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Objective: The aim of this study was to evaluate the efficacy of ultrasound-guided multiple injection costotransverse block (MICB) and compare it with erector spinae plane block (ESPB) for poststernotomy pain relief in pediatric cardiac surgical patients., Design: A prospective, randomized, double-blind, comparative study., Setting: At a single institution tertiary referral cardiac center., Participants: A total of 90 children with acyanotic congenital heart disease requiring surgery via sternotomy., Interventions: Children were allocated randomly to 1 of the 3 following groups: ESPB (group 1), MICB (group 2), or Control (group 3). Participants in groups 1 and 2 received 4 mg/kg of 0.2% ropivacaine for bilateral ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal analgesia, and fentanyl/tramadol was used for rescue analgesia., Measurements and Main Results: The modified objective pain score (MOPS) was evaluated at 0, 1, 2, 4, 6, 8, 10, and 12 hours postextubation. After all exclusions, 84 patients were analyzed. The MOPS score was found to be significantly lower in ESPB and MICB groups compared to the control group until 10 hours postextubation (p < 0.05), with no statistically significant difference at the 12th hour (p = 0.2198). The total intraoperative fentanyl consumption (p = 0.0005), need for fentanyl supplementation on incision (p < 0.0001), and need for rescue opioid requirement in the postoperative period (p = 0.034) were significantly lower in both the ESPB and MICB groups than the control group. There were no statistically significant differences in both primary and secondary outcomes between the ESPB and MICB groups., Conclusion: Ultrasound-guided MICB was effective and comparable to ESPB for post-sternotomy pain management in pediatric cardiac surgical patients., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To evaluate the efficacy of incisional ropivacaine infiltration by presternal multi-orifice catheter to manage poststernotomy pain in pediatric cardiac surgery., Design: A prospective, randomized, and double-blind comparative study., Setting: At a single-institution tertiary referral cardiac center., Participants: The study comprised 200 children undergoing cardiac surgeries through a midline sternotomy., Interventions: Children were allocated randomly to 1 of 3 groups. Group A (n = 65) and group B (n = 64) received 0.375% ropivacaine infusion and intermittent bolus, respectively, by presternal multi-orifice catheter, whereas Group C (n = 64) did not receive any local anesthetic (LA) drug. Postoperatively, intravenous paracetamol was used for multimodal analgesia, and fentanyl was given as rescue analgesia, respectively., Measurements and Main Results: Pain was assessed by a Modified Objective Pain Score (MOPS) for 48 hours postextubation. Group B had significantly lower early MOPS at the first hour, but in the later period, the mean MOPS was lower in group A. The requirement of the first rescue analgesia was 3 ± 1.51, 6.1 ± 2.26, and 2.6 ± 0.87 hours for groups A (n = 60), B (n = 60), and C (n = 60), respectively. The 48-hour fentanyl consumption was significantly lower (p < 0.001) in group A (0.5 ± 0.68 µg/kg) and group B (0.7 ± 0.86 µg/kg) than the control group (3.4 ± 0.68 µg/kg). The length of intensive care unit stay was lower (p < 0.001) in groups A and B than in group C; however, the length of hospital stay was comparable (p = 0.07)., Conclusion: LA bolus and infusion through presternal multi-orifice catheter provided effective analgesia postoperatively. However, the bolus was more efficacious in the early phase but equivalent in later periods. Therefore, bolus and LA infusion can be used for steady poststernotomy pain relief in children undergoing cardiac surgeries., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Regional analgesia continues to evolve with the introduction of ultrasound-guided fascial plane blocks. Erector spinae plane block (ESPB) is a novel technique gaining recent acceptability as a perioperative modality of analgesia in various thoracic and abdominal surgeries. However, literature on the use of ESPB in pediatric cardiac surgery is limited., Design: A prospective, randomized, single-blind, comparative study., Setting: Single-institution tertiary referral cardiac center., Participants: Eighty children with acyanotic congenital heart disease