Comparison of preincisional and postincisional parasternal intercostal block on postoperative pain in cardiac surgery

Abstract

Background The optimum cardiac surgical pain management has known to maintain hemodynamic stability and, reduces respiratory and cardiovascular complications. Postoperative parasternal intercostal block has shown to reduce postoperative analgesic consumption after cardiac surgery. Therefore, this study sought to investigate the effectiveness of the preoperative ultrasound guided parasternal block in reducing postoperative pain after cardiac surgery. Methods This was a randomized, prospective, interventional, single blind study comprised of 90 adult patients scheduled for cardiac surgery involving sternotomy. Preoperatively and postoperatively, 0.25% bupivacaine administered in 4 mL aliquots into the anterior (2nd‐6th) intercostal spaces on each side about 2 cm lateral to the sternal edge with a total volume of 40 mL under ultrasound guidance and direct vision, respectively. Postoperative pain was rated according to visual analogue scale. Secondary outcomes included intraoperative and postoperative fentanyl consumptions, dosages of rescue medications, and time to extubation. Main results There was no significant differences in visual analogue score visual analogue score at all time points till 24 hours postoperatively. Intraoperative fentanyl requirements (microgram/kg) before cardiopulmonary bypass was significantly lower in pre‐incisional group than the post‐incisional group (0.16 ± 0.43 vs 0.68 ± 0.72; P = .0001). Furthermore, there were no significant difference in total fentanyl requirement (7.20 ± 2.66 vs 8.37 ± 3.13; P = .06) and tramadol requirement (0.02 ± 0.15 vs 0.07 ± 0.26; P = .28) within first 24 hours. However, time to extubation was significantly higher in the preoperative group (P = .02). Conclusions Preoperative and postoperative parasternal intercostal block provide comparable pain relief during the postoperative period.

Regional analgesia in Cardiac anesthesia: Welcoming a new era in perioperative pain management.

“…Zhang and collaborators described on their study a significantly lower consumption of intraoperative opioids in the intervention group, that goes in hand with prior studies that have shown similar results when the block is performed after induction of anesthesia [6,7]. In a study by Padala et al, patients who received blocks pre-incision had decreased fentanyl administration intraoperatively compare to patients who received the block prior to sternotomy closure [7].…”

“…Studies based on patient satisfaction have shown that the majority of patients continue to have mild to moderate sternotomy pain especially with movement and coughing up to post-operative day three or later [9]. Whether the block was placed post-induction or prior to sternal closure, Padala's study showed timing of placement of regional block did not seem to affect the total opioid requirement nor the pain scores for up to 24 hours postoperatively [7]. Another study by Lee and collaborators, evaluated if the administration of Liposomal Bupivacaine would prolong the analgesic effect of the regional block.…”

Regional analgesia in cardiac anesthesia: Welcoming a new era in perioperative pain management

“…5 Zhang et al described in their study a significantly lower consumption of intraoperative opioids in the intervention group, which goes in hand with prior studies that have shown similar results when the block is performed after induction of anesthesia. 6,7 In a study by Padala et al, 7 patients who received blocks preincision had decreased fentanyl administration intraoperatively compare to patients who received the block before sternotomy closure. In Zhang's study, the block group had faster extubation times, decreased pain scores up to 24 h after surgery, and decreased postoperative opioid administration.…”

“…9 Whether the block was placed postinduction or before sternal closure, Padala's study showed the timing of placement of the regional block did not seem to affect the total opioid requirement nor the pain scores for up to 24 h postoperatively. 7 Another study by Lee et al, 10 evaluated if the administration of liposomal bupivacaine would prolong the analgesic effect of the regional block. This formulation of bupivacaine can have analgesic effects up to 72-96 h. In the study, the parasternal intercostal block was placed just before sternotomy closure.…”

“…Studies based on patient satisfaction have shown that the majority of patients continue to have mild to moderate sternotomy pain especially with the movement and coughing up to postoperative day 3 or later 9 . Whether the block was placed postinduction or before sternal closure, Padala's study showed the timing of placement of the regional block did not seem to affect the total opioid requirement nor the pain scores for up to 24 h postoperatively 7 . Another study by Lee et al, 10 evaluated if the administration of liposomal bupivacaine would prolong the analgesic effect of the regional block.…”