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We appreciate Dr Chen’s feedback [1Chen T. Confounding factors on the evaluation of parasternal intercostal block for sternotomy (letter).Ann Thorac Surg. 2019; 108: 1584Abstract Full Text Full Text PDF Scopus (1) Google Scholar] regarding our report [2Lee C.Y. Robinson D.A. Johnson Jr., C.A. et al.A randomized controlled trial of liposomal bupivacaine parasternal intercostal block for sternotomy.Ann Thorac Surg. 2019; 107: 128-134Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar], and we thank the editors for the opportunity to respond to his letter. First, we did not control for intraoperative nonopioid analgesic administration; however, an institutionally standardized anesthetic regimen was implemented for all study subjects. In the postoperative period, nonopioid analgesic administration was protocolized as described in the article. The bupivacaine (Exparel) group had a lower, although not statistically significant, incidence of breakthrough ketorolac (Toradol) administration (5/38 vs 14/41). Second, although we agree that parasternal intercostal blocks are not commonly performed during sternotomy, the efficacy of this method has been demonstrated previously by randomized-controlled trials using shorter-acting local anesthetics [3Barr A.M. Tutungi E. Almeida A.A. Parasternal intercostal block with ropivacaine for pain management after cardiac surgery: a double-blinded, randomized, controlled trial.J Cardiothorac Vasc Anesth. 2007; 21: 547-553Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 4McDonald S.B. Jacobsohn E. Kopacz D.J. et al.Parasternal block and local anesthetic infiltration with levobupivacaine after cardiac surgery with desflurane: the effect on postoperative pain, pulmonary function, and tracheal extubation times.Anesth Analg. 2005; 100: 25-32Crossref PubMed Scopus (80) Google Scholar, 5Tokgӧz O. Beyaz S.G. Tanriverdi B. Effects of parasternal block and local anesthetic infiltration by levobupivacaine on postoperative pain and pulmonary functions after off-pump coronary artery bypass graft surgery.Turkish J Thorac Cardiovasc Surg. 2011; 19: 24-29Google Scholar]. Lastly, postoperative pain scores were collected by clinical nurses. The collection of pain scores by a second party can introduce imprecision and bias; however, pain is subjective. During the initial postoperative period, scores were obtained using a validated nonverbal pain scale. Once extubated, patients scored pain according to the numeric rating scale. We attempted to minimize additional bias by standardizing the time intervals and frequency of pain score collection, and by including total opioid usage as an objective measure of pain severity. Optimal postoperative pain management remains an important and challenging issue in cardiothoracic surgery. Our study is unique in being a non–industry-sponsored, prospective, randomized-controlled trial examining the efficacy of bupivacaine for use as an intercostal nerve block in patients undergoing cardiothoracic surgery. Prior reports demonstrated decreased postoperative narcotic use and shorter lengths of stay with use of bupivacaine, but were limited by the retrospective nature and use of historical controls [6Dominguez D.A. Ely S. Bach C. et al.Impact of intercostal nerve blocks using liposomal versus standard bupivacaine on length of stay in minimally invasive thoracic surgery patients.J Thorac Dis. 2018; 10: 6873-6879Crossref PubMed Scopus (33) Google Scholar, 7Parascandola S.A. Ibañez J. Keir G. et al.Liposomal bupivacaine versus bupivacaine/epinephrine after video-assisted thoracoscopic wedge resection.Interact CardioVasc Thorac Surg. 2017; 24: 925-930Crossref PubMed Scopus (30) Google Scholar]. There are now a few ongoing randomized-controlled trials evaluating intercostal nerve blocks with bupivacaine in patients undergoing thoracotomy and minimally invasive thoracic surgery. It will be interesting to see the results of these studies. Confounding Factors on the Evaluation of Parasternal Intercostal Block for SternotomyThe Annals of Thoracic SurgeryVol. 108Issue 5PreviewI read with great interest the article by Lee and colleagues [1]. The authors performed a randomized trial on 79 patients undergoing cardiac surgical procedures and concluded that liposomal bupivacaine does not provide an opioid-sparing benefit or any secondary outcome benefit compared with placebo. The authors should be applauded for performing a well-designed study in an important topic (eg, acute pain) in patients undergoing an operation [2, 3]. The need to reduce postoperative opioid prescription is an important public health issue in perioperative medicine [4, 5]. Full-Text PDF