Enhanced recovery after surgery (ERAS) initiatives, involving a multimodal approach to treating surgical patients, have been linked to major improvements in clinical outcomes and cost.
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At its core, ERAS revolves around the concept that patient outcomes can be improved through multiple incremental steps acting synergistically throughout the entire perioperative period to modulate the physiologic response to surgical stress.2
Although most initial ERAS efforts focused on adult surgical patients, the practice increasingly has become embraced within pediatric surgical subspecialties to optimize care. In fact, many of these principles have been established previously within the field of congenital heart surgery to promote early extubation and mobilization, decreased intensive care unit (ICU) and hospital lengths of stay, and reduced costs.3
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Importantly, regardless of patient population or type of surgery, a unifying theme among all ERAS, or other fast-track anesthesia protocols, is a focus on pain management strategies aimed at minimizing systemic opioid administration.In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Yamamoto et al. describe d findings from their single-center experience using a combination of preemptive, preoperative real-time ultrasound-guided transversus thoracic muscle plane (TTP) block and rectus sheath block (RSB) for perioperative pain management in the chest and epigastric area in pediatric patients undergoing cardiac surgery.
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Following anesthetic induction, but prior to surgical incision, patients received a TTP block followed by RSB with ropivacaine. The authors acknowledged that objectively evaluating the effectiveness of this pain management strategy in pediatric patients posed a challenge; however, they reported that the combination of TTP block and RSB successfully facilitated a reduction in intraoperative fentanyl requirements among study patients.Specifically, they noted that before the implementation of this regional anesthesia approach, institutional protocols involved administering 5 μg/kg of fentanyl during anesthetic induction, 5 μg/kg of fentanyl before commencing cardiopulmonary bypass (CPB), and an additional 5 μg/kg of fentanyl given following CPB. Supplemental doses of fentanyl were given based on the length of the surgery, in addition to a continuous intravenous infusion of 0.5 μg/kg/h of fentanyl initiated during CPB for postoperative analgesia. The authors described this as a “fast-track anesthesia” protocol, which allowed for extubation to be performed in the operating room.
After instituting the combination of TTP block and RSB, investigators observed significant time delays before patients began resuming spontaneous respirations, as well as delayed emergence from general anesthesia. The authors hypothesized that these delays occurred because the amount of fentanyl administered during the surgery was similar to that given before the addition of the combined TTP block and RSB to the protocol. This led to a revised anesthetic approach in which the authors administer 5 μg/kg of fentanyl at anesthetic induction and then another 5 μg/kg of fentanyl only before CPB, eliminating both routine fentanyl administration following CPB and supplemental discretionary fentanyl boluses (which the authors state were no longer required). Ultimately, the authors concluded that the amount of intraoperative fentanyl administered was reduced dramatically following the addition of the combined regional anesthetic technique to their practice.
Nasr et al. highlighted pertinent contemporary literature regarding the use of regional techniques to reduce perioperative opioid consumption and influence outcomes in patients undergoing pediatric cardiac surgery.
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Most notably, this included a systematic review and meta-analysis by Monahan et al., which included a total of 605 patients from 14 randomized controlled trials.6
Pain scores in patients receiving regional anesthesia were reduced significantly at each measured point between 0 and 24 hours postoperatively. There were, however, no observable differences in other measurable outcomes, such as duration of mechanical ventilation, length of ICU stay, or length of hospital stay. No adverse outcomes associated with the regional anesthesia techniques (eg, respiratory depression, local anesthetic systemic toxicity, permanent neurologic complications) were reported in any of the trials.Regarding the TTP block, the effectiveness of this specific technique for providing perioperative analgesia in pediatric cardiac surgery patients was evaluated recently in a single-center prospective study by Zhang et al.
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A total of 100 pediatric patients undergoing open cardiac surgery (ages 6-to-60 months) were randomized into 2 groups to undergo either bilateral TTP block (TTP group) or no TTP block (control group). Patients within the TTP group had significantly lower postoperative pain scores (measured with the Modified Objective Pain Score) until 24 hours after extubation, while also having significantly lower intraoperative and postoperative fentanyl requirements than control group patients. Additionally, time to extubation and lengths of stay in both the ICU and hospital were significantly shorter in the TTP group. No complications were reported in any of the patients receiving TTP blocks. These findings led the authors to conclude that by providing effective analgesia that reduces perioperative fentanyl consumption, bilateral TTP blocks accelerate recovery in pediatric cardiac surgery patients.First described by Ueshima et al., the TTP block is a relatively new technique.
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This truncal block, targeting the anterior branches of the intercostal nerves near the sternum, involves injection of local anesthetic into the fascial plane between the transversus thoracic and internal intercostal muscles. When performed between the third and fourth (or fourth and fifth ribs) just lateral to the sternum, multiple anterior branches of the intercostal nerves (T2-T6) are blocked.11
Although the TTP block shows promise for treating sternotomy-associated pain, Yamamoto et al. astutely recognized that discomfort in the epigastric region caused by chest tubes placed through the rectus abdominis muscle also represents an important source of postoperative pain after cardiac surgery. Thus, they created a combined technique of both RSB and TTP blocks to address postoperative pain resulting from both etiologies.The RSB, described as far back as 1899, became popular in the 1990s for use in pediatric patients undergoing umbilical hernia repair for its ability to provide effective pain relief for abdominal or other midline surgical incisions.
