High Versus Low Dose Serratus Anterior Plane Block After Minimally Invasive Valve Surgery.

During the last two decades, cardiac surgical techniques have changed dramatically. Evidence for good short and long-term outcomes after endovascular and minimally invasive procedures is rising. This shift made it possible to avoid sternotomy and thus facilitating earlier patient recovery without compromising safety. Therefore, enhanced recovery after surgery (ERAS) protocols have been implemented to aim for early extubation and ambulation. While policies for early extubation and discharge from the hospital have been implemented, the analgesic regimen has not been modified. Opioids remain the standard treatment in the postoperative setting after cardiac surgery despite known side effects such as nausea, constipation and the risk of addiction. Neuraxial anaesthesia techniques, which require fewer opioids in cardiac surgery, have been studied and validated but not yet implemented.

In 2013, the serratus anterior plane (SAP) block was described as a pain relief option for chest surgery. This anaesthesia technique injects local anaesthetics under the serratus muscle and between the latissimus dorsi and serratus anterior using ultrasound. Successful pain relief with this SAP block has been reported in thoracotomy, chest surgery, and rib fractures. In our previous study, we demonstrated a 40% reduction in morphine consumption during the first 24 hours after total endoscopic aortic valve replacement with an SAP block compared to a control group without an SAP block. Lower pain scores were also observed in the SAP group

As such, in this proposed study, we aim to optimise the intensity of the Serratus anterior plane block (SAPB) to decrease opioid requirements further and to encounter more favourable secondary clinical outcome parameters. One strategy to increase the duration of action of plane blocks is injecting higher doses of local anaesthetics. A meta-analysis by De Oliveira et al. on transabdominal plane (TAP)-blocks for abdominal surgery showed a correlation between the local anaesthetic dose and the late block effect, impacting both pain scores and opioid consumption. In a randomised controlled trial by Suresh, a TAP block with bupivacaine 1.25 mcg/kg was compared to a TAP block with bupivacaine 2.5 mcg/kg, revealing a longer duration of analgesia and a lower need for additional analgesics up to 24 hours post-surgery. Moreover, loading doses up to 2mg/kg body weight are recommended for truncal blocks in general, but the mean injected dose in our intervention group was 1.25mg/kg, considering a mean patient body weight of 79.2kg. Notably, a pharmacokinetic study by Maximos and colleagues on an adrenalised bupivacaine mixture after pectointercostal fascial plane block (PIFB) after cardiac surgery showed that, despite injecting 2mcg/kg adrenalised bupivacain, both total and free arterial serum bupivacaine levels were 10-20 times lower than levels associated with neurologic or cardiovascular toxicity in the literature.

In conclusion, we are convinced we can safely improve the late effects of our SAPB compared to our first study by increasing the dose of the local anesthetic injectate.

• Opioid consumption during predetermined time intervals after surgery [Time frame: Every 4 hours until 24 hours after placement of the SAP block]
• Opioid free patients first 24 postoperative hours [Time frame: First 24 hours]
• Postoperative pain score in rest and on deep respiration [Time frame: 4, 8, 12 and 24 hours after performing the SAP block and at postoperative day 7.]
• Overall patient Satisfaction with analgesic therapy [Time frame: 24 hours after performing the SAP block at postoperative day 1.]
• Time to extubation [Time frame: Throughout study completion, an average of 7 days]
• Time to first mobilization [Time frame: Intended at 6 hours after surgery]
• Postoperative nausea and vomiting (PONV) [Time frame: 24 hours after performing the SAP block at postoperative day 1]
• Constipation [Time frame: Until postoperative day 7]
• ICU length of stay [Time frame: Until postoperative day 7]
• Hospital length of stay [Time frame: Throughout study completion, an average of 7 days]
• Pneumonia [Time frame: Until postoperative day 7]
• Quality of recovery [Time frame: At postoperative day 2 and 7]