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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 259-263

Ultra sound guided erector spinae plane block for perioperative analgesia in post coronary artery bypass grafting sternal dehiscence (Type 2b) patient posted for pectoralis major flap


Department of Anaesthesiology and Critical Care, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission14-Apr-2020
Date of Decision22-Oct-2020
Date of Acceptance29-Nov-2020
Date of Web Publication27-May-2022

Correspondence Address:
Bhimala Naga Ramya
Department of Anaesthesiology, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry - 605 014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_35_20

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  Abstract 


Sternal dehiscence is a grave complication after cardiac surgery. Deep sternal dehiscence usually requires debridement and flap coverage as the mainstay of management. The perioperative period is considered very challenging and the anesthetic technique has a direct impact on the risk of perioperative complications. Perioperative pain management is usually carried out with the help of regional anesthetic techniques as they offer various benefits for this patient population, including the provision of high-quality analgesia, reduced requirements for opioids and nonsteroidal anti-inflammatory drugs, and reduced autonomic system activation. Conventionally, regional anesthesia techniques such as epidural and paravertebral blocks have been shown to provide effective analgesia and enhance postoperative recovery. However, these techniques were associated with minimal but unacceptable complications. Ultrasound-guided erector spinae plane (ESP) block is a recently described technique providing thoracic analgesia. This is the first case report to our knowledge, which describes the use of ESP block as perioperative analgesic technique for pectoralis flap in a high-risk cardiovascular patient.

Keywords: Erector spinae plane block, pectoralis major flap, post coronary artery bypass graft, sternal dehiscence


How to cite this article:
Ramya BN, Ranjan R V, Nagalakshmi P, George SK. Ultra sound guided erector spinae plane block for perioperative analgesia in post coronary artery bypass grafting sternal dehiscence (Type 2b) patient posted for pectoralis major flap. CHRISMED J Health Res 2021;8:259-63

How to cite this URL:
Ramya BN, Ranjan R V, Nagalakshmi P, George SK. Ultra sound guided erector spinae plane block for perioperative analgesia in post coronary artery bypass grafting sternal dehiscence (Type 2b) patient posted for pectoralis major flap. CHRISMED J Health Res [serial online] 2021 [cited 2022 Jul 7];8:259-63. Available from: https://www.cjhr.org/text.asp?2021/8/4/259/346100




  Introduction Top


Sternal wound infection and dehiscence have been reported to occur in 0.2%–10%, and mortality rate in such cases range from 5% to 20%.[1] Management of sternal wound infection includes multiple debridements, resuturing/rewiring, vacuum-assisted closure therapy, flap coverage with muscle flaps such as pectoralis major, rectus abdominis, latissimus dorsi, and omentum. In these patients pectoralis major flap was used commonly in combination with rectus abdominis muscle or omentum.[2] Uncontrolled pain may exacerbate sympathetic activity and unacceptable hemodynamic changes, especially in post coronary artery bypass grafting patients. Hence, adequate multimodal preemptive analgesia is paramount. This has conventionally been managed with high doses of intravenous (IV) opioids or neuraxial anesthesia. Both of these approaches have their own concerns, risks and complications. Recently, erector spinae plane (ESP) block, a safe, simple and effective interfascial plane block, has been described for thoracic surgeries.

We report a case of sternal wound dehiscence patient posted for pectoralis major flap in whom ultrasound-guided continuous ESP block was given for perioperative analgesia.


  Case Report Top


A 53-year-old male, case of status post CABG (triple vessel grafting done 3 months back), now presented with sternal dehiscence and his body mass index was 19.5 kg/m2. He is a known case of Diabetic, Hypertensive on regular medication. His wound swab showed acid-fast bacilli positive and was started on anti-tubercular therapy. Wound debridement and negative pressure wound dressing were initiated for 3 weeks under general anesthesia and spontaneous ventilation. After 3 weeks, when edema settled and wound showed healthy granulation tissue [Figure 1], team of CTVS/Plastic/Anesthesia departments decided to proceed with left pectoralis major flap cover. His complete hemogram was within the normal limits, and electrocardiogram showed QT prolongation of 450 ms, T-wave inversion in leads I and V1–V4. ECHO – mild LV dysfunction, EF– 45%. Computed tomography thorax-showed left diaphragmatic palsy, left lower lobe consolidation and collapse [Figure 2].
Figure 1: Sternal dehiscence post negative pressure wound dressing

