Background: Postoperative sternal pain is one of the most important factors affecting patients’ quality of life during the early post-operative days. Optimal pain management after cardiac surgery improve comfort and wellbeing of the patients. Conventionally used techniques of postoperative analgesia mostly provided by intravenous route, have their own side effects, causing a delay in tracheal extubation. Parasternal intercostals block is one such technique which has several potential advantages and devoid of the above side effects.
Objective: To study the effect and effi cacy of parasternal intercostals block analgesia with two different doses of ropivacaine for post-operative analgesia in patients undergoing coronary artery bypass grafting (CABG).
Design: Randomized, prospective, double blind study
Setting: Tertiary health care teaching hospital
Participants: One hundred and twenty adult cardiac surgical patients scheduled for elective coronary artery bypass grafting.
Intervention: 0.75% ( group R1) and 0.5% (group R2) ropivacaine injection with 5 doses of 4 ml each on each side of Parasternal intercostals space with a total dose of ropivacaine 200 mg and 300 mg respectively or same volume of saline (group S) prior to surgical incision.
Measurements and results: The average time of extubation was signifi cantly lower in R1 and R2 group compared to S group, being 5.15±1.13,5.24±0.88 and 7.29±1.41 hours respectively (p <0.0010).The length of ICU stay was 1.67±0.57 days in group R1,2.0±0.61 days in group R2 and 2.11±0.64 days in group S ( p=0.007) . A similar fi nding was also present when the duration of hospital stay was concerned. The cumulative 24 hr fentanyl dose was signifi cantly higher in group S compared to that of R1 and R2. (186.73±28.3, 217±36.8 and 344±68.2 μ gm respectively, p, 0.01).VAS score was highest in S group of patients with a mean of 5.08±0.82 for all the time periods, whereas that for group R1 and R2 was 3.64±0.84 and 3.77±0.71 respectively except that at post extubation. Statistical signifi cance was observed for VAS score during inter group comparison (R1 vs S, p<0.001, R2 vs. S,p<0.001). The mean heart rate and mean arterial pressure remained in higher side in group S patients when compared to the other two groups (p < 0.01 in each case). One patient in group R1, three in group R2 and seven in group S had arrhythmia during their ICU stay. Two patients from each R2 and S group had evidence of pneumonia and none of the patients in any group had evidence of sternal wound infection during the course of stay and one month follow up period.
Conclusion: Parasternal intercostals block for postoperative pain relief for adult cardiac surgical patients is a simple technique, which is easy to perform and appears to be a useful adjunct to post-operative pain relief during the postoperative period. 0.75 % ropivacaine is more effi cacious than that of 0.5% when used in the same route without any additional side effects. Unlike neuroaxial blocks, it can be used in patients who are anti-coagulated perioperatively and have deranged coagulation parameters.
Published on: Feb 23, 2017 Pages: 7-13
University of Parma, Italy
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Democritus University of Thrace , Greece
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University of Athens , Greece
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Peter J Catalano
Tufts University, USA
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Wei Min HUANG
Nanyang Technological University, Singapore
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