Avoiding the Internal Mammary Artery During Parasternal Blocks: Ultrasound Identification and Technique Considerations.

Fascial plane chest wall blocks are an integral component to optimal multimodal postoperative analgesia in breast and cardiothoracic surgery, facilitating faster functional recovery and earlier discharge. Pectoral nerves block and serratus plane block have been used to treat postsurgical pain after breast and cardiothoracic surgeries; however, they cannot be used to anesthetize the anterior chest wall. Ultrasound parasternal block, or pectointercostal fascial block and transversus thoracis muscle plane block are two novel ultrasound-guided anesthetic and analgesic techniques that block the anterior cutaneous branches T2 to T6 intercostal nerves, providing anesthesia and analgesia to the anterior chest wall. Ultrasound parasternal block/pectointercostal fascial block and transversus thoracis muscle plane block are performed in the region of the internal mammary artery and could be considered to treat post-thoracotomy pain. This anatomic region is innervated by the anterior cutaneous branches T2-to-T6 intercostal nerves, which are obliterated during cardiac surgery artery harvesting. At the level of the fourth parasternal rib interspace, the internal mammary artery can be identified between the internal intercostal muscle and transversus thoracis muscle as a longitudinal pulsatile structure approximately 1.5 cm from the lateral border of the sternum. The transversus thoracis muscle is variable in many people and, thus, is an unreliable target and is difficult to visualize with ultrasound. Moreover, patients with a history of coronary artery bypass grafting could have tissue disruption in the transversus thoracis plane because of the internal mammary artery harvest, making transversus thoracis muscle identification more difficult. Despite ultrasound parasternal block and transversus thoracis muscle plane block having good safety profiles and reduced risk of complications, pneumothorax, local anesthetic systemic toxicity, and internal mammary artery injury or hematoma should be considered. If the block is performed before cardiac surgery, both the right and left internal mammary arteries could be damaged. The injury could render the internal mammary artery unusable for bypass grafting. If the block is performed after left internal mammary artery harvesting at the end of coronary artery bypass grafting, only the right internal mammary artery could be damaged. In patients in whom the internal mammary artery has been surgically used and the transversus thoracis muscle is difficult to visualize, ultrasound parasternal block should be considered. In patients in whom the internal mammary artery could be difficult to visualize or considering that it is in the vicinity of the transversus thoracis muscle plane block target and that the transversus thoracis muscle is difficult to visualize with ultrasound after internal mammary artery harvesting, then ultrasound parasternal block should be considered. The authors believe that ultrasound parasternal block is the safer regional technique for protecting the internal mammary artery and the pleura because it is more superficial. For this reason, ultrasound parasternal block also could be performed by inexperienced anesthesiologists. Although ultrasound parasternal block is more superficial, its superiority in terms of safety is yet to be proven. Additional studies are warranted to validate the authors' hypothesis.

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.

Factors to consider for fascial plane blocks' success in acute and chronic pain management.

The outcome of fascial plane blocks (FPBs) has a certain variability that may depend on many factors, which can be divided into three main categories: operator-related, patient-related and drug-related. Operator-related factors include personal skills, choice of needle and injection modalities. Patient variables include anthropometric features, the type of targeted fascia, anatomical variants, patient positioning, muscle tone and breathing. Ultimately, efficacy, onset, and duration of fascial blocks may be affected by characteristics of the injected solution, including the type of local anesthetic, volume, concentration, pH, temperature and the use of adjuvants. In this article, we investigated all the factors that may influence the outcome of FPBs from a generic perspective, without focusing on any specific technique. Also, we provided suggestions to optimize techniques for everyday practitioners and insights to researchers for future studies.

Anesthesiologists ultrasound-guided regional anesthesia core curriculum: a Delphi consensus from Italian regional anesthesia experts.

