Intraoperative Management and Outcome: The operation was performed using five small incisions in the right thorax, from intercostal interspaces 2-5 (Figure 2). The surgeon then performed cryoablation nerve block on right intercostal spaces 2-5 under camera vision. After replacing the mitral valve, two 24 Blake chest tubes were placed. Approximately five hours after ESP catheter placement, a ropivacaine 0.2% infusion was started through the catheter at a continuous rate of 3mL/hour with an intermittent bolus of 12mL every 2 hours. The patient was then extubated in the operating room. On arrival to the ICU, the patient endorsed a pain score of 4/10 on the numerical rating scale. He received a total of 0.4mg of IV hydromorphone in the ICU on postoperative day (POD) 0 as well as acetaminophen every 8 hours. On POD 1 the patient received a total of 10mg of oxycodone and experienced minimal pain afterwards. On postoperative day 2 the patient’s chest tubes were removed and he was transferred to the floor, still with minimal to no pain, at which point the ESP catheter was removed uneventfully. The patient was discharged from the hospital on POD 5.

Discussion: There are few quality randomized controlled trials (RCTs) on ESP catheters for cardiac surgery. A review from 2021 included seven studies on this topic and concluded that ESP block may be associated with improved analgesia postoperatively. The authors add that, while most studies report no complications from ESP block, the data for cardiac patients on anticoagulation is not robust (1). This review included two RCTs, the first of which compared thoracic epidural analgesia to bilateral ESP catheters for 50 patients undergoing median sternotomy. Pain scores were comparable between the two groups up until 12 hours post-extubation and no complications were noted in either group (2). In the second RCT, 106 patients scheduled for cardiac surgery were randomized to receive bilateral ESP blocks or intravenous paracetamol and tramadol. The ESP group had significantly lower postoperative pain scores and longer duration of analgesia (3). An RCT from 2023 included 72 patients who all received right-sided ESP catheters for right mini-thoracotomy, but half of the patients received ropivacaine 0.5% while the other half received saline through the catheters. No complications related to catheter placement were noted, but opioid consumption did not significantly differ between groups (4). Analgesia involving cryoablation along with erector spinae continuous block in thoracotomy has not been well researched but may offer a potentially great benefit. Based on our positive experience in this case report and other recent cases, we continue to incorporate right-sided ESP catheters as part of the multimodal regimen for robotic mitral valve surgery. Overall, though, the data for ESP blocks in cardiac surgery remains limited and more quality RCTs are needed.

References: