Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

Summary Serratus anterior plane and pectoral nerves blocks are recently described alternatives to established regional anaesthesia techniques in cardiac surgery, thoracic surgery and trauma. We performed a systematic review to establish the current state of evidence for the analgesic role of these fascial plane blocks in these clinical settings. We identified relevant studies by searching multiple databases and trial registries from inception to June 2019. Study heterogeneity prevented meta‐analysis and studies were instead qualitatively summarised and stratified by type of surgery and comparator. We identified 51 studies: nine randomised control trials; 13 cohort studies; 19 case series; and 10 case reports. The majority of randomised controlled trials studied the serratus anterior plane block in thoracotomy or video‐assisted thoracoscopic surgery, with only two investigating pectoral nerves blocks. The evidence in thoracic trauma comprised only case series and reports. Results indicate that single‐injection serratus anterior plane and the pectoral nerves blocks reduce pain scores and opioid consumption compared with systemic analgesia alone in cardiothoracic surgery, cardiac‐related interventional procedures and chest trauma for approximately 6–12 h. The duration of action appears longer than intercostal nerve blocks but may be shorter than thoracic paravertebral blockade. Block duration may be prolonged by a continuous catheter technique with potentially similar results to thoracic epidural analgesia. There were no reported complications and the risk of haemodynamic instability appears to be low. The current evidence, though limited, supports the efficacy and safety of serratus anterior plane and the pectoral nerves blocks as analgesic options in cardiothoracic surgery.

Background. An optimal opioid-sparing multimodal analgesic regimen to treat severe pain can enhance recovery after total knee arthroplasty. We hypothesized that adding 5 recently described IV and regional interventions to multimodal analgesic regimen can further reduce opioid consumption. Methods. In a double-blinded fashion, seventy-eight patients undergoing elective total knee arthroplasty were randomized to either (1) a control group (n=39) that received spinal anesthesia with intrathecal morphine, periarticular local anesthesia infiltration, IV dexamethasone and a single injection adductor canal block or (2) a study group (n=39) that received the same set of analgesic treatments plus 5 additional interventions - local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, intraoperative IV dexmedetomidine and ketamine, and postoperatively, 1 additional IV dexamethasone bolus, and 2 additional adductor canal block injections. The primary outcome measure was 24-hour cumulative opioid consumption after surgery and secondary outcomes were other analgesic, patient recovery and functional outcomes and adverse events. Results. Opioid consumption was not different between groups at 24 hours (oral morphine equivalents, mean ± SD), study: 23.7 ± 18.0 mg vs. control: 29.3 ± 18.7 mg; mean difference [95% CI], −5.6 mg [-2.7, 13.9]; P = 0.189) and all other time points after surgery. There were no major differences in pain scores, quality of recovery, or time to reach rehabilitation milestones. Hypotensive episodes occurred more frequently in the study group (25/39 (64.1%) vs. 13/39 (33.3%), p= 0.010). Conclusions. In the presence of periarticular local anesthesia infiltration, intrathecal morphine, single shot adductor canal block and dexamethasone, the addition of 5 analgesic interventions – local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, IV dexmedetomidine, IV ketamine, an additional IV dexamethasone dose and repeated adductor canal block injections – failed to further reduce opioid consumption, pain scores or improve functional outcomes after total knee arthroplasty.