ABSTRACT
INTRODUCTION: Working on the institutional Enhanced Recovery After Surgery (ERAS Cardio) protocol for off-pump coronary artery bypass graft surgery (OP-CABG) we have noticed that patients treated according to the modified anesthesia protocol had not only significantly shorter time of respiratory support and intensive care unit stay but also lower postoperative troponin T concentration than patients who had standard fentanyl/sevoflurane-based anesthesia. AIM: To compare the perioperative course of patients undergoing OP-CABG surgery and receiving standard fentanyl/sevoflurane anesthesia and those anesthetized according to the institutional ERAS Cardio protocol with remifentanil, sevoflurane, and bilateral extensor spinae plane (ESP) block. MATERIAL AND METHODS: Design: a prospective, open-label, observational study performed in a tertiary health center. Participants: 30 consecutive patients undergoing off-pump coronary bypass graft surgery. Interventions: 15 patients had standard anesthesia with etomidate, fentanyl, and rocuronium for induction and fentanyl/sevoflurane for maintenance (standard group); 15 others had bilateral single shot ESP block, then etomidate, remifentanil and rocuronium for induction, and remifentanil/sevoflurane for maintenance of anesthesia. RESULTS: Median time to extubation was 7.6 (5.5-12.5) h and 1.7 (1-3.25) h in "standard care" and ERAS groups, respectively (p = 0.00002). Length of stay in the intensive care unit was also shorter for patients in the ERAS group 20.5 (18-24) vs. 48 (42-48) h (p = 0.00001). Troponin concentration increased to a lesser extent in patients from the ERAS group: an increase of 151.8 (71.9-174.3) ng/ml vs. 253.8 (126.6-373.1) ng/ml, p = 0.008. CONCLUSIONS: Remifentanil/sevoflurane anesthesia combined with bilateral ESP block shortens mechanical ventilation time and ICU stay, and decreases postoperative troponin-T concentration in patients undergoing off-pump coronary bypass graft surgery.
ABSTRACT
BACKGROUND: Effective postoperative pain control remains a challenge for patients undergoing cardiac surgery. Novel regional blocks may improve pain management for such patients and can shorten their length of stay in the hospital. To compare postoperative pain intensity in patients undergoing cardiac surgery with either erector spinae plane (ESP) block or combined ESP and pectoralis nerve (PECS) blocks. METHODS: This was a prospective, randomized, controlled, double-blinded study done in a tertiary hospital. Thirty patients undergoing mitral/tricuspid valve repair via mini-thoracotomy were included. Patients were randomly allocated to one of two groups: ESP or PECS + ESP group (1:1 randomization). Patients in both groups received a single-shot, ultrasound-guided ESP block. Participants in PECS + ESP group received additional PECS blocks. Each patient had to be extubated within 2 h from the end of the surgery. Pain was treated via a patient-controlled analgesia (PCA) pump. The primary outcome was the total oxycodone consumption via PCA during the first postoperative day. The secondary outcomes included pain intensity measured on the visual analog scale (VAS), patient satisfaction, Prince Henry Hospital Pain Score (PHHPS), and spirometry. RESULTS: Patients in the PECS + ESP group used significantly less oxycodone than those in the ESP group: median 12 [interquartile range (IQR): 6-16] mg vs. 20 [IQR: 18-29] mg (p = 0.0004). Moreover, pain intensity was significantly lower in the PECS + ESP group at each of the five measurements during the first postoperative day. Patients in the PECS + ESP group were more satisfied with pain management. No difference was noticed between both groups in PHHPS and spirometry. CONCLUSIONS: The addition of PECS blocks to ESP reduced consumption of oxycodone via PCA, reduced pain intensity on the VAS, and increased patient satisfaction with pain management in patients undergoing mitral/tricuspid valve repair via mini-thoracotomy. TRIAL REGISTRATION: The study was registered on the 19th July 2018 (first posted) on the ClinicalTrials.gov identifier: NCT03592485.
