title: A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks.
abstract: Regional analgesia has entered cardiac anesthesia in the form of spinal or epidural analgesia. However, the risk of spinal or epidural hematoma is a constant worry. Alternative regional techniques might be applicable in cardiac surgery. The purpose of this study is to present a novel technique of bilateral single-shot paravertebral blocks (BSS-PVB) for cardiac surgery via median sternotomy and compare its efficacy versus high thoracic epidural analgesia (TEA). Fifty-two patients were compared in this prospective cohort audit. In 26 patients, cardiac surgery was performed using low-dose fentanyl/BSS-PVB (bilateral blocks of 3 mL bupivacaine 0.5% each, T1-7) and general anesthesia; in another 26 patients, TEA (bupivacaine 0.125% at 10 mL/hour) and general anesthesia were used. Patients were assigned to cohorts according to their preoperative data and types of surgery. All patient data are shown as mean +/- SD; pain scores were compared between groups using the t test immediately, 6 hours, and 24 hours after surgery (P < .05). In the BSS-PVB-group (19 men, 7 women), mean age was 65 +/- 11 years, weight 74 +/- 16 kg, ejection fraction 59% +/- 12%, and duration of surgery 130 +/- 27 minutes; in the TEA-group (17 men, 9 women), mean age was 63 +/- 10 years, weight 75 +/- 16 kg, ejection fraction 58% +/- 12%, and duration of surgery 113 +/- 27 minutes. These data and preoperative comorbidity variables were not significantly different between the two groups. In each group, 18 patients underwent off-pump coronary artery bypass grafting, 3 on-pump and 5 mitral valve replacements. All patients were successfully immediately extubated. Postoperative pain scores were at any point significantly lower with TEA, immediately at 2.4 +/- 2.2 versus 3.7 +/- 2.6, at 6 hours at 1.1 +/- 1.5 versus 2.4 +/- 1.8, and at 24 hours at 1.0 +/- 1.4 versus 2.3 +/- 1.6 (0 = no pain, 10 = maximum pain). There was no complications related to epidural catheter placement or BSS-PVB. Using both techniques, immediate extubation after cardiac surgery is feasible; TEA provides better pain relief after cardiac surgery than BSS-PVB.
authors.affiliation: Department of Anesthesiology, McGill University Health Center, Montréal, Québec, Canada.
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Olivier
authors.forename: David
authors.initials: D
authors.lastname: Bracco
authors.forename: Philippe
authors.initials: P
authors.lastname: Nguyen
authors.forename: Nhien
authors.initials: N
authors.lastname: Le
authors.forename: Nicolas
authors.initials: N
authors.lastname: Noiseux
authors.forename: Thomas
authors.initials: T
authors.lastname: Hemmerling
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000767:Anesthesia, Epidural / Q000379:methods*; D047549:Coronary Artery Bypass, Off-Pump / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000209:etiology; D059408:Pain Management; D010149:Postoperative Pain / Q000145:classification / Q000209:etiology; D011446:Prospective Studies; D013249:Sternum / Q000601:surgery*