Bilateral continuous erector spinae plane block for cardiac surgery: case series
Multimodal analgesia in cardiac surgery sternotomy includes bilateral continuous erector spinae plane block (BC-ESPB). However, the effectiveness of the local anesthetic regimens is still uncertain.
The purpose of this study was to assess pain control achieved with a multimodal analgesia regimen including BC-ESPB at the level of T5 with PCA with a 0.125 % bupivacaine infusion and rescue boluses.
This is a descriptive case series study which recruited 11 adult patients undergoing cardiac surgery through sternotomy in whom multimodal analgesia including BC-ESPB was used, between February and April 2021, at a fourth level institution.
All patients reported pain according to the numeric rating scale (NRS) ≤ 3 both at rest and in motion, at extubation and then 4 and 12 hours after surgery. After 24 hours the pain was NRS ≤ 3 in 100 % of the patients at rest and in 63.6 % in motion. At 48 h 81 % of the patients reported pain NRS ≤ 3 at rest and in motion. At 72h all patients reported pain NRS ≤ 3 at rest and 82 % in motion. The average intraoperative use of fentanyl was 2.35 µg/kg and postoperative hydromorphone was 5.3, 4.1 and 3.3 mg at 24, 48 and 72 hours, respectively.
Hence, bilateral ESP block in continuous infusion plus rescue boluses allows for proper control of acute intra and post-operative pain.
Macaire P, Ho N, Nguyen T, Nguyen B, Vu V, Quach C, et al. Ultrasound-Guided continuous thoracic erector spinae plane block within an enhanced recovery program is associated with decreased opioid consumption and improved patient postoperative rehabilitation after open cardiac surgery—a patient-matched, controlled. J Cardiothorac Vasc Anesth. 2019;33(6):1659-67. doi: https://doi.org/10.1053/j.jvca.2018.11.021
Zubrzycki M, Liebold A, Skrabal C, et al. Assessment and pathophysiology of pain in cardiac surgery. J Pain Res. 2018;11:1599-611. doi: https://doi.org/10.2147/JPR.S162067
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. 2020;68(5):410-6. doi: https://doi.org/10.1055/s-0038-1668496.
Caruso TJ, Lawrence K, Tsui BCH. Regional anesthesia for cardiac surgery. Curr Opin Anaesthesiol. 2019;32(5):674-82. doi: https://doi.org/10.1097/ACO.0000000000000769
Guay J, Kopp S. Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass. Cochrane Database Syst Rev. 2019;3(3):CD006715. doi: https://doi.org/10.1002/14651858.CD006715.pub3
Naganuma M, Tokita T, Sato Y, Kasai T, Kudo Y, Suzuki N, et al. Efficacy of preoperative bilateral thoracic paravertebral block in cardiac surgery requiring full heparinization: A propensity-matched study. J Cardioth Vasc Anesth. 2022;36(2):477-82. doi: https://doi.org/10.1053/j.jvca.2021.05.001
Liu H, Emelife PI, Prabhakar A, Moll V, Kendrick JB, Parr AT, et al. Regional anesthesia considerations for cardiac surgery. Best Pract Res Clin Anaesthesiol. 2019;33(4):387-406. doi: https://doi.org/10.1016/j.bpa.2019.07.008
Kelava M, Alfirevic A, Bustamante S, Hargrave J, Marciniak D. Regional anesthesia in cardiac surgery: An overview of fascial plane chest wall blocks. Anesth Analg. 2020;131(1):127-35. doi: https://doi.org/10.1213/ANE.0000000000004682
Vilīte B, Strīķe E, Rutka K, Leibuss R. Pain management in intensive care unit patients after cardiac surgery with sternotomy approach. Acta Medica Litu. 2019;26(1):51-63. doi: https://doi.org/10.6001/actamedica.v26i1.3956
Schwartz RH, Urits I, Viswanath O, Urman RD, Kaye AD, Eskander JP. Use of an erector spinae plane block for perioperative pain control in coronary artery bypass graft surgery. J Clin Anesth. 2020;61:109652. doi: https://doi.org/10.1016/j.jclinane.2019.109652.
Kumar AK, Chauhan S, Bhoi D, Kaushal B. Pectointercostal Fascial Block (PIFB) as a novel technique for postoperative pain management in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2021;35(1):116-22. doi: https://doi.org/10.6001/actamedica.v26i1.395610.1053/j.jvca.2020.07.074
Khera T, Murugappan KR, Leibowitz A, Bareli N, Shankar P, Gilleland S, et al. Ultrasound-guided pecto-intercostal fascial block for postoperative pain management in cardiac surgery: a prospective, randomized, placebo-controlled trial. J Cardiothorac Vasc Anesth. 2021;35(3):896-903. doi: https://doi.org/10.1053/j.jvca.2020.07.058.
