Fascial plane blocks for cardiothoracic surgery: a narrative review.

In recent years, there has been a growing awareness of the limitations and risks associated with the overreliance on opioids in various surgical procedures, including cardiothoracic surgery.This shift on pain management toward reducing reliance on opioids, together with need to improve patient outcomes, alleviate suffering, gain early mobilization after surgery, reduce hospital stay, and improve patient satisfaction and functional recovery, has led to the development and widespread implementation of enhanced recovery after surgery (ERAS) protocols.In this context, fascial plane blocks are emerging as part of a multimodal analgesic in cardiac surgery and as alternatives to conventional neuraxial blocks for thoracic surgery, and there is a growing body of evidence suggesting their effectiveness and safety in providing pain relief for these procedures. In this review, we discuss the most common fascial plane block techniques used in the field of cardiothoracic surgery, offering a comprehensive overview of regional anesthesia techniques and presenting the latest evidence on the use of chest wall plane blocks specifically in this surgical setting.

Continuous Erector Spinae Plane Block for Pain Management in a Pediatric Kidney Transplant Recipient: A Case Report and Review of the Current Literature.

Pain management in patients undergoing kidney transplantation requires careful consideration due to their altered physiology, and potential risks associated with certain analgesic options. In recent years, personalized and multimodal approaches have proven to be pivotal in perioperative pain management, as well as in children. Implementing regional analgesia methods offers a valuable solution in many pediatric surgical settings and the erector spinae plane block (ESPB) could represent a possible analgesic strategy in pediatric patients undergoing renal transplantation. Here, we report the case of a 13-year-old child who underwent living-donor kidney transplantation (LDKx) and received continuous erector spinae plane block (ESPB) for perioperative pain management. This multimodal approach with continuous ESPB resulted in optimal pain control without the need for opioids, allowing for early mobilization and for an optimal postoperative course.

Which ultrasound-guided parasternal intercostal nerve block for post-sternotomy pain? Results from a prospective observational study.

BACKGROUND: Parasternal intercostal blocks (PSB) have been proposed for postoperative analgesia in patients undergoing median sternotomy. PSB can be achieved using two different approaches, the superficial parasternal intercostal plane block (SPIP) and deep parasternal intercostal plane block (DPIP) respectively. METHODS: We designed the present prospective, observational cohort study to compare the analgesic efficacy of the two approaches. Cardiac surgical patients who underwent full sternotomy from January to September 2022 were enrolled and divided into three groups, according to pain control strategy: morphine, SPIP, and DPIP group. Primary outcomes were was postoperative pain evaluated as absolute value of NRS at 12 h. Secondary outcomes were the NRS at 24 and 48 h, the need for salvage analgesia (both opioids and NSAIDs), incidence of postoperative nausea and vomiting, time to extubation, mechanical ventilation duration, and bowel disfunction. RESULTS: Ninety-six were enrolled. There was no significant difference in terms of median Numeric Pain Rating Scale at 24 h and at 48 h between the study groups. Total postoperative morphine consumption was 1.00 (0.00-3.00), 2.00 (0.00-5.50), and 15.60 mg (9.60-30.00) in the SPIP, DPIP, and morphine group, respectively (SPIP and DPIP vs morphine: p < 0.001). Metoclopramide consumption was lower in SPIP and DPIP group compared with morphine group (p = 0.01). There was no difference in terms of duration of mechanical ventilation and of bowel activity between the study groups. Two pneumothorax occurred in the DPIP group. CONCLUSIONS: Both SPIP and DPIP seem able to guarantee an effective pain management in the postoperative phase of cardiac surgeries via full median sternotomy while ensuring a reduced consumption of opioids and antiemetic drugs.

Imaging overpressurised fracture networks and geological barriers hindering fluid migrations across a slow-deformation seismic gap.

