Randomized clinical trial of continuous transversus thoracis muscle plane block for patients undergoing open heart valve replacement surgery.

The optimal analgesia regimen after open cardiac surgery is unclear. The aim of this study was to investigate the beneficial effects of continuous transversus thoracis muscle plane (TTMP) blocks initiated before surgery on open cardiac surgery outcomes. A group of 110 patients were randomly allocated to either receive bilateral continuous TTMP blocks (TTP group) or no nerve block (SAL group). The primary endpoint was post-operative pain at 4, 8, 16, 24, 48 and 72 h after extubation at rest and exercise. The secondary outcome measures included analgesia requirements (sufentanil and flurbiprofen axetil administration), time to extubation, incidence of reintubation, length of stay in the ICU, incidence of post-operative nausea and vomiting (PONV), time until return of bowel function, time to mobilization, urinary catheter removal and length of hospital stay. The length of stay in the ICU and length of hospital stay were significantly longer in the SAL group than in the TTP group. NRS scores at rest and exercise were significantly lower in the TTP group than in the SAL group at all time points. The TTP group required significantly less intraoperative and post-operative sufentanil and post-operative dynastat consumption than the SAL group. Time to extubation, time to first flatus, time until mobilization and time until urinary catheter removal were significantly earlier in the TTP group than in the SAL group. The incidence of PONV was significantly lower in the TTP group. Bilateral continuous TTMP blocks provide effective analgesia and accelerate recovery in patients undergoing open heart valve replacement surgery.

Comparison of the effects of transversus thoracic muscle plane block and pecto-intercostal fascial block on postoperative opioid consumption in patients undergoing open cardiac surgery: a prospective randomized study.

BACKGROUND: There is an association exists between cardiac surgery, performed through median sternotomy, and a considerable postoperative pain. OBJECTIVES: The aim of the current study is to compare the effects of transversus thoracic muscle plane block (TTMPB) and pecto-intercostal fascial plane block (PIFB) upon postoperative opioid consumption among the patients who underwent open cardiac surgery. METHODS: The present prospective, randomized, comparative study was conducted among 80 patients who underwent elective on-pump cardiac surgery with sternotomy. The subjects were randomly assigned to two groups with each group containing 40 individuals. For the TTMPB group, bilateral ultrasound-guided TTMPB was adopted in which 20 ml of 0.25% bupivacaine was used on each side. In case of PIFB group, bilateral ultrasound-guided PIFB was adopted with the application of 20 ml of 0.25% bupivacaine on each side. The researchers recorded the first time for rescue analgesia, the overall dosage of rescue analgesia administered in the first 24 h after the operation and the postoperative complications. RESULTS: The PIFB group took significantly longer time to raise the first request for rescue analgesia (7.8 ± 1.7 h) than the TTMPB group (6.7 ± 1.4 h). Likewise, the PIFB group subjects had a remarkably lower 'overall morphine usage' in the first 24 h after the operation (4.8 ± 1.0 mg) than TTMPB group (7.8 ± 2.0 mg). CONCLUSION: Bilateral ultrasound-guided PIFB provided a longer time for the first analgesic demand than bilateral ultrasound-guided TTMPB in patients undergoing open cardiac surgery. In addition to this, the PIFB reported less postoperative morphine usage than the TTMPB and increases satisfaction in these patients. TRIAL REGISTRATION: This study was registered at Clinical Trials.gov on 28/11/2022 (registration number: NCT05627869).

Effect of transverse thoracic muscle plane block on postoperative cognitive dysfunction after open cardiac surgery: A randomized clinical trial.

