Abstract
To date, the use of multimodal techniques can allow substantial opioid-sparing and can reduce pain by using the local and systemic effects of different types of analgesics. Aims: This case report describes a modified ERAS protocol specific for cardiac surgery with the ultrasound-guided block of the deep plane of the serratus muscle (SAP deep block) in a multimodal opioid-sparing approach. \ Two male patients, aged 62 and 67, undergoing elective mini-invasive off-pump Cardiopulmonary Bypass Grafting (CPB), were treated with an opioid-sparing multimodal anesthesiological approach based on the continuous ultrasound-guided SAP deep block. The continuous ultrasound-guided SAP deep block alone can be used in the case of mini-left thoracotomy off-pump cardiopulmonary bypass grafting implementing a multi-modal opioid-sparing strategy. It seems effective in obtaining good (2 hours) weaning from mechanical ventilation, quick (36 hours) discharge from post-operative intensive care, and good post-operative pain control (NRS < 5) even in elderly and frail patients.
Highlights
The mainstay for pain treatment in cardiac-surgery is the administration of parenteral opioids even if these drugs are associated with many side effects, including the risk of sedation with respiratory depression, paralytic ileus, nausea and vomiting [1, 2]
We describe two cases of elective myocardial revascularization using a mini-invasive surgical procedure associated with an opioid-sparing anesthesiological approach based on continuous SAP block
Levobupivacaine (0.375%) 30 ml was injected as a start dose and, after catheter insertion, an elastomeric pump with levobupivacaine (0.125%) was connected to the catheter to obtain a constant infusion of the local anesthetic at 5 ml/h for 48 hours
Summary
The mainstay for pain treatment in cardiac-surgery is the administration of parenteral opioids even if these drugs are associated with many side effects, including the risk of sedation with respiratory depression, paralytic ileus, nausea and vomiting [1, 2]. In severely ill patients, such as patients candidate to cardiac surgery, there is the necessity to reduce the side effects of opioid administration, and there is growing interest in multimodal opioid-sparing approaches that can adequately address pain through the additive or synergistic effects of different types of analgesics improving patients compliance and reducing the discomfort [3]. In this context, locoregional anesthesia can bring essential advantages in the prevention of cognitive dysfunctions and intraoperative complications.This type of approach allows the fulfillment of opioid-sparing or opioid-free anesthesia, entirely consistent with the minimally invasive surgical evolution, facilitating rapid postoperative recovery.
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