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Figure 2: CT thorax showing left lower lobe consolidation

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We planned to proceed under general anesthesia with left continuous ESP block. After obtaining informed written consent, IV access was secured with 16G venflon. ASA standard monitors were connected. Under strict aseptic precautions, patient in sitting position [Figure 3], using high-frequency linear transducer (6–13 MHz) left ESP block was given in-plane technique using 8 cm 18G Tuohy needle inserted in craniocaudal direction at T2 level and 20G catheter was inserted 3–4 cm beyond the needle tip, 20 ml of 0.125% bupivacaine bolus was given [Figure 4] and [Figure 5].
Figure 3: Sonographic anatomy

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Figure 4: Sonographic picture showing needle and drug spread

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Figure 5: Sonographic pictures showing needle and catheter placement

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The patient was preoxygenated with 100% O2, premedicated with Injection midazolam 2 mg, Injection fentanyl 100 mcg, induced with Injection etomidate 10 mg, muscle relaxation achieved using Injection vecuronium 7 mg and intubated with 8.5 mm endotracheal tube. The right radial arterial line was secured and transduced for IBP monitoring. Left internal jugular vein was cannulized with 7.5 F triple lumen catheter. Intraoperatively capillary blood glucose (CBG) was monitored and started on insulin infusion, vitals were maintained. Intermittent ESP bolus doses were given with 0.125% bupivacaine 5 ml at an interval of 2 h. Left pectoralis rotation flap was done to cover the sternal dehiscence [Figure 6]. The surgery lasted for 6 h with a total blood loss of about 600 ml. Crystalloids and colloid were used to maintain the hemodynamics. At the conclusion of the procedure, inhalation anesthetic was discontinued, and residual neuromuscular blockade was reversed with Injection neostigmine 3 mg and Injection glycopyrrolate 0.6 mg and the patient was extubated. Postoperative analgesia was assessed using visual analog scale (VAS) score, which was <2/10 throughout his postoperative stay. We continued erector spinae continuous infusion with 0.125% bupivacaine at 4 ml/h. His VAS score throughout this postoperative phase was never above 4/10. Along with erector spinae infusion, IV injection of paracetamol 1 g BD was given on POD 1. The infusion continued, and the patient was pain-free for the rest of postoperative period with no opioid requirement. The patient's pain remained well controlled on oral multimodal analgesia after ESP catheter removal, and he was discharged from the hospital on POD 10.
Figure 6: Mobilized pectoralis flap

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  Discussion Top


The dehiscence after median sternotomy incision, which is used as surgical access for cardiac surgery, is one of its major complications and it increases the patient's morbidity and mortality. Superficial sternal wound infection (SSWI), which involves the skin, subcutaneous tissue, and the muscle, has an incidence of 0.5%–8%, with an associated morbidity and mortality rate ranging from 0.5% to 9%.[3] SSWI can be managed successfully with the help of antibiotics and wound dressing. The incidence of deep sternal wound infection (DSWI) ranges between 0.5% and 6.8%,[4],[5],[6] with in-hospital mortality rates between 7% and 47%.[7]

Various classifications are available in the literature, which are designed according to the anatomical site [Table 1][4] and depending upon the extension of the wound [Table 2].[5] According to the above classification, our patient belonged to Type 2b Jones class and Type A Greig class. Aggressive management with wound debridement and Negative pressure wound therapy removes excessive fluid, decreases wound edema, accelerates wound healing and granulation tissue formation, stabilizes chest wall, increases sternal blood flow and has been shown to improve early and long-term survival in patients with DSWI.[6] Once the wound heals, debridement, and closure with muscle or myocutaneous flap has gained popularity.[8] The use of pectoralis major flap has contributed to decrease the mortality rate of about 7.9%–9.5%.[9]
Table 1: Classification proposed by Jones in 1997 based on anatomical site[4] plus a type including sepsis

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Table 2: Classification proposed by Greig in 2007, considering the regional location of the wound[5]

