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Open Access Special Issue

Regional anesthesia for cardiothoracic surgery

  • Polona Gams1
  • Juš Kšela2,*,
  • Maja Šoštarič3

1Department of Anesthesiology and Intensive Care, Surgery Bitenc, 4204 Golnik, Slovenia

2Clinical Department of Cardiovascular Surgery, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia

3Clinical Department of Anesthesiology and Intensive care, University Medical Center Ljubljana, 1000 Ljubljana, Slovenia

DOI: 10.22514/sv.2022.064 Vol.19,Issue 3,May 2023 pp.21-29

Submitted: 08 April 2022 Accepted: 01 June 2022

Published: 08 May 2023

*Corresponding Author(s): Juš Kšela E-mail:


Cardiac and thoracic surgery have been connected to high perioperative opioid use for a long time. With increasing knowledge of regional anesthesia in the thoracic region, thoracic nerve blocks have become supplemental methods of analgesia. As part of multimodal analgesia, they are important factors of enhanced recovery after surgery and contribute to a diminished opioid use. Myofascial nerve blocks are more superficial than the classic thoracic epidural anesthesia or paravertebral block and are therefore safer for use in anticoagulated patients. In this article, we present a number of thoracic blocks; the paraneuraxial paravertebral block; the myofascial plane blocks which are the retrolaminar block, the erector spinae plane block, the serratus anterior plane block, the pectoral nerves I and II block, the transversus thoracis plane block and the parasternal intercostal nerve block; the perineural intercostal nerve block and also local anesthetic infusion by a wound catheter. We conclude with local experience from a cardiac and thoracic surgical center.


Regional anesthesia; Cardiac anesthesia; Thoracic anesthesia; Nerve block; Pain management

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Polona Gams,Juš Kšela,Maja Šoštarič. Regional anesthesia for cardiothoracic surgery. Signa Vitae. 2023. 19(3);21-29.


[1] Ochroch J, Usman A, Kiefer J, Pulton D, Shah R, Grosh T, et al. Reducing opioid use in patients undergoing cardiac surgery—preoperative, intraoperative, and critical care strategies. Journal of Cardiothoracic and Vascular Anesthesia. 2021; 35: 2155–2165.

[2] Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology. 2009; 111: 657–677.

[3] Sengupta S. Post-operative pulmonary complications after thoracotomy. Indian Journal of Anaesthesia. 2015; 59: 618.

[4] Marshall K, McLaughlin K. Pain management in thoracic surgery. Thoracic Surgery Clinics. 2020; 30: 339–346.

[5] Kolettas A, Lazaridis G, Baka S, Mpoukovinas I, Karavasilis V, Kioumis I, et al. Postoperative pain management. Journal of Thoracic Disease. 2015; 7: S62–S72.

[6] Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, Brunelli A, Cerfolio RJ, Gonzalez M, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery after Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). European Journal of Cardio-Thoracic Surgery. 2019; 55: 91–115.

[7] Charlesworth M, Klein A. Enhanced recovery after cardiac surgery. Anesthesiology Clinics. 2022; 40: 143–155.

[8] Sostaric M, Gersak B, Novak-Jankovic V. The analgesic efficacy of local anesthetics for the incisional administration following port access heart surgery: bupivacaine versus ropivacaine. The Heart Surgery Forum. 2010; 13: E96–E100.

[9] Chin KJ. Thoracic wall blocks: from paravertebral to retrolaminar to serratus to erector spinae and back again—a review of evidence. Best Practice & Research Clinical Anaesthesiology. 2019; 33: 67–77.

[10] Boezaart A, Warltier D. Perineural infusion of local anesthetics. Anesthesiology. 2006; 104: 872–880.

[11] Chiu K, Wu C, Wang M, Lu C, Shieh J, Lin T, et al. Local infusion of bupivacaine combined with intravenous patient-controlled analgesia provides better pain relief than intravenous patient-controlled analgesia alone in patients undergoing minimally invasive cardiac surgery. The Journal of Thoracic and Cardiovascular Surgery. 2008; 135: 1348–1352.

[12] Fiorelli A, Izzo AC, Frongillo EM, Del Prete A, Liguori G, Di Costanzo E, et al. Efficacy of wound analgesia for controlling post-thoracotomy pain: a randomized double-blind study. European Journal of Cardio-Thoracic Surgery. 2016; 49: 339–347.

