Regional Analgesia for Cardiac Surgery. Part 2: Peripheral Regional Analgesia for Cardiac Surgery

Abstract

The introduction of regional analgesia in the past decades have revolutionized postoperative pain management for various types of surgery, particularly orthopedic surgery. Nowadays, they are being constantly introduced into other types of surgeries including cardiac surgeries. Neuraxial and paravertebral plexus blocks for cardiac surgery are considered as deep blocks and have the risk of hematoma formation in the setting of anticoagulation associated with cardiac surgeries. Moreover, hemodynamic compromise resulting from sympathectomy in patients with limited cardiac reserve further limits the use of neuraxial techniques. A multitude of fascial plane blocks involving chest wall have been developed, which have been shown the potential to be included in the regional analgesia armamentarium for cardiac surgery. In myofascial plane blocks, the local anesthetic spreads passively and targets the intermediate and terminal branches of intercostal nerves. They are useful as important adjuncts for providing analgesia and are likely to be included in “Enhanced Recovery after Cardiac Surgery (ERACS)” protocols. There are several small studies and case reports that have shown efficacy of the regional blocks in reducing opioid requirements and improving patient satisfaction. This review article discusses the anatomy of various fascial plane blocks, mechanism of their efficacy, and available evidence on outcomes after cardiac surgery.

Comparison of traditional and upper thoracic epidural analgesia after off‐pump coronary artery bypass graft surgery: A Quasi‐experimental study

“…Cardiac surgery requires anticoagulants, and it is not widely accepted due to concerns about neuraxial hematoma following anticoagulants. 1 , 14 , 21 , 22 , 23 , 24 , 25 , 26 A few trials have demonstrated the safety of regional anesthetic and analgesic techniques in the context of possible anticoagulation during cardiac surgery. 1 , 19 Regional blocks have enormous potential to be integrated into hospitals' acute pain management paradigms following cardiac surgery, given their initial success in decreasing pain scores and reducing opiate usage.…”

“… 1 , 19 Regional blocks have enormous potential to be integrated into hospitals' acute pain management paradigms following cardiac surgery, given their initial success in decreasing pain scores and reducing opiate usage. 26 …”

“… 33 Providing adequate perioperative analgesia has been shown to improve hemodynamics and immunologic responses, which may lead to improved outcomes after heart surgery. 26 …”

Is It Time for Paradigm Shift in Pain Management for Cardiac Surgery Patients?

“…Devarajan et al explored evidence behind the use of various neuraxial and non-neuraxial regional analgesic techniques in a two-part review. 6,7 It is clear that epidural blocks will not be re-entering the cardiac surgical arena because of concerns over epidural hematoma, despite their advantages. However, spinal opioids are making a comeback, with renewed interest in their clinical use and research for ERAS protocols.…”

Ultrasound-Guided PECS II + Serratus Plane Fascial Blocks Are Associated with Reduced Opioid Consumption and Lengths of Stay for Minimally Invasive Cardiac Surgery: An Observational Retrospective Study

“…There are several regional analgesia options for cardiac surgery pain management: peridural analgesia, paravertebral block, erector spinae plane (ESP) block, serratus plane block and PECS II block. These techniques were enhanced by comprehensive utilization of ultrasound guidance, the latter being cost-effective, readily accessible, reliable imaging and having multiple advantages [ 8 , 9 , 10 , 11 , 12 , 13 ].…”