undergoing cardiac surgery through midline sternotomy., Interventions: The subjects were allocated randomly into 2 groups: ESPB (group B, n = 40) received ultrasound-guided bilateral ESPB at the level of T 3 transverse process and control (group C, n = 40) receiving no block., Measurements and Main Results: The postoperative pain was assessed using Modified Objective Pain Scores (MOPS) which were evaluated at 0, 1, 2, 4, 6, 8, 10, and 12 hours after extubation. Group B demonstrated significantly reduced MOPS as compared with group C until the 10th postoperative hour (p < 0.0001), with comparable MOPS at the 12th hour. The consumption of postoperative rescue fentanyl was also significantly less in group B in comparison to group C (p < 0.0001) with a longer duration to first rescue dose requirement in group B. In addition, the group B showed lower postoperative sedation scores and intensive care unit stay in contrast to group C., Conclusion: Ultrasound-guided bilateral ESPB presents a simple, innovative, reliable, and effective postoperative analgesic modality for pediatric cardiac surgeries contemplated through a midline sternotomy., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To evaluate the role of echocardiographic right ventricular function parameters in predicting postoperative vasoactive inotrope requirement after tetralogy of Fallot repair., Design: Prospective observational study., Setting: A tertiary care hospital., Participants: Fifty-two children undergoing elective intracardiac repair., Interventions: Comprehensive transesophageal echocardiography was performed before and after surgery. Fractional shortening, fractional area change, tricuspid annular plane systolic excursion (TAPSE), right ventricular myocardial performance index, tricuspid annular velocities (S', E', A'), and right ventricular global longitudinal strain and strain rate (RV Gls and RV Glsr) were measured. The ratio of peak systolic pressure of the right and left ventricles (P rv/lv ) was measured directly from the surgical field pre- and post-repair. The inotrope requirement during first 24 postoperative hours was calculated using the mean Vasoactive-Inotropic Score (VIS). Pearson correlation analysis was used to study the relation between echocardiographic parameters and VIS as well as P rv/lv and VIS. Receiver operating characteristic analysis was used to study the predictive strength of parameters., Measurements and Main Results: Among the measured parameters, both pre- and post-repair TAPSE had significant negative correlation with the mean VIS (p < 0.05). Both pre- and post-repair right ventricular myocardial performance index and S', E', A', RV Gls, RV Glsr, P rv/lv also had significant correlation with the mean VIS (p < 0.05). Of these, TAPSE, RV Gls, RV Glsr, and P rv/lv had significant predictive strength (p < 0.05) and reasonable sensitivity and specificity (area under the curve > 0.6) for predicting high mean VIS (VIS > 20)., Conclusion: Tricuspid annular plane systolic excursion, RV Gls, RV Glsr, and P rv/lv could predict a postoperative high mean VIS with significant strength and reasonable sensitivity and specificity., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To examine the analgesic efficacy of bilateral erector spinae plane (ESP) block compared with conventional treatment for pain after cardiac surgery in adult patients., Design: A prospective, randomized, controlled, single-blinded study., Setting: Single-center tertiary teaching hospital., Participants: One hundred and six adult patients undergoing elective cardiac surgery with cardiopulmonary bypass., Interventions: Patients were randomized into 2 groups. Patients in group 1 (ESP block group, n = 53) received ultrasound-guided bilateral ESP block with 3 mg/kg of 0.375% ropivacaine before anesthesia induction at the T6 transverse process level. Patients in group 2 (paracetamol and tramadol group, n = 53) received paracetamol (1 gm every 6 hours) and tramadol (50 mg every 8 hours) intravenously in the postoperative period. The primary study outcome was to evaluate pain at rest using an 11-point numeric rating scale (NRS). Mann-Whitney U test was used for comparing NRS scores., Measurements and Main Results: The postoperative pain level after extubation and duration of analgesia during which NRS was < 4 of 10 was compared between the groups. The median pain score at rest after extubation