Bilateral Erector Spina Block Versus Parasternal Block in Adult Heart Surgery
Condition: Morphine Consumption; Pain, Postoperative
MeSH terms: Pain, Postoperative
Study type: Interventional

Summary: 
      Inadequate pain relief after cardiac surgery increases morbidity and results in a high
      incidence of persistent poststernotomy pain syndrome. The use of special opioid-based
      analgesia causes adverse effects such as nausea, vomiting, sedation, urinary retention,
      respiratory depression and delayed tracheal extubation. Regional anesthesia techniques such
      as pectoralis nerve block and serratus anterior block provide analgesia in the sternum and
      pain relief in the lateral / posterior chest Wall. Erector spinae (ESP) block, a new and
      simple myofascial block, provides wide multi-dermatomal sensory block. In the T5 spinous
      process, bilateral ESP block provides analgesia from T2 to T9 sensory level, resulting in
      both somatic and visceral analgesia by blocking both the dorsal and ventral of the spinal
      nerves, including the sympathetic chain. This block may provide adequate analgesia for median
      sternotomy because the main nerve supply to the sternal region is from T2 to T6. Median
      sternotomy incision and mediastinal tube regions are the major source of pain in patients
      undergoing cardiac surgery. The anterior and posterior branches of the intercostal nerves
      give nerves to the sternum. Parasternal local anesthetic infiltration around the sternum is
      effective in providing early postoperative analgesia and reducing opioid requirements and
      therefore has positive effects on healing. This simple and fast technique can be used even
      for anticoagulated patients.
    

Detailed description: 
      99 patients will be included in the study. Group C (Control, n = 31), Group ES (Erector
      Spina, n = 31), Group PS (Parasternal Intercostal Block n = 31) will be randomized.
      Randomization was achieved by randomly assigning patients to computer-generated random
      numbers. It will be explained that patients can receive both intravenous analgesia treatment
      and both blocks that are thought to be done. Patients will be told to express the degree of
      postoperative pain in the preoperative preparation room using a numerical scoring scale (NRS)
      between 0 and 10 (no pain at 0, no pain at 10). The vascular access will be opened in the
      pre-operative preparation room and 2 mg demizolam will be made. All preoperative cardiac
      drugs, except antiplatelet and anticoagulants, will be continued until the morning of
      surgery.

      Demographic structures, cardiopulmonary bypass time, aortic cross clamp time, surgical time,
      ejection / fraction values will be recorded.

      Weight and height of patients will be recorded (BMI). Preoperative, blood group and typing,
      full hemogram, liver function tests, renal function tests, chest radiography,
      electrocardiography, 2D transthoracic echocardiography and coronary angiography will be done
      as routine investigations.

      Platelet count, bleeding time, clotting time, prothrombin time, activated partial
      thromboplastin time will be checked in all patients.

      Constructional blocks:

        1. ESP (Erector Spina Plane) Block Group

        2. 2. Parasternal Block Group

        3. Control Group The control group will not receive any Erector Spina block and
           Paravertebral Block. Only PCA (Patient Control Analgesia) and intravenous analgesic
           (Morphine) drug will be used.

      The same surgical and anesthesia team will manage the patients. 6 channel ECG and
      non-invasive arterial pressure monitoring will be performed after the patients are admitted
      to the operation room. A peripheral intravenous line with a 16-gauge needle and a right
      radial artery with a 20-gauge needle will be performed. Blood will be taken for preoperative
      blood gas. Midazolam 0.01 (mg / kg), fentanyl (5-8 μg / kg) and rocuronium (0.6 mg / kg) will
      be used for induction of anesthesia. After anesthesia, central venous catheter and urinary
      catheter will be inserted. During general anesthesia Sevoflurane will be used in the
      air-oxygen mixture with a concentration of 50% oxygen. Normocapnic variation will be provided
      (PCO2 = 35-45). A rocuronium 0.6 mg / kg will be used every 30 minutes. All patients will
      undergo median sternotomy. Heparin 300-500 Units / kg to be administered. Activeted clotting
      time (ACT) will be kept> 400 throughout the procedure. Esophageal temperature will be
      monitored. The mean arterial pressure throughout the operation will be maintained above 60 mm
      Hg. Peroperative blood sample will be taken from the radial artery 3-5 minutes after the
      cross-clamp is removed. Heparin will be neutralized with protamine 1: 1.3. After the
      operation, patients will be transferred to the intensive care unit.

      In the intensive care unit, patients will be extubated when the respiratory effort occurs,
      when the patient is awake, blood gas values are within normal range, body temperature is
      normal and hemodynamically stable. Morphine consumption by PCA and NRS scores will be
      monitored and recorded at 1, 3, 6, 12 and 24 hours after extübation. MAP (Mean arterial
      pressure), PH, PO2 (Blood gas) follow-ups will be recorded in the first blood gas, extubation
      and postoperative 1,2, 4,6,12, 24 hours.Paracetamol 1 g and Tramadol 1mg/kg intravenously
      will be administered to the patient if NRS> 3 when the patient is extubated.

      If the patient's consciousness and hemodynamic status do not allow pain assessment, the
      patient will be excluded from the study. After the surgery, the investigator who evaluates
      NRS scores in the ICU will not know which group the patient is.

      Oral feeding at postoperative hour, intensive care unit stay day, Side effects Nausea,
      Vomiting, Itching to be followed
    

Intervention name(s): Erector spina plane block
Intervention type(s): Other
Intervention description(s): While the patient is in the sitting position, an area containing 2 cm lateral of the T5 spinous process will be cleaned with povidone iodine. A high frequency ultrasound linear probe covered with a sterile sheath will be placed 2 cm to the side of the T5 spinous process, first to the right or left. After demonstrating the T5 transverse process and the erector spinae muscle on top, the 22-gauge, 80 mm insulated Quincke-type needle will be inserted into the skin at an angle of about 30 degrees from the cranial to the caudal, using an in-plane technique. When the transverse process is touched, the needle is withdrawn and after a negative aspiration test with 0.5 mL of normal saline and after a hypo-echogenic display and hydrodissection, a local anesthetic solution will be applied to the fascia under the erector spinae muscle.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Investigator)
Primary purpose: Prevention
Keywords: Erector Spinae Block, Parasternal block, Cardiac surgery