The transversus thoracis muscle plane (TTMP) block provides effective analgesia in cardiac surgery patients. The aim of this study was to assess whether bilateral TTMP blocks can reduce the incidence of postoperative cognitive dysfunction (POCD) in patients undergoing cardiac valve replacement. A group of 103 patients were randomly divided into the TTM group (n = 52) and the PLA (placebo) group (n = 51). The primary endpoint was the incidence of POCD at 1 week after surgery. Secondary outcome measures included a reduction of intraoperative mean arterial pressure (MAP) >20% from baseline, intraoperative and postoperative sufentanil consumption, length of stay in the ICU, incidence of postoperative nausea and vomiting (PONV), time to first faeces, postoperative pain at 24 h after surgery, time to extubation and the length of hospital stay. Interleukin (IL)-6, TNF-α, S-100ß, insulin, glucose and insulin resistance were measured at before induction of anaesthesia, 1, 3and 7 days after surgery. The MoCA scores were significantly lower and the incidence of POCD decreased significantly in TTM group compared with PLA group at 7 days after surgery. Perioperative sufentanil consumption, the incidence of PONV and intraoperative MAP reduction >20% from baseline, length of stay in the ICU, postoperative pain at 24 h after surgery, time to extubation and the length of hospital stay were significantly decreased in the TTM group. Postoperatively, IL-6, TNF-α, S-100ß, HOMA-IR, insulin, glucose levels increased and the TTM group had a lower degree than the PLA group at 1, 3 and 7 days after surgery. In summary, bilateral TTMP blocks could improve postoperative cognitive function in patients undergoing cardiac valve replacement.

Perioperative Pain Management With Bilateral Pecto-intercostal Fascial Block in Pediatric Patients Undergoing Open Cardiac Surgery.

Purposes: Pediatric open cardiac surgical patients usually suffer from acute pain after operation. The current work aimed to explore the impact of bilateral PIFB in children suffering from open cardiac surgery. Methods: This work randomized altogether 110 child patients as bilateral PIFB (PIF) and non-nerve block (SAL) groups. This work adopted post-operative pain at exercise and rest statuses as the primary endpoint, whereas time-to-drain removal/extubation/initial defecation, intraoperative/post-operative fentanyl use, and length of ICU and hospital stay as the secondary endpoints. Results: MOPS were significantly higher at 24-h post-operatively at coughing and rest statuses in SAL group compared with PIF group. Meanwhile, PIF group exhibited markedly lower intraoperative/post-operative fentanyl use amounts, as well as markedly reduced time-to-extubation/initial flatus, and length of ICU/hospital stay. Conclusion: Bilateral PIFB in pediatric open cardiac surgical patients provide effective analgesia and lower the length of hospital stay.

Parasternal After Cardiac Surgery (PACS): a prospective, randomised, double-blinded, placebo-controlled trial study protocol for evaluating a continuous bilateral parasternal block with lidocaine after open cardiac surgery through sternotomy.

BACKGROUND: Multimodal analgesia that provides optimal pain treatment with minimal side effects is important for optimal recovery after open cardiac surgery. Regional anaesthesia can be used to block noxious nerve signals. Because sternotomy causes considerable pain that lasts several days, a continuous nerve block is advantageous. Previous studies on continuous sternal wound infusion or parasternal blocks with long-acting local anaesthetics have shown mixed results. This study aims to determine whether a continuous bilateral parasternal block with lidocaine, which is a short-acting local anaesthetic that has a favourable safety/toxicity profile, results in effective analgesia. We hypothesise that a 72-hour continuous parasternal block with 0.5% lidocaine at a rate of 7 ml/hour on each side provides effective analgesia and reduces opioid requirement. We will evaluate whether recovery is enhanced. METHODS: In a prospective, randomised, double-blinded manner, 45 patients will receive a continuous parasternal block with either 0.5% lidocaine or saline. The primary endpoint is cumulated intravenous morphine by patient-controlled analgesia at 72 hours. Secondary end-points include the following: (1) the cumulated numerical rating scale (NRS) score recorded three times daily at 72 hours; (2) the cumulated NRS score after two deep breaths three times daily at 72 hours; (3) the NRS score at rest and after two deep breaths at 2, 4, 8 and 12 weeks after surgery; (4) oxycodone requirement at 2, 4, 8 and 12 weeks after surgery; (5) Quality of Recovery-15 score preoperatively compared with that at 24, 48 and 72 hours, and at 2, 4, 8 and 12 weeks after surgery; (6) preoperative peak expiratory flow compared with postoperative daily values for 3 days; and (7) serum concentrations of interleukin-6 and lidocaine at 1, 24, 48 and 72 hours postoperatively compared with preoperative values. DISCUSSION: Adequate analgesia is important for quality of care and vital to a rapid recovery after cardiac surgery. This study aims to determine whether a continuous parasternal block with a short-acting local anaesthetic improves analgesia and recovery after open cardiac procedures. TRIAL REGISTRATION: The study was registered in the European Clinical Trials Database on 27/9/2019 (registration number: 2018-004672-35).