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A meta-analysis by Hamill et al. concluded that abdominal wall blocks, including the RSB, reduced pain and opioid use in children undergoing abdominal surgery.13
Although several methods have been described for the performance of this technique in children, the ultimate goal is to block the terminal branches of the ninth, 10th, and 11th intercostal nerves within the rectus sheath.14
In the combined RSB and TTP block technique of Yamamoto et al., the layer between the rectus abdominis muscle and the posterior layer of the rectus sheath was the target for the RSB.Although neuraxial techniques have been used as an adjunctive approach for reducing opioid administration in pediatric cardiac surgery patients, their use is limited by concerns for potential spinal or epidural hematoma formation during full heparinization required for cardiopulmonary bypass.
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Therefore, promising evidence for the successful utilization of regional anesthesia in this scenario, such as the reports featured in this editorial, brings attention to alternative techniques for addressing the critically important issue of perioperative pain management in pediatric cardiac surgery patients. Although not formal ERAS protocols per se, these regional anesthesia strategies parallel the core concept of this enhanced recovery strategy. In particular, they do so by serving as an early incremental step in a multimodal process designed to preemptively modulate the physiologic response to surgical stress.As always, these types of promising reports and studies lead to further questions and, ultimately, the need for additional focused investigations. Certainly, future large prospective, randomized studies are necessary to confirm feasibility, efficacy, and opioid-sparing effects to help make more definitive conclusions regarding these techniques.
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Additionally, more evidence is needed to assess efficacy among different patient groups. For example, it is clear that patients with single-ventricle physiology after superior cavopulmonary anastomosis (Glenn) and total cavopulmonary anastomosis (Fontan) benefit from early extubation after surgery to eliminate the deleterious effects of positive-pressure ventilation (and associated increased intrathoracic pressures) on an underlying physiology dependent on a passive pulmonary circulation arrangement.17
Since cardiac output immediately increases as mean pulmonary artery pressures decrease following extubation and cessation of positive-pressure ventilation, it is reasonable to hypothesize that this patient population in particular is likely to benefit from management strategies geared toward promoting an enhanced and accelerated postoperative recovery process.Although not unique to this topic, additional challenges lie in obtaining multidisciplinary buy-in and support from all stakeholders on the pediatric cardiac surgery team. In particular, this is likely to be the case in many institutions where regional anesthesia currently is not, or is rarely, being performed in pediatric patients undergoing open cardiac surgical procedures. Clearly, more evidence supporting the safety and efficacy of these techniques will be critical to help gain support for the introduction of these regional anesthetic strategies to the perioperative management plan and assist in advancing their routine incorporation into practice.
Conflict of Interest
None.
References
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- Embracing change: The era for pediatric ERAS is here.Pediatr Surg Int. 2019; 35: 631-634
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- Selected 2018 highlights in congenital cardiac anesthesia.J Cardiothorac Vasc Anesth. 2019; 33: 2833-2842
- Preoperative implementation of transverse thoracic muscle plane block and rectus sheath block combination for pediatric cardiac surgery.J Cardiothorac Vasc Anesth. 2020; 34: 3363-3368
- Regional analgesia added to general anesthesia compared with general anesthesia plus systemic analgesia for cardiac surgery in children: A systematic review and meta-analysis of randomized clinical trials.Anesth Analg. 2019; 128: 130-136
- Efficacy of bilateral transversus thoracis muscle plane block in pediatric patients undergoing open cardiac surgery.J Cardiothorac Vasc Anesth. 2020; 34: 2430-2434
- Blocking of multiple anterior branches of intercostal nerves (Th2-6) using a transversus thoracic muscle plane block.Reg Anesth Pain Med. 2015; 40: 388
- Clinical experiences of ultrasound-guided transversus thoracic muscle plane block: A clinical experience.J Clin Anesth. 2015; 27: 428-429
- Ultrasound-guided transversus thoracic muscle plane block: A cadaveric study of the spread of injectate.J Clin Anesth. 2015; 27: 696
- Regional techniques for cardiac and cardiac-related procedures.J Cardiothorac Vasc Anesth. 2019; 33: 532-546
- The rectus sheath block in paediatric anaesthesia: New indications for an old technique?.Paediatr Anaesth. 1996; 6: 463-466
- Rectus sheath and transversus abdominis plane blocks in children: A systematic review and meta-analysis of randomized trials.Paediatr Anaesth. 2016; 26: 363-371
- Ultrasonography-guided rectus sheath block in paediatric anaesthesia—A new approach to an old technique.Br J Anaesth. 2006; 97: 244-249
- Caudal epidural morphine for control of pain following open heart surgery in children.Anesthesiology. 1989; 70: 418-421
- 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: 263-309
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Published online: September 17, 2020
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- Preoperative Implementation of Transverse Thoracic Muscle Plane Block and Rectus Sheath Block Combination for Pediatric Cardiac SurgeryJournal of Cardiothoracic and Vascular AnesthesiaVol. 34Issue 12
- PreviewSystemic intravenous administration of opioids is the main treatment strategy for intraoperative and postoperative pain management in patients undergoing cardiac surgery with sternotomy. However, using lower doses of opioids may achieve the well-established benefits of the fast-track approach, with minimal opioid-related side effects. Postoperative pain is coupled with a long stay in the intensive care unit. Although neuraxial anesthesia has some benefits, its use remains controversial due to the potential development of epidural hematoma after anticoagulation for cardiopulmonary bypass and coagulopathy after cardiac surgery.
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