In Response.

Abstract

Fascial plane blocks are increasingly used at our institution as adjuncts to postoperative analgesia in cardiac surgery despite current low-level evidence on their efficacy and safety. It is our belief that the clinically observed benefits warrant consideration of such adjunctive techniques, which may lead to enhanced recovery and decreased postoperative opioid utilization and its associated short- and long-term side effects. We thank Drs de Souza and Maguire1 for their interest and comments on our recent review of regional anesthesia in cardiac surgery focusing on chest wall fascial plane blocks.2 We would like to emphasize that a detailed anatomical description of anatomy, and most important, nerves providing sensory innervation to the chest wall area, is described under the subtitle Chest Wall Innervation, which is also supplemented by Figures 1 and 2. We would like to thank Drs de Souza and Maguire for noticing a discrepant statement referring to the same anatomical considerations under our discussion on erector spine plane (ESP) block clinical applications. As described under the Chest Wall Innervation section and pointed out by the authors, each spinal nerve exits an intervertebral foramen and then divides into a dorsal and ventral ramus. While the dorsal rami supply the muscles, bones, joints, and skin of the posterior trunk, the ventral rami innervate lateral and anterior trunk. Every procedure performed in medicine is associated with minor or major complications. In our review, we discuss both reported and potential complications. At the time of manuscript preparation, we were not aware of reported complications involving the ESP block and could only discuss potential theoretical complications. We thank the authors for the updated information and reports on local anesthetic systemic toxicity, pneumothorax, and other complications associated with the ESP block.3,4 With its increased clinical utilization, we will likely see more reports on associated complications. As with any procedure, especially when there is no or minimal evidence, to avoid both known and theoretical complications, we advocate for sound clinical judgment and consideration of risks and benefits in each individual patient. We invite colleagues to reach out and share their clinical experiences with the described blocks for cardiac surgical procedures while awaiting more objective evidence on their safety and efficacy in this clinical setting. Marta Kelava, MDAndrej Alfirevic, MD, FASESergio Bustamante, MDJennifer Hargrave, DO, FASADonn Marciniak, MDDepartment of Cardiothoracic AnesthesiologyAnesthesiology InstituteCleveland ClinicCleveland, Ohio[email protected]