Individualized Analysis and Treatment of Difficult Weaning From Ventilation Following Open Cardiac Surgery in Young Children With Congenital Heart Disease.

Aims: The study explores the leading causes of postoperative extubation difficulties in pediatric patients (neonates and toddlers) with congenital heart diseases and establishes individualized treatment for different reasons. Method: We retrospectively analyzed medical records of 4,971 pediatric patients with congenital heart defects treated in three tertiary Congenital Heart Disease Centres in China from January 2005 to December 2020, from whom we selected those with difficulty extubation but successful weaning during the postoperative period. Next, we performed an analysis of risk factors and reported the combined experience of individualized treatment for successful extubation. Results: Seventy-five pediatric patients were identified in our database, among whom 23 had airway stenosis, 17 had diaphragmatic dysfunction, and 35 had pulmonary infection. The patients were all successfully weaned from the ventilator after an individualized treatment plan. In addition, the intubation time in the airway stenosis group was 17.7 ± 9.0, 33.6 ± 13.9 days in the diaphragmatic dysfunction group, and 11.9 ± 3.8 days in the pulmonary infection group. Conclusion: Given the primary reasons for difficult weaning following open-heart surgery in pediatric patients with congenital heart diseases, an individualized treatment scheme can achieve the ideal therapeutic effect where patients can be weaned faster with a shorter intubation period.

Sensory Assessment and Block Duration of Deep Parasternal Intercostal Plane Block in Patients Undergoing Cardiac Surgery: A Prospective Observational Study.

INTRODUCTION: There has been increasing interest in using deep parasternal intercostal plane (PIP) block as a supplement to multimodal analgesia regimens in cardiac surgery. The aim of this study was to observe cutaneous sensory block distribution and its duration for deep PIP blocks in patients undergoing open cardiac surgery. METHODS: This observational, prospective clinical study consisted of 113 participants. All patients received bilateral ultrasound-guided deep PIP block with 40 ml 0.33% ropivacaine. The primary study outcome was cutaneous sensory block distribution of deep PIP blocks in patients undergoing open cardiac surgery. Secondary outcome included block duration in all participants. The area of cutaneous sensory block was tested by using a cold stimulus (ice cube) 30 min after the end of deep PIP block administration. Cutaneous sensory testing was performed once every hour after extubation until the return of normal sensation. RESULTS: Thirty minutes after bilateral deep PIP block administration, the successful block rate of dermatomes T4 to T6 was almost 100%. However, T2 (percentage of left T2 block: 64.6%; percentage of right T2 block: 42.5%) and T3 (percentage of left T3 block: 88.5%; percentage of right T3 block: 87.6%) had a lower percentage of success. A few patients had blocked dermatomes at T1 or T7 (percentage of left T1 block: 7.08%; percentage of right T1 block: 2.65%; percentage of left T7 block: 6.19%; percentage of right T7 block: 10.6%). The mean effective duration of the deep PIP block was 17 h. CONCLUSION: Bilateral deep PIP blocks can produce a widespread cutaneous sensory blockade with variable dermatomal distribution in the mid-sternum for a considerable effective duration. TRIAL REGISTRATION: This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100047755).

The Effect of Low Preoperative Ejection Fraction on Mortality After Cardiac Surgery in Indonesia.

