Article Type : Research Article
Authors : Oliveira Loyola S, Siqueira Elmiro G, Weyler Nery M, Henrique de Souza A and Gardenghi G
Keywords : Analgesia; Opiate substitution treatment; Thoracic surgery; Neuromuscular blockade
Cardiac surgery with sternotomy is
related to a mechanism of intense trauma with the use of a large amount of
opioids, which does not always provide good analgesic control, in addition to
generating chemical dependence. The persistence of pain in the thoracic region
in the postoperative period is common with conventional analgesia performed
only with opioids, which slows the recovery, increasing costs and morbidity.
New approaches to the analgesic control of these surgeries become important as
they may be related to a better response to physiotherapy and cardiopulmonary
rehabilitation and, consequently, a shorter hospital stay, which would reduce
the costs of the surgery in addition to ensuring a more comfortable
postoperative period for patients. Blocking the thoracic transverse muscle
plane has become a promising pioneering technique for analgesic control in the
postoperative period of cardiac surgery. We describe a case report in which
this block gave better postoperative analgesic control, compared to the usual
care in the intensive care unit.
Nowadays, cardiovascular
surgeries are losing a large space for transcutaneous procedures. Even when the
surgical indication is superior in the literature to the detriment of the
transcutaneous procedure, some patients opt for these because they have a minor
trauma mechanism and a much more comfortable postoperative. Thus, pain in the
postoperative period becomes an important factor in the patient's therapeutic
decision and thus influencing in some cases even the prognosis [1].
The sternotomy performed
in myocardial revascularization surgeries is associated with an intense trauma
mechanism that leads to great difficulty in controlling analgesics in the
postoperative period. The use of high doses of opioids is not always effective
for a good analgesic control and, in addition, it can generate chemical
dependence which confers greater morbidity and expenses [1]. Adequate control of postoperative pain is
fundamental for the patient's full recovery, avoiding the possible chronicity
of pain, contributing to better patient satisfaction, facilitating physical
therapy and cardiopulmonary rehabilitation, reducing the length of hospital stay,
with a reduced risk of pulmonary infection and complications [2].
An increase in the
incidence of pulmonary complications can arise with postoperative ventilation
restricted by pain, which can result in hypoventilation, atelectasis,
pneumonia, and increased length of hospital stay. Thus, it is important to
treat surgical chest pain properly and in such a way as to minimize the need
for significant opioid administration [2].
Chronic and opioid abuse,
currently threatening the health of the global population, has forced health
care providers to reconsider possible analgesic options. Great efforts have
been made to maximize analgesia, with the implantation of regional anesthetic
techniques, in an attempt to reduce pain in multimodal analgesic techniques. These
efforts were associated with improvements in ultrasound imaging technology and
a renewed interest in the anatomical study that resulted in an increase in
fascial plane blocks to assist in the provision of perioperative analgesia [3].
Chronic pain can develop
after inadequate management of acute pain with isolated use of opioids,
contributing to additional physiological and psychological stress and consuming
disproportionate physical and financial resources3.The aim of this study was to
report a case of analgesic control in the postoperative period of cardiac
surgery with ultrasound-guided blockade of the thoracic transverse muscle plane
(TTMP) before the physiotherapy sessions, in the intensive care unit
environment. The present case report was evaluated by the research ethics
committee linked to Brazil Platform and receiving its approval under number
CAAE: 08 498819.8.0000.0033.
A 50-year-old male patient, overweight, sedentary, ex-smoker, with multivessel coronary artery disease (CAD). Denies hypertension, diabetes and a positive history of early family CAD. Patient had cardiac catheterization on 05/29/2020 showing a right dominance pattern, with right coronary artery (RCA) with 100% lesion in the proximal third, anterior descending artery (ADA) with 90% lesion in the proximal third and another 100% lesion in the middle third, circumflex artery (CX) with lesions of 95% and 70% in the middle third.
Figure
1:
Application of the visual analogue pain scale in the postoperative period of
cardiac surgery, performed before and after blocking the thoracic transverse
muscle plane.
On 06/03/2020, he
underwent cardiac surgery for myocardial revascularization with left mammary
bypass to diagonal and ADA, bypass for right marginal and RCA and bypass with
left radial artery for first left marginal and sequential second left marginal.
During surgery, neurological monitoring was performed by
electroencephalographic bispectral index, mild sedation by pre-anesthetic
medication, spinal anesthesia with 0.5% Bupivacaine 40mg + Dimorf 200mcg +
Sufentanil 15mcg. He was intubated with sequential venous induction with
Ketamin S + 1% propofol + Rocuronium, maintenance with sevoflurane. Activated
clotting time (ACT) of 96 seconds and post protamine ACT of 154 minutes.
Extracorporeal circulation time of 102 minutes and aortic clamping time of 76
minutes, successfully and without complications during the surgery.
In the first postoperative day, the patient evolved with significant dependent ventilatory pain, when evaluated by the service's assistance team, using the visual analogue pain scale (VAS) as demonstrated in (Figure 1), preventing physical therapy and cardiovascular rehabilitation.
Figure
2:
Technique for performing thoracic transverse muscle plane block guided by
ultrasound. A. Positioning of the linear probe 3 centimeters from the sternal
border, at the level of the 4-5º intercostal space, longitudinal direction with
cephalic indicator and identification of the plane; B. Performing an anesthetic
button before inserting the Touhy 17G needle; C. Puncture performed in a plane
and insertion of a 17G epidural catheter into the plane of the transverse
thoracic muscle after injection of 20mL of anesthetic solution.
The usual pharmacological
care measures were attempted orally to control pain, with no satisfactory
response from the patient. He also had allodynia in the sternal region, without
associated inflammatory signs, and the anesthesiology team was activated.
