Regional anesthesia for sternotomy and bypass—Beyond the epidural

Abstract

Summary Systemic opioids have been the main stay for the management of perioperative pain in children undergoing cardiac surgery with sternotomy. The location, distribution, and duration of pain in these children have not been studied as extensively as in adults. Currently, there is no consensus to the dose of opioids required to provide optimum analgesia and attenuate the stress response while minimizing their unwanted side effects. At present there is a tendency to use lower dose aiming for early extubation and minimize opioid‐related side effects, but this may not obtund the stress response in all children. The development of chronic pain although rare when compared to adults is still a risk that needs further investigation. Regional anesthetic techniques, by blocking the afferent impulses, have been shown to be advantageous in reducing the stress response to surgery as well as pain and opioid requirements in children up to 24 hours after cardiac surgery. Central neuraxial blockades have not gained wide spread acceptance in these procedures due to the worry of hematoma, although rare, leading to catastrophic neurological outcomes. This review focuses on blocks outside the vertebral column, ie, peripheral nerve blocks, performed either in the front or the back of the chest wall to target the thoracic intercostal nerves. Techniques of ultrasound‐guided bilateral single shot paravertebral block and erector spinae block posteriorly and transversus thoracic plane block anteriorly are discussed. In addition, parasternal block and wound infiltration by surgeon as well as continuous local anesthetic infusion via catheters placed at end of procedures are summarized. Current evidence available for use of these techniques in children undergoing cardiac surgery are reviewed. These are based on small studies and case series and further studies are required to evaluate the risks and benefits of local anesthetic blocks in children undergoing cardiac surgery.

Transversus Thoracic Muscle Plane Block for Analgesia After Pediatric Cardiac Surgery

“…It has been reported that superficial blockade of these nerves close to the surgical site could effectively control the pain associated with sternotomy, and thus risks of a central approach could be avoided. 15 The blockade of these nerves was performed by Chaudhary et al for the first time by the parasternal block technique in pediatric cardiac surgery practice. 16 These authors performed local anesthetic infiltration bilaterally to each intercostal space for the blockade of the Th2 to Th6 intercostal nerves before closure of the sternum; it was reported that postoperative opioid consumption was less, pain scores were lower, and time to extubation was shorter in pediatric patients who underwent parasternal block.…”

Surgical Closure of Atrial Septal Defects in Young Children—A Review of Anesthesia Care in Sternotomy and Thoracotomy Approaches

“…It also may reduce stress response activation and in adults, reduce the incidence of chronic pain, which for thoracotomies is 20% to 60% but much lower in children (1.9%-16%) and even lower in sternotomies. [6][7][8][9] Historically, regional techniques for cardiac surgery included spinal, epidural, and caudal anesthesia. Their use was limited because of possible serious complications such as an epidural hematoma associated with anticoagulation.…”

Preoperative Implementation of Transverse Thoracic Muscle Plane Block and Rectus Sheath Block Combination for Pediatric Cardiac Surgery

“…13 Inadequate postoperative pain control is a substantial problem after surgery and results in reduced mobilization, increased morbidity, extended hospital stay, 14 development of chronic pain, 15 and loss of motivation for additional treatment, especially in pediatric patients. Therefore, there is a need for effective postoperative analgesic strategies, such as peripheral nerve blocks other than neuraxial anesthesia, for cardiac surgery with sternotomy, 1,4 with the minimization of opioidrelated side effects. [4][5][6] Advantages, Achievements, and Safety of TTP Block as a…”

“…The intercostal muscle layer consists of the following 3 layers: the external intercostal muscle, the internal intercostal muscle, and the innermost intercostal muscle. 1 The target layer for the TTP block, located between the intercostal muscle layer and the transverse thoracic muscle, is identified via ultrasound as a white line (Fig 1, B and C).…”

“…Systematic intravenous administration of opioids is the main treatment strategy for both intraoperative and postoperative pain management in patients undergoing cardiac surgery with sternotomy. 1 However, there also is a trend toward using lower doses of opioids, with the aim of achieving the well-established benefits of the fast-track anesthesia approach, 2 such as early extubation 3 ; rapid recovery; early mobilization; and minimization of opioid-related side effects, 4,5 including opioid-induced hyperalgesia. 6 After cardiac surgery, patients also experience pain and discomfort in the epigastric area due to chest drainage tubes and in the chest area from the sternotomy.…”