Aydin ME, Ahiskalioglu A, Ates I, Tor IH, Borulu F, Erguney OD, et al. Efficacy of ultrasound-guided transversus thoracic muscle plane block on postoperative opioid consumption after cardiac surgery: a prospective, randomized, double-blind study. J Cardiothorac Vasc Anesth. 2020;34(11):2996-3003. doi: https://doi.org/10.1053/j.jvca.2020.06.044
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(3):323-7. doi: https://doi.org/10.4103/aca.ACA_16_18
Toscano A, Capuano P, Galatà M, Tazzi I, Rinaldi M, Brazzi L. Safety of ultrasound-guided serratus anterior and erector spinae fascial plane blocks: A retrospective analysis in patients undergoing cardiac surgery while receiving anticoagulant and antiplatelet drugs. J Cardiothorac Vasc Anesth. 202236(2):483-8. doi: https://doi.org/10.1053/j.jvca.2021.05.037
Forero M, Adhikary SD, López H, Tsui C, Chin KJ. The erector spinae plane block a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621-7. doi: https://doi.org/10.1097/AAP.0000000000000451
Huang W, Wang W, Xie W, Chen Z, Liu Y. Erector spinae plane block for postoperative analgesia in breast and thoracic surgery: A systematic review and meta-analysis. J Clin Anesth. 2020;66(1023):109900. doi: https://doi.org/10.1016/j.jclinane.2020.109900.
Manazir D, Mddnb A, Parveen DS, Mayank D, Msmch Y, Obaid D, et al. A randomized double blind controlled trial to assess the efficacy of ultrasound-guided erector spinae plane block in cardiac surgery. J Cardiothorac Vasc Anesth. 2021;35(12):3574-80. doi: https://doi.org/10.1053/j.jvca.2021.03.009.
Raj N. Regional anesthesia for sternotomy and bypass—Beyond the epidural. Paediatr Anaesth. 2019;29(5):519-29. doi: https://doi.org/10.1111/pan.13626
Muñoz-Leyva F, Chin KJ, Mendiola WE, Cubillos J, Moreno DA, Zhong-Lin C, et al. Bilateral continuous erector spinae plane (ESP) blockade for perioperative opioid-sparing in median sternotomy. J Cardiothorac Vasc Anesth. 2019;33(6):1698-703. doi: https://doi.org/10.1053/j.jvca.2018.05.047
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(2):368-75. doi: https://doi.org/10.1053/j.jvca.2018.05.050.
Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendations. JAMA Surg. 2019;154(8):755-66. doi: https://doi.org/10.1001/jamasurg.2019.1153
Gregory AJ, Grant MC, Manning MW, Cheung AT, Ender J, Sander M, et al. Enhanced recovery after cardiac surgery (ERAS Cardiac) recommendations: An important first step-but there is much work to be done. J Cardiothorac Vasc Anesth. 2020;34(1):39-47. doi: https://doi.org/10.1053/j.jvca.2019.09.002
Fernández-Rivera BJ. Fast track y ultrafast track en cirugía cardiaca: Pros y contras. Rev Mex Anest. 2010;33:56-8.
Cove ME, Ying C, Taculod JM, Oon SE, Oh P, Kollengode R,et al. Multidisciplinary extubation protocol in cardiac sur-gical patients reduces ventilation time and length of stay the intensive care unit. Ann Thorac Surg. 2016;102:28-34. doi: https://doi.org/10.1016/j.athoracsur.2016.02.071
Hawkes C, Dhileepan S, Foxcroft D. Early extubation foradult cardiac surgical patients. Cochrane Database Syst Rev. 2003:CD003587. doi: https://doi.org/10.1002/14651858.CD003587
Guerrero Gómez A, González Jaramillo N, Castro Pérez JA. Ultra-fast-track extubation vs. conventional extubation after cardiac surgery in a cardiovascular reference centre in Colombia. A longitudinal study. Rev Española Anestesiol y Reanim. 2019;66(1):10-7. doi: http://dx.doi.org/10.1016/j.redare.2018.06.007.
Bainbridge D, Cheng D. Current evidence on fast track cardiac recovery management. Eur Heart J Suppl. 2017;19:A3-7. doi: https://doi.org/10.1093/eurheartj/suw053