INTRODUCTION: The need for a standardized core curriculum in regional anesthesia has become essential, particularly with the integration of ultrasound revolutionizing and exponentially increasing clinical practice and possibilities. In fact, numerous novel techniques, often overlapping, can confuse practitioners. This study aims to establish a core curriculum for upper limb, lower limb, paraspinal and fascial plane blocks for residency training, addressing potential educational gaps caused by the multitude of techniques, through a Delphi consensus process involving recognized Italian regional anesthesia experts. METHODS: A steering committee was formed in order to select a panel of experts in regional anesthesia. A three-round Delphi consensus was planned: two rounds of electronic voting and a final round of mixed electronic voting and round table discussion. The consensus was defined as ≥ 75% agreement for inclusion and lower than ≤ 25% agreement for exclusion from the core curriculum list. Techniques reaching the 50% threshold were included with low consensus. RESULTS: Twenty-nine techniques were selected to be included in the ultrasound-guided regional anesthesia core curriculum. Twenty-two were included with strong consensus: Upper limb: interscalene brachial plexus block, supraclavicular brachial plexus block, infraclavicular brachial plexus block, axillary brachial plexus block, intermediate cervical plexus block Lower limb: femoral nerve block, pericapsular nerve group block, adductor canal block, sciatic nerve block (transgluteal approach, infragluteal approach, and at the popliteal fossa), ankle block Paraspinal/fascial plane blocks: erector spinae plane block, deep serratus anterior plane block, superficial pectointercostal plane block, interpectoral plane block, pectoserratus plane block, rectus sheath block, ilioinguinal iliohypogastric nerves block, transversus abdominis plane block (with subcostal and midaxillary approaches) The remaining seven techniques were included with low consensus: superficial cervical plexus block, lumbar plexus block, fascia iliaca block (suprainguinal approach), anterior quadratus lumborum block, lateral quadratus lumborum block, paravertebral block, and serratus anterior plane block. CONCLUSIONS: This curriculum aims to standardize training and ensure that residents acquire the essential skills required for effective and safe practice regardless of the residents' subsequent specialization. By incorporating these techniques, educational programs can provide a structured and consistent approach to regional anesthesia, enhancing the quality of patient care and improving outcomes.

A Modified Approach to a Parasternal Block: A Case Report.

The parasternal block is an ultrasound-guided interfascial plane block that provides anesthesia of the medial quadrants of the breast. The original approach provided injections in the fascial plane between the pectoral major and external intercostal muscles. We observed that this technique might limit an adequate diffusion of the injectate due to the anatomical convexity of the ribs, which might hinder fascial hydrodissection. We suggest a modified approach by positioning the tip of the needle on the rib dome to reduce the local anesthetic volume and obtain a more homogeneous and longitudinal spread into the target fascial compartment.

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.

Orthodontic-aided extraction of impacted third molar to improve the periodontal status of the neighboring tooth.

OBJECTIVES: In the present clinical report, we describe the management and the long-term (3-year) outcome of a periodontally compromised lower second molar healed by orthodontic-aided extraction of the neighboring impacted third molar. METHODS: A healthy 21-year-old woman referred signs and symptoms of pericoronitis of impacted tooth 48 and periodontal injury on the distal aspect of tooth 47. The wisdom tooth was surgically exposed, and an orthodontic appliance was anchored to the neighboring teeth to stimulate eruption. After 5 months, third molar could be easily extracted. RESULTS: Three years after extraction, clinical and radiographic controls revealed a complete healing of the periodontal defect. CONCLUSIONS: Orthodontic-aided extraction of impacted third molars may improve the periodontal status of the neighboring tooth. This protocol is not free from drawbacks and limitations and should be applied only when third-molar extraction is associated with a concrete risk of postoperative complications.

Ultrasound-guided parasternal blocks: techniques, clinical indications and future prospects.

Fascial plane blocks represent anesthetic procedures performed to manage perioperative and chronic pain. Recently, many fascial blocks techniques have been described increasing their field of applications. They offer anesthetic and analgesic efficacy, easy of execution and low risk of complications. The newest techniques recently described are the ultrasound parasternal blocks (US-PSB) which provide analgesia to the antero-medial chest wall. In particular, the antero-medial chest wall blocks are performed to provide analgesia and anesthesia in several and different surgeries such as median sternotomy, breast surgery, implantable cardioverter-defibrillator implantation and in the management of acute and chronic pain. The nervous target for these blocks is represented by the anterior branches of the intercostal nerves which enter the intercostal (ICM) and pectoralis major (PMM) muscles innervating the antero-medial region of chest wall, the main cause of poststernotomy pain. Local anesthetic is injected deep to PMM and superficial to the ICM or between the internal thoracic muscle (IIM) and transversus thoracis muscle (TTM). So, essentially these blocks may be described as superficial or deep parasternal-intercostal plane blocks, based on where the target nerves are hunted. Even if they all provide analgesia to the antero-medial chest wall, the anatomical injection site represents the main peculiarity that differentiates these techniques. To date, a common nomenclature for antero-medial chest wall blocks or parasternal-intercostal plane blocks is not yet well defined and a standardized nomenclature is needed to ensure an adequate communication among anesthesiologists.