There is an ongoing debate on the processes producing background seismicity and deformation transients across seismic gaps, i.e., regions that lack historical large-magnitude earthquakes. Essential missing elements are geophysical images that resolve sources of geophysical unrest. Here, we apply seismic scattering and absorption tomography to data recorded during the 2010-2014 seismic sequence within the Mt. Pollino seismic gap region (Southern Italy). The tomographic models show high sensitivity to fluid content, deformed fractured structures, and impermeable layers stopping fluid migrations. They bridge the gaps between geological and geophysical models and provide a highly-resolved image of the source of seismic and deformation unrest within this seismic gap. High absorption topping the western Pollino seismic volume appears pressurized between the low-Vp/Vs and low-scattering San Donato metamorphic core and a deep basement. Absorbing fluids can only migrate laterally to the east, blocked in the west and southwest by deep low-scattering barriers associated with east-dipping faults and to the north and southeast by saturated overpressurized low-scattering basins. This eastern migration is only partially effective, producing seismicity across the lowest boundary of the high-absorption volume. Our results showcase the potential of seismic scattering and absorption when imaging structures causing geophysical unrest processes across fault networks.

Erector spinae plane block versus paravertebral block for postoperative pain management in thoracic surgery: a systematic review and meta-analysis.

INTRODUCTION: The 2018 guidelines for enhanced recovery in thoracic surgery recommend paravertebral block (PVB) for postoperative pain management. However, recent studies demonstrate that erector spinae plane block (ESPB) achieves similar postoperative pain control with reduced block-related complications. EVIDENCE ACQUISITION: We conducted a meta-analysis of randomized controlled trials to evaluate the analgesic efficacy and safety of ESPB versus PVB for pain management after thoracic surgery. PubMed, Embase, and Scopus were searched through December 2022 (PROSPERO registration - CRD42023395593). Primary outcomes were postoperative pain scores, resting at 6, 12, 24, and 48 hours, and at movement at 24 and 48 hours. Secondary outcomes included opioid consumption at 24 and 48 hours, and incidence of postoperative nausea and vomiting or block-related complications in the first 48 hours. EVIDENCE SYNTHESIS: Ten randomized control trials enrolling a total of 624 total patients were included. There were no significant differences in pain scores, resting or at movement, at any time points except reduced resting pain scores at 12 hours with PVB (mean difference [MD]) 0.60, 95% confidence interval [CI] 0.32 to 0.88). Opioid consumption demonstrated no significant differences at 24 hours; PVB reduced opioid consumption at 48 hours (MD 0.40, 95% CI -0.09 to 0.89). There were no significant differences in postoperative nausea or vomiting. ESPB exhibited a nonsignificant trend toward reduced cumulative block-related complications (risk difference [RD] 0.05, 95% CI -0.10 to 0.00). CONCLUSIONS: Compared with PVB, ESPB is safe and demonstrates no clinically significant differences in pain management after thoracic surgery.

Telemedicine in Patients Affected by Chronic Liver Disease: A Scoping Review of Clinical Outcomes and the Devices Evaluated.

For patients with chronic liver disease (CLD), telemedicine is emerging as a useful tool to prevent liver decompensation or hospitalization, allowing access to and the decentralization of care, even for patients with limited resources. However, research and attendant evidence are still lacking; thus, this review aims to systematically explore the topic of telemonitoring for CLD to describe the currently used tools and clinical outcomes. The review was conducted by using key terms on PubMed/EMBASE and searching for observational studies or clinical trials (according to PRISMA recommendations) that were published between 6 April 2013 and 6 April 2023 to keep the technological framework limited to the last 10 years. The studies were described and grouped according to the aim of telemonitoring, the underlying disease, and the tools adopted to achieve remote monitoring. A total of 32 articles met the inclusion criteria. Of these, 11 articles report the successful use of a telehealth program to support and improve access to care in the management of HCV-related cirrhosis, eight articles examine the efficacy of telemedicine for remote monitoring interventions to prevent or decrease the risk of decompensation in high-risk patients, and five articles examine improvements in the physical performance and quality of life of cirrhotic patients through telehealth rehabilitation programs. Four studies were completed during the recent COVID-19 pandemic. Telehealth has the potential to provide and expand treatment access and reduce barriers to care for the most disadvantaged patients and might be able to reduce the need for hospital readmission for CLD, though most practice to test feasibility is still in the pilot stage.

Management of harlequin syndrome under ECPELLA support: A report of two cases and a proposed approach.