[13] Rawal N. Epidural technique for postoperative pain. Regional Anesthesia and Pain Medicine. 2012; 37: 310–317.

[14] Šoštarič M, Mavri A, Vene N, Poredoš P, Kodrič N. Management of antithrombotic therapy in patients undergoing regional anesthesia. Slovenian Medical Journal. 2009; 78: 619–625.

[15] Caruso TJ, Lawrence K, Tsui BCH. Regional anesthesia for cardiac surgery. Current Opinion in Anaesthesiology. 2019; 32: 674–682.

[16] Svircevic V, van Dijk D, Nierich AP, Passier MP, Kalkman CJ, van der Heijden GJ, et al. Meta-analysis of thoracic epidural anesthesia versus general anesthesia for cardiac surgery. Anesthesiology. 2011; 114: 271-282.

[17] Landoni G, Isella F, Greco M, Zangrillo A, Royse CF. Benefits and risks of epidural analgesia in cardiac surgery. British Journal of Anaesthesia. 2015; 115: 25–32.

[18] Horlocker TT, Wedel DJ, Benzon H, Brown DL, Enneking KF, Heit JA, et al. Regional anesthesia in the anticoagulated patient. Regional Anesthesia and Pain Medicine. 2003; 28: 172–197.

[19] Zangrillo A, Bignami E, Biondi-Zoccai GGL, Covello RD, Monti G, D’Arpa MC, et al. Spinal analgesia in cardiac surgery: a meta-analysis of randomized controlled trials. Journal of Cardiothoracic and Vascular Anesthesia. 2009; 23: 813–821.

[20] Piccioni F, Segat M, Falini S, Umari M, Putina O, Cavaliere L, et al. Enhanced recovery pathways in thoracic surgery from Italian VATS Group: perioperative analgesia protocols. Journal of Thoracic Disease. 2018; 10: S555–S563.

[21] Bouman EAC, Sieben JM, Balthasar AJR, Joosten EA, Gramke H, van Kleef M, et al. Boundaries of the thoracic paravertebral space: potential risks and benefits of the thoracic paravertebral block from an anatomical perspective. Surgical and Radiologic Anatomy. 2017; 39: 1117–1125.

[22] Novak-Jankovič V. Regional anaesthesia in thoracic and abdominal surgery. Acta Clinica Croatica. 2019; 58: 96–100.

[23] Yeung JH, Gates S, Naidu BV, Wilson MJ, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. The Cochrane database of systematic reviews. 2016; 2: Cd009121.

[24] Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interactive CardioVascular and Thoracic Surgery. 2014; 18: 626–635.

[25] Liang XL, An R, Chen Q, Liu HL. The analgesic effects of thoracic par-avertebral block versus thoracic epidural anesthesia after thoracoscopic surgery: a meta-analysis. Journal of Pain Research. 2021; 14: 815–825.

[26] El Shora HA, El Beleehy AA, Abdelwahab AA, Ali GA, Omran TE, Hassan EA, et al. Bilateral paravertebral block versus thoracic epidural analgesia for pain control post-cardiac surgery: a randomized controlled trial. The Thoracic and Cardiovascular Surgeon. 2020; 68: 410–416.

[27] Voscopoulos C, Palaniappan D, Zeballos J, Ko H, Janfaza D, Vlassakov K. The ultrasound-guided retrolaminar block. Canadian Journal of Anesthesia/Journal Canadien D’AnesthéSie. 2013; 60: 888–895.

[28] Damjanovska M, Stopar Pintaric T, Cvetko E, Vlassakov K. The ultrasound-guided retrolaminar block: volume-dependent injectate dis-tribution. Journal of Pain Research. 2018; 11: 293–299.

[29] Onishi E, Toda N, Kameyama Y, Yamauchi M. Comparison of clinical efficacy and anatomical investigation between retrolaminar block and erector spinae plane block. BioMed Research International. 2019; 2019: 1–8.

[30] Nobukuni K, Hatta M, Nakagaki T, Yoshino J, Obuchi T, Fujimura N. Retrolaminar versus epidural block for postoperative analgesia after minor video-assisted thoracic surgery: a retrospective, matched, non-inferiority study. Journal of Thoracic Disease. 2021; 13: 2758–2767.

[31] Sugiyama T, Kataoka Y, Shindo K, Hino M, Itoi K, Sato Y, et al. Retrolaminar block versus paravertebral block for pain relief after less-invasive lung surgery: a randomized, non-inferiority controlled trial. Cureus. 2021; 13: e13597.