in group 1 was 0 of 10 until hour 6, 3 of 10 at hour 8, and 4 of 10 at hours 10 and 12 postextubation. These were significantly less in comparison with group 2 (p = 0.0001). Patients in group 1 had a significantly higher mean duration of analgesia (8.98 ± 0.14 hours), during which NRS was < 4 of 10, compared with group 2 (4.60 ± 0.12 hours) (p = 0.0001)., Conclusion: ESP block safely provided significantly better pain relief at rest for longer duration as compared to intravenous paracetamol and tramadol., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to compare the relative efficacy of ultrasound-guided serratus anterior plane block (SAPB), pectoral nerves (Pecs) II block, and intercostal nerve block (ICNB) for the management of post-thoracotomy pain in pediatric cardiac surgery., Design: A prospective, randomized, single-blind, comparative study., Setting: Single-institution tertiary referral cardiac center., Participants: The study comprised 108 children with congenital heart disease requiring surgery through a thoracotomy., Interventions: Children were allocated randomly to 1 of the 3 groups: SAPB, Pecs II, or ICNB. All participants received 3 mg/kg of 0.2% ropivacaine for ultrasound-guided block after induction of anesthesia. Postoperatively, intravenous paracetamol was used for multimodal and fentanyl was used for rescue analgesia., Measurements and Main Results: A modified objective pain score (MOPS) was evaluated at 1, 2, 4, 6, 8, 10, and 12 hours post-extubation. The early mean MOPS at 1, 2, and 4 hours was similar in the 3 groups. The late mean MOPS was significantly lower in the SAPB group compared with that of the ICNB group (p < 0.001). The Pecs II group also had a lower MOPS compared with the ICNB group at 6, 8, and 10 hours (p < 0.001), but the MOPS was comparable at hour 12 (p = 0.301). The requirement for rescue fentanyl was significantly higher in ICNB group in contrast to the SAPB and Pecs II groups., Conclusion: SAPB and Pecs II fascial plane blocks are equally efficacious in post-thoracotomy pain management compared with ICNB, but they have the additional benefit of being longer lasting and are as easily performed as the traditional ICNB., (Copyright © 2018. Published by Elsevier Inc.)

Objective: Concerns have been raised about differences in the safety profile of potato- versus waxy maize-derived hydroxyethyl starch (HES). The objective of this study was to compare 2 HES solutions derived from 2 different source materials (potato versus waxy maize) for their dose-related effects on hemostasis and organ function when used to prime the cardiopulmonary bypass circuit (CPB)., Design: A prospective, randomized, controlled study., Setting: Tertiary care center., Participants: Eighty patients undergoing coronary artery bypass grafting (CABG) on CPB., Interventions: For priming the CPB circuit, the HESPRL group received 1000 mL of potato-derived balanced 6% HES 130/0.42 along with 500 mL of Ringer's lactate; the HESP group received 1,500 mL of potato-derived balanced 6% HES 130/0.42; the HESMRL group received 1000 mL of waxy maize-derived balanced 6% HES 130/0.4 along with 500 mL of Ringer's lactate, and the HESM group received 1500 mL of waxy maize-derived balanced 6% HES 130/0.4., Measurements and Main Results: There were no significant differences in 24-hour mediastinal drainage, rate of re-exploration, blood product usage, coagulation parameters, and measures of pulmonary, renal, and hepatic function with respect to plant source of HES, when equivalent doses were used. Sonoclot activated clotting time (SonACT) was significantly higher and clot rate (CR) significantly lower at end of surgery (T1) and 24 hours after surgery (T2) in the HESP and HESM groups compared with the HESPRL and HESMRL groups. Compared with baseline, CR and platelet function were significantly lower at T1, PaO2/FIO2 ratio decreased significantly at T1 and T2, and serum bilirubin and transaminases increased significantly at T2 in all 4 groups., Conclusions: There was no significant difference in cumulative 24-hour mediastinal drainage when potato-derived balanced 6% HES 130/0.42 or waxy maize-derived balanced 6% HES 130/0.4 was used to prime the CPB circuit in patients undergoing CABG. In equal doses, both starches exerted the same effect on blood coagulation and pulmonary, renal, and hepatic function., (Copyright © 2014 Elsevier Inc. All rights reserved.)