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Regional anesthesia considerations for cardiac surgery

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Pain is a significant consequence of cardiac surgery and newer techniques in cardiac anesthesia have provided an impetus for the development of multimodal techniques to manage acute pain in this setting. In this regard, regional anesthesia techniques have been increasingly used in many cardiac surgical procedures, for the purposes of reducing perioperative consumption of opioid agents and enhanced recovery after surgery. The present investigation focuses on most currently used regional techniques in cardiac surgical procedures. These regional techniques include chest wall blocks (e.g., PECS I and II, SAP, ESB, PVB), sternal blocks (e.g., TTMPB, PSINB), and neuraxial blocks (e.g., TEA, high spinal anesthesia). The present investigation also summarizes indications, technique, complications, and potential clinical benefits of these evolving regional techniques. Cardiac surgery patients may benefit from application of these regional techniques with well controlled indications and careful patient selections.

Introduction

Cardiovascular disease accounts for more than one-third of deaths globally [1] and more than $300 billion in direct and indirect costs in the United States alone [2]. It is very likely to remain the leading cause of mortality and morbidity for the elderly worldwide. The total number of elderly citizens in the United States will almost double between 2017 and 2060 [3]. The increase in elderly population will undoubtedly increase the prevalence of cardiovascular diseases, so will the volume of cardiovascular interventional procedures [4]. Patients undergoing cardiovascular surgery often involve both extremes of age. Though congenital cardiac surgery is relatively stable in incidence, cardiac surgery and interventional procedure for congenital heart disease have been evolving. Minimally invasive cardiac procedures such as transcatheter aortic valve replacements (TAVR) are enabling older and sicker patients to undergo interventional/surgical procedures. In late 1980s and early 1990s, high-dose opiate anesthetic strategies that promoted cardiovascular/hemodynamic stability were very common practice with the consequence of significantly longer time of postoperative mechanical ventilation in the intensive care unit (ICU), especially before fentanyl became available in clinical utilization. Use of fentanyl significantly shortened the postoperative intubation time and length of ICU stay in cardiac surgery patients. Opioid doses in the perioperative care of cardiac surgery patient have gone through a process of gradual and constant decline, due to several reasons, the economic requirement to shorten postoperative intubation times and length of ICU stay, the sociopolitical efforts to curb the opioid crisis which may be associated with perioperative use of narcotics. Several countries are currently battling “opioid epidemics” related to uncontrolled illegal market of heroin, inappropriate prescription of opioid type medications for chronic pain patients and the misuse of opioids in postsurgical patients. Enormously strong advocacy for minimal or opioid-minimizing enhanced recovery protocols has been steadily gaining popularity in perioperative settings. All of these has led to the multimodal analgesia approach in perioperative care. Neuraxial and peripheral nerve blocks have become essential components of these multimodal analgesic protocols [5] (see Fig. 1, Fig. 2, Fig. 3).

The ever-tightening human and financial resources in the health care system have also pushed regional anesthetic techniques to be increasingly used as part of an opioid-sparing, multimodal, pain regimen during pediatric and adult cardiac surgery in order to promote early extubation, reduce postoperative complications, minimize the length of ICU and hospital stay, and reduce overall cost of perioperative care [6]. Interestingly, the use of regional anesthesia techniques in cardiac surgery dates back to 1954 when one of the first heart surgeries was performed under thoracic epidural analgesia [7]. Neuraxial analgesia in cardiac surgery has been described for decades [8], [9]. Advantages of thoracic epidural analgesia include decreased incidence of cardiovascular events (stroke, myocardial ischemia) [8], [10], [11].], fewer respiratory complications, decreased incidence of renal failure, lower infection rates, shorter ICU length of stay, decreased cost of anesthesia, and earlier hospital discharge [11]. Another advantage of thoracic epidural analgesia is the ability to provide analgesia continuously throughout the perioperative period. Multiple clinical trials have confirmed the safety of thoracic epidurals [12], but remaining concerns over spinal and epidural hematomas and other potential complications have hindered its widespread adoption and still represent an ongoing controversy [13]. Additionally, the risk of often-existed post-cardiopulmonary bypass coagulopathy further complicates the use of neuraxial techniques. Concurrent aspirin use with systemic heparinization is a known risk factor for epidural hematoma after neuraxial instrumentation [14], [15]. High spinal anesthesia is another neuraxial technique infrequently used by cardiac anesthesiologists. One worthy-mentioning advantage of a high spinal technique might be a blunted stress response [16] and a lower risk of spinal or epidural hematoma with the use of a small (27G) needle. A Canadian group has recently described their high thoracic spinal technique in practice for over 20 years with more than 10,000 patients without a single spinal or epidural hematoma [17]. The most commonly administered block of the paraxial nervous system is probably the paravertebral block (PVB). Although the anatomy of paravertebral space was known for many years, reproducible successful PVB became achievable routinely only recently due to the ability of the operator to locate the paravertebral space and avoid damaging the pleura [18]. Recently the ultrasound-guided PVB has been shown to be a safe and effective analgesic method compared with thoracic epidural analgesia ∗[19], [20]. The advantages from PVB include the hemodynamic stability when compared to thoracic epidural analgesia [21] and less nausea, hypotension, and urinary retention [20].