[32] Abdelbaser I, Mageed NA, Elfayoumy SI, Magdy M, Elmorsy MM, ALseoudy MM. The effect of ultrasound-guided bilateral thoracic retrolaminar block on analgesia after pediatric open cardiac surgery: a randomized controlled double-blind study. Korean Journal of Anesthesi-ology. 2022; 75: 276–282.

[33] Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block. Regional Anesthesia and Pain Medicine. 2016; 41: 621–627.

[34] Thiruvenkatarajan V, Adhikary S, Pruett A, Forero M. Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: a case study and a literature review on the spread of local anaesthetic in the erector spinae plane. Indian Journal of Anaesthesia. 2018; 62: 75.

[35] Gams P, Danojević N, Bitenc M, Šoštarič M. Continuous erector spinae plane block as part of opioid-sparing postoperative analgesia after video-assisted thoracic surgeries: Series of 4 cases. Indian Journal of Anaesthesia. 2020; 64: 516.

[36] De Cassai A, Tonetti T. Local anesthetic spread during erector spinae plane block. Journal of Clinical Anesthesia. 2018; 48: 60–61.

[37] Toscano A, Capuano P, Galatà M, Tazzi I, Rinaldi M, Brazzi L. Safety of ultrasound-guided serratus anterior and erector spinae fascial plane blocks: a retrospective analysis in patients undergoing cardiac surgery while receiving anticoagulant and antiplatelet drugs. Journal of Cardiothoracic and Vascular Anesthesia. 2022; 36: 483–488.

[38] Huang W, Wang W, Xie W, Chen Z, Liu Y. Erector spinae plane block for postoperative analgesia in breast and thoracic surgery: a systematic review and meta-analysis. Journal of Clinical Anesthesia. 2020; 66: 109900.

[39] Singh N, Nagaraja P, Ragavendran S, Asai O, Bhavya G, Manjunath N, et al. Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Annals of Cardiac Anaesthesia. 2018; 21: 323.

[40] Ahiskalioglu A, Yayik AM, Demir U, Ahiskalioglu EO, Celik EC, Ekinci M, et al. Preemptive analgesic efficacy of the ultrasound-guided bilateral superficial serratus plane block on postoperative pain in breast reduction surgery: a prospective randomized controlled study. Aesthetic Plastic Surgery. 2020; 44: 37–44.

[41] Blanco R, Parras T, McDonnell JG, Prats-Galino A. Serratus plane block: a novel ultrasound-guided thoracic wall nerve block. Anaesthesia. 2013; 68: 1107–1113.

[42] Qiu L, Bu X, Shen J, Li M, Yang L, Xu Q, et al. Observation of the analgesic effect of superficial or deep anterior serratus plane block on patients undergoing thoracoscopic lobectomy. Medicine. 2021; 100: e24352.

[43] Kunigo T, Murouchi T, Yamamoto S, Yamakage M. Spread of injectate in ultrasound-guided serratus plane block: a cadaveric study. JA Clinical Reports. 2018; 4: 10.

[44] Liu X, Song T, Xu H, Chen X, Yin P, Zhang J. The serratus anterior plane block for analgesia after thoracic surgery. Medicine. 2020; 99: e20286.

[45] Toscano A, Capuano P, Costamagna A, Burzio C, Ellena M, Scala V, et al. The serratus anterior plane study: continuous deep serratus anterior plane block for mitral valve surgery performed in right minithoracotomy. Journal of Cardiothoracic and Vascular Anesthesia. 2020; 34: 2975–2982.

[46] Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery. Spanish Journal of Anesthesiology and Reanimation. 2012; 59: 470–475.

[47] Versyck B, van Geffen GJ, Chin KJ. Analgesic efficacy of the Pecs II block: a systematic review and meta-analysis. Anaesthesia. 2019; 74: 663–673.

[48] Hussain N, Brull R, McCartney CJL, Wong P, Kumar N, Essandoh M, et al. Pectoralis-II myofascial block and analgesia in breast cancer surgery. Anesthesiology. 2019; 131: 630–648.

[49] Helander EM, Webb MP, Kendrick J, Montet T, Kaye AJ, Cornett EM, et al. PECS, serratus plane, erector spinae, and paravertebral blocks: a comprehensive review. Best Practice & Research Clinical Anaesthesiology. 2019; 33: 573–581.

