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49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting
March 21-23, 2024 | The Hilton Bayfront San Diego | San Diego, California
5212
JUST A SMALL INCISION: POST-OPERATIVE ANALGESIA FOR A SURPRISE STERNOTOMY
Poster Presenter
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Part of Topic
Medically Challenging Cases
INTRODUCTION
Poor pain control after sternotomy associated with respiratory complications (1), increased myocardial oxygen demand (2), delayed mobilization (3), and prolonged hospital stay (4). Persistent acute pain post-sternotomy requiring opioids also associated with the development of chronic pain (5). Pectointercostal fascial plane block targets anterior cutaneous branches of intercostal nerves 2-6, which innervate the sternum. Parasternal blocks associated with decreased post-operative pain and opioid consumption (6, 7).
CASE VIGNETTE
71/F, h/o thymoma with prior excision was scheduled for repeat mass excision, thymic resection, and possible partial upper sternotomy. PMH: hypertension, hyperlipidemia, type 2 diabetes mellitus, alcohol use disorder. Home meds: losartan, atorvastatin, metformin, quetiapine. Pre-op physical examination, laboratory values, and other tests unremarkable. Pre-procedure huddle: surgical team claims resection possible through typical mediastinoscopy incision, minimal chance of conversion to sternotomy.
CASE DETAILS
Plan: GETA, large-bore IV access. Intra-op: attending surgeon enters the OR and immediately prepares for sternotomy. Arterial line placed. Case otherwise uneventful and patient extubated. Post-op: Patient reported significant pain in the PACU. After obtaining informed consent from family, T4-5 epidural catheter was placed. 10mL of 0.2% ropivacaine was administered through the epidural catheter, resulting in significant pain reduction. Epidural bupivacaine 0.05% and hydromorphone 10mcg/mL infusion started at 5mL/hr. POD 1: Patient still with significant pain. Unable to increase epidural infusion rate due to hypotension. POD 2: epidural infusion changed to bupivacaine 0.05% only and PO oxycodone PRN ordered. Epidural infusion briefly paused but restarted when pain increased significantly. Epidural removed. Bilateral pectointercostal fascial plane catheters placed. Intermittent bolus dosing with 0.2% ropivacaine 6mLs q2hrs. POD 3-6: improvement in pain. POD 7: parasternal catheters removed. POD 8: patient discharged home
DISCUSSION
Patient’s acute post-sternotomy pain inadequately controlled with an epidural due to hypotension but improved after placement of bilateral pectointercostal fascial plane catheters. Advantages: possibility of placement in an anticoagulated patient, less effect on hemodynamics, easier positioning. Disadvantages: surgical dressing may obstruct catheter placement (although in our experience surgical teams have been willing to redress), risk of pneumothorax, hemothorax, pericardial puncture, IMA injury, neurovascular bundle injury. Inconsistent results from studies–true benefit of parasternal blocks unclear and continued investigation warranted.
REFERENCES
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6.Barr AM, Tutungi E, Almeida AA. Parasternal intercostal block with ropivacaine for pain management after cardiac surgery: a double-blind, randomized, controlled trial. J CardiothoracVascAnesth. 2007 Aug;21(4):547-53. doi: 10.1053/j.jvca.2006.09.003. Epub 2006 Dec 22. PMID: 17678782.
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