CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 3, May/June 2022 AFRICA 153 Evaluation of the effect of different block techniques on open-heart surgery in the postoperative period: a prospective observational study Seray Turkmen, Mehmet Mutlu Abstract Background: Open-heart surgery is associated with severe postoperative pain. Adequate analgesia after open-heart surgery improves patients’ early postoperative recovery, extubation, ambulation and early discharge from hospital. Regional anaesthesia techniques are the new hope for adequate postoperative analgesia after cardiac surgery and are widely used for early pain management in the first six hours. Methods: A total of 100 patients with the American Society of Anesthesiologists physical status classification I–III, aged 18 years and over, undergoing open-heart surgery with sternotomy for coronary artery bypass grafting or valve replacement under general anaesthesia, were included in this study. For postoperative analgesia, 50 patients with pectoral nerve (PECS II) block and 50 with parasternal (PS) block were consecutively enrolled in one of the groups at the end of the surgery and compared in terms of sedation scores, ventilation duration, pain scores at rest after extubation, block duration, total morphine consumption and complications. Results: The block duration in the PS group was statistically significantly higher than in the PECS II group (p = 0.001, p < 0.05, respectively). The visual analogue scale scores at rest in the fourth and sixth hours were statistically significantly higher in the PECS II group than in the PS group (p = 0.001, p = 0.001, p < 0.01). Cumulative morphine consumption in the PECS II group was statistically significantly higher than in the PS group in the fourth, sixth, 12th and 24th hours (p = 0.001, p = 0.001, p = 0.001, p = 0.001, p = 0.001, p < 0.01, respectively). Conclusion: PS block provided longer block duration with lower postoperative pain and sedation scores than the PECS II block, with lower cumulative morphine consumption. Keywords: PECS II block, parasternal block, cumulative morphine consumption Submitted 30/12/21, accepted 14/3/22 Published online 25/3/22 Cardiovasc J Afr 2022; 153–156 www.cvja.co.za DOI: 10.5830/CVJA-2022-016 Open-heart surgery is associated with severe postoperative pain.1 Sternotomy and rib retractions are the primary source of postoperative pain.2 Adequate analgesia after open-heart surgery improves patients’ early postoperative recovery, extubation, ambulation and early discharge from hospital. Inadequate postoperative pain control is strictly associated with decreased pulmonary function, atelectasis and pneumonia, leading to delayed extubation and discharge from the intensive care unit, with a prolonged hospital stay and increased mortality and morbidity rates.3,4 Postoperative pain management is the main consideration after surgery, and yet there is still a pursuit for the best approach to it. Regional anaesthesia techniques are the new hope for adequate postoperative analgesia after cardiac surgery and are widely used for early pain management in the first six hours. They are preferable to parenteral systemic opioid treatments because of their side effects and complications; however, opioids are still the first choice in the early postoperative period.4 Regional anaesthesia techniques also reduce the use of postoperative parenteral analgesics.5 Paravertebral blocks and thoracal epidural analgesia provide adequate postoperative analgesia but have limited use after cardiac surgery because of anticoagulant drug use, leading to severe complications such as haematomas.6 The parasternal (PS) block is safe in anticoagulated patients and provides sufficient postoperative analgesia after cardiac surgery.5,7 Other alternatives are erector spinae plane and pectoral nerve (PECS) blocks.8 These blocks are effective on the anterior branches of the thoracic intercostal nerves from T2 to T6 at different anatomical regions, and this is essential for postoperative pain relief associated with sternotomy after open-heart surgery.1 PECS blocks were described by Blanco et al. for the first time for breast surgery and were used for postoperative pain relief after anterior thoracic wall surgery.9 PECS blocks are performed under ultrasound guidance with a two‑plane approach. The first plane is between the pectoralis muscles (PECS I) and the second plane is between the serratus anterior and the pectoralis minor muscle (PECS II) at the level of the third rib. PECS I blocks the lateral and medial pectoral nerves, whereas PECS II blocks the anterior branches of the thoracic intercostal nerves from T2 to T6, thoracodorsal nerve and long thoracic nerve. This study aimed to compare the efficacy of ultrasound‑guided PECS II block with the PS block in patients undergoing open-heart surgery via a midline sternotomy. We hypothesised that the PECS II block could provide superior postoperative analgesia for patients undergoing cardiac surgery with midline sternotomy than a PS block. Department of Anesthesiology and Reanimation, Prof Dr Cemil Tascioglu City Hospital, Istanbul, Turkey Seray Turkmen, MD Mehmet Mutlu, MD, drmmutlu@gmail.com
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