Sono-guided nerve blocks for cardio-thoracic surgery

1. Sono-guided nerve blocks
for cardio-thoracic surgery
2022. 5. 1.
Boohwi Hong
Practical point

2.  Sternotomy,
 Vascular catheters,
 Sternal/rib retraction,
 Pericardiotomy,
 Internal mammary artery (IMA) harvesting,
 Surgical manipulation of the parietal pleura,
 Presence of chest tube,
 Musculoskeletal trauma during thoracotomy.
Pain related to cardiac surgery

3. • Improved perioperative management
• ERAS and fast-track program
• Anticoagulation: Neuraxial analgesia X
• Multimodal opioid-sparing approaches
• Non-opioid analgesics
• Regional analgesia, Fascial plane block !!
Minimal invasive cardiac surgery

4. • Minimally invasive techniques
• Mortality, Complication
• Postop pulmonary function,
• Better pain control
compared with Thoracotomy
• But, still severe pain
Video Assisted Thoracic Surgery

5. TPVB
Parasternal block

6. Injection in the plane between the pectoralis major and pectoralis minor mus
Injection in the plane between the pectoralis minor and serratus anterior mu
Injection in the plane superficial to the serratus anterior
muscles
Injection in the plane between the posterior surface of the
serratus anterior muscle and the periosteum of the rib
Injection in the plane superficial to the internal
intercostal muscles and ribs and deep to the
pectoralis major muscle
Injection in the plane between the internal
intercostal and the transversus thoracis
muscles

7. Injection in the tissue between two transverse processes,
posterior to the superior costotransverse ligament or
halfway between the posterior aspect of the transverse
process and the pleura.

8. Prof. Jeffrey C. Gadsden
#Blocktober 2021
Parasternal blocks

9. Superficial parasternal intercostal plane block

10. • 김형태 선생님 사진
KJA 2017 February 70(1): 77-80
Hyungtae Kim

11. Deep parasternal intercostal plane block

13. Sternum
Transverse
Pleura
IIM
Pec M
Pec M
IIM

14. • 0.25% ropivacaine
• Four injections of 15 mL
• Maintain hemodynamic stability
• IntraOP remifentanil consumption
• Decrease in proinflammatory response
Sternotomy

15. Pediatric cardiac surgery
Modified objective pain score

16. Interpectoral plane block
Pectoserratus plane block

17. • 78-year-old man, severe mitral regurgitation.
• MVR via right anterior thoracotomy
• POD1, after extubation, he complained of 10/10 pain
• Shallow breathing and splinting due to pain
• Facemask oxygen at 8 L/min
• 30 mL of 0.2% ropivacaine
• 2/10, “breathe easier.”
• POD3&4 8 to10/10 incisional pain
• Liposomal bupivacaine (Exparel)

18. ICD, PECS + SupraClavicular n.

19. Pectoral branch of Thoracoacromial artery

20. Prof. Ki-Jinn Chin
Erector Spinae Plane Block

21. Erector Spinae Plane Block
Intermittent automatic boluses of ropivacaine 0.2% every 6
hours
Intraoperative and postoperative opioid consumption,
optimized rapid patient mobilization, and chest tube removal

22. Erector Spinae Plane Block

23. Pediatric cardiac surgery

25. Can J Anesth/J Can Anesth (2021) 68:387–
Interconnective tissue

26. Journal of Anesthesia (2021) 35:102–111 Can J Anesth/J Can Anesth (2021) 68:387–
Costotransverse Foramen

28. • Injection in the tissue between two transverse processes,
posterior to the superior costotransverse ligament or
halfway between the posterior aspect of the transverse process
and the pleura.
Intertransverse process block

30. STIL block
CT block
MTP block
ITP block

31. Retrolaminar block
Costotransverse
foramen block

32. Incomplete posterior wall of TPVS
Previous concept Present findings

33. Medial Slit = Costotransverse Foramen
Reg Anesth Pain Med 2021;46:699–703
IAP

34. Loose connective tissue in Retro-SCTL space
Retro-SCTL space broadly communicated with the
TPVS via slits, costotransverse space, intervertebral
foramen, and erector spinae compartment.
Retro-SCTL space

35. Levator costarum Rotator costarum

36. Intersegmental spreading
Costotransverse space

38. Anesthesiology 2015; 123:459-74
Inferior articular process level

39. Inferior articular process level
Retrolamina block

40. Time lag of over 10 s between the RL and CTF injec
CTF block vs RL block

41. Paravertebral spread after the erector spinae plane block may be slow.
Spread after the inter-transverse process block is quicker.
A slight change in the needle tip can significantly influence paravertebral spread.

42. Thoracic paravertebral block

43. Paramedian Sagittal
Paramedian Sagittal Oblique
TPVB Sonoanatomy

44. IIM
TP
Transverse appraoch

45. Journal of Pain Research 2020:13 1713–17
TP IAP

46. TPVB, ESPB, INB, SPB, Control
21 RCT
1391 Patients

47. 감사합니다
Boohwi Hong
koho0127@gmail.com