The use of ECPELLA in patients with severe lung disease may result in an unfavorable phenomenon of differential hypoxia. The simultaneous evaluation of three arterial blood samples from different arterial line (right radial artery, left radial artery, ECMO arterial line) in patients at risk of Harlequin syndrome (also called differential hypoxemia (DH)) can localize the "mixing cloud" along the aorta. Focusing the attention on the "mixing cloud" position instead of on isolated flows of Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO) and Impella CP makes the decision making easier about how to modify MCSs flows according to the clinical context. Herein, we present two cases in which ECPELLA configuration was used to treat a cardiogenic shock condition and how the ECPELLA-induced hypoxia was managed.

Ground motion prediction equations as a proxy for medium properties variation due to geothermal resources exploitation.

Sub surface operations for energy production such as gas storage, fluid injection or hydraulic fracking modify the physical properties of the crust, in particular seismic velocity and anelastic attenuation. Continuously measuring these properties may be crucial to monitor the status of the reservoir. Here we propose a not usual use of the empirical ground-motion prediction equations (GMPEs) to monitor large-scale medium properties variations in a reservoir during fluid injection experiments. In practice, peak-ground velocities recorded during field operations are used to update the coefficients of a reference GMPE whose variation can be physically interpreted in terms of anelastic attenuation and seismic velocity. We apply the technique to earthquakes recorded at The Geysers geothermal field in Southern California and events occurred in the St. Gallen (Switzerland) geothermal field. Our results suggest that the GMPEs can be effectively used as a proxy for some reservoir properties variation by using induced earthquakes recorded at relatively dense networks.

Is continuous Erector Spinae Plane Block (ESPB) better than continuous Serratus Anterior Plane Block (SAPB) for mitral valve surgery via mini-thoracotomy? Results from a prospective observational study.

Aims: Chest wall blocks are effective alternatives for postoperative pain control in mitral valve surgery in right mini-thoracotomy (mini-MVS). We compared the efficacy of Serratus Anterior plane block (SAPB) and Erector Spinae plane block (ESPB) on postoperative pain relief after mini-MVS. Settings and Design: It is a prospective, observational study. Material and Methods: A total of 85 consecutive patients undergoing continuous SAPB and continuous ESPB for mini-MVS from March 2019 to October 2020 were included. The primary outcome was the assessment of postoperative pain evaluated as absolute value of NRS at 12, 24 and 48 h. Secondary outcomes were assessment of salvage analgesia (both opioids and NSAIDs), incidence of mild adverse effects (i.e. nausea, vomiting, and incorrect catheter placement) and timing of postoperative course (ICU and hospital length of stay, duration of mechanical ventilation, ventilator-free days). Results: The median NRS was 0.00 (0.00-3.00) at 12 h and 0.00 (0.00-2.00) at 24 and 48 h. No significant differences were observed between groups. Postoperative morphine consumption in the first 24 h was similar in both groups (P = 0.76), whereas between 24 and 48 h was significantly less in the ESPB group compared with SAPB group, P = 0.013. NSAIDs median consumption and Metoclopramide consumption were significantly lower in the ESPB group compared to SAPB group (P = 0.002 and P = 0.048, respectively). Conclusions: ESPB, even more than SAPB, appears to be a feasible and effective strategy for the management of postoperative pain, allowing good quality analgesia with low consumption of opioids, NSAIDs and antiemetic drugs.

Awake cardiac surgery using the novel pectoralis-intercostal-rectus sheath (PIRS) plane block and subxiphoid approach.

BACKGROUND: Postoperative pain after cardiac surgery is a very important issue and affects recovery, risk of postoperative complications and quality of life. The pain management has been traditionally based on intravenous opioids with growing evidence suggesting the use of opioid-free and opioid-sparing techniques to reduce its adverse effects. CASE PRESENTATION: We report the case of a 75-year-old frail patient underwent awake mediastinal revision with subxiphoid access due to deep sternal wound infection using a pectoralis-intercostal rectus sheath (PIRS) plane block. During the procedure the patient never reported pain receiving acetaminophen 1 g every 8 h for postoperative pain management without others pain relievers. CONCLUSION: Ultrasound guided PIRS block could be an effective and safe analgesic technique to manage sternal and subxiphoid drainage pain in patients undergoing cardiac surgery via subxiphoid approach.

Transversus thoracic plane block and rectus sheath block for left ventricular assist device implantation via full median sternotomy: A case report.