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Perioperative goals in such patients are mainly to maintain cardiac output, avoiding hypoxia, hypercarbia, acidosis and providing good adequate analgesia. Perioperative pain management plays a vital role in the management of patients undergoing cardiac or noncardiac surgery in cardiac patients. Uncontrolled pain may result in exacerbated sympathetic activity, which compromises hemodynamics, increases oxygen consumption, tachycardia, myocardial infarction, increased risk of pulmonary and immune function impairment, delayed mobilization, thromboembolism, and prolonged hospital stay.[10] The American Society of Anesthesiologist task force on the management for acute postoperative pain, recommends the use of multimodal techniques for pain management.[11] These include regional analgesia, IV, and oral analgesics. Opioids are the mainstay as oral analgesics/iv analgesics; however, it can cause nausea, vomiting, pruritus, and respiratory depression. Regional anesthesia has played an important role in enhanced recovery pathways for other surgical services and allows for reduced systemic opioid use during intraoperative and postoperative care. Among the regional anesthesia techniques, thoracic epidural and paravertebral blocks have been described in literature to reduce the postoperative pain in cardiac surgery with improved outcomes. Until now, the role of regional anesthesia has remained somewhat limited in cardiac surgery because of safety concerns inherent in using paravertebral and neuraxial techniques with anticoagulated patients.[12] However, with the recent development of the ESP block, regional anesthesia may be able to be safely integrated into enhanced recovery pathways for cardiac patients in noncardiac as well as cardiac surgeries.

ESP block was first described by Forero M et al.[13] in 2016 for the treatment of chronic thoracic neuropathic pain and postoperative pain in thoracic surgery. Cadaveric studies of thoracic ESP blocks show that spread often includes T2–T6 levels and could be expected to anesthetize thoracotomies, anterior thoracic procedures such as breast surgeries, pectoralis flaps, and mid-sternotomy incisions.[14] ESP block has easily recognizable sonoanatomy with easy insertion of the indwelling catheter. After identifying the level of intervertebral space, spinous process and transverse process are identified as trident signs with lamina (saw-tooth pattern). Then, three muscles are identified trapezius, rhomboid major, and erector spinae with simmering pleura between the transverse process. Moreover, local anesthetic is deposited between the deep fascial plane of erector spinae muscle and superficial to the tip of the transverse process.[15]

There is limited literature available on the efficacy of ESP block on cardiac surgery, which involves median sternotomy. Nagaraja et al.[16] published their randomized controlled trial (RCT) of postoperative analgesia in 106 adult cardiac surgery patients, comparing ESP block with thoracic epidural for open-heart surgeries. The authors reported VAS score was <4 for 48 h in the ESP group and ESP as an effective alternative to epidural analgesia. That median pain scores at rest were lower after extubation in the ESP group, which also had a longer mean duration of analgesia. Similarly, ESP block has started replacing epidural or paravertebral block for thoracic surgery. There are various case reports and case series describing the successful use of ESP catheters for posterolateral thoracotomy analgesia.[17],[18] ESP blocks are showing promise as a regional anesthesia technique for breast surgery and breast implant surgery analgesia. Few small RCTs have shown effective analgesia and reduced postoperative opioid consumption when compared with the standard care in patients undergoing surgery for breast cancer.[19] As the literature review indicates ESP as an effective method of maintaining perioperative analgesia, we decided to provide analgesia through the ESP route. Our surgical team decided to do sternal debridement, anterior thoracic incision and left-sided pectoral muscle flap to cover the sternal dehiscence. Since ESP covers all these areas effectively, we decided to perform continuous ESP block catheter. We secured the ESP using 20G epidural catheter and gave bolus followed by continuous infusion for 48 h. The patient had good pain-free period throughout 48 h postoperatively with VAS <4.

Acknowledgment

Department of cardiothoracic surgery.

