Ultrasound-guided blocks for cardiovascular surgery: which block for which patient?

Purpose of review Regional anesthesia blocks may benefit patients undergoing cardiovascular surgery. This review coincides with the evolution of ultrasound-guided fascial plane blocks, societal concerns regarding opioid misuse and changing expectations regarding surgical recovery. Recent findings Paravertebral block and thoracic epidural analgesia have comparable postoperative analgesic profiles following thoracotomy; however, the former has a more favorable complication profile. Limited trials have compared these modalities in cardiac surgery. The mechanism of action of continuous paravertebral blockade may be systemic. Bilateral continuous paravertebral (and other continuous peripheral nerve blocks) should be used with caution in adult patients having cardiac surgery because of the risk of systemic local anesthetic toxicity and bleeding. Novel ultrasound-guided blocks: erector spinae, serratus anterior, pectoral, transversus thoracic muscle and pecto-intercostal fascial plane blocks potentially reduce postoperative opioid requirements; however, they require further investigation before their routine use can be recommended in adult cardiovascular surgical practice. The mechanism of action of erector spinae block is not fully elucidated. Summary Ultrasound-guided fascial plane blocks may reduce postoperative opioid requirements. Investigation into the safety and efficacy of bilateral continuous ultrasound-guided blockade for cardiac surgery is required. Trial protocols should be embedded into enhanced recovery after surgery programs. Patient-reported and long-term outcomes are recommended.