Fascial plane blocks for cardiothoracic surgery: a narrative review

Abstract

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.

Keywords: Cardiac surgery; ERAS; Fascial plane blocks; Locoregional anesthesia; Pain management.

Fig. 1

A Superficial parasternal block. Patient and probe position. The needle is inserted with the in-plane approach in the cranial to caudal or caudal to cranial direction. B Ultrasound landmarks of superficial and deep parasternal block. From top to bottom: pectoralis major muscle, external intercostal muscle, internal intercostal muscle, transversus thoracis muscle, pleura, ribs. PMM, pectoralis major muscle; EIM, external intercostal muscle; IIM, internal intercostal muscle; TTM, transversus thoracis muscle

Fig. 2

A Superficial parasternal block. At level of second and fourth intercostal spaces, the local anesthetic is injected between the pectoralis major muscle and the external intercostal muscles. PMM, pectoralis major muscle; EIM, external intercostal muscle; N, needle; LA, local anesthetic. B Superficial parasternal block–modified approach. The injection on the dome of the rib allows a more homogeneous and longitudinal diffusion of local anesthetic, obtaining a better dermatomal coverage. PMM, pectoralis major muscle; IIM, internal intercostal muscle; EIM, external intercostal muscle; N, needle; LA, local anesthetic

Fig. 3

A The internal mammary artery can be identified between the internal intercostal and transversus thoracis muscles. This anatomical plane represents the target of the transversus thoracis plane block. PMM, pectoralis major muscle; EIM, external intercostal muscle; IIM, internal intercostal muscle; TTM, transversus thoracis muscle; IMA, internal mammary artery. B Ultrasound anatomy after left internal mammary artery harvesting. Patients can have tissue disruption in the transversus thoracis plane muscle after the internal mammary artery harvest, making transversus thoracis muscle identification more difficult, and the deep parasternal intercostal plane block almost impossible to perform. PMM, pectoralis major muscle; EIM, external intercostal muscle; IIM, internal intercostal muscle

Fig. 4

A Patient and probe position. The patient is in the supine position and a high-frequency linear probe is placed just below the tube emergence from the skin. B The local anesthetic injected between the rectus abdominis muscle and its sheath. LRAM, left rectus abdominis muscle; LAMS, left abdominis muscle sheath; N, needle

Fig. 5

A PECS 1 before injection of local anesthetic. B PECS 1 after injection of local anesthetic, which spreads into the fascial layers between pectoral major and minor muscles. PMM, pectoralis major muscle; PMm, pectoralis minor muscle; N, needle; LA, local anesthetic

Fig. 6

A PECS 2 before injection of local anesthetic. B PECS 2 after injection of local anesthetic, which spreads into the fascial layers between pectoral minor and serratus anterior muscles. PMM, pectoralis major muscle; PMm, pectoralis minor muscle; SM, serratus anterior muscle; N, needle; LA, local anesthetic

Fig. 7

A Sono-anatomy of SAPB: In the superficial SAPB, the target is the interfascial plane between LD and SAM; in the deep SAPB, the target is the interfascial plane between SAM and the periosteum of the V rib. B Deep SAPB: the needle is advanced in-plane in the interfascial plane between the SAM and the V rib and LA is injected. LD, latissimus dorsi; SAM, serratus anterior muscle; P, pleura; LA, local anesthetic; N, needle

Fig. 8

A Placement of the SAPB catheter with the patient in supine position. B Ultrasound visualization of the SAPB catheter between the SAM and the rib. SAM, serratus anterior muscle

Fig. 9

A ESPB performed with the patient in sitting position before general anesthesia induction. B Sono-anatomy of the ESPB block: trapezius (uppermost), rhomboid (middle), and erector spinae (lowermost) are identified. The hyperechoic T4 transverse process is individuated inferior to the erector spinae muscle. TR, trapezius muscle; RH, rhomboid muscle; ESM, erector spinae muscle; T4, transverse process

Fig. 10

A ESPB: the needle is advanced with an in-plane approach in caudo-cranial direction to reach the interfascial plane between the transverse process and the erector spinae muscle. B Ultrasound visualization of the ESPB catheter between the ESM and the transverse process. ESM, erector spinae muscle; LA, local anesthetic; N, needle; T4, transverse process