INTRODUCTION
Cardiovascular diseases are prevalent in the general population globally
and affect most of the older adult population. With the increase in
longevity in recent years, there has been a considerable increase in
surgical procedures related to cardiovascular
diseases.1 The Society for Enhanced Recovery after
Cardiac Surgery (ERASĀ® Cardiac) recommends effective perioperative pain
control to improve patient outcomes. The goals of pain management are to
alleviate suffering, gain early mobilization after surgery, reduce
hospital stay, and improve patient satisfaction and functional
recovery.2
The pain was most intense during the first two days after cardiac
surgery and subsequently decreased. Inadequate acute postoperative pain
control after cardiac surgery may result in chronic pain, which affects
the quality of life. Seventeen percent of patients report chronic pain
one year after cardiac surgery.3 Inadequate acute
postoperative pain control can also increase pulmonary complications due
to the inability to breathe, cough, and clear
secretions.4 The leading causes of pain in cardiac
surgery procedures are sternotomy/thoracotomy incisions, chest
retraction, internal mammary artery harvesting, chest tubes, sternal
wires, and visceral pain.5 Sternal pain is transmitted
by the intercostal nerves raised from the T2-T6 spinal nerve
roots.6 The mechanism of cardiovascular surgical pain
can be represented as neuropathic and somatic pain, as it is commonly
identical to postoperative pain.
The use of multimodal perioperative pain management strategies in
current anesthesia practices is recommended instead of systemic
analgesics or opioids only. In addition to pharmacological therapies,
regional anesthesia (RA) interventions should be considered for every
patient. The limited use of neuraxial procedures or paravertebral block
in cardiac surgery with potential hemodynamic instability, full
heparinization, and hemodilution is challenging for
anesthesiologists.7 Chest wall fascial plane blocks
are increasingly used to provide postoperative pain relief and decrease
opioid consumption in patients undergoing cardiac surgery and show good
results with fewer side effects when compared to central blocks, such as
thoracic epidural analgesia or systemic analgesia, considering patients
at high cardiovascular risk. In recent years, the development of new RA
techniques, due to the role of ultrasonography, has enabled several new
fascial plane blocks.8 Fascial plane blocks are often
technically more accessible and less invasive than neuraxial analgesia
for cardiac surgery. Several randomized controlled trials have compared
the associations between regional anesthesia techniques and
postoperative opioid consumption, pain scores, and complications, but
the results are inconsistent for cardiac surgery.9 In
addition, there are not enough studies comparing the effects of
different fascial plane blocks in this subset of patients; hence, it
would be of relevance to examine this aspect.
We hypothesized that the use of single-shot RA techniques would be
associated with superior pain control and reductions in 24-h
postoperative opioid consumption compared with placebo or systemic
analgesics alone. This systematic review and network meta-analysis (NMA)
aimed to compare the effects of single-shot ultrasound-guided RA
techniques on open cardiac surgery.