Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Pediatric Anesthesia, Stanford University School of Medicine.
Stanford University School of Medicine, Stanford, California, USA.
Curr Opin Anaesthesiol. 2019 Oct;32(5):674-682. doi: 10.1097/ACO.0000000000000769.
Anesthesia for cardiac surgery has traditionally utilized high-dose opioids to blunt the sympathetic response to surgery. However, recent data suggest that opioids prolong postoperative intubation, leading to increased morbidity. Given the increased risk of opioid dependency after in-hospital exposure to opioids, coupled with an increase in morbidity, regional techniques offer an adjunct for perioperative analgesia. The aim of this review is to describe conventional and emerging regional techniques for cardiac surgery.
Well-studied techniques such as thoracic epidurals and paravertebral blocks are relatively low risk despite lack of widespread adoption. Benefits include reduced opioid exposure after paravertebral blocks and reduced risk of perioperative myocardial infarction after epidurals. To further lower the risk of epidural hematoma and pneumothorax, new regional techniques have been studied, including parasternal, pectoral, and erector spinae plane blocks. Because these are superficial compared with paravertebral and epidural blocks, they may have even lower risks of hematoma formation, whereas patients are anticoagulated on cardiopulmonary bypass. Efficacy data have been promising, although large and generalizable studies are lacking.
New regional techniques for cardiac surgery may be potent perioperative analgesic adjuncts, but well-designed studies are needed to quantify the effectiveness and safety of these blocks.
心脏手术的麻醉传统上使用大剂量阿片类药物来减轻手术对交感神经的反应。然而，最近的数据表明，阿片类药物会延长术后插管时间，导致发病率增加。鉴于住院期间接触阿片类药物后阿片类药物依赖的风险增加，再加上发病率增加，区域技术为围手术期镇痛提供了辅助手段。本综述的目的是描述心脏手术的常规和新兴区域技术。
尽管尚未广泛采用，但胸硬膜外和椎旁阻滞等经过充分研究的技术风险相对较低。其益处包括椎旁阻滞后阿片类药物暴露减少，硬膜外阻滞后围手术期心肌梗死风险降低。为了进一步降低硬膜外血肿和气胸的风险，已经研究了新的区域技术，包括胸骨旁、胸肌和竖脊肌平面阻滞。由于与椎旁和硬膜外阻滞相比，这些技术较浅，因此形成血肿的风险可能更低，而患者在体外循环时接受抗凝治疗。尽管缺乏大型且可推广的研究，但疗效数据令人鼓舞。
心脏手术的新区域技术可能是有效的围手术期镇痛辅助手段，但需要进行精心设计的研究来量化这些阻滞的有效性和安全性。
