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Pain after median sternotomy remains one of the most challenging aspects of cardiac anesthesia and recovery. Despite advances in surgical technique and multimodal analgesia, many patients experience moderate to severe discomfort in the early postoperative period. This pain is not merely distressing—it directly interferes with deep breathing, coughing, and mobilization, all essential components of enhanced recovery pathways. When pain limits these functions, pulmonary complications such as atelectasis and pneumonia become more likely, leading to longer mechanical ventilation and ICU stays. Regional anesthesia has become an increasingly important tool in addressing this issue, providing effective, targeted analgesia without the hemodynamic risks associated with neuraxial techniques. The ultrasound-guided parasternal (pecto-intercostal plane) block is one of the most widely adopted options for median sternotomy. By anesthetizing the anterior cutaneous branches of the intercostal nerves (T2–T6), it provides substantial relief from sternal pain and reduces opioid consumption. However, the parasternal block does not consistently cover the lower sternum and epigastric region—precisely where mediastinal and pleural drains emerge. Pain at these drain exit sites can persist even when the sternum itself is well controlled, compromising respiratory exercises and delaying extubation. The rectus sheath block (RSB), traditionally used for midline abdominal incisions, targets the anterior cutaneous branches of T6–T9 and may therefore complement the parasternal block by extending coverage to this critical epigastric zone. This study set out to determine whether combining the rectus sheath block with the parasternal block could improve pain control and respiratory recovery after cardiac surgery via median sternotomy. Study objective and methods The primary objective of the study was to determine whether parasternal and rectus sheath blocks improve pain at rest at extubation compared to parasternal and epigastric infiltration. Design: Single-centre, single-blinded, randomized controlled superiority trial. Setting: University Hospital, Italy. Population: 58 adult patients (ASA I–IV) undergoing elective cardiac surgery via […]
December 9, 2025
Direct oral anticoagulants (DOACs) have transformed anticoagulation therapy, offering safer and more convenient alternatives to traditional agents like warfarin. However, managing DOACs around high bleeding risk procedures such as neuraxial anesthesia and deep peripheral nerve blocks remains a complex clinical challenge. This post explores the latest 2025 evidence and guidance from the American Society of Regional Anesthesia and Pain Management (ASRA) and the evolving Perioperative Anticoagulant Use for Surgery Evaluation (PAUSE) protocol. Why is DOAC management critical in regional anesthesia? DOACs are widely prescribed for conditions like atrial fibrillation and venous thromboembolism. Approximately 10–15% of DOAC-treated patients will undergo procedures that require temporary cessation of anticoagulation. Neuraxial anesthesia and deep peripheral nerve blocks are increasingly used, with benefits such as: Improved pulmonary outcomes Enhanced bowel function Opioid-sparing effects Yet these benefits must be balanced against the risk of bleeding complications, including the rare but severe spinal epidural hematoma. Understanding the risks What is spinal epidural hematoma? A spinal epidural hematoma is a rare complication of neuraxial anesthesia that can lead to permanent neurological damage. Risk factors include: Advanced age Renal dysfunction Coagulopathies Use of anticoagulants like DOACs Estimated risk: Lumbar: 7.5 per 10,000 procedures Thoracic: up to 3.6 per 10,000 procedures Comparing the ASRA guidelines vs. the PAUSE protocol ASRA guidelines (2025 update) DOAC interruption: 72 hours minimum before neuraxial or deep nerve block procedures Dabigatran with CrCl < 50 mL/min: 120-hour interruption Resumption: Minimum 24 hours after needle removal Testing: DOAC level testing recommended (<30 ng/mL) if interruption is shorter or in special populations (elderly, obese, renal dysfunction) Heparin bridging: No longer recommended PAUSE protocol Standardised approach based on bleeding risk and DOAC pharmacokinetics DOAC interruption: 2 days (60–68 hours), 4 days for dabigatran with CrCl <50 mL/min Resumption: 2–3 days post-procedure Testing: Not required Major bleeding rates: ~3% […]
December 8, 2025
Chronic postsurgical pain (CPSP) is a serious yet often underestimated consequence of surgery. Affecting up to 60% of adults, depending on the type of operation, CPSP significantly impairs quality of life, functional recovery, and psychological health. In response to this pressing issue, the concept of transitional pain services (TPS) emerged in 2014. TPS is a comprehensive, multidisciplinary strategy designed to bridge acute postoperative care and long-term recovery, aiming to prevent the development of chronic pain. A recent scoping review published in Anesthesiology assessed the global implementation and effectiveness of TPS programs. It offers a detailed analysis of existing research, highlighting the promise and challenges of TPS in clinical practice. What is a transitional pain service (TPS)? TPS is a multicomponent, patient-centered perioperative program that integrates care across the surgical timeline; before, during, and after surgery. The primary objectives are: To prevent the progression from acute to chronic pain To reduce prolonged opioid use To improve postoperative recovery and psychological outcomes Core components of TPS include: Patient education and expectation setting Psychological support (e.g., cognitive behavioral therapy, mindfulness, acceptance and commitment therapy) Multimodal analgesia Opioid tapering strategies Longitudinal follow-up, often beyond hospital discharge TPS teams typically consist of anesthesiologists, pain specialists, psychologists, nurses, physiotherapists, and coordinators, ensuring a holistic approach. Key findings from the scoping review This review analyzed 15 studies involving 7,981 patients across various countries and surgical specialties. Study characteristics: 7 retrospective chart reviews 5 prospective cohort studies 1 randomized controlled trial (RCT) 2 mixed design studies Most studies focused on orthopedic, transplant, and spine surgeries Major outcomes assessed: Postoperative opioid consumption Pain intensity and interference CPSP incidence (only 1 study assessed this as a secondary outcome) What did the review reveal? 1. Evidence on CPSP prevention is very limited Only one RCT assessed CPSP directly and found no […]
December 5, 2025
