Liposomal Bupivacaine–Based Erector Spinae Block for Cardiac Surgery

Inadequate pain relief after cardiac surgery increases morbidity and persistent post-sternotomy syndrome significantly, regional analgesia could improve control outcomes in surgery.1Deneuville M. Bisserier A. Regnard J.F. et al.Continuous intercostal with 0.5% bupivacaine thoracotomy: A randomized study.Ann Thorac Surg. 1993; 55: 381-385Abstract Full Text PDF PubMed Scopus (51) Google Scholar, 2Gust R. Pecher S. Gust al.Effect of patient-controlled on pulmonary complications coronary artery bypass grafting.Crit Care Med. 1999; 27: 2218-2223Crossref (104) 3Roberge C.W. McEwen The effects local anesthetics postoperative pain.AORN J. 1998; 68: 1003-1012Crossref (32) 4Scott N.B Turfrey D.J. Ray D.A. al.A prospective study the potential benefits thoracic epidural anesthesia patients undergoing grafting.Anesth Analg. 2001; 93: 528-535Crossref (257) Scholar Opioid-based has many adverse such as nausea, vomiting, sedation, urinary retention, respiratory depression, delayed tracheal extubation. Neuraxial deep techniques, paravertebral block, are concerning because administration heparin antiplatelet agents perioperative period.5Landoni G. Isella F. Greco al.Benefits risks surgery.Br J Anaesth. 2015; 115: 25-32Abstract (62) Erector spinae plane (ESP) block recently been studied an effective safe modality sternotomy or thoracotomy. Bilateral ESP performed at T5 spinous process provides from T2-to-T9 sensory level results both somatic visceral by blocking dorsal ventral rami spinal nerves including sympathetic chain.6Chin K.J. Adhikary Sarwani N. al.The analgesic efficacy pre-operative bilateral erector blocks having hernia repair.Anaesthesia. 2017; 72: 452-460Crossref (205) 7Altiparmak B. Korkmaz Toker al.Potential mechanism for unilateral blockade laparoscopic cholecystectomy.Can 2020; 67: 161-162Crossref (6) 8Vidal E. Giménez H. Forero al.Erector block: cadaver to determine its action.Rev Esp Anestesiol Reanim. 2018; 65: 514-519Crossref (55) 9Schwartzmann Peng P. Maciel M.A. al.Mechanism Insights a magnetic resonance imaging study.Can 1165-1166Crossref (83) provide adequate median major nerve supplies sternum T2 T6.10Ilfeld B.M. Continuous peripheral blocks: An update published evidence comparison novel, alternative modalities.Anesth 124: 308-335Crossref (136) Several case reports small studies have confirmed surgery; however, larger-scale, controlled needed prove effectiveness.11Leyva F.M. Mendiola W.E. Bonilla A.J. minimally invasive mitral valve surgery.J Cardiothorac Vasc Anesth. 32: 2271-2274Abstract (28) 12Wong Navaratnam Boltz al.Bilateral continuous pediatric patient.J Clin 47: 82-83Crossref (24) 13Macaire Ho Nguyen T. al.Ultrasound-guided within enhanced recovery program is associated decreased opioid consumption improved patient rehabilitation open surgery-a patient-matched, before-and-after study.J 2019; 33: 1659-1667PubMed (61) 14Nagaraja P.S. Ragavendran Singh N.G. al.Comparison management surgery.Ann Card 21: 323-327Crossref 15Muñoz-Leyva Chin opioid-sparing sternotomy.J 2010; 1698-1703Abstract (5) 16Adhikary S.D. Prasad Soleimani option anticoagulated left ventricular assist device implantation: series.J 1063-1067Abstract (38) single-shot regular (bupivacaine ropivacaine) only lasts 10 -to-16 hours injection inadequate long-term surgery. centers adopted infusion techniques using catheters inserted into under ultrasound guidance.14Nagaraja However, catheter carry bleeding, infection, cumbersome insertion, difficulty manage maintain. single-shot, long-lasting would be highly desirable easy-to-manage approach. authors present hypothesized that liposomal (Exparel; Pacira BioSciences, Inc, Parsippany, NJ), longer better intraoperative surgical patients17Kendall M.C. Castro Alves L.J. De Oliveira Jr, Liposome compared plain reduce postsurgical pain: updated meta-analysis trials.Pain Res Treat. 20185710169PubMed opioids consumption. Institutional Review Board University Louisville approved study, individual informed consent was waived (Institutional No. 19.0584). This retrospective prospectively collected medical data via cardiopulmonary Jewish Hospital (Louisville, KY) between January 1 May 31, 2019. Patients who received (ESPB) preoperatively were included (ESPB group), 16 matched eight ESPB propensity score–based greedy match method. Strengthening Reporting Observational Studies Epidemiology checklist used.18Von Elm Altman D.G. Egger (STROBE) statement: Guidelines reporting observational studies.Rev Salud Publica. 