Skip to main content

Acute Pain Management Protocol for Cardiac Procedures

  • Chapter
  • First Online:
First Aid Perioperative Ultrasound

Abstract

Regional anesthesia for cardiac surgery has fostered more interest with the implementation of enhanced recovery after surgery (ERAS) protocols and “fast-track” programs in the last decade (Grant et al. Anesth Analg. 131:1852-61, 2020; Cheng. Can J Anaesth. 52:12–7, 2005). Neuraxial, paraneuraxial, fascial plane, and directly targeted nerve blocks have all been described in the literature with varying efficacy and safety profiles. Currently, for both median sternotomy and thoracotomy approaches in open cardiac procedures, fascial plane nerve blocks are largely preferred due to their safety profile in the setting of heparinization, ease of performance, as well as their efficacy in randomized controlled trials (RCT) (Warfield et al. Curr Opin Anaesthesiol 33:692–7, 2020; Adhikary et al. J Cardiothorac Vasc Anesth. 33:1063-7, 2019).

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

Abbreviations

ASRA:

American Society of Regional Anesthesia and Pain Medicine

BMI:

Body Mass Index

CABG:

Coronary Artery Bypass Grafting

ERAS:

Enhanced Recovery After Surgery

ESP:

Erector Spinae Plane

ICNB:

Intercostal Nerve Block

ICU:

Intensive Care Unit

IIM:

Internal Intercostal Muscle

IMA:

Internal Mammary Artery

LAST:

Local Anesthetic Systemic Toxicity

PIFB:

Pectointercostal Fascia Block

PTPS:

Post-Thoracotomy Pain Syndrome

PVB:

Paravertebral Block

RCT:

Randomized Controlled Trial

SAP:

Serratus Anterior Plane

TTM:

Transversus Thoracis Muscle

TTP:

Transversus Thoracis Plane

References

  1. Grant MC, Isada T, Ruzankin P, Gottschalk A, Whitman G, Lawton JS, et al. Opioid-sparing cardiac anesthesia: secondary analysis of an enhanced recovery program for cardiac surgery. Anesth Analg. 2020;131(6):1852–61.

    Article  CAS  PubMed  Google Scholar 

  2. Cheng DC. Regional analgesia and ultra-fast-track cardiac anesthesia. Can J Anaesth. 2005;52(1):12–7.

    Article  PubMed  Google Scholar 

  3. Warfield DJ, Barre S, Adhikary SD. Current understanding of the fascial plane blocks for analgesia of the chest wall: techniques and indications update for 2020. Curr Opin Anaesthesiol. 2020;33(5):692–7.

    Article  PubMed  Google Scholar 

  4. Adhikary SD, Prasad A, Soleimani B, Chin KJ. Continuous erector spinae plane block as an effective analgesic option in anticoagulated patients after left ventricular assist device implantation: a case series. J Cardiothorac Vasc Anesth. 2019;33(4):1063–7.

    Article  PubMed  Google Scholar 

  5. Kumar AK, Chauhan S, Bhoi D, Kaushal B. Pectointercostal fascial block (PIFB) as a novel technique for postoperative pain management in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2021;35(1):116–22.

    Article  CAS  PubMed  Google Scholar 

  6. Dowling R, Thielmeier K, Ghaly A, Barber D, Boice T, Dine A. Improved pain control after cardiac surgery: results of a randomized, double-blind, clinical trial. J Thorac Cardiovasc Surg. 2003;126(5):1271–8.

    Article  CAS  PubMed  Google Scholar 

  7. Kaushal B, Chauhan S, Saini K, Bhoi D, Bisoi AK, Sangdup T, et al. 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. 2019;33(2):418–25.

    Article  PubMed  Google Scholar 

  8. Cheng DC, Karski J, Peniston C, Raveendran G, Asokumar B, Carroll J, et al. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective, randomized, controlled trial. Anesthesiology. 1996;85(6):1300–10.

    Article  CAS  PubMed  Google Scholar 

  9. Cheng DC, Karski J, Peniston C, Asokumar B, Raveendran G, Carroll J, et al. Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg. 1996;112(3):755–64.

    Article  CAS  PubMed  Google Scholar 

  10. Hutton M, Brull R, Macfarlane AJR. Regional anaesthesia and outcomes. BJA Educ. 2018;18(2):52–6.

    Article  CAS  PubMed  Google Scholar 

  11. Chin KJ, Versyck B, Pawa A. Ultrasound-guided fascial plane blocks of the chest wall: a state-of-the-art review. Anaesthesia. 2021;76(Suppl 1):110–26.

