Efficacy of opioid-sparing analgesia after median sternotomy with continuous bilateral parasternal subpectoral plane blocks

Morgan T Harloff; Kamen Vlassakov; Kia Sedghi; Andrew Shorten; Edward D Percy; Dirk Varelmann; Tsuyoshi Kaneko; Nerve Block Working Group

doi:10.1016/j.jtcvs.2023.02.018

Efficacy of opioid-sparing analgesia after median sternotomy with continuous bilateral parasternal subpectoral plane blocks

J Thorac Cardiovasc Surg. 2024 Jun;167(6):2157-2169.e4. doi: 10.1016/j.jtcvs.2023.02.018. Epub 2023 Feb 23.

Authors

Morgan T Harloff¹, Kamen Vlassakov², Kia Sedghi³, Andrew Shorten², Edward D Percy¹, Dirk Varelmann², Tsuyoshi Kaneko⁴; Nerve Block Working Group

Affiliations

¹ Division of Cardiac Surgery, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
² Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
³ Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Department of Anesthesiology, Inova Fairfax Hospital, Falls Church, Va.
⁴ Division of Cardiac Surgery, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. Electronic address: [email protected].

PMID: 37212769
DOI: 10.1016/j.jtcvs.2023.02.018

Abstract

Objectives: Regional anesthetic techniques, traditionally underutilized in cardiac surgery, may play a role in multimodal analgesia, effectively improving pain control and reducing opioid consumption. We investigated the efficacy of continuous bilateral ultrasound-guided parasternal subpectoral plane blocks following sternotomy.

Methods: We reviewed all opioid-naïve patients who underwent cardiac surgery via median sternotomy under our enhanced recovery after surgery protocol between May 2018 and March 2020. Patients were grouped based on postoperative pain management strategy-those who received standard Enhanced Recovery After Surgery (ERAS) multimodal analgesia alone (no nerve block group) versus those receiving ERAS multimodal analgesia plus continuous bilateral parasternal subpectoral plane blocks (block group). In the block group, parasternal subpectoral plane catheters were placed under ultrasound-guidance on each side of the sternum with initial 0.25% ropivacaine bolus, followed by continuous 0.125% bupivacaine infusions. Postoperative patient-reported numerical rating scale pain scores and opioid consumption in morphine milligram equivalents were compared through postoperative day 4.

Results: Of 281 patients included in the study, the block group comprised 125 (44%) patients. Although baseline characteristics, type of surgery, and length of stay were similar between groups, average numerical rating scale pain scores and opioid consumption were significantly lower in the block group through postoperative day 4 (all P values < .05). We also observed a 44% reduction in total opioid consumption after surgery in the block group (75.1 vs 133.1 MME; P = .001) and 1 less hospital day requiring opioids (4.2 vs 3 days; P = .001).

Conclusions: Continuous bilateral parasternal subpectoral plane blocks may further reduce poststernotomy pain and opioid consumption within the context ERAS multimodal analgesia.

Keywords: continuous parasternal subpectoral plane block; enhanced recovery after surgery; opioid-sparing analgesia.

MeSH terms

Aged
Analgesics, Opioid* / administration & dosage
Analgesics, Opioid* / therapeutic use
Anesthetics, Local / administration & dosage
Cardiac Surgical Procedures / adverse effects
Cardiac Surgical Procedures / methods
Enhanced Recovery After Surgery
Female
Humans
Male
Middle Aged
Nerve Block* / methods
Pain Management / methods
Pain Measurement
Pain, Postoperative* / diagnosis
Pain, Postoperative* / etiology
Pain, Postoperative* / prevention & control
Retrospective Studies
Ropivacaine / administration & dosage
Sternotomy* / adverse effects
Treatment Outcome
Ultrasonography, Interventional