20185710169Google All hour before preoperative area single experienced anesthesiologist (J.H.). turned lateral decubitus position. After skin disinfection, high-frequency 6-to-13 MHz linear array transducer placed parallel longitudinal orientation 3-to-4 cm process. identifying three muscle layers above hyperechoic transverse shadow trapezius, rhomboid major, spinae, 10- cm, 22-gauge echogenic needle one away short edge transducer, in-plane beam, about 30-degree angle insertion caudal-to-cranial direction. endpoint tip lying over below muscle. position hydrodissection indicating fluid spread lifting Then, real-time guidance careful negative aspiration, shot mL Exparel (113 mg) diluted saline (30- volume total) performed. same 30- mixture repeated contralateral side considered successful when evident 15 minutes later T3 T4 T8 T10 vertebral anterior, lateral, posterior hemothoraces without any accompanying hemodynamic changes (Fig 1). sevoflurane-based according fast-track protocol. Either sufentanil fentanyl used intermediate intravenous bolus heart rate increased 20% baseline excluded other reasons but pain. No given separation closure, except there based vital signs attending anesthesiologist. transferred intensive care unit (ICU) extubated per Alternative assessment Acetaminophen-hydrocodone acetaminophen-oxycodone tablets control, goal visual analog scale (VAS) score (0-10) <4 rest. VAS scores recorded location Sixteen selected pool 77 cases cases. Opioid intraoperatively groups 4.25 ± 4.37 ?g/kg 11.25 5.78 fentanyl, respectively. Intraoperative group significantly lower than (p < 0.05) 2). Total weighted 4 (0.064 0.056 mg/kg) 12 (0.203 0.097 also (0.349 0.057 mg/kg 0.334 0.094 mg/kg, respectively; p 0.05). no difference 24, 48, 72 extubation (0.449 0.264 v 0.553 0.179 [p = 0.49], 0.693 0.412 0.959 0.259 0.28], 0.945 0.605 1.247 0.184 0.36]). Frequencies breakthrough (0-1.4), 2 (0.8-3), 2.5 (0.8-4.6), (1.6-6.2), (0-5) 1.75 (0.4-2.2), (1.4-2.6), (0.9-3), 3.5 (3.5-4.7), 2.8 (1.6-3.9) 0 hours, 24 48 highest 8 (0-8.2), 7 (4.9-10), 7.5 (5.7-8.4), (5.4-9.6), (0-9.8) 7.8 (2-10), (4.8-9.1), 8.5 (6.0-9.2), (7.1-9.0), 5 (2.4-8.7) 0-to-4 4-to-12 12-to-24 24-to-48 48-to-72 There statistically significant differences these two > Length mechanical ventilation 11.1 5.6 3.9 0.18). Lengths ICU hospital stay 58 45 versus 43 0.53) 5.7 1.0 days 4.2 2.0 0.74), 3). first report bupivacaine–based surgeries. whether long-acting anesthetic–based technique help minimize use series clinical trial described utility reported replacement implantation through thoracotomy approach.11Leyva Scholar,16Adhikary It adult patients.12Wong Scholar,15Muñoz-Leyva More recently, trials reported.19Krishna S.N. Chauhan Bhoi D. Kaushal Hasija Sangdup Bisoi A.K. Spinae Plane Block Acute Post-Surgical Pain Adult Cardiac Surgical Patients: Randomized Controlled Trial.J 368-375Crossref (95) Scholar14Nagaraja Krishna al. paracetamol plus tramadol; had rest Nagaraja found not inferior surgery.14Nagaraja Macaire conducted consecutive, demonstrated decrease 48-hour consumption, it optimized rapid mobilization chest tube removal surgery.13Macaire These proved can powerful technique. further usage group. should useful Because length (on average least 5-6 hours) time, most recommended instead result necessary effect this population. catheter-based infusions undesirable issues hematoma, dislodgement, need more nurse training.5Landoni As catheter-based, infusions, extended-release extend duration anesthesia. In 2011, (and currently only) formulation US Food Drug Administration wound infiltration (Exparel). Compared bupivacaine, increase delay peak plasma concentration.20Beiranvand Moradkhani M.R. Bupivacaine control.Drug (Stuttg). 365-369https://doi.org/10.1055/s-0043-121142Crossref (14) We reduced Although mean values those extubation, groups. For quality satisfaction measurements, neither frequency nor during Those outcome less prominent catheter–based possibly shorter bupivacaine.13Macaire Scholar,14Nagaraja addition, our sample size made evaluation very difficult. several limitations study. First, nonstandardized protocol difficult detect outcomes. Second, nature bias almost inevitable. logistic regression–based balance cofounding variables. method allows treatment otherwise may invalid lack confounding usually much larger data, balanced diagnosis standardized variance ratio all variables matching acceptable dealing relatively samples.21Staffa S.J. Zurakowski Five steps successfully implement evaluate research studies.Anesth 127: 1066-1073Crossref (65) Scholar,22Schulte P.J. Mascha E.J. Propensity methods: Theory practice research.Anesth 1074-1084Crossref (53) Third, final distribution solution might variations and, thus, efficacy. anesthetic well-designed compare reveal safety each technology. Liposomal total intraoperatively, well Additional (Table 1).Table 1Patient Demographic Characteristics, Medical History, Surgery Parameters Before MatchingCharacteristicsTotal Population n 85ESPB Group 8Control Pool 77Age (y)61 (58-63)61.5 (60-72)61 (57-64)Female (%)18 (21%)3 (37.5%)15 (19.5%)Body mass index29 (28-31)30.5 (25.1-38)29 (28-31)Length (min)318 (305-331)306 (259-376)318 (305-333)Type CABG60555 Mitral valve826 Aortic valve303 + valve202 tricuspid valve312 valve101 CABG aortic ASD repair101 Ascending aorta replacement504Diabetes mellitus28 (33%)2 (25%)26 (34%)Hemoglobin (g/L)14.0 1.614.2 2.313.9 1.5Serum creatinine (mg/dL)1.07 0.511.07 0.441.07 1.52Preoperative prescription12 (14%)2 (25%)10 (13%)NOTE. Data presented standard deviation, (95% confidence interval median), number (percentage).Abbreviations: ASD, atrial septal defect; CABG, grafting. Open table new tab