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

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.

Year in Review 2020: Noteworthy Literature in Cardiothoracic Anesthesiology

“…Delving further into the benefits of regional anesthesia for cardiac surgery, Kar and Ramachandran provide an extensive review of non-neuraxial nerve blocks for pain relief following sternotomy in cardiac surgery. 31 While thoracic epidurals (TEA) provide excellent analgesia, it is rarely the analgesic modality of choice for cardiac surgery due to the inherent risk of epidural hematoma in the setting of systemic heparinization. While non-neuraxial nerve blocks are commonly studied in the setting of thoracotomy and minimally invasive cardiac surgery, their use for pain relief following sternotomy merits attention.…”

Regional analgesia in cardiac anesthesia: Welcoming a new era in perioperative pain management

“…A good example is the TTMP block where the local anesthetic is deposited in the TTMP block is similar to the described approach for the parasternal nerve block 3,4 . Nomenclature aside, Kar and Ramachandran 2 showed there are few prospective randomized control studies published on newer nonneuraxial regional techniques for postoperative pain control after cardiac surgery.…”

“…Historically, the mainstay for pain management in this population has been the usage of narcotic analgesics but with the recognition that overprescription of opioids may be contributing to the opioid pandemic, adoption of a multimodal approach for pain management has been gaining more popularity among institutions in the United States. Neuraxial analgesia and anesthesia have been used in the past but their impact in hemodynamics added to the risk associated with heparinization and coagulopathy has limited its use in cardiac surgery 2 . Newer regional anesthesia/analgesia methods utilizing ultrasound guidance are associated with a lower risk of complications when compared to the neuraxial approach.…”

“…Neuraxial analgesia and anesthesia have been used in the past but their impact in hemodynamics added to the risk associated with heparinization and coagulopathy has limited its use in cardiac surgery. 2 Newer regional anesthesia/analgesia methods utilizing ultrasound guidance are associated with a lower risk of complications when compared to the neuraxial approach. Regional blocks that cover poststernotomy pain include transverse thoracic muscle plane (TTMP) block, parasternal block, pectointercostal fascial blocks (PIFBs), and erector spinae plane blocks.…”

“…2 Out of all these newer techniques, the number of published prospective double-blinded studies is limited. 2 A contributing factor to the difficulty finding literature for these types of blocks is the description of the technique by the authors. A good example is the TTMP block where the local anesthetic is deposited in the TTMP block is similar to the described approach for the parasternal nerve block.…”