garcia PD, Alvarez SL, Miguel FJ, Perez MF. A novel ultrasound-guided block: A promising alternative for breast analgesia. Aesthet Surg J. 2014;34:198–200.
    1. Raza I, Narayanan M, Venkataraju A, Ciocarlan A. Bilateral subpectoral interfascial plane catheters for analgesia for sternal fractures: A case report. Reg Anesth Pain Med. 2016;41:607–9.
    1. Liu V, Mariano ER, Prabhakar C. Pecto-intercostal fascial block for acute poststernotomy pain: A case report. A A Pract. 2018;101:319–22.
    1. Ueshima H, Kitamura A. Blocking of multiple anterior branches of intercostal nerves (Th2-6) using a transversus thoracic muscle plane block. Reg Anesth Pain Med. 2015;40:388.
    1. Ueshima H, Hara E, Marui T, Otake H. The ultrasound-guided transversus thoracic muscle plane block is effective for the median sternotomy. J Clin Anesth. 2016;29:83.
    1. Ueshima H, Otake H. Continuous transversus thoracic muscle plane block is effective for the median sternotomy. J Clin Anesth. 2017;37:174.
    1. Fujii S, Roche M, Jones PM, Vissa D, Bainbridge D, Zhou JR. Transversus thoracis muscle plane block in cardiac surgery: A pilot feasibility study. Reg Anesth Pain Med. 2019;44:556–60.
    1. Fujii S, Vissa D, Ganapathy S, Johnson M, Zhou J. Transversus thoracic muscle plane block on a cadaver with history of coronary artery bypass grafting. Reg Anesth Pain Med. 2017;42:535–7.
    1. Del Buono R, Costa F, Agro FE. Parasternal, pecto-intercostal, pecs, and transverse thoracic muscle plane blocks: A rose by any other name would smell as sweet. Reg Anesth Pain Med. 2016;41:791–2.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi