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Point of Technique
Cardiac Critical Care
7 (
2
); 104-105
doi:
10.25259/JCCC_20_2023

Rectus Sheath Block in Cardiac Surgery

Department of Cardiac Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
Department of Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, 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: Jose J, Magoon R, Kaushal B. Rectus sheath block in cardiac surgery. J Card Crit Care TSS 2023;7:104-5.

Abstract

The importance of a procedure-specific pain management regime is being ardently discussed across diverse operative settings. The same becomes only more relevant in a peculiarly invasive cardiac surgical setting. In this context, we report the technical considerations of performing a rectus sheath block in cardiac surgery.

Keywords

Cardiac surgery
Drain site pain
Opioid sparing
Rectus sheath block
Ultrasound guided

  • 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]

Figure 1:: Depiction of the ultrasound (USG) probe positioned 2–3 cm below the xiphoid process (a), Sonoanatomy of the rectus sheath block, visualizing the needle inserted in-plane with the tip located between rectus abdominal muscle and its’ posterior sheath (b), USG-image showing local anesthetic administration within the rectus sheath (c).

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

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  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.
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  5. , , , . Implementation of bilateral rectus sheath blocks in conjunction with transversus thoracis plane and pectointercostal fascial blocks for immediate postoperative analgesia after cardiac surgery. Cureus. 2022;14:e26592.
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  6. , , . Pectoralis-intercostal-rectus sheath (PIRS) plane block with catheters. A new technique to provide analgesia in cardiac surgery. J Cardiothorac Vasc Anesth. 2020;34:846-7.
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  8. , , , . Opioid free cardiac surgery: Opportunities and obstacles. J Cardiothorac Vasc Anesth. 2020;34:567-8.
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