2Regional anesthesia considerations for cardiac surgery
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
References (74)
- et al.
The society of thoracic surgeons adult cardiac surgery database: 2018 update on outcomes and quality
Ann Thorac Surg
(2018 Jan) - et al.
Enhanced recovery for cardiac surgery
J Cardiothorac Vasc Anesth
(2018 Dec) - et al.
Epidural analgesia improves outcome in cardiac surgery: a meta-analysis of randomized controlled trials
J Cardiothorac Vasc Anesth
(2010 Aug) Benefits of neuraxial anesthesia in patients undergoing cardiac surgery
J Cardiothorac Vasc Anesth
(1997)- et al.
Neuraxial blockade and hematoma in cardiac surgery: estimating the risk of a rare adverse event that has not (yet) occurred
Chest
(2000) - et al.
Paravertebral block for thoracic surgery
J Cardiothorac Vasc Anesth
(2018) - et al.
Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery
Rev Esp Anestesiol Reanim
(2012) - et al.
Ultrasound-guided serratus anterior plane block versus thoracic epidural analgesia for thoracotomy pain
J Cardiothorac Vasc Anesth
(2017 Feb) - et al.
Pectoralis-serratus interfascial plane block vs thoracic paravertebral block for unilateral radical mastectomy with axillary evacuation
J Clin Anesth
(2016 Nov) - et al.
Association of serratus anterior plane block for minimally invasive direct coronary artery bypass surgery with higher opioid consumption: a retrospective observational study
J Cardiothorac Vasc Anesth
(2018 Dec)
Comparison of the efficacy of ultrasound-guided serratus anterior plane block, pectoral nerves II block, and intercostal nerve block for the management of postoperative thoracotomy pain after pediatric cardiac surgery
J Cardiothorac Vasc Anesth
Bilateral erector spinae plane block for acute post-surgical pain in adult cardiac surgical patients: a randomized controlled trial
J Cardiothorac Vasc Anesth
Continuous erector spinae plane (ESP) block for postoperative analgesia after minimally invasive mitral valve surgery
J Cardiothorac Vasc Anesth
Transapical transcatheter aortic valve implantation performed with an erector spinae plane block
J Clin Anesth
Ultrasound-guided pectoral nerves (PECS) block: complications observed in 498 consecutive cases
J Clin Anesth
Persistent postsurgical pain: risk factors and prevention
Lancet
Successful use of serratus and transversus thoracic plane blocks for subcutaneous implantable cardioverter-defibrillator placement
J Cardiothorac Vasc Anesth
Regional techniques for cardiac and cardiac-related procedures
J Cardiothorac Vasc Anesth
Addition of transversus thoracic muscle plane block to pectoral nerves block provides more effective perioperative pain relief than pectoral nerves block alone for breast cancer surgery
Br J Anaesth
Continuous transversus thoracic muscle plane block is effective for the median sternotomy
J Clin Anesth
Cardiovascular diseases (CVDs)
Heart disease and stroke statistics—2016 update [Internet]
Circulation
Older Americans month
Regional analgesia in cardiothoracic surgery: a changing paradigm toward opioid-free anesthesia?
Ann Card Anaesth
Factors contributing to success or failure in the use of a pump oxygenator for complete by-pass of the heart and lung, experimental and clinical
Surgery
Intrathecal and epidural anesthesia and analgesia for cardiac surgery
Anesth Analg
Anaesthesia for coronary artery bypass surgery supplemented with subarachnoid bupivacaine and morphine: a report of 18 cases
Can J Anaesth
Epidural catheterization in cardiac surgery: the 2012 risk assessment
Ann Card Anaesth
Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American society of regional anesthesia and pain medicine evidence-based guidelines (Third Edition)
Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American society of regional anesthesia and pain medicine evidence-based guidelines (Fourth Edition)
Reg Anesth Pain Med
High spinal anesthesia for cardiac surgery: effects on beta-adrenergic receptor function, stress response, and hemodynamics
Anesthesiology
Neuraxial anesthesia for cardiac surgery: thoracic epidural and high spinal anesthesia - why is it different?
HSR Proc Intensive Care Cardiovasc Anesth
Bilateral paravertebral block versus thoracic epidural analgesia for pain control post-cardiac surgery: a randomized controlled trial
Thorac Cardiovasc Surg
Continuous paravertebral block for post-cardiothoracic surgery analgesia: a systematic review and meta-analysis. Continuous paravertebral block for post-cardiothoracic surgery analgesia: a systematic review and meta-analysis
Eur J Cardiothorac Surg
Comparison of continuous thoracic epidural with paravertebral block on perioperative analgesia and hemodynamic stability in patients having open lung surgery
Reg Anesth Pain Med
The “pecs block”: a novel technique for providing analgesia after breast surgery
Anaesthesia
Efficacy of bilateral pectoralis nerve block for ultrafast tracking and postoperative pain management in cardiac surgery
Ann Card Anaesth
Cited by (23)
Sternotomy Wound Infiltration With Liposomal Versus Plain Bupivacaine for Postoperative Analgesia After Elective Cardiac Surgery
2023, Journal of Cardiothoracic and Vascular AnesthesiaOpioid-Free Cardiac Surgery: A Multimodal Pain Management Strategy With a Focus on Bilateral Erector Spinae Plane Block Catheters
2022, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :The SAP catheters have even been used successfully for postoperative analgesia for a bilateral lung transplant in 2019.48 The PIFB and TTP blocks also have promising results by providing analgesia of the anterior branches of the T2-T7 intercostal nerves, which provide innervation to the mammary region of the chest.49 These blocks have been shown to provide adequate analgesia for sternal fractures, anterior chest trauma, as well as for median sternotomy and anterior minimally invasive thoracotomies.42
Perioperative analgesia by erector spinae plane block in left ventricular assist implant
2022, Revista Espanola de Anestesiologia y ReanimacionHow We Would Treat Our Own Pulmonary Hypertension if We Needed to Undergo Cardiac Surgery
2022, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :Dexmedetomidine was found to help control systemic and pulmonary pressures and heart rate in cardiac surgical patients and to reduce the duration of intensive care unit stay and postoperative delirium.91 Lastly, postoperative pain control frequently is augmented by regional techniques, including erector spinae, pectoral, and serratus anterior plane blocks.92 Each of these has a distinct distribution and side-effect profile, and the choice of regional technique generally is dictated by provider experience.93
Mechanisms, Prevention, and Treatment of Atrial Fibrillation After Cardiac Surgery: A Narrative Review
2021, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :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.