Background: Among cardiac surgery patients, low preoperative left ventricular ejection fraction (LVEF) is common and has been associated with poor outcomes. The objective of this study was to assess the association between LVEF and postoperative mortality in patients undergoing open-heart surgery in several hospitals in Indonesia. Methods: We conducted a multicenter study with the retrospective design using data from patients undergoing open-heart surgery in 4 institutions in Indonesia. Data regarding LVEF and other potential risk factors were extracted from medical records and compiled in one datasheet. Statistical analyses were performed to assess if low LVEF was associated with postoperative mortality and identify other potential risk factors. Results: A total of 4789 patients underwent cardiac surgery in participating centers during the study period. Of these, 189 subjects (3.9%) had poor preoperative LVEF. Poor LVEF was associated with postoperative mortality (adjusted OR 2.761, 95% CI 1.763-4.323, p < 0.001). Based on types of surgery, LVEF had a significant association with mortality only in CABG patients, while there was no such association in valve surgery and inconclusive in congenital surgery patients. Other significant independent predictors of in-hospital mortality included age more than 65 years old, non-elective surgery, the complexity of procedures, history of cardiac surgery, organ failure, CARE score ≥ 3, NYHA class ≥ III, and poor right ventricular function. Conclusion: Patients with low preoperative LVEF undergoing open-heart surgery had a higher risk of postoperative mortality. Cardiac surgery can be performed with acceptable mortality rates. Accurate selection of patients, risk/benefit evaluation, and planning of surgical and anesthesiological management are mandatory to improve outcomes.

Indonesian Study: Triiodothyronine for Infants Less than 5 Months Undergoing Cardiopulmonary Bypass.

This study evaluates the efficacy and safety of oral triiodothyronine on time to extubation for infants less than 5 months undergoing heart surgery in Indonesia, and primarily relates to patients in emerging programs with high malnutrition and mortality. In this randomized, double-blind, placebo-controlled trial, oral triiodothyronine (T3, Tetronine®) 1 µg/kg-body weight/dose or placebo (saccharum lactis) was administered via nasogastric tube every 6 h for 60 h to treatment group. A total of 120 patients were randomized into T3 (61 patients) and placebo (59 patients) groups. The majority of the patients had moderate to severe malnutrition (55.83%) with a high post-operative mortality rate of 23.3%. The T3 group showed significantly higher serum FT3 levels from 1 until 48 h post cross-clamp removal (p < 0.0001), lower incidence of low cardiac output syndrome at both 6 h (28 [45.9%] vs. 39 [66.1%] patients, p = 0.03, OR 2.3, 95% CI: 1.10-4.81) and 12 h after cross-clamp removal (25 [41.7%] vs. 36 [63.2%], p = 0.02, OR 2.40, 95% CI: 1.14-5.05). Although not statistically significant, the treatment group had shorter median (IQR) intubation time (2.59 [1.25-5.24] vs. 3.77 [1.28-6.64] days, p = 0.16, HR 1.36, 95% CI: 0.88-2.09)] and lower mortality (10 [16.4%] vs. 18 [30.5%], p = 0.07]. Patients with Aristotle score < 10.0 (low risk) receiving T3 had faster extubation than placebo patients (p = 0.021, HR of 1.90, 95% CI: 1.10-3.28) and were significantly less likely to require CPR or experience infection (p = 0.027, OR 8.56, 95% CI:0.99-73.9 and p = 0.022, OR 4.09 95% CI: 1.16-14.4, respectively). Oral T3 supplementation reduced overall incidence of low cardiac output syndrome and significantly reduced the time to extubation in low-risk patients. Therefore, prophylactic oral T3 administration may be beneficial in these patients.Trial Registration: ClinicalTrials.gov NCT02222532.

Continuous Pecto-Intercostal Fascial Block Provides Effective Analgesia in Patients Undergoing Open Cardiac Surgery: A Randomized Controlled Trial.

