Advertisement

Parasternal Intercostal Nerve Blocks in Patients Undergoing Cardiac Surgery: Evidence Update and Technical Considerations

      In the Enhanced Recovery After Surgery era, parasternal intercostal nerve block has been proposed to improve pain control and reduce opioid use in patients undergoing cardiac surgery. However current literature has reported conflicting evidence about the effect of this multimodal pain management, as procedural variations might pose a significant bias on outcomes evaluation. In this setting, the infiltration of the parasternal plane into 2 intercostal spaces, second and fifth, with a local anesthetic spread under or above the costal plane with ultrasound guidance, seem to be standardized in theory, but significant differences might be observed in clinical practice. This narrative review summarizes and defines the optimal techniques for parasternal plane blocks in patients undergoing cardiac surgery with full median sternotomy, considering both pectointercostal fascial block and transversus thoracic plane block. A total of 10 randomized trials have been published, in adjunct to observational studies, which are heterogeneous in terms of techniques, methods, and outcomes. Parasternal block has been shown to reduce perioperative opioid consumption and provide a more favorable analgesic profile, with reduced postoperative opioid-related side effects. A trend toward reduced intensive care unit stay or duration of mechanical ventilation should be confirmed by adequately powered randomized trials or registry studies. Differences in operative technique might impact outcomes and, therefore, standardization of the procedure plays a pivotal role before reporting specific outcomes. Parasternal plane blocks might significantly improve outcomes of cardiac surgery with full median sternotomy, and should be introduced comprehensively in Enhanced Recovery After Surgery protocols.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Abadi A
        • Cohen R.
        Evaluation of an enhanced recovery after surgery protocol including parasternal intercostal nerve block in cardiac surgery requiring sternotomy.
        Am Surg. 2021; 87: 1561-1564
        • Bousquet P
        • Labaste F
        • Gobin J
        • et al.
        Bilateral parasternal block and bilateral erector spinae plane block reduce opioid consumption in during cardiac surgery.
        J Cardiothorac Vasc Anesth. 2021; 35: 1249-1250
        • Padala S
        • Badhe AS
        • Parida S
        • et al.
        Comparison of preincisional and postincisional parasternal intercostal block on postoperative pain in cardiac surgery.
        J Card Surg. 2020; 35: 1525-1530
        • Sepolvere G
        • Coppolino F
        • Tedesco M
        • et al.
        Ultrasound-guided parasternal blocks: Techniques, clinical indications and future prospects.
        Minerva Anestesiol. 2021; 87: 1338-1346
        • Sepolvere G
        • Di Zazzo F
        • Merola L
        • et al.
        The correct internal mammary artery anatomy: A topic for ultrasound parasternal block.
        Saudi J Anaesth. 2021; 15: 233-234
        • Sepolvere G
        • Fusco P
        • Tedesco M
        • et al.
        Bilateral ultrasound-guided parasternal block for postoperative analgesia in cardiac surgery: Could it be the safest strategy?.
        Reg Anesth Pain Med. 2020; 45: 316-317
        • Sepolvere G
        • Tedesco M
        • Cristiano L.
        Ultrasound parasternal block as a novel approach for cardiac sternal surgery: Could it be the safest strategy?.
        J Cardiothorac Vasc Anesth. 2020; 34: 2284-2286
        • Sepolvere G
        • Tedesco M
        • Cristiano L.
        Ultrasound guided parasternal block with dexmedetomidine as effective approach for postoperative analgesia in cardiac surgery.
        Minerva Anestesiol. 2020; 86: 789-790
        • Sepolvere G
        • Tognu A
        • Tedesco M
        • et al.
        Avoiding the internal mammary artery during parasternal blocks: Ultrasound identification and technique considerations.
        J Cardiothorac Vasc Anesth. 2021; 35: 1594-1602
        • Hu M
        • Wang Y
        • Hao B
        • et al.
        Evaluation of different pain-control procedures for post-cardiac surgery: A systematic review and network meta-analysis.
        Surg Innov. 2022; 29: 269-277
        • Raj N.
        Regional anesthesia for sternotomy and bypass-beyond the epidural.
        Paediatr Anaesth. 2019; 29: 519-529
        • Nachiyunde B
        • Lam L.
        The efficacy of different modes of analgesia in postoperative pain management and early mobilization in postoperative cardiac surgical patients: A systematic review.
        Ann Card Anaesth. 2018; 21: 363-370
        • McDonald SB
        • Jacobsohn E
        • Kopacz DJ
        • et al.
        Parasternal block and local anesthetic infiltration with levobupivacaine after cardiac surgery with desflurane: The effect on postoperative pain, pulmonary function, and tracheal extubation times.
        Anesth Analg. 2005; 100: 25-32
        • Barr AM
        • Tutungi E
        • Almeida AA.
        Parasternal intercostal block with ropivacaine for pain management after cardiac surgery: A double-blind, randomized, controlled trial.
        J Cardiothorac Vasc Anesth. 2007; 21: 547-553
        • Baki ED
        • Kavrut Ozturk N
        • Ayoglu RU
        • et al.
        Effects of parasternal block on acute and chronic pain in patients undergoing coronary artery surgery.
        Semin Cardiothorac Vasc Anesth. 2016; 20: 205-212
        • Bloc S
        • Perot BP
        • Gibert H
        • et al.
        Efficacy of parasternal block to decrease intraoperative opioid use in coronary artery bypass surgery via sternotomy: A randomized controlled trial.
        Reg Anesth Pain Med. 2021; 46: 671-678
        • Vilvanathan S
        • Saravanababu MS
        • Sreedhar R
        • et al.
        Ultrasound-guided modified parasternal intercostal nerve block: Role of preemptive analgesic adjunct for mitigating poststernotomy pain.
        Anesth Essays Res. 2020; 14: 300-304
        • Kumar AK
        • Chauhan S
        • Bhoi D
        • et al.
        Pectointercostal fascial block (PIFB) as a novel technique for postoperative pain management in patients undergoing cardiac surgery.
        J Cardiothorac Vasc Anesth. 2021; 35: 116-122
        • Kaya C
        • Dost B
        • Dokmeci O
        • et al.
        Comparison of ultrasound-guided pectointercostal fascial block and transversus thoracic muscle plane block for acute poststernotomy pain management after cardiac surgery: A prospective, randomized, double-blind pilot study.
        J Cardiothorac Vasc Anesth. 2022; 36: 2313-2321
        • Khera T
        • Murugappan KR
        • Leibowitz A
        • 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: 896-903
        • Zhang Y
        • Gong H
        • Zhan B
        • et al.
        Effects of bilateral Pecto-intercostal Fascial Block for perioperative pain management in patients undergoing open cardiac surgery: A prospective randomized study.
        BMC Anesthesiol. 2021; 21: 175
        • Li J
        • Lin L
        • Peng J
        • et al.
        Efficacy of ultrasound-guided parasternal block in adult cardiac surgery: A meta-analysis of randomized controlled trials.
        Minerva Anestesiol. 2022; 88: 719-728
        • Ozturk NK
        • Baki ED
        • Kavakli AS
        • et al.
        Comparison of transcutaneous electrical nerve stimulation and parasternal block for postoperative pain management after cardiac surgery.
        Pain Res Manag. 2016; 20164261949