Discussion
TNF-α, inflammation, RSB, pain, Transverse thoracic muscle plane block, tissue damage, trauma
SYSTEMIC INFLAMMATORY RESPONSE, INFLAMMATION, HEMODYNAMIC INSTABILITY
This trial demonstrated that PIFB combined with RSB can reduce intravenous opioid consumption until 48 h after cardiac surgery and did not reduce perioperative systemic inflammation.Intravenous opioid consumption within 24 h after surgery was significantly decreased in the PIFB + RSB group (2.33 ± 1.77 mg vs 3.81 ± 2.24 mg, Cardiac surgery is commonly performed via median sternotomy, which causes catastrophic pain, particularly sternal splitting. Full heparinization and hemodynamic instability make the use of epidural analgesia or paravertebral block controversial. Transverse thoracic muscle plane block and PIFB, aiming at the anterior chest wall innervated by branches of intercostal nerves, can achieve the same analgesia for sternotomy in cardiac surgery [The duration of a single shot for regional anesthesia is limited, even for long-acting local anesthetics. Surprisingly, a single shot of PIFB combined with RSB in our trial decreased opioid consumption until 48 h after surgery. The long duration of combined regional techniques can be explained as follows. The addition of dexamethasone, as a safe and effective adjunct, can further prolong the duration of long-acting local anesthetics [There was no difference in time to drainage removal, ability to ambulate, or LOS in the ICU and hospital between the two groups. Although opioid consumption was decreased in our trial, the effect on early recovery was mild. Actually, the process of recovery is related to a series of programs, including adequate postoperative analgesia, surgeon-based preferences, and protocols for system perioperative care [Sawing the sternum and cardiopulmonary bypass in cardiac surgery made patients experience severe systemic inflammation associated with poor outcomes. IL-6, IL-10 and TNF-α are important cytokines that are related to surgical trauma and the degree of tissue damage, and the levels of these cytokines reflect the systemic inflammatory response to some extent [Chest tube-related pain has been recognized gradually, and this pain is described as piercing and occurring upon breathing and coughing. In addition, the pain related to chest tubes is severe and persistent, and many protocols have been administered to address this problem. Injection of bupivacaine into the pleural and mediastinal drains has been concluded to relieve pain after cardiac surgery [There are some limitations in this trial. First, PIFB and RSB were conducted after anesthesia induction to maximize patient comfort, so we cannot check the spread range of regional blocks according to the patients’ sense. Successful nerve block was uncertain merely from total intraoperative opioid consumption and hemodynamics. However, all regional blocks were guided under ultrasound, and the spread of the drug was definitely observed. Second, our sample size was based on the primary outcome, and it was small to detect the differences in postoperative early outcomes. However, we conducted a randomized controlled trial to explore the efficacy of PIFB combined with RSB. Combined regional techniques could provide adequate analgesia for median sternotomy in cardiac surgery.