BACKGROUND: Traditionally, pain management after left ventricular assist device (LVAD) implantation via median sternotomy have been based on intravenous opioids but, in the era of enhanced recovery after surgery, a multimodal opioid-sparing analgesia could represent a valid alternative reducing opioids related side effects. CASE REPORT: We described the successfully use of an opioid-sparing regimen for pain management after LVAD implantation via median sternotomy based on two ultrasound-guided fascial plane wall blocks. Bilateral ultrasound-guided transversus thoracic plane block was performed to manage sternotomy pain; additionally, unilateral left ultrasound-guided rectus sheath block was performed to provide somatic pain relief for left abdominal wall structures superficial to the peritoneum within which the LVAD driveline was inserted. The patient was extubated on Day 1 and good quality analgesia (numerical rating scale <3) was obtained, without using nonsteroidal antiinflammatory drugs or opioids. The patient was discharged from Intensive Care Unit on Day 3 and during hospitalization (lasted 24 days) there was no need for rescue analgesia administration.

Chronic postsurgical pain and quality of life after right minithoracotomy mitral valve operations.

OBJECTIVES: Chronic postsurgical pain (CPSP) is a relatively common complication after cardio-thoracic operations with well-known consequences in terms of return to normal activities and quality of life. Little is known about the prevalence and severity of CPSP after minimally invasive cardiac surgery. The aim of this study was to measure the rate of CPSP in patients undergoing right minithoracotomy mitral valve (MV) surgery and to compare the effectiveness of different approaches to pain control. METHODS: A prospective observational study was conducted between March 2019 and September 2020. All patients undergoing right minithoracotomy MV surgery treated with morphine, continuous serratus anterior plane block (SAPB), or continuous erector spinae plane block (ESPB) were included. The Brief Pain Inventory questionnaire was used to evaluate 6-month CPSP and quality of life. RESULTS: A total of 100 patients were enrolled: postoperative pain control was obtained with morphine in 26 cases, with SAPB in 37 cases, and with ESPB in 37 cases. Median intensive care unit and hospital length of stay were 1 day and 6 days, respectively. Pain severity index was lower than 10 in 81 patients, and no differences were recorded between groups (p = .59). No patients reported chronic use of medications for pain management or severe pain interference in daily activities at follow-up. DISCUSSION: Right minithoracotomy approach is not burdened by a high incidence of CPSP: pain severity index was lower than 10 in more than 90% of patients. Then, in our experience, chronic pain seems not to be related to the type of perioperative analgesia adopted.

Safety of Ultrasound-Guided Serratus Anterior and Erector Spinae Fascial Plane Blocks: A Retrospective Analysis in Patients Undergoing Cardiac Surgery While Receiving Anticoagulant and Antiplatelet Drugs.

OBJECTIVES: Chest wall blocks are an effective strategy for postoperative pain control in minimally invasive cardiac surgery, but, in the absence of clinical trials evaluating their safety in the presence of anticoagulant and antiplatelet drugs, it still is recommended to follow the same guidelines developed for the neuraxial procedures and for peripheral blocks. DESIGN: Retrospective observational study. SETTING: AOU Città della Salute e della Scienza di Torino, University of Turin, Italy. PARTICIPANTS: Between March 28, 2019 and October 19, 2020, 70 patients who underwent mitral valve surgery via right minithoracotomy were enrolled: 35 treated with continuous erector spinae plane block (ESPB) and 35 with continuous serratus anterior plane block (SAPB). INTERVENTIONS: The primary objective was the evaluation of the number of blocks performed or catheters removed while coagulation was abnormal or antithrombotic and anticoagulant therapies were in progress. MEASUREMENTS AND MAIN RESULTS: Eleven patients (15.7%) received fascial plane block with international normalized ratio (INR) > 1.40, four patients (5.71%) with a platelet count <80 × 103, and one patient received ESPB block during dual-antiplatelet therapy. In 16 patients (22.9%), the catheter was removed with an INR > 1.40, in five patients (7.1%) with a platelet count <80 × 103, and in 53 patients (75.71%) despite low-molecular-weight heparin at therapeutic dose. The median antagonist dose of vitamin K at the time of catheter removal was 2.5 mg (range 2.5-3.44 mg) in both groups. No major adverse effects directly attributable to the blocks were observed. CONCLUSIONS: The authors did not find any problems related to the use of continuous ESPB and SAPB, although they were performed in the presence of anticoagulation and in a context with a high risk of bleeding such as cardiac surgery.