Regional Analgesia for Cardiac Surgery Part 1. Current status of neuraxial and paravertebral blocks for adult cardiac surgery

Abstract

Cardiac surgeries are known to produce moderate to severe pain. Pain management has traditionally been based on intravenous opioids. Poorly controlled pain can result in increased incidence of respiratory complications such as atelectasis and pneumonia leading to prolonged intubation and intensive care unit length of stay and subsequent prolonged hospital stay. Adequate perioperative analgesia improves hemodynamics and immunologic responses, which would result in better outcomes after cardiac surgery. Opioid sparing “Enhanced Recovery After Surgery” protocols are increasingly being incorporated into cardiac surgeries. This will reduce opioid requirements and opioid-related side effects and facilitate fast-tracking of patients. Regional analgesia can be provided by neuraxial blocks, fascial plane blocks, peripheral nerve blocks, or simply by the infiltration of the wound with local anesthetics for cardiac surgery. Neuraxial analgesia is provided through epidural, spinal, and paravertebral routes. Though they are being replaced by peripheral fascial plane blocks, epidural and spinal analgesia are still being used in some centers. In this article, neuraxial forms of analgesia are focused. We sought to review epidural analgesia and its impact in suppressing hemodynamic stress response, reducing pulmonary complications, and development of chronic pain. The relationship between intraoperative heparinization and potential neuraxial hematoma is discussed. Other neuraxial options such as spinal and paravertebral analgesia and their usefulness, benefits, and limitations are also reviewed.

Comparison of traditional and upper thoracic epidural analgesia after off‐pump coronary artery bypass graft surgery: A Quasi‐experimental study

“…Cardiac surgery requires anticoagulants, and it is not widely accepted due to concerns about neuraxial hematoma following anticoagulants. 1 , 14 , 21 , 22 , 23 , 24 , 25 , 26 A few trials have demonstrated the safety of regional anesthetic and analgesic techniques in the context of possible anticoagulation during cardiac surgery. 1 , 19 Regional blocks have enormous potential to be integrated into hospitals' acute pain management paradigms following cardiac surgery, given their initial success in decreasing pain scores and reducing opiate usage.…”

“…Spinal and epidural instrumentation entails risk, with epidural hematoma formation being the most feared complication 25–28 . Patients who did not receive thromboprophylaxis have a hematoma formation rate of one in every 220,000 spinal anesthesia cases and one in every 150,000 epidural anesthesia cases but in cardiac surgery, it is approximately 1:3552 observed by Landoni and colleagues 29 .…”

Peripheral Regional Anesthesia Using Local Anesthetics: Old Wine in New Bottles?

“…For decades, opioids, with their potent analgesic effectiveness, have been the mainstay of postoperative pain management. However, opioids may also lead to adverse events, e.g., prolonged length of hospital stay (LOS) due to dose-related side effects such as respiratory depression, sedation, postoperative nausea and vomiting (PONV), tolerance and hyperalgesia, urinary retention or the development of bowel dysfunction [ 5 , 6 , 7 ]. Additionally, when considering the current opioid crisis, effective pain control considerably reduces the need for opioids after surgical procedures.…”

Ultrasound-Guided PECS II + Serratus Plane Fascial Blocks Are Associated with Reduced Opioid Consumption and Lengths of Stay for Minimally Invasive Cardiac Surgery: An Observational Retrospective Study

“…There are several regional analgesia options for cardiac surgery pain management: peridural analgesia, paravertebral block, erector spinae plane (ESP) block, serratus plane block and PECS II block. These techniques were enhanced by comprehensive utilization of ultrasound guidance, the latter being cost-effective, readily accessible, reliable imaging and having multiple advantages [ 8 , 9 , 10 , 11 , 12 , 13 ].…”