BACKGROUND: The optimal analgesia regimen after open cardiac surgery has been unclear. The aim of this study was to investigate the beneficial effects of continuous pecto-intercostal fascial blocks (PIFB) initiated before surgery on outcomes after open cardiac surgery. METHODS: A group of 116 patients were randomly allocated to receive either bilateral continuous PIFB (PIF group) or the same block with saline (SAL group). The primary endpoint was postoperative pain at 4, 8, 16, 24, 48, and 72 hours after extubation at rest and during exercise. The secondary outcome measures included analgesia requirements (sufentanil and flurbiprofen consumption), time to extubation, length of stay in the intensive care unit, incidence of postoperative nausea and vomiting, time until return of bowel function, time to mobilization, time to urinary catheter removal, and the length of hospital stay. RESULTS: The length of stay in the intensive care unit (29 ± 7 hours vs 13 ± 4 hours, P < 0.01) and length of hospital stay (8.9 ± 0.9 days vs 6.5 ± 1.1 days, P < 0.01) were significantly longer in the SAL group than in the PIF group. Resting pain scores (2 hours after extubation: 1.1 vs 3.3, P < 0.01; 4 hours after extubation: 1.0 vs 3.5, P < 0.01; 8 hours after extubation: 1.2 vs 3.7, P < 0.01; 16 hours after extubation: 1.3 vs 3.7, P < 0.01; 24 hours after extubation: 1.4 vs 2.8, P < 0.01; 48 hours after extubation: 0.9 vs 2.2, P < 0.01; 72 hours after extubation: 0.8 vs 2.1, P < 0.01) and dynamic pain scores (2 hours after extubation: 1.4 vs 3.7, P < 0.01; 4 hours after extubation: 1.3 vs 3.8, P < 0.01; 8 hours after extubation: 1.4 vs 3.5, P < 0.01; 16 hours after extubation: 1.2 vs 3.4, P < 0.01; 24 hours after extubation: 1.1 vs 3.1, P < 0.01; 48 hours after extubation: 1.0 vs 2.9, P < 0.01; 72 hours after extubation: 0.9 vs 2.8, P < 0.01) were significantly lower in the PIF group than in the SAL group at all time points. The PIF group required significantly less intraoperative sufentanil consumption (123 ± 32 µg vs 63 ± 16 µg, P < 0.01), postoperative sufentanil consumption (102 ± 22 µg vs 52 ± 17 µg, P < 0.01), and postoperative flurbiprofen consumption (350 ± 100 mg vs 100 ± 100 mg, P < 0.01) than the SAL groups. Time to extubation (8.9 ± 2.4 hours vs 3.2 ± 1.3 hours, P < 0.01), time to first flatus (43 ± 6 hours vs 30 ± 7 hours, P < 0.01), time until mobilization (35 ± 5 hours vs 24 ± 7 hours, P < 0.01), and time until urinary catheter removal (47 ± 9 hours vs 31 ± 4 hours, P < 0.01) were significantly earlier in the PIF group than in the SAL group. The incidence of postoperative nausea and vomiting was significantly lower in the PIF group (9.1% vs 27.3%, P < 0.01). CONCLUSION: Bilateral continuous PIFB reduced the length of hospital stay and provided effective postoperative pain relief for 3 days.

Ultrasound-Guided Continuous Parasternal Intercostal Block Relieves Postoperative Pain After Open Cardiac Surgery: A Case Series.

Pain after open cardiac surgery can be severe and may persist for several days, potentially developing into chronic postsurgical pain. Herein the authors describe three patients who underwent open cardiac surgery via traditional median sternotomy approach. Postoperative pain was relieved in these patients via a novel, straightforward, ultrasound-guided parasternal intercostal block, peripheral regional anesthetic technique. This plane block, thus, may represent an effective regional anesthetic strategy and a valuable component of a multimodal analgesic approach for patients who have undergone open cardiac surgery with median sternotomy.

Lifesaving Treatment of Aortic Valve Staphylococcus aureus Endocarditis: Daptomycin and Early Surgical Therapy.

Infective endocarditis (IE) is an uncommon infection in children. The recommended treatment for native valve endocarditis secondary to methicillin-susceptible Staphylococcus aureus infection is antistaphylococcal penicillins such as nafcillin or oxacillin. If the initial therapy fails in IE, it can lead to catastrophic results. Nowadays, daptomycin is the best alternative antimicrobial agent to treat children with severe infections, when standard antimicrobial therapy does not yield a result. Herein, in this article, we described a case of a 16-year-old boy who had aortic valve S. aureus endocarditis with septic embolization and stroke. The patient was successfully treated only with daptomycin as well as surgical therapy in the early phase of the infection.

Effects of bilateral Pecto-intercostal Fascial Block for perioperative pain management in patients undergoing open cardiac surgery: a prospective randomized study.