Degermation and antisepsis were performed from the sternal region to the
hemiclavicular line bilaterally with chlorhexidine and placement of sterile
drapes. Positioning the longitudinally linear ultrasound probe 3 centimeters from
the sternal border at the level of the 4-5th intercostal space, with a cephalic
indicator on each side and the thoracic transverse muscle plane. Puncture was
performed with a 17G Tuohy needle after anesthetic button and injected 20mL of
0.25% Ropivacaine on each side. Then, a 17G epidural catheter was inserted in
the same plane (visible to the ultrasound) and left 5 centimeters in the
referred fascial plane. At the end, fixation was performed by means of
tunneling and bandage for new injections (Figure 2).
Table
1: Painful
perception of the patient using the visual analogue pain scale before and after
blocking the TTMP and during the physical therapy sessions performed after the
blockage.
|
Pre |
Post 30 min |
|
1st PO day (10.30 AM) |
1st blockage |
8 |
2 |
1st physiotherapy session (14.24 PM) |
|
2 |
2 |
1st PO day (7.10 PM) |
2nd blockage |
0 |
0 |
2nd physiotherapy session (08.00 PM) |
|
0 |
0 |
2nd PO day (9.20 AM) |
3rd blockage |
2 |
0 |
3rd physiotherapy session (10.00 AM) |
|
0 |
0 |
|
|
|
|
TTMP: thoracic transverse muscle
plane; PO: postoperative; Data presented in absolute numbers based on the
points indicated on the visual analog scale of pain by the patient. |
Our case report was able
to demonstrate decreased pain levels after the adoption of the
ultrasound-guided TTMP block. In the postoperative period of cardiovascular
surgeries, the control of chest pain may become a major challenge. High doses
of opioids are not always effective for good analgesic control and, in
addition, the incidence of opioid addiction increases as larger amounts are
administered postoperatively [4], which significantly increases costs and
morbidity [1].
The chronic use of
opioids has become a major concern, in the USA opioid dependence has already
been declared a public health emergency. In 2017 there were 47,600 deaths
related to its use, which already represents more deaths each year than
collisions. Motor vehicles or breast cancer [4]. The prescription of opioids on
discharge from the postoperative period of cardiac surgery increases the risk
of chemical dependence, with approximately 1 in 10 patients undergoing cardiac
surgery can develop its chronic use [4]. The TTMP block thus becomes an
important adjuvant therapy not only for analgesic control, but also for
reducing the need for opioids, especially after hospital discharge, and might
be an option in cases like the one here described.
The persistence of pain
in the thoracic region due to ineffective analgesia can limit pulmonary
expansion, making it difficult to perform physiotherapy and cardiopulmonary
rehabilitation in addition to increasing the likelihood of chronic pain. Poorly
controlled acute surgical pain can be highly debilitating and has been
associated with chronic pain seen in about 20% of patients after sternotomy [5].
Restricted postoperative ventilation can result in atelectasis,
hypoventilation, pneumonia, and increased hospital stay [2]. To combat such
complications, the performance of postoperative physiotherapy is essential and
proves to be effective in restoring ventilatory capacity and minimizing
complications, as previously demonstrated by our group [6]. In the case
presented here, the analgesia induced by the TTMP block enabled all sessions to
be carried out without complications.
Historically, TTMP block
was initially used in the resection of breast cancer with contraindication to
general anesthesia. It can be done by injecting 15 mL of levobupivacaine
(0.15%) between the transverse thoracic muscle and the internal intercostal
muscle between the third and fourth left ribs in connection with the sternum. A
landmark to identify the TTMP is the short-axis view of the internal thoracic
artery and vein, which superficially locates the transverse chest muscle. When
the tip of the needle is considered to achieve TTMP on the ultrasound image, a
small amount (less than 2 mL) of the local anesthetic test dose is injected
after confirmation of negative aspiration. If the local anesthetic spreads are
seen above the costal cartilage in the sagittal parasternal view, then the
local anesthetic was injected superficially into the internal intercostal
muscle. The local spread of the anesthetic deep in the costal cartilages
indicates an appropriate block [7].
It is important to
highlight that the TTMP blocks are not free of drawbacks. Potential
complications are rare and include bleeding, infection, pneumothorax and local
anesthetic intoxication [8]. Because this technique is performed with
ultrasound guidance, it greatly reduces the risk of both pneumothorax and
bleeding and poisoning by local anesthetic, it also has the advantage of not
entering the neuroaxis and thus not presenting contraindications in relation to
the use of anticoagulation [9].
Thus, TTMP blocks may
become an optional analgesia modality in cardiovascular surgeries, considering
that it not only provides better analgesic control, sparing opioids, reducing
chronic pain and length of hospital stay, but also has an exceptionally low
rate of possible complications. In order to obtain better pain control in the
postoperative period of cardiac surgeries, involving other professionals in the
discussion about therapeutic options, as in the case in question, where the
anesthesiology team was called, was essential for the presentation of a new
path that made it possible to decrease the patient's pain, since the
conventional analgesic measures proposed by the attending physician in the
intensive care unit were not effective.
The major limitation of
this article is the fact that it is only a case report involving a single
patient. For TTMP blocks to be considered a therapeutic option at massive
levels, randomized clinical trials are necessary and shall be performed in the
future.
In the present case, the
TTMP block was effective in reducing pain in the postoperative period of
cardiac surgery and may be a tool in the anesthesiology arsenal.
TTMP: Thoracic Transverse
Muscle Plane; CAD: Coronary Artery Disease; ADA: Anterior Descending Artery; RCA:
Right Coronary Artery; CX: Circumflex Artery; ACT: Activated Clotting Time;
VAS: Visual Analogue Pain Scale