    Article  PubMed  Google Scholar 

  12. Chin KJ, Pawa A, Forero M, Adhikary S. Ultrasound-guided fascial plane blocks of the thorax: pectoral I and II, serratus anterior plane, and erector spinae plane blocks. Adv Anesth. 2019:187–205.

    Google Scholar 

  13. Novak-Jankovič V, Markovič-Božič J. Regional anaesthesia in thoracic and abdominal surgery. Acta Clin Croat. 2019;58(Suppl 1):96–100.

    PubMed  PubMed Central  Google Scholar 

  14. Chen N, Qiao Q, Chen R, Xu Q, Zhang Y, Tian Y. The effect of ultrasound-guided intercostal nerve block, single-injection erector spinae plane block and multiple-injection paravertebral block on postoperative analgesia in thoracoscopic surgery: a randomized, double-blinded, clinical trial. J Clin Anesth. 2020;59:106–11.

    Article  PubMed  Google Scholar 

  15. Caruso TJ, Lawrence K, Tsui BCH. Regional anesthesia for cardiac surgery. Curr Opin Anaesthesiol. 2019;32(5):674–82.

    Article  PubMed  Google Scholar 

  16. Macaire P, Ho N, Nguyen T, Nguyen B, Vu V, Quach C, et al. Ultrasound-guided continuous thoracic erector spinae plane block within an enhanced recovery program is associated with decreased opioid consumption and improved patient postoperative rehabilitation after open cardiac surgery-a patient-matched, controlled before-and-after study. J Cardiothorac Vasc Anesth. 2019;33(6):1659–67.

    Article  PubMed  Google Scholar 

  17. Adhikary SD, Pruett A, Forero M, Thiruvenkatarajan V. Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: a case study and a literature review on the spread of local anaesthetic in the erector spinae plane. Indian J Anaesth. 2018;62(1):75–8.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Jack JM, McLellan E, Versyck B, Englesakis MF, Chin KJ. The role of serratus anterior plane and pectoral nerves blocks in cardiac surgery, thoracic surgery and trauma: a qualitative systematic review. Anaesthesia. 2020;75(10):1372–85.

    Article  CAS  PubMed  Google Scholar 

  19. Khera T, Murugappan KR, Leibowitz A, Bareli N, Shankar P, Gilleland S, et al. Ultrasound-guided Pecto-intercostal fascial block for postoperative pain management in cardiac surgery: a prospective, randomized, placebo-controlled trial. J Cardiothorac Vasc Anesth. 2021;35(3):896–903.

    Article  CAS  PubMed  Google Scholar 

  20. Mittnacht AJC, Shariat A, Weiner MM, Malhotra A, Miller MA, Mahajan A, et al. Regional techniques for cardiac and cardiac-related procedures. J Cardiothorac Vasc Anesth. 2019;33(2):532–46.

    Article  PubMed  Google Scholar 

  21. Huang AP, Sakata RK. Pain after sternotomy - review. Braz J Anesthesiol. 2016;66(4):395–401.

    Article  PubMed  Google Scholar 

  22. Weissman C. Pulmonary complications after cardiac surgery. Semin Cardiothorac Vasc Anesth. 2004;8(3):185–211.

    Article  PubMed  Google Scholar 

  23. Maxwell C, Nicoara A. New developments in the treatment of acute pain after thoracic surgery. Curr Opin Anaesthesiol. 2014;27(1):6–11.

    Article  PubMed  Google Scholar 

  24. Kamalipour H, Vafaei A, Parviz Kazemi A, Khademi S. Comparing the prevalence of chronic pain after sternotomy in patients undergoing coronary artery bypass grafting using the internal mammary artery and other open heart surgeries. Anesth Pain Med. 2014;4(3):e17969.

    PubMed  PubMed Central  Google Scholar 

  25. Memtsoudis SG, Cozowicz C, Nagappa M, Wong J, Joshi GP, Wong DT, et al. Society of anesthesia and sleep medicine guideline on intraoperative management of adult patients with obstructive sleep apnea. Anesth Analg. 2018;127(4):967–87.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Doğan Bakı E, Kavrut Ozturk N, Ayoğlu RU, Emmiler M, Karslı B, Uzel H. Effects of parasternal block on acute and chronic pain in patients undergoing coronary artery surgery. Semin Cardiothorac Vasc Anesth. 2016;20(3):205–12.

