Regional Techniques for Cardiothoracic and Cardiac-Related Procedures

Abstract Pain intensity after cardiac surgery is often severe and is not adequately treated. Inadequately treated postoperative pain has adverse physiologic effects in the postoperative period and is a risk factor of the development of chronic pain. Chronic pain following sternotomy has an incidence ranging from 11% to 56% at 1 year after surgery. Multimodal pain management, including regional anesthesia, has an increasingly important role. The use of regional anesthesia provided good hemodynamic stability, analgesia, less opioid use, and allowed for early extubation. Neuraxial anesthesia have been extensively studied in the context of cardiac surgery, but the risk of neuraxial hematoma in the setting of full heparinization limits the use of this modality. Compared to neuraxial techniques, paravertebral blocks may offer the advantage of a lower risk of bleeding complications. Alternatives to neuraxial blocks have become available. Parasternal blocks include pecto-intercostal fascial block (PIFB) and transversus thoracic plane (TTP) block, or parasternal infiltration done by the surgeon. Other fascial plane blocks, including pectoral nerve, serratus anterior plane, and erector spinae, are found useful based on the type of the procedure. Reports of the successful use of these blocks in minimally invasive cardiac surgery keeps emerging as well. Literature is still evolving about the successful use of certain blocks in conventional cardiac pacemakers and recently in subcutaneously implantable cardioverter-defibrillators (S-ICDs). Potential benefits include better analgesia and less use of general anesthesia, which can be especially helpful.