With the advent of minimally invasive cardiac surgery, fast track anesthesia techniques and ERAS protocols [6], multimodal analgesia including the use of regional anesthesia techniques moved back into the focus with an emphasis on blocking peripheral nerves in neural planes under ultrasound guidance. Chest wall blocks are newer, simpler alternatives to neuraxial analgesic techniques. Blanco initially described the pectoralis fascial block (PECS) I to provide anesthesia to the pectoral muscles and its modification (PECS II) to further provide anesthesia to the lateral chest wall in breast surgery [22], [23]. The use of PECS blocks in cardiac surgery has recently been described as alleviating pain and coughing [24], [25], ∗[26].

Another regional technique related to PECS is the serratus anterior plane (SAP) block that covers the hemithorax [27]. The SAP block has been mainly utilized in thoracic surgical procedures [28], [29], [30]. Recently, SAP, PECS II and intercostal nerve blocks (ICNB) were found to be equally efficacious in pediatric cardiac surgery with the former two having the benefit of extended duration [31].

A newer addition to the growing number of fascial blocks is the erector spinae block (ESB) [32]. Based on a cadaveric study, the ESB might have the advantage to offer analgesia for a median sternotomy [33]. This analgesic coverage would make the ESB a PVB by proxy in clinical practice [34]. Initial case reports and clinical studies in cardiac surgery patients have shown the safety of its use and promising analgesic efficiency [35], [36], [37]. ESB has also been successfully used in transapical transcatheter aortic valve implantation [38]. One of the most important reasons that fascial plane blocks are readily embraced by many anesthesia practitioners is the presumed better safety profile compared with neuraxial techniques; they are easy to administer, especially with the use of ultrasound; and they have fewer associated side effects. However, even peripheral nerve blocks may potentially pose some risks in cardiac surgery patients. The lack of laterality could require bilateral blocks for a standard sternotomy which significantly increases the risk of high local anesthetic plasma concentrations [39].

Patients on oral anticoagulant and antiplatelet drugs, two commonly used drugs in cardiac surgery patients, are at increased risk for hematoma formation as described in a large clinical trial using ultrasound-guided pectoralis blocks for breast surgery [40]. The most recent American Society of Regional Anesthesia and Pain Medicine (ASRA) guidelines on regional anesthesia in patients receiving antithrombotic therapy acknowledge that the risk after plexus and peripheral techniques remains undefined and recommends in coagulopathic patients that neuraxial guidelines are applied to deep plexus or peripheral blocks. For other plexus or peripheral techniques, management depends on site compressibility, vascularity, and consequence of bleeding [15]. Regional anesthesia technique, both neuraxial and peripheral, is an essential part of a multimodal analgesic regimen in traditional and fast track cardiac surgery patient. It also serves as a rescue technique for postoperative patient with poor pain control. Table 1 summarizes the benefits and current controversies of regional anesthesia in cardiac patient (see Table 1).

Section snippets

Chest wall blocks in cardiac surgery

Innervation of chest wall is mainly via anterior division of thoracic Intercoastal nerves from T2 to T6. Axillary apex is supplied by Intercostobrachialis nerve (branch of T2). Pectoralis muscles are supplied by Lateral pectoral nerve (C5-C7) and Medial pectoral nerve (C8-T1). Long thoracic nerve (C5-C7) supplies Serratus anterior and Thoracodorsal nerve (C6-C8) supplies Latissimus dorsi. As per the American Society of Anesthesiologist (ASA) 2016 guidelines, Enhanced Recovery After Surgery

Serratus anterior plane block (SAP)

First described by Blanco et al., in 2013. SAP block is technically much easier to perform than the PECS block in general. SAP block has easily identifiable anatomic landmarks and anticipated hemithorax analgesia [27]. Serratus anterior is fan shaped muscle originating from 1st through 9th rib, and runs posteriorly inserting at the medial border of the scapula's ventral surface. It is innervated by the long thoracic nerve (C5-C7) and helps in lifting the arm above 90° [27], [42]. Recently

Erector spinae block (ESB)

ESB block with or without PECS block attains complete ipsilateral hemithoracic anesthesia with excellent results [43]. The ESB block offers excellent analgesia with precision, safety and easy to do, while reducing the complications from neuraxial techniques [35], [43]. ESB block just like the PECS and SAP block can be used as single injection block technique or as continuous infusion via a catheter for postoperative analgesia [43].

