ESP Block in cardiac & thoracic surgeries
to provide a safe and efficient analgesia opioid free

Friday October 19th 2018
VinMec Central Park International Hospital (Ho Chi Minh City)

Registration: Dead Line October 12th limited seats ++++
CME credits by VinMec & Vietnamese MOH in process

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Challenges to provide pain free opioid free open heart surgeries, thoracic and breast surgeries

The pain after open cardiac surgery

In 2017 Open heart surgeries still present moderate to severe acute post operative pain [1,2]. The pain may originate from the surgical incision, the sternotomy, the mediastinal drains and the thoracic spine (costo-transverse and costo-vertebral joints). A painful postoperative period after cardiac surgery may promote pathophysiologic transformation in major organs which could lead to extensive postoperative morbidity [3]. Breakthrough pain during movement and physiotherapy is important after open cardiac surgery limiting the daily activity programs of the patients and rehabilitation.

The current multimodal analgesia associating paracetamol, nefopam, NSAIDs and opioids is not optimal. It may have shown good efficacy for postoperative pain at rest, without reaching the full pain relief.

The use of opioids generated well-known side effects as delay in recovery time and hospital stay [4], nausea-vomiting, pruritus, respiratory depression, dependency and induced hyperalgesia syndrome and pain chronicisation after surgery [5].

The risk of chronic pain is increased when patients present high acute pain episods after surgery during three or four days [6]. After cardiac surgery the prevalence to develop a chronic pain is between 27 to 48% with moderate to severe pain more than one year after the surgery [7].

The evidences concerning the use of regional anesthesia analgesia techniques for post-op pain relief:
The impact of epidural and paravertebral blockade, spinal analgesia, nerve blocks, and new regional anaesthesia techniques on main procedure-specific postoperative outcomes is very important in opioids decreased use in the context of fast-track programs that are fully suggested after cardiac surgery [8].

Andrea et al showed in a Cochrane group meta-analysis that regional anesthesia techniques are able to prevent chronic pain after surgery compared to opioids or multimodal analgesia techniques [9].

Many studies show that a complete pain relief after surgery improves the surgical outcome and the quality of life of the patients

The techniques of regional anesthesia available for open heart surgeries:

• A continuous LA IV infusion after cardiac surgery can reduce pain score at 72 hours, shorten time to ambulation, and reduce morphine consumption at 48 hours.

• Thoracic epidural analgesia and intrathecal morphine administration that can effectively treat pain, but have several concerns related to their potential complications due to the peri-operative anticoagulation and the unacceptable risk of epidural hematoma [10].

• The bilateral continuous paravertebral block that has equivalent analgesic effects to epidural analgesia but It is an advanced technique of regional anesthesia and not all anesthesiologists are skilled to perform such advanced technique.

• Bilateral Parasternal multi-hole catheter inserted by the surgeon was described and published but it provides only the anterior pain relief

• The serratus plane block may block only external part of the sternal and the drain pain. It will not block the thoracic back pain

The ESP Block recently described [11] is an inter-fascial block described as a safe quite simple technique, far from risky anatomical structures. Already a Prospective study on 59 adults for open heart surgeries was presented at the world congress of ASRA as oral communication [12] and a case reported by the team of Stanford University [13]. It was used also as rescue analgesia for thoracic surgery [14]. It has been published also in thoracic pediatric surgeries [15].

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MAIN REFERENCES

1 Milgrom LB, Brooks JA, Qi R, Bunnell K, Wuestfeld S, Beckman D. Pain levels experienced with activities after cardiac surgery. Am J Crit Care 2004; 13:116-125.