BACKGROUND: Open cardiac surgical patients may experience severe acute poststernotomy pain. The ultrasound-guided Pecto-intercostal Fascial Block (PIFB) can cover anterior branches of intercostal nerves from T2 to T6. The aim of this study was to investigate the effect of bilateral PIFB in patients undergoing open cardiac surgery. METHODS: A group of 108 patients were randomly allocated to either receive bilateral PIFB (PIFB group) or no nerve block (SALI group). The primary endpoint was postoperative pain. The secondary outcome measures included intraoperative and postoperative sufentanil and parecoxib consumption, time to extubation, time to first feces, length of stay in the ICU and the length of hospital stay. Insulin, glucose, insulin resistance and interleukin (IL)-6 at 1, 2, 3 days after surgery were mearsured. The homeostasis model assessment (HOMA-IR) was used to measure perioperative insulin resistance. RESULTS: The PIFB group reported significantly less sufentanil and parecoxib consumption than the SALI group. Compared to the PIFB group, the SALI group had higher Numerical Rating Scale (NRS) pain scores at 24 h after operation both at rest and during coughing. The time to extubation, length of stay in the ICU and length of hospital stay were significantly decreased in the PIFB group compared with the SALI group. The PIFB group had a lower insulin, glucose, IL-6, HOMA-IR level than the SALI group 3 days after surgery. CONCLUSION: Bilateral PIFB provides effective analgesia and accelerates recovery in patients undergoing open cardiac surgery. TRIAL REGISTRATION: This study was registered in the Chinese Clinical Trial Registry ( ChiCTR 2000030609 ) on 08/03/2020.

Bilateral transversus thoracis muscle plane block provides effective analgesia and enhances recovery after open cardiac surgery.

BACKGROUND: The mid-sternum is the main source of pain after open cardiac surgery. The aim of this study was to investigate the effect of bilateral transversus thoracis muscle plane (TTMP) blocks on open cardiac surgery. METHODS: Sixty patients were randomly divided into two groups: bilateral TTMP blocks (TP group) or no nerve block (CO group). The primary endpoint was perioperative sufentanil consumption. The secondary outcome measures included postoperative pain, flurbiprofen axetil administration, quality of sleep after extubation, time to extubation, time to the return of gastrointestinal function, time to drain removal, the Intensive Care Unit (ICU) stay time, and hospital stay. RESULTS: The TP group reported significantly less sufentanil and flurbiprofen axetil consumption than the CO group. The CO group had higher Numerical Rating Scale (NRS) pain scores at 1, 2, 6, 12, and 24 h after extubation both at rest and during movement than the TP groups. Compared with the CO group，time to extubation, time to the first bowel movement, ICU stay time, and hospital stay were significantly decreased in the TP group. The TP group was rated as better in the quality of the two nights of sleep after extubation. CONCLUSION: Bilateral TTMP blocks can provide good perioperative analgesia for patients undergoing open cardiac surgery and promote postoperative recovery.

Open Cardiac Surgery in a Patient With Chronic Budd-Chiari Syndrome.

Budd-Chiari syndrome (BCS) is a rare congestive hepatopathy arising from hepatic venous outflow obstruction. The clinical presentation of BCS varies depending on the presence of collateral veins. The authors report a rare case of infective endocarditis and chronic primary BCS in a 50-year-old man who underwent open cardiac surgery. Due to the presence of dilated collateral veins flowing directly into the inferior vena cava, cardiopulmonary bypass was established by arterial cannulation of the ascending aorta, with venous cannulation of the upper portion of the superior vena cava, as well as the dilated collateral vein. Mitral valve replacement and tricuspid valvuloplasty were performed uneventfully, and the patient then was admitted to the intensive care unit. Patients with primary BCS need to be evaluated rigorously preoperatively and intraoperatively for collateral flow to establish cardiopulmonary bypass.

Critical Review and Meta-Analysis of Postoperative Sedation after Adult Cardiac Surgery: Dexmedetomidine Versus Propofol.

