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Point of Technique
Cardiac Critical Care
7 (
2
); 100-101
doi:
10.25259/JCCC_19_2023

Pecto-Intercostal Fascial Block in Cardiac Surgical Patients

Department of Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
Department of Cardiac Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
Department of Anaesthesiology, Gandhi Medical College, Bhopal, Madhya Pradesh, India
Corresponding author: Dr. Brajesh Kaushal, Department of Anaesthesiology, Gandhi Medical College, Bhopal, Madhya Pradesh, India. brajeshkaushal3@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Magoon R, Jose J, Kaushal B. Pecto-intercostal fascial block in cardiac surgical patients. J Card Crit Care TSS 2023;7:100-1.

  • Despite an ever-growing motivation towards minimal invasion in cardiac surgery, the majority of open-heart surgery continues to employ a median sternotomy incision which results in significant acute postoperative pain with subsequently enhanced predisposition to persistent post-sternotomy pain (PSP).[1-3]

  • Ultrasound (USG)-guided pecto-intercostal fascial block (PIFB) has been recently proposed to effectively manage the median sternotomy pain wherein García Simón and Fajardo Perez suggest a decreased risk of major complications (including, vascular injury and pneumothorax) with PIFB as opposed to the transversus thoracis muscle plane block.[1-4]

  • We often perform a bilateral PIFB for our cardiac surgical patients undergoing median sternotomy, mostly after induction of general anesthesia. With the patient in a supine position, a high-frequency L 12–3 MHz linear USG probe (EPIQ7C, PHILIPS, Holland) is placed 2–3 cm lateral to the corresponding sternal edge in the 4th intercostal space [Figure 1a]. Using a 21-gauge ×100 mm Stimuplex A block needle (B. Braun, Melsungen, Germany), an in-plane approach is employed to reach the target PIFB between the pectoralis major and external intercostal muscles [Figure 1b]. Following hydro-dissection with saline to confirm the desired plane for local anesthetic (LA) injection [Figure 1c], 20 mL of dilute concentrations of 0.25–0.3% ropivacaine is injected on each side, which tends to be within the safe limits of the LA dose as per the body weight of the patient.

  • Meanwhile, we practice a single-injection PIFB (akin to research groups like Wang et al.[2]) and rely on the LA spread visualized under USG-guidance, independent researchers also employ 2–3-injection PIFB technique equally dividing the LA volumes accordingly.[1,3]

  • Nonetheless, recent literature on the efficacy-safety of PIFB is encouraging wherein one can achieve adequate post-sternotomy pain relief with an acceptable degree of opioid-sparing closely governed by institutional analgesic practices.[1-5]

  • Interestingly, Sahoo et al. report a seminal use of PIFB in a 63-year-old lady suffering from severe persistent PSP following coronary artery bypass grafting, propounding the role of the former in chronic pain settings as well.[6]

Figure 1:
Depiction of the ultrasound (USG) probe placed 2–3 cm lateral to the corresponding sternal border (a); Sonoanatomy of pecto-intercostal fascial plane (PIFB) with in-plane needle tract and the tip visualized between the pectoralis major (PMM) and the intercostal muscle (b); USG-image showing the LA agent injected into the PIFB (c). One can note the glistening white structure as the pleura where R4 denotes the fourth rib.

Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

Conflicts of interest

There are no conflicts of interest.

Financial support and sponsorship

Nil.

References

  1. , , , . Effects of bilateral Pectointercostal Fascial Block for perioperative pain management in patients undergoing open cardiac surgery: A prospective randomized study. BMC Anesthesiol. 2021;21:175.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , , , , , et al. Effects of pecto-intercostal fascial block combined with rectus sheath block for postoperative pain management after cardiac surgery: A randomized controlled trial. BMC Anesthesiol. 2023;23:90.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , , . Pectointercostal Fascial Block (PIFB) as a novel technique for postoperative pain management in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2021;35:116-22.
    [CrossRef] [PubMed] [Google Scholar]
  4. , . Safer alternatives to transversus thoracis muscle plane block. Reg Anesth Pain Med 2019:rapm-2019-100666.
    [CrossRef] [PubMed] [Google Scholar]
  5. . Implications of practice variability: Comment. Anesthesiology. 2020;133:943-4.
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  6. , , , , , , et al. Pectoral-intercostal fascial plane block in chronic post-sternotomy pain. Ann Card Anaesth. 2022;25:97-9.
    [CrossRef] [PubMed] [Google Scholar]

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