Somani S, Makhija N, Chauhan S, Bhoi D, Das S, Bandi SG, Rajashekar P, Bisoi AK.
J Cardiothorac Vasc Anesth. 2024 Apr;38(4):974-981. doi: 10.1053/j.jvca.2023.12.037. Epub 2023 Dec 29.
PMID: 38326195 Clinical Trial.
Take Home Points
- The study compared the effectiveness of two regional anesthesia techniques: the erector spinae plane block (ESPB) and the multi-injection costotransverse block (MICB) for post-sternotomy pain in children.
- Patients in the ESPB and MICB groups required less intraoperative fentanyl, fewer opioids postoperatively, and experienced faster extubation and ICU discharge than the control group. However, hospital stay durations were similar across groups.
- Both ESPB and MICB significantly reduced postoperative pain in children after sternotomy compared to the control group. Mean MOPS (modified objective pain score) values were substantially lower in the ESPB and MICB groups up to 10 hours post-extubation, with no significant differences observed between the two techniques at any time point.
Commentary by Katarzyna Dlugosz Sledz and Olga Pawalek (Houston, Texas, USA)
Summary
Pain after cardiac surgery may lead to sympathetic nervous system activation and an increased hormonal stress response, as well as immune function, which may contribute to myocardial ischemia, cardiac arrhythmias, hypercoagulability, pulmonary complications, and increased rates of delirium and wound infection. Exposure to unalleviated pain early in life has immediate and long-lasting consequences for sensory perception, stress responsiveness, changes in brain development, cognition, and emotional health that are characterized by a hyposensitivity and/or hypersensitivity in response to acute versus chronic and/or severe stimuli.
The authors of the article compared the effectiveness of two regional anesthesia techniques for managing postoperative pain in children undergoing cardiac surgery via sternotomy: the erector spinae plane block (ESPB) and the multi-injection costotransverse block (MICB). The primary objective of the study was to determine whether MICB is as effective as ESPB in reducing post-sternotomy pain in children. The authors hypothesized that MICB might offer superior analgesia due to the broader distribution of the anesthetic agent in the thoracic paravertebral space, as suggested by previous cadaveric studies [1-5].
This was a prospective, randomized, double-blind, controlled trial involving 90 children aged 8 months to 10 years with acyanotic congenital heart defects undergoing cardiac surgery via sternotomy. Participants were randomly assigned to one of three groups: ESPB (n = 29), MICB (n = 28), or a control group (n = 29). In the ESPB and MICB groups, regional anesthesia was administered bilaterally under ultrasound guidance after the induction of general anesthesia, using 0.2% ropivacaine at a dose of 4 mg/kg. The control group did not receive regional anesthesia.
Postoperative pain management included intravenous paracetamol as part of multimodal analgesia, with fentanyl or tramadol provided as rescue analgesics. Pain levels were assessed using the Modified Objective Pain Score (MOPS) at specific time points following extubation. The study also monitored intraoperative fentanyl use, its frequency of administration in response to surgical incision, and postoperative opioid requirements.
The study found that both ESPB and MICB significantly reduced postoperative pain in children after sternotomy compared to the control group. Mean MOPS values were substantially lower in the ESPB and MICB groups up to 10 hours post-extubation, with no significant differences observed between the two techniques at any time point. Patients in the ESPB and MICB groups required less intraoperative fentanyl, fewer opioids postoperatively, and experienced faster extubation and ICU discharge than the control group. However, hospital stay durations were similar across all groups.
Opinion
The Holy Grail of pediatric cardiac anesthesiology is developing a pain management approach that combines high efficacy, ease of implementation, and minimal risk of complication.
The multi-injection costotransverse block (MICB) is a relatively new technique in regional anesthesia that has recently gained attention for its potential to provide effective analgesia while mitigating certain risks associated with traditional paravertebral blocks (PVB), such as pleural puncture. Cadaver studies have demonstrated that MICB achieves consistent dye spread into the thoracic paravertebral space, comparable to PVB, whereas the erector spinae plane block (ESPB) shows only partial spread.
However, this study did not establish the superiority of MICB over ESPB in a clinical setting.
When considering ease of implementation, the authors found the two techniques comparable. Of interest, a single anesthesiologist performed all the blocks. However, MICB is a technique that requires multiple injections along the intercostal spaces, making it potentially more time-consuming and technically demanding compared to the single-injection approach used in ESPB. The timing of the block in relation to extubation is not reported, as the blocks were performed preoperatively, and cardiac surgeries can vary widely in duration. The surgical time was around 180 mins with 14–28 minutes SD.
What about complications? Currently, there is limited data on specific risks directly attributed to the MICB. Nevertheless, it is generally considered safer than traditional PVB due to its technique, which minimizes the risk of pleural puncture or damage to subcostal vessels. Studies suggest MICB has a favorable safety profile, with minimal reported adverse effects in clinical evaluations. As with any regional block, potential risks include local anesthetic toxicity, infection, hematoma, or incomplete analgesia depending on the skill of the practitioner and anatomical variability [6-11].
The methodology presented in the article has several strengths, but also some limitations.
Strengths:
- Randomization: The random allocation of patients to study groups minimizes the risk of systematic differences between groups, enhancing the reliability of the results.
- Double-blind design: Neither the patients nor the individuals assessing pain were aware of group assignments, reducing the risk of placebo effects and bias in pain evaluation.
- Control group: Including a control group allows for a comparison of the effectiveness of the tested anesthesia methods with no intervention.
- Objective pain assessment methods: Using the Modified Objective Pain Scale (MOPS) standardizes pain assessment and minimizes subjectivity.
- Standardized anesthesia protocol: Apart from the studied nerve blocks, all children received the same general anesthesia protocol, reducing the influence of other factors on the outcomes.
Limitations:
- Small sample size: The study included only 84 patients, which may limit the generalizability of the findings to the broader population of children undergoing cardiac surgery.
- Lack of blinding for fentanyl administration: Anesthesiologists were aware of group assignments, which could have influenced decisions regarding fentanyl dosing during surgery.
- Potential influence of other factors on extubation time and ICU stay: Factors such as the clinical condition of the patient or postoperative complications might have affected extubation time and ICU duration.
- No assessment of long-term analgesic effects: The study evaluated postoperative pain only up to 12 hours after extubation, providing no data on the long-term pain-relief effects of the tested methods.
- Subjective evaluation of block performance: The ease of performing ESPB and MICB blocks was assessed subjectively by a single anesthesiologist, which could introduce bias.
To summarize the above consideration the article presents valuable findings that significantly contribute to the field of regional anesthesia for children undergoing cardiac surgery. However, as the authors note, further multicenter studies with larger sample sizes are needed to validate these results.
While MICB shows promise, additional evaluation is necessary to assess its safety, efficacy, and potential advantages over other established techniques, but Its novelty makes it an exciting area for further clinical research.
References
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- Aygun H, Kiziloglu I, Ozturk NK, etal. Use of ultrasound guided single shot costotransverse block (intertransverseprocess) in breast cancer surgery: A prospective, randomized, assessor blinded, controlled clinical trial. BMC Anesthesiol 2022; 22:110.
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