OBJECTIVE: To evaluate reports from the published literature of all randomized clinical trials (RCT) comparing postoperative sedation with dexmedetomidine versus propofol in adult patients, after open cardiac surgery. DESIGN: A computerized search on Medline, EMBASE, Web of Science, and Agency for Healthcare Research and Quality databases was completed through June 2020. Meta-analysis of all published RCT comparing dexmedetomidine versus propofol utilization in the postoperative phase, using the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. SETTING: Assemblage and critical discussion of 11 RCTs comparing postoperative sedation from standard published reports from 2003 to 2019. PARTICIPANTS: The study comprised 1,184 patients and analyzed critical discussion of time-based parameters (time to extubation, intensive care unit length of stay, and hospital length of stay) and nontime-dependent factors (delirium, bradycardia, and hypotension). MEASUREMENTS AND MAIN RESULTS: Time to extubation was significantly reduced in the dexmedetomidine group (standardized mean difference [SMD] = -0.70, 95% confidence interval [CI] -0.98 to -0.42, p < 0.001); however, no difference in mechanical ventilation time was observed (SMD = -0.72, 95% CI -1.60 to 0.15, N.S.). Dexmedetomidine significantly reduced the intensive care unit length of stay (SMD = 0.23, 95% CI -1.06 to -0.16, p = 0.008), but this did not translate into a reduced hospital length of stay (SMD = -1.13, 95% CI -2.43 to 0.16, N.S). For nontime-dependent factors, incidence of delirium was unaffected between groups (odds ratio [OR]: 0.68, 95% CI 0.43-1.06, N.S), and higher rates of bradycardia (OR: 3.39, 95% CI: 1.20-9.55, p = 0.020) and hypotension (OR: 1.68, 95% CI 1.09-2.58, p = 0.017) were reported with propofol. CONCLUSIONS: Despite the ICU time advantages afforded by dexmedetomidine over propofol, the former did not seem to contribute to an overall reduction in hospital length of stay or improvement in postoperative outcomes of heart valve surgery and CABG patients.

Efficacy of Bilateral Transversus Thoracis Muscle Plane Block in Pediatric Patients Undergoing Open Cardiac Surgery.

OBJECTIVES: Adequate pain management is crucial for pediatric patients undergoing open cardiac surgery. The aim of the present study was to investigate the effect of a bilateral transversus thoracis muscle plane (TTP) block on open cardiac surgery outcomes. SETTING: First Affiliated Hospital of Nanchang University. PARTICIPANTS: Patients ages 6 to 60 months undergoing cardiac surgical procedures were included. INTERVENTIONS: A group of 100 children were randomly allocated to receive either bilateral TTP block (TTP group) or no nerve block. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was postoperative pain, which was measured with the Modified Objective Pain Score. The secondary outcome measures included intraoperative and postoperative fentanyl consumption; time to extubation; time to first feces; length of stay in the intensive care unit; length of hospital stay; and possible complications such as ropivacaine allergy, pneumothorax, hematomas, infections, and injuries to the internal mammary artery and vein. The TTP group had a significantly lower Modified Objective Pain Score until 24 hours after extubation than the no nerve block group. The TTP group reported significantly less fentanyl consumption. Time to extubation and lengths of stay in the intensive care unit and hospital were significantly decreased in the TTP group. CONCLUSION: Bilateral TTP blocks provide effective analgesia and accelerate recovery in pediatric patients.

Decreasing Postoperative Blood Loss by Topical vs. Intravenous Tranexamic Acid in Open Cardiac Surgery (DEPOSITION) study: Results of a pilot study.

BACKGROUND: Cardiac surgery patients are at high risk for postoperative bleeding. Intravenous (IV) tranexamic acid (TxA) is a commonly used antifibrinolytic drug, but is associated with postoperative seizures. We conducted this pilot randomized controlled trial (RCT) to determine the feasibility of a larger trial that will be designed to investigate the impact of TxA administration route, intrapericardial (IP) vs IV, on postoperative bleeding and seizures. METHODS: In this single-center, double-blinded, pilot RCT we enrolled adult patients undergoing nonemergent on-pump cardiac operations through a median sternotomy. Participants were randomized to IP or IV TxA groups. The primary outcomes were cumulative chest tube drainage, transfusion requirements, and incidence of postoperative seizures. RESULTS: A total of 97 participants were randomized to the intervention and control groups. Baseline characteristics were similar in both groups. Most participants underwent a CABG and/or aortic valve replacement. There was no statistical difference. The IP TxA group was found to have a tendency for less chest tube drainage in comparison to the IV TxA group, 500.5 (370.0-700.0) and 540.0 (420.0-700.0) mL, respectively, which was not statistically significant (P = 0.2854). Fewer participants in the IP TxA group with cardiac tamponade and/or required a reoperation for bleeding and fewer packed red blood cell transfusions. None of the IP TxA group developed seizure vs one from the IV TxA group. CONCLUSION: This is the first known pilot RCT to investigate the role of TxA route of administration in open cardiac surgery. Intrapericardial TxA shows promising results with decreased bleeding, transfusion requirements, reoperations, and postoperative seizures. A larger RCT is needed to confirm these results and lead to a change in practice.

