Regional Anesthesia in Cardiac Surgery: An Overview of Fascial Plane Chest Wall Blocks

Abstract

Optimal analgesia is an integral part of enhanced recovery after surgery (ERAS) programs designed to improve patients’ perioperative experience and outcomes. Regional anesthetic techniques in a form of various fascial plane chest wall blocks are an important adjunct to the optimal postoperative analgesia in cardiac surgery. The most common application of fascial plane chest wall blocks has been for minimally invasive cardiac surgical procedures. An abundance of case reports has been described in the anesthesia literature and reports appear promising, yet higher-level safety and efficacy evidence is lacking. Those providing anesthesia for minimally invasive cardiac procedures should become familiar with fascial plane anatomy and block techniques to be able to provide enhanced postsurgical analgesia and facilitate faster functional recovery and earlier discharge. The purpose of this review is to provide an overview of contemporary fascial plane chest wall blocks used for analgesia in cardiothoracic surgery. Specifically, we focus on relevant anatomic considerations and technical descriptions including pectoralis I and II, serratus anterior, pectointercostal fascial, transverse thoracic muscle, and erector spine plane blocks. In addition, we provide a summary of reported local anesthetic doses used for these blocks and a current state of the literature investigating their efficacy, duration, and comparisons with standard practices. Finally, we hope to stimulate further research with a focus on delineating mechanisms of action of novel emerging blocks, appropriate dosing regimens, and subsequent analysis of their effect on patient outcomes.

Anesthesia for minimally invasive cardiac surgery

“…The PECS I block targets the medial and lateral pectoral nerves and may block the intercostobrachial nerve and the intercostal nerve (ICN) branches anteriorly (31). The PECS II block targets the long thoracic nerve and thoracodorsal nerve (31).…”

“…The PECS I block targets the medial and lateral pectoral nerves and may block the intercostobrachial nerve and the intercostal nerve (ICN) branches anteriorly (31). The PECS II block targets the long thoracic nerve and thoracodorsal nerve (31). The literature evaluating PECS blocks for MICS is sparse, there are several reports of it being used with varying success in TA TAVI procedures (32).…”

Surgical Closure of Atrial Septal Defects in Young Children—A Review of Anesthesia Care in Sternotomy and Thoracotomy Approaches

“…It is not known which block is superior in cardiac surgery via either approach, but there are theoretical advantages to an ESP block for sternotomy. 10,[13][14][15] Another group from the authors' hospital reported 3 pediatric patients (age 3 days, 14 days, and 4 years) who received an SAP block before coarctation repair via thoracotomy. They received less postoperative opioid and had a shorter LOS compared with historic controls.…”

Point-of-Care Ultrasound (POCUS) for the Cardiothoracic Anesthesiologist

“…Interfascial plane blocks play an emerging role in perioperative pain management. 83 Due to the risks associated with epidural and paravertebral techniques, interfascial plane blocks (see Table 10) are a safer alternative for patients after cardiac surgery and can be incorporated readily into a multimodal pain management plan for a number of cardiac, thoracic, and vascular procedures, due to their relative ease of performance and low level of complications. 84,85 The implementation of these blocks into multimodal cardiac enhanced recovery pathways helps to minimize opioid consumption, reduce nausea and vomiting, reduce postoperative ventilatory time, improve patient satisfaction, and provide cost reductions.…”