Beyond the spine: Local anesthetic blocks in pediatric cardiac surgery

Abstract

Pediatric patients with congenital heart defects undergoing cor‐ rective or palliative heart surgery with the aid of an extracorpo‐ real circulation are a vulnerable group of patients. Extracorporeal circulation is well known to cause a systemic inflammation reaction syndrome (SIRS) including sometimes massive tissue edema, pulmo‐ nary affection, renal, cardiovascular, and moreover neurological dis‐ orders.1 Multiple stimuli‐like contact with artificial surfaces during ECC, hypothermia, and surgical stress are enhancing factors. In the past decade, it could be demonstrated that the development of a strong inflammatory reaction is associated with poor clinical out‐ come. Therefore multiple approaches are undertaken to control or blunt the systemic inflammatory reaction. Besides excellent pain control regional anesthesia in cardiac patients is known to have several benefits. In several studies in adult as well as in children it could be shown that high spinal or thoracic epidural anesthesia could effectively alter the inflammatory response after open heart sur‐ gery.2,3 Not only inflammation but also decreasing the sympathetic activity and the linked effects on the postischemic myocardium are potential benefits of high spinal or epidural anaesthesia in children with congenital heart defects.4 Criticism of the spinal or epidural technique never stopped because there is a small but ever promi‐ nent risk of bleeding complications due to systemic anticoagulation during extracorporeal circulation and rarely impaired coagulation problems immediate after the surgical procedure.5 In nearly every clinical report dealing with spinal or epidural techniques in children undergoing open heart surgery the careful measurements of risk vs benefits are being discussed. The Review by Naveen Raj in the current edition of Pediatric Anesthesia is summarizing alternative techniques of regional anesthesia for heart surgery in children beyond spinal or epidural anaesthesia. He is offering a comprehensive overview about the most common tech‐ niques, describing the benefits and drawbacks and explaining the most appropriate technique of thoracic blocks. Besides the abovementioned problems associated with heart surgery, he focused on a very import‐ ant point and that is the multimodal approach to pain control. It is a fact that not only pain from the operation wound but also from lines, drains chest tubes etc may cause a massive discomfort in children. The modern approach to pediatric surgery includes the basic principles of enhanced recovery strategies.6 Children specially do not want to stay in hospitals; they want to be at home with their parents. Besides this understandable desire of our small patients, we nowadays aim for a reduction in ventilation time, fast recovery, and early mobilization due to the well‐known benefits of the fast‐track approach.7 These benefits are not only patient comfort but also and most important an improvement in outcome.8 Of course besides all known benefits of re‐ gional spinal or epidural anesthesia in cardiac surgical patients, there is always a risk as mentioned. If one can avoid these risks but adopt all benefits its more than worth to look at these techniques. If we are able to save systemic opioids with local blocks, we could offer a major benefit to our pediatric patients. Naveen Raj is asking four reflective questions at the end of his brilliant article. If this review article would stimulate the scientific community to give answers to these questions, it might lead to a massive benefit for our children.