Pain Characteristics and Pain Interference Among Patients Undergoing Open Cardiac Surgery.

PURPOSE: The aim of this study was to analyze postoperative pain severity, pain characteristics, and factors that affect pain for patients undergoing open cardiac surgery. DESIGN: A descriptive, cross-sectional study design was used. METHODS: This study was conducted on 70 patients who underwent open cardiac surgery at a state hospital in North Cyprus. Data were gathered using the Patient Information Form and Brief Pain Inventory-Short Form. FINDINGS: Patients who underwent open cardiac surgery experienced severe pain. Postoperative pain had a negative impact on deep breathing, coughing, and physical exercise. The patients' postoperative pain severity and postoperative pain interference show a statistically significant relationship between gender, alcohol consumption, prior surgical experience, and satisfaction with pain management (P < .05). A moderately positive and statistically significant correlation was found between the worst pain intensity of the patients in the last 24 hours and their pain interference (P < .05). CONCLUSIONS: Patients with open cardiac surgery experienced severe pain that restricted their activities. Patients should be informed about pain characteristics they will experience and effective pain management methods to reduce pain.

Ultrasound-Guided Continuous Thoracic Erector Spinae Plane Block Within an Enhanced Recovery Program Is Associated with Decreased Opioid Consumption and Improved Patient Postoperative Rehabilitation After Open Cardiac Surgery-A Patient-Matched, Controlled Before-and-After Study.

OBJECTIVES: Open cardiac surgery may cause severe postoperative pain. The authors hypothesized that patients receiving a bundle of care using continuous erector spinae plane blocks (ESPB) would have decreased perioperative opioid consumption and improved early outcome parameters compared with standard perioperative management. DESIGN: A consecutive, patient-matched, controlled before-and-after study. SETTING: Two tertiary teaching hospitals. PARTICIPANTS: The study comprised 67 consecutive patients undergoing elective cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: In a controlled before-and-after trial, this study compared a historical group of 20 consecutive open cardiac surgery patients matched with a prospective group of 47 consecutive patients receiving continuous bilateral ESPB (0.25 mL/kg/side of ropivacaine 0.5%) after general anesthesia induction. For postoperative analgesia, both groups received paracetamol. The control group received intravenous (IV) morphine, 0.5 mg/h, and IV nefopam, 100 mg/24 h. In the ESPB group, 8 hours after the loading dose, catheters were connected to a pump infusing intermittent automatic boluses of ropivacaine 0.2% every 6 hours. If needed, for both groups, rescue analgesia was provided with IV ketorolac, 30 mg, and IV morphine, 30 µg/kg. MEASUREMENTS AND MAIN RESULTS: Morphine consumption in the first 48 hours was significantly decreased in the ESPB group (40 [25-45] mg in the control group compared with 0 [0-0] mg in the ESPB group [p < 0.001]) as was intraoperative sufentanil (0.8 [0.6-0.9] µg/kg/h and 0.2 [0.16-0.3] µg/kg/h, respectively; p < 0.001). Times to chest tube removal, first mobilization, pain (Visual Analogue Scale) values 2 hours after chest tube removal, pain values at rest 1 month after surgery, and postoperative adverse events were significantly decreased in the ESPB group. There was no difference for extubation time and pain during first mobilization. CONCLUSION: The authors report for the first time that the use of a bundle of care including a continuous bilateral ESPB is associated with a significant decrease in intraoperative and postoperative opioid consumption, optimized rapid patient mobilization, and chest tube removal after open cardiac surgery.