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      Fascial plane blocks for cardiothoracic surgery: a narrative review

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          Abstract

          In recent years, there has been a growing awareness of the limitations and risks associated with the overreliance on opioids in various surgical procedures, including cardiothoracic surgery.

          This shift on pain management toward reducing reliance on opioids, together with need to improve patient outcomes, alleviate suffering, gain early mobilization after surgery, reduce hospital stay, and improve patient satisfaction and functional recovery, has led to the development and widespread implementation of enhanced recovery after surgery (ERAS) protocols.

          In this context, fascial plane blocks are emerging as part of a multimodal analgesic in cardiac surgery and as alternatives to conventional neuraxial blocks for thoracic surgery, and there is a growing body of evidence suggesting their effectiveness and safety in providing pain relief for these procedures.

          In this review, we discuss the most common fascial plane block techniques used in the field of cardiothoracic surgery, offering a comprehensive overview of regional anesthesia techniques and presenting the latest evidence on the use of chest wall plane blocks specifically in this surgical setting.

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          Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS)

          Timothy Batchelor, Neil J. Rasburn, Etienne Abdelnour-Berchtold … (2019)
          Enhanced recovery after surgery is well established in specialties such as colorectal surgery. It is achieved through the introduction of multiple evidence-based perioperative measures that aim to diminish postoperative organ dysfunction while facilitating recovery. This review aims to present consensus recommendations for the optimal perioperative management of patients undergoing thoracic surgery (principally lung resection). A systematic review of meta-analyses, randomized controlled trials, large non-randomized studies and reviews was conducted for each protocol element. Smaller prospective and retrospective cohort studies were considered only when higher-level evidence was unavailable. The quality of the evidence base was graded by the authors and used to form consensus recommendations for each topic. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society and the European Society for Thoracic Surgery. Recommendations were developed for a total of 45 enhanced recovery items covering topics related to preadmission, admission, intraoperative care and postoperative care. Most are based on good-quality studies. In some instances, good-quality data were not available, and subsequent recommendations are generic or based on data extrapolated from other specialties. In other cases, no recommendation can currently be made because either equipoise exists or there is a lack of available evidence. Recommendations are based not only on the quality of the evidence but also on the balance between desirable and undesirable effects. Key recommendations include preoperative counselling, nutritional screening, smoking cessation, prehabilitation for high-risk patients, avoidance of fasting, carbohydrate loading, avoidance of preoperative sedatives, venous thromboembolism prophylaxis, prevention of hypothermia, short-acting anaesthetics to facilitate early emergence, regional anaesthesia, nausea and vomiting control, opioid-sparing analgesia, euvolemic fluid management, minimally invasive surgery, early chest drain removal, avoidance of urinary catheters and early mobilization after surgery. These guidelines outline recommendations for the perioperative management of patients undergoing lung surgery based on the best available evidence. As the recommendation grade for most of the elements is strong, the use of a systematic perioperative care pathway has the potential to improve outcomes after surgery.
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            Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery.

            R. Blanco, M. FAJARDO, T. Parras Maldonado (2012)
            The Pecs block (pectoral nerves block) is an easy and reliable superficial block inspired by the infraclavicular block approach and the transversus abdominis plane blocks. Once the pectoralis muscles are located under the clavicle the space between the two muscles is dissected to reach the lateral pectoral and the medial pectoral nerves. The main indications are breast expanders and subpectoral prosthesis where the distension of these muscles is extremely painful. A second version of the Pecs block is described, called "modified Pecs block" or Pecs block type II. This novel approach aims to block at least the pectoral nerves, the intercostobrachial, intercostals III-IV-V-VI and the long thoracic nerve. These nerves need to be blocked to provide complete analgesia during breast surgery, and it is an alternative or a rescue block if paravertebral blocks and thoracic epidurals failed. This block has been used in our unit in the past year for the Pecs I indications described, and in addition for, tumorectomies, wide excisions, and axillary clearances. The ultrasound sequence to perform this block is shown, together with simple X-ray dye images and gadolinium MRI images to understand the spread and pathways that can explain the benefit of this novel approach. Copyright © 2012 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.
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              Serratus plane block: a novel ultrasound-guided thoracic wall nerve block.

              R. Ernesto Blanco, T Parras, J McDonnell … (2013)
              We present a novel ultrasound-guided regional anaesthetic technique that may achieve complete paraesthesia of the hemithorax. This technique may be a viable alternative to current regional anaesthetic techniques such as thoracic paravertebral and central neuraxial blockade, which can be technically more challenging and have a higher potential side-effect profile. We performed the serratus block at two different levels in the midaxillary line on four female volunteers. We recorded the degree of paraesthesia obtained and performed fat-suppression magnetic resonance imaging and three-dimensional reconstructions of the spread of local anaesthetic in the serratus plane. All volunteers reported an effective block that provided long-lasting paraesthesia (750-840 min). There were no side-effects noted in this initial descriptive study. While these are preliminary findings, and must be confirmed in a clinical trial, they highlight the potential for the serratus plane block to provide analgesia following surgery on the thoracic wall. We suggest that this novel approach appears to be safe, effective, and easy to perform, and is associated with a low risk of side-effects.
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                Author and article information

                Contributors
                Paolo Capuano:
                ORCID: http://orcid.org/0000-0002-8236-5147
                paolocapuano89@gmail.com
                Journal
                Journal ID (nlm-ta): J Anesth Analg Crit Care
                Journal ID (iso-abbrev): J Anesth Analg Crit Care
                Title: Journal of Anesthesia, Analgesia and Critical Care
                Publisher: BioMed Central (London )
                ISSN (Electronic): 2731-3786
                Publication date (Electronic): 11 March 2024
                Publication date PMC-release: 11 March 2024
                Publication date Collection: 2024
                Volume: 4
                Electronic Location Identifier: 20
                Affiliations
                [1 ]Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione (IRCCS-ISMETT), UPMCI (University of Pittsburgh Medical Center Italy), ( https://ror.org/04dxgvn87) Palermo, Italy
                [2 ]Department of Anesthesia and Cardiac Surgery Intensive Care Unit, Casa Di Cura San Michele, ( https://ror.org/00z3eck08) Maddaloni, Caserta, Italy
                [3 ]Department of Anesthesia, Critical Care and Emergency, “Città Della Salute E Della Scienza” Hospital, Turin, Italy
                [4 ]Intensive Care Unit, Department of Anesthesia, G. Mazzini Hospital, Teramo, Italy
                [5 ]Department of Cardioanesthesia and Intensive Care, Policlinico San Martino IRCCS Hospital – IRCCS Cardiovascular Network, Genoa, Italy
                [6 ]Department of Anesthesia and Intensive Care Unit and Pain Therapy, Mater Dei Hospital, Bari, Italy
                [7 ]Intensive Care Unit, Department of Anesthesia, S. Maria Goretti Hospital, Latina, Italy
                Author information
                http://orcid.org/0000-0002-8236-5147
                Article
                Publisher ID: 155
                DOI: 10.1186/s44158-024-00155-5
                PMC ID: 10926596
                PubMed ID: 38468350
                SO-VID: f7b9e446-2c47-493e-8dc5-ac2c3140ff8f
                Copyright © © The Author(s) 2024
                License:

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 20 October 2023
                Date accepted : 23 February 2024
                Categories
                Subject: Review
                Custom metadata
                issue-copyright-statement © Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care 2024

                Keywords: fascial plane blocks,locoregional anesthesia,cardiac surgery,eras,pain management
                Data availability:
                Keywords: fascial plane blocks, locoregional anesthesia, cardiac surgery, eras, pain management

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