Continuous Erector Spinea Block Versus Intravenous Analgesia in Coronary Bypass Surgery
Condition: Erector Spinea Block in Open Heart Surgery
Study type: Interventional

Summary: 
      Adequate postoperative pain relief in patients in cardiac surgery is very essential.
      multimodal techniques for perioperative pain management post cardiac surgery include
      intravenous patient controlled analgesia, thoracic epidural and paravertebral blockade.
      Analgesia through thoracic epidural is the gold standard technique for post-sternotomy pain
      control but it has serious complications. ESP block is an easy technique compared to
      paravertebral block and less hazardous than thoracic epidural. Hence, this study will compare
      continuous bilateral erector spinae block guided by ultrasound with intravenous analgesia
      which is the standard method for pain management in cardiac surgery.
    

Detailed description: 
      Analgesia through thoracic epidural is the gold standard technique for post-sternotomy pain
      control. in spite of its serious complications such as epidural hematoma with or without
      paraplegia that enhanced by heparin administered during cardiac bypass surgery..

      Paravertebral blockade is comparable to Thoracic epidural analgesia in cardiac surgery but it
      may cause complications such as vascular injuries and pneumothorax.

      Erector spinae block is recently implemented technique for treatment and analgesia of
      thoracic neuropathic pain and post mastectomy syndrome. ESP block is an easy technique
      compared to paravertebral block and less hazardous than thoracic epidural.

      This study will compare continuous bilateral erector spinae block guided by ultrasound versus
      intravenous analgesia for pain management in cardiac surgery Patients will be enrolled in the
      study will be divided into two groups In Group A: 20 patients will receive fentanyl after
      induction and intubation in the dose of ( 3-52mcg/kg ) according to the patients haemodynamic
      parameters and the decision of the anaesthesia team at skin incision, before starting
      Cardiopulmonary bypass and again after bypass and before sternal closure. Once the surgical
      procedure is ﬁnished, patients will be transferred to ICU. After ICU transfer acetaminophen 1
      gm/6hrs will be given regularly and NSAID if there is no contraindication after extubation.
      morphine 0.5mg/kg as rescue analgesia will be started upon arrival till extubation.

      In Group B: 20 patients will have bilateral ESP block will be done under general anaesthesia
      bolus dose 15 ml of 0.25% bupivacaine will be injected in each of the catheters followed by a
      continuous infusion of 0.125% plain bupivacaine at the rate of 8 ml/h starting in ICU for 48
      h after extubation. patients will receive intraoperative boluses of fentanyl according to the
      patients' haemodynamic and the decision of the anaesthesia team at skin incision, before
      starting Cardiopulmonary bypass and again after bypass and before sternal closure. Once the
      surgical procedure is ﬁnished, patients will be transferred to ICU morphine 0.5mg/kg as
      rescue analgesia will be started upon arrival till extubation. Infusion rate will be titrated
      according to haemodynamics, pain assessment, and complications. After extubation
      acetaminophen 1gm/6hrs will be given regularly.
    

Intervention name(s): continous erector spinea block; intravenous narcotics
Intervention type(s): Other; Drug
Intervention description(s): Ultrasound guided erector spinea block will be performed while the patient is in left lateral position ) the US probe will be placed in longitudinal parasagittal plane lateral to the T5 spinous process. An 18-gauge epidural needle will be inserted in-plane in a cranial-to-caudal direction until the tip is deep to erector spinae muscle. A 5 cm of epidural catheter will be threaded in cephalad direction. The same steps will be performed on the other side, after the negative aspiration for blood, bolus dose 15 ml of 0.25% bupivacaine will be injected in each of the catheters followed by a continuous infusion of 0.125% plain bupivacaine at the rate of 0.1 ml/kg/h.; intervention: injection of boluses of intra venous Narcotic drugs (fentanyl) in the dose of (1-2mcg/kg) during the surgery after induction of anesthesia then fentanyl infusion through the postoperative first 24 hours postoperative till extubation then intravenous pethidine till 48 hours after surgery.
Other intervention name(s): iv narcotics and NSAID
Intervention MeSH terms: Narcotics
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: erector spinea block, open heart surgeries,analgesia