    Article  PubMed  Google Scholar 

  27. Murata H, Hida K, Hara T. Transverse thoracic muscle plane block: tricks and tips to accomplish the block. Reg Anesth Pain Med. 2016;41(3):411–2.

    Article  PubMed  Google Scholar 

  28. Bignami E, Landoni G, Biondi-Zoccai GG, Boroli F, Messina M, Dedola E, et al. Epidural analgesia improves outcome in cardiac surgery: a meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth. 2010;24(4):586–97.

    Article  PubMed  Google Scholar 

  29. Hill SE, Keller RA, Stafford-Smith M, Grichnik K, White WD, D'Amico TA, et al. Efficacy of single-dose, multilevel paravertebral nerve blockade for analgesia after thoracoscopic procedures. Anesthesiology. 2006;104(5):1047–53.

    Article  CAS  PubMed  Google Scholar 

  30. Vogt A, Stieger DS, Theurillat C, Curatolo M. Single-injection thoracic paravertebral block for postoperative pain treatment after thoracoscopic surgery. Br J Anaesth. 2005;95(6):816–21.

    Article  CAS  PubMed  Google Scholar 

  31. Landoni G, Isella F, Greco M, Zangrillo A, Royse CF. Benefits and risks of epidural analgesia in cardiac surgery. Br J Anaesth. 2015;115(1):25–32.

    Article  CAS  PubMed  Google Scholar 

  32. Guay J, Kopp S. Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass. Cochrane Database Syst Rev. 2019;3:CD006715.

    PubMed  Google Scholar 

  33. Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. 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. 2018;43(3):263–309.

    Article  PubMed  Google Scholar 

  34. Hadzic A. Hadzic's textbook of regional anesthesia and acute pain management. 2nd ed. New York: McGraw-Hill Education; 2017.

    Google Scholar 

  35. Capdevila M, Ramin S, Capdevila X. Regional anesthesia and analgesia after surgery in ICU. Curr Opin Crit Care. 2017;23(5):430–9.

    Article  PubMed  Google Scholar 

  36. Chakravarthy M. Regional analgesia in cardiothoracic surgery: a changing paradigm toward opioid-free anesthesia? Ann Card Anaesth. 2018;21(3):225–7.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Magoon R, Kaushal B, Chauhan S, Bhoi D, Bisoi AK, Khan MA. A randomised controlled comparison of serratus anterior plane, pectoral nerves and intercostal nerve block for post-thoracotomy analgesia in adult cardiac surgery. Indian J Anaesth. 2020;64(12):1018–24.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Essandoh M, Hussain N, Alghothani Y, Bhandary S. Chest wall fascial PlaneBlocks: a safe and effective analgesic strategy for minithoracotomy cardiac surgery. J Cardiothorac Vasc Anesth. 2020;34(11):3168–9.

    Article  PubMed  Google Scholar 

  39. Haskins SC, Memtsoudis SG. Fascial plane blocks for cardiac surgery: NewFrontiers in analgesia and nomenclature. Anesth Analg. 2020;131(1):125–6.

    Article  PubMed  Google Scholar 

  40. Kelava M, Alfirevic A, Bustamante S, Hargrave J, Marciniak D. Regional anesthesia in cardiac surgery: an overview of fascial plane chest wall blocks. Anesth Analg. 2020;131(1):127–35.

    Article  PubMed  Google Scholar 

  41. Sepolvere G, Tedesco M, Fusco P, Scimia P, Cristiano L. Fascial plane blocks in cardiac surgery: a future to discover. Minerva Anestesiol. 2021;87(3):382–3.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Dennis J. Warfield Jr. .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Walker, J., Bose, R., Jordan, A., Warfield, D.J. (2023). Acute Pain Management Protocol for Cardiac Procedures. In: Li, J., Jiang, W., Vadivelu, N. (eds) First Aid Perioperative Ultrasound. Springer, Cham. https://doi.org/10.1007/978-3-031-21291-8_27

Download citation

  • DOI: https://doi.org/10.1007/978-3-031-21291-8_27

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-21290-1

  • Online ISBN: 978-3-031-21291-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics