Chest Wall Nerve Blocks for Cardiothoracic, Breast Surgery, and Rib-Related Pain

Ultrasound-guided erector spinae plane block in coronary artery bypass surgery: the role of local anesthetic volume-a prospective, randomized study

BACKGROUND

Erector spinae plane block has been shown to help with pain management in different regions and many areas with different indications. However, the effectiveness of this block in cardiac surgery has been shown in the literature, the optimal volume remains unclear. The aim of this study is to determine the analgesic efficacy of two different volumes of local anesthetic injection used in ultrasound-guided bilateral-thoracic erector spinae plane block in patients undergoing coronary artery bypass graft.

METHODS

This study was conducted on adult patients undergoing surgery with coronary artery bypass graft, and 70 patients were analyzed in each group. Group 20 received erector spinae plane block with 20 ml of 0.25% bupivacaine, Group 30 received 30 ml of 0.25% bupivacaine bilaterally. Postoperative sternotomy and chest tube-related pain were evaluated using the numerical rating scale (NRS) at rest and during movement.

RESULTS

There were significant differences between the groups regarding rescue tramadol consumption was higher in Group 20 than in Group 30 (25/35 vs. 2/35, p < 0.001). In addition, there were substantial differences between the two groups concerning the time of the first-rescue analgesic requirement. The mean time ± standard deviation was 11.26 ± 9.57 h and 24.03 ± 4.12 h in Groups 20 and 30 (p < 0.001). The median scores, both at sternotomy and chest tubes, were significantly lower in Group 30 than in Group 20 at the different time points after the surgery (p < 0.05).

CONCLUSIONS

In coronary artery bypass graft surgery, erector spinae plane block performed with 30 ml instead of 20 ml on each side resulted in less pain in the sternum and chest tube region, less need for rescue analgesics, and delayed first-rescue analgesic requirement.

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.

Effects of ultrasound-guided regional anesthesia in cardiac surgery: a systematic review and network meta-analysis

BACKGROUND

The objective of this systematic review and network meta-analysis was to compare the effects of single-shot ultrasound-guided regional anesthesia techniques on postoperative opioid consumption in patients undergoing open cardiac surgery.

METHODS

This systematic review and network meta-analysis involved cardiac surgical patients (age > 18 y) requiring median sternotomy. We searched PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science. The effects of the single-shot ultrasound-guided regional anesthesia technique were compared with those of placebo and no intervention. We conducted a risk assessment of bias for eligible studies and assessed the overall quality of evidence for each outcome.

RESULTS

The primary outcome was opioid consumption during the first 24 h after surgery. The secondary outcomes were pain after extubation at 12 and 24 h, postoperative nausea and vomiting, extubation time, intensive care unit discharge time, and length of hospital stay. Fifteen studies with 849 patients were included. The regional anesthesia techniques included pecto-intercostal fascial block, transversus thoracis muscle plane block, erector spinae plane (ESP) block, and pectoralis nerve block I. All the regional anesthesia techniques included significantly reduced postoperative opioid consumption at 24 h, expressed as morphine milligram equivalents (MME). The ESP block was the most effective treatment (-22.93 MME [-34.29;-11.56]).

CONCLUSIONS

In this meta-analysis, we concluded that fascial plane blocks were better than placebo when evaluating 24 h MMEs. However, it is still challenging to determine which is better, given the paucity of studies available in the literature. More randomized controlled trials are required to determine which regional anesthesia technique is better.

TRIAL REGISTRATION

PROSPERO; CRD42022315497.

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

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