Rectus Sheath Block in Cardiac Surgery

Pain after cardiac surgery is peculiarly multifactorial demanding a procedure-specific pain management approach. For instance, we have recognized many of our patients reporting significant pain at the drain-insertion site in the post-operative period.^[1,2]

Ultrasound or USG-guided rectus sheath block (RSB) in this context can provide an effective analgesic cover for the subxiphoid drainage pain in addition to offering somatic analgesia pertaining to the median incisions.^[1-3]

We thus usually perform a bilateral RSB for our cardiac surgical patients. 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 below the xiphoid in the corresponding epigastric region [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 plane between the rectus abdominis muscle and its’ posterior sheath (PS) [Figure 1b]. Following hydro-dissection with normal saline to confirm the desired plane, 15 mL of dilute concentrations of 0.25– 0.3% ropivacaine is injected on each side [Figure 1c].

Originally described by Schleich way back in 1899,^[4] it is quite recently that Wang et al. combined RSB with pecto-intercostal fascial block in cardiac surgical patients to demonstrate a significant reduction in the post-operative opioid requirement.^[2]

Meanwhile Everett et al. also suggest RSB as a safe inclusion to the multimodal perioperative analgesic schemes in cardiac surgery,^[5] independent researchers are showcasing an ever-increasing interest in composite analgesic liaisons such as pectoralis-intercostal-rectus sheath plane block with indwelling catheters.^[6]

Indeed, deliberating the opportunities surrounding the provision of procedure-specific analgesia in cardiac surgery is particularly pertinent in the era of enhanced recovery propounding the need for effective and safe perioperative opioid-sparing practices.^[2,5-8]