Department of plastic surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Landes G, Harris PG, Sampalis JS, Brutus JP, Cordoba C, Ciaburro H, et al. Outcomes in the management of sternal dehiscence by plastic surgery: A ten-year review in one university center. Ann Plast Surg 2007;59:659-66.  Back to cited text no. 1
    
2.
Bhatia VY, Menon PA, Mishra S, Mehta SH. Pectoralis major muscle flap in the treatment of post CABG sternal defects. Int J Cardiovasc Res 2013;2:Available from: https://www.scitechnol.com/pectoralis-major-muscle-flap-in-the-treatment-of-post-cabg-sternal-defects-drGm.php?article_id=531. [Last accessed on 2019 Apr 03].  Back to cited text no. 2
    
3.
Lazar HL, Salm TV, Engelman R, Orgill D, Gordon S. Prevention and management of sternal wound infections. J Thorac Cardiovasc Surg 2016;152:962-72.  Back to cited text no. 3
    
4.
Jones G, Jurkiewicz MJ, Bostwick J, Wood R, Bried JT, Culbertson J, et al. Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience. Ann Surg 1997;225:766-76.  Back to cited text no. 4
    
5.
Greig AV, Geh JL, Khanduja V, Shibu M. Choice of flap for the management of deep sternal wound infection--an anatomical classification. J Plast Reconstr Aesthet Surg 2007;60:372-8.  Back to cited text no. 5
    
6.
Morisaki A, Hosono M, Murakami T, Sakaguchi M, Suehiro Y, Nishimura S, et al. Effect of negative pressure wound therapy followed by tissue flaps for deep sternal wound infection after cardiovascular surgery: Propensity score matching analysis. Interact Cardiovasc Thorac Surg 2016;23:397-402.  Back to cited text no. 6
    
7.
Cotogni P, Barbero C, Rinaldi M. Deep sternal wound infection after cardiac surgery: Evidences and controversies. World J Crit Care Med 2015;4:265-73.  Back to cited text no. 7
    
8.
Hugo NE, Sultan MR, Ascherman JA, Patsis MC, Smith CR, Rose EA. Single-stage management of 74 consecutive sternal wound complications with pectoralis major myocutaneous advancement flaps. Plast Reconstr Surg 1994;93:1433-41.  Back to cited text no. 8
    
9.
Ascherman JA, Patel SM, Malhotra SM, Smith CR. Management of sternal wounds with bilateral pectoralis major myocutaneous advancement flaps in 114 consecutively treated patients: Refinements in technique and outcomes analysis. Plast Reconstr Surg 2004;114:676-83.  Back to cited text no. 9
    
10.
Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiol Clin North Am 2005;23:21-36.  Back to cited text no. 10
    
11.
American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012;116:248-73.  Back to cited text no. 11
    
12.
Chaney MA. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg 2006;102:45-64.  Back to cited text no. 12
    
13.
Forero M, Rajarathinam M, Adhikary S, Chin KJ. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: a case series. Scand J Pain 2017;17:325-9.  Back to cited text no. 13
    
14.
Yang HM, Choi YJ, Kwon HJ, O J, Cho TH, Kim SH. Comparison of injectate spread and nerve involvement between retrolaminar and erector spinae plane blocks in the thoracic region: A cadaveric study. Anaesthesia 2018;73:1244-50.  Back to cited text no. 14
    
15.
Kot P, Rodriguez P, Granell M, Cano B, Rovira L, Morales J, et al. The erector spinae plane block: A narrative review. Korean J Anesthesiol 2019;72:209-20.  Back to cited text no. 15
    
16.
Nagaraja PS, Ragavendran S, Singh NG, Asai O, Bhavya G, Manjunath N, et al. Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Ann Card Anaesth 2018;21:323-7.  Back to cited text no. 16
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17.
Kelava M, Anthony D, Elsharkawy H. Continuous Erector Spinae Block for Postoperative Analgesia After Thoracotomy in a Lung Transplant Recipient. J Cardiothorac Vasc Anesth 2018;32:e9-11.  Back to cited text no. 17
    
18.
Nath S, Bhoi D, Mohan VK, Talawar P. USG-guided continuous erector spinae block as a primary mode of perioperative analgesia in open posterolateral thoracotomy: A report of two cases. Saudi J Anaesth 2018;12:471-4.  Back to cited text no. 18
    
19.
Altıparmak B, Korkmaz Toker M, Uysal Aİ, Gümüş Demirbilek S. Comparison of the efficacy of erector spinae plane block performed with different concentrations of bupivacaine on postoperative analgesia after mastectomy surgery: Ramdomized, prospective, double blinded trial. BMC Anesthesiol 2019;19:31.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]



 

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