[50] Nagaraja P, Kumar K, Kalyane R, Singh N, Krishna M, Babu B, et al. Efficacy of bilateral pectoralis nerve block for ultrafast tracking and postoperative pain management in cardiac surgery. Annals of Cardiac Anaesthesia. 2018; 21: 333.

[51] Fujii S, Bairagi R, Roche M, Zhou JR. Transversus thoracis muscle plane block. BioMed Research International. 2019; 2019: 1–6.

[52] Zhang Y, Li X, Chen S. Bilateral transversus thoracis muscle plane block provides effective analgesia and enhances recovery after open cardiac surgery. Journal of Cardiac Surgery. 2021; 36: 2818–2823.

[53] Murata H, Hida K, Hara T. Transverse thoracic muscle plane block. Regional Anesthesia and Pain Medicine. 2016; 41: 411–412.

[54] Shokri H, Ali I, Kasem AA. Evaluation of the analgesic efficacy of bilateral ultrasound-guided transversus thoracic muscle plane block on post-sternotomy pain: a randomized controlled trial. Local and Regional Anesthesia. 2021; 14: 145–152.

[55] Abdelbaser II, Mageed NA. Analgesic efficacy of ultrasound guided bilateral transversus thoracis muscle plane block in pediatric cardiac surgery: a randomized, double-blind, controlled study. Journal of Clinical Anesthesia. 2020; 67: 110002.

[56] Bloc S, Perot BP, Gibert H, Law Koune JD, Burg Y, Leclerc D, et al. Efficacy of parasternal block to decrease intraoperative opioid use in coronary artery bypass surgery via sternotomy: a randomized controlled trial. Regional Anesthesia and Pain Medicine. 2021; 46: 671–678.

[57] Chaudhary V, Chauhan S, Choudhury M, Kiran U, Vasdev S, Talwar S. Parasternal intercostal block with ropivacaine for postoperative analgesia in pediatric patients undergoing cardiac surgery: a double-blind, randomized, controlled study. Journal of Cardiothoracic and Vascular Anesthesia. 2012; 26: 439–442.

[58] Chen H, Song W, Wang W, Peng Y, Zhai C, Yao L, et al. Ultrasound-guided parasternal intercostal nerve block for postoperative analgesia in mediastinal mass resection by median sternotomy: a randomized, double-blind, placebo-controlled trial. BMC Anesthesiology. 2021; 21: 98.

[59] Lopez-Rincon RM, Kumar V. (ed.) Ultrasound-Guided Intercostal Nerve Block. StatPearls Publishing: Treasure Island (FL). 2021.

[60] Chen N, Qiao Q, Chen R, Xu Q, Zhang Y, Tian Y. The effect of ultrasound-guided intercostal nerve block, single-injection erector spinae plane block and multiple-injection paravertebral block on postoperative analgesia in thoracoscopic surgery: a randomized, double-blinded, clinical trial. Journal of Clinical Anesthesia. 2020; 59: 106–111.

[61] Lee J, Lee DH, Kim S. Serratus anterior plane block versus intercostal nerve block for postoperative analgesic effect after video-assisted thoracoscopic lobectomy. Medicine. 2020; 99: e22102.

[62] Guerra-Londono CE, Privorotskiy A, Cozowicz C, Hicklen RS, Memt-soudis SG, Mariano ER, et al. Assessment of intercostal nerve block analgesia for thoracic surgery. JAMA Network Open. 2021; 4: e2133394.

[63] Kaushal B, Magoon R, Chauhan S, Bhoi D, Bisoi A, Khan M. A randomised controlled comparison of serratus anterior plane, pectoral nerves and intercostal nerve block for post-thoracotomy analgesia in adult cardiac surgery. Indian Journal of Anaesthesia. 2020; 64: 1018.

[64] Mijovski G, Podbregar M, Kšela J, Jenko M, Šoštarič M. Effectiveness of wound infusion of 0.2

[65] Dowling R, Thielmeier K, Ghaly A, Barber D, Boice T, Dine A. Improved pain control after cardiac surgery: results of a randomized, double-blind, clinical trial. The Journal of Thoracic and Cardiovascular Surgery. 2003; 126: 1271–1278.

[66] Agarwal S, Nuttall GA, Johnson ME, Hanson AC, Oliver WC Jr. A prospective, randomized, blinded study of continuous ropivacaine infusion in the median sternotomy incision following cardiac surgery. Regional Anesthesia and Pain Medicine. 2013; 38: 145–150.

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