Paravertebral (PVB)

Paravertebral blocks are another type of chest wall block that can be employed for cardiac surgery. These blocks, although originally performed based on landmark technique, have recently been performed under ultrasound guidance, generally by in-plane approach and can be performed around the thoracic and lumbar vertebrae [20], [44]. A continuous catheter approach is used in order to provide continuous analgesia for patients [20]. When compared to thoracic epidural analgesia, PVB is associated

Indications

PSB and TTMPB can be effective for sternal fractures or surgeries at or near the sternum, such as median sternotomy, thymectomy, mediastinoscopy, or pericardial window [57]. These blocks may also be useful for sub-xiphoid incisions. PSB blocks have been studied in both adults and children and proven to be effective [58], [59]. The TTMPB block has been studied in adults but no study exists in the pediatric population yet. Both blocks can be used preoperatively, intraoperatively, or

Technique

There are some important anatomic structures to consider when performing sternal blocks. The transversus thoracic muscle has attachments to the costal cartilages of the second to sixth ribs, as well as attachments to the sternum, and xiphoid process. It functions to depress the costal cartilages during expiration and is innervated by the intercostal nerves [61], [62]. This muscle is continuous with the transversus abdominis muscle. The internal mammary vessels are also important structures to

Transversus thoracic muscular plane block

The TTMPB intends to anesthetize the anterior cutaneous terminal branches of the intercostal nerves that supply the medial and parasternal areas of the chest wall (T2-T7). It can be performed bilaterally using ultrasound guidance and either as a single shot or continuous infusion with a catheter. The technique described below can be used in normal sized adult patients (see Table 2).

Step 1: A linear, high-frequency ultrasound transducer is placed in the parasagittal plan in the midsternal area

Parasternal intercostal nerve block

Parasternal intercostal nerve block (PSINB) is intended to anesthetize the anterior branches of the intercostal nerves (see Fig. 4). To perform PSINB, local anesthetic is injected between the pectoralis major muscle (PM) and the external intercostal muscle (EIM) [65]. The anterior branches of the intercostal nerve penetrate through these two muscles to innervate the internal mammary area. Therefore, infiltration of local anesthetic into this area should block to anterior branches of the

Complications

Complications such as hematoma, infection, local anesthetic systemic toxicity (LAST) syndrome, nerve injury, and pneumothorax may occur after a parasternal intercostal nerve or TTMPB. Care should be taken to perform these blocks under sterile technique to avoid infection. While pneumothorax is rare, providers performing these blocks should be prepared to perform needle decompression or insert a chest tube if necessary. LAST is also rare, however, local anesthetic uptake from the intercostal

Neuraxial techniques in cardiac surgery

It is well known that cardiac surgery is associated with significant postoperative morbidity and mortality. In addition to significant stress, cardiac surgery may cause a shift in the myocardial oxygen supply/demand ratio, increased catabolism, and impaired immune function [16]. In an effort to diminish some of these risks, alternative anesthesia techniques in cardiac surgery have become the subject of numerous studies. Although the standard practice remains general anesthesia as the mainstay

Thoracic epidural anesthesia

Most TEA studies were performed with Ropivacaine or bupivacaine bolus on the day of surgery between C7 and T3. The duration of the epidural analgesia may vary based on the need for postoperative analgesia, which is one of the benefits of this technique [71]. In the setting of invasive surgery, pain control becomes a significant factor for patient recovery. Epidural analgesia may be used for extended periods of time after surgery to provide pain relief without the side effect profile of other

TEA technique

Casalino et al. described one technique for TEA in cardiac surgery. “One hour before being taken to the operating room, patients are injected intramuscularly with atropine (10 μg/kg), fentanyl (1 μg/kg), and droperidol (0.35 mg/kg). An epidural 19-gauge catheter is inserted at the level of the T3–T4 intervertebral space and advanced 4 cm in the attempt to reach the T1 vertebral body. A test dose of 2 mL of 2% lidocaine is administered in order to exclude subarachnoid displacement of the

High spinal anesthesia

Most high spinal anesthesia techniques studied used intrathecal hyperbaric bupivacaine. Although less studied than TEA, high spinal anesthesia has shown to significantly reduce atrial beta-receptor dysfunction and lower serum epinephrine, norepinephrine, and cortisol levels in CABG patients. The effects of this perioperative reduction in stress hormones remain unclear. Spinal anesthesia is also associated with a reduction in mean arterial pressure. These patients were shown to require more

The Winnipeg technique for spinal anesthesia

The anesthetic technique used for delivering a high or total-spinal anesthetic is outlined as follows (Dr. Trevor W. R. Lee, contributing author, personal communication, July 3, 2007) “Patients are premedicated with oral diazepam (0.1 mg/kg), and peripheral venous and arterial access are obtained in the operating room. Central venous access can be placed pre- or post-induction. Volume repletion and intravenous volume loading is accomplished with 500 mL Pentaspan (Bristol-Myers Squib, New York,

Complications and indications

The most widely known and discussed risks of neuraxial anesthesia are epidural hematoma, epidural abscess, and spinal cord infarction. These risks seem to be intuitive due to systemic heparinization which is necessary for open heart surgery. However, recent data has shown minimal a incidence of these complications. The risk of epidural hematoma in cardiac surgery patients has been theorized to occur in about 1 in 857 patients [11], ∗[12], [71]. Patients with reduced platelets, poor platelet

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      The various fascial plane chest wall blocks (pectoralis I and II, serratus anterior, and erector spine plane blocks) are safe alternatives to TEA. They could help to provide pain relief and facilitate early recovery after cardiac surgery.50,51 Of particular interest are the minimally invasive cardiac surgical procedures, because they often need an intercostal access through a small thoracotomy.

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