2 Lahtinen P, Kokki H, Hynynen M. Pain after cardiac surgery: A prospective co-hort study of 1-year incidence and intensity. Anesthesiology 2006; 105:794-800
3 Mueller XM, Tinguely F, Tevaearai HT, Revelly JP, Chioléro R, von Segesser LK. Pain location, distribution, and intensity after cardiac surgery. Chest 2000; 118:391–6.
4 Gan TJ, Robinson SB, Oderda GM, Scranton R, Pepin J, Ramamoorthy S.Impact of postsurgical opioid use and ileus on economic outcomes in gastrointestinal surgeries.Curr Med Res Opin. 2015 Apr;31(4):677-86.
5 Fletcher D, Martinez V. Opioid-induced hyperalgesia in patients after surgery: a systematic review and a meta-analysis. Br J Anaesth. 2014 Jun;112(6):991-1004.
6 Perkins FM, Kehlet H: Chronic pain as an outcome of surgery. Anesthesiology 2000; 93:1123–33
7 Kalso E, Mennander S, Tasmuth T, Nilsson E: Chronic post-sternotomy pain. Acta Anaesthesiol Scand 2001; 45:935–9
8 Carli F, Kehlet H, Baldini G, Steel A, McRae K, Slinger P, Hemmerling T, Salinas F, Neal JM. Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways. Reg Anesth Pain Med. 2011 Jan-Feb;36(1):63-72
9 Andreae MH1, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth. 2013 Nov;111(5):711-20.
10 Liu SS, Block BM, Wu CL. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: a meta-analysis. Anesthesiology 2004;101:153–61
11 Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain. Reg Anesth Pain Med. 2016 Sep-Oct;41(5):621-7
12 Nga Ho, Binh Nguyen, Tan Nguyen, Viet Vu, Chinh Quach, Vincente Rocques, Philippe Macaire Analgesia opioid free with Bilateral ESP catheters for open heart Surgeries in Adults RAPM 2018 ASRA 277
13 Tsui BCH, Navaratnam M2 Boltz G, Maeda K, Caruso TJ. Bilateral automatized intermittent bolus erector spinae plane analgesic blocks for sternotomy in a cardiac patient who underwent cardiopulmonary bypass: A new era of Cardiac Regional Anesthesia. J Clin Anesth. 2018 Apr 19;48:9-10
14 Forero M, Rajarathinam M, Adhikary S, Chin KJ. Continuous Erector Spinae Plane Block for rescue analgesia in thoracotomy a!er Epirural Failure: A case report. A A Case Report. 2017 May 15;8(10):254256.
15 Erector spinae plane block for postoperative analgesia in pediatric oncological thoracic surgery. Muñoz F, Cubillos J, Bonilla AJ, Chin KJ. Can J Anaesth. 2017 Aug;64(8):880-882.

The expertise of VinMec Anaesthesia teams

The anesthesia teams of VinMec International Hospitals central park and Times City performed between May 2017 and April 2018:

400 Bilateral ESP catheters for 200 adults open heart surgeries.
68 bilateral ESP catheters for 34 Infants open heart surgeries.

ESP Catheters for
o Breast surgeries
o Thoracic surgeries
o Live donor Liver with asymmetrical blockade

During this period the data collected in open heart surgeries showed no complication or major incident. One incident: a catheter placed in Intra-vascular providing inefficient analgesia. Since an additive safety test was created to prevent such miss-location.

The success rate of bilateral efficient analgesia opioid free is 98,6%.

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First world cases presented during World Congress of regional anaesthesia and pain medicine in New York City April 2018.
First Prospective study on ESP catheters for open heart surgery in submission

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Program: Friday October 19th 2018
General Learning Objectives of this symposium

The Thoracic Erector Spinae Plane Blockade (ESPB) is a regional anesthesia technique recently described by Forero M in November 2016 [1], whereby local anesthetic (LA) is injected in the inter Fascial space between posteriorly the fascia of Erector Spinae Muscles (IFS-ESP) (the iliocostalis, longissimus, and spinalis muscles) and anteriorly the inter-transverse ligament to achieve multi-metameric analgesia for thoracic or upper abdominal surgery.. Compared to the other techniques of regional anaesthesia qualified as advanced techniques or techniques for skillet anesthesiologists perform by only few anesthesiologists in the world, ESPB technique is as a quite simple technique, far from risky anatomical structures [2].

The objectives are to learn how to do it safely and get the latest data from the 120 Articles published in the past 18 months.

Upon successful completion of the course, the Participant will be able to:

  • 1. Know the requirements to perform regional anaesthesia analgesia in Thoracic surgeries.
  • 2. Know the neuro and sono anatomy required to perform ESP blocks
  • 3. Know the safety processes
  • 4. Know how to manage analgesia by Interfascial catheters
  • 5. Know the process and tips for the ultrasonographic scan for ESP blocks.
  • 6. Know the infusion regimen of local anaesthetics for ESP blocks

References
1 The Erector Spinae Plane Block. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJReg Anesth Pain Med 2016;41:621–7.
2 El-Boghdadly K, Pawa A.The erector spinae plane block: plane and simple. Anaesthesia. 2017 Apr;72(4):434-438.

 

Lecture 1 : Anatomy for ESP – Pr Philippe Macaire

1. To know y of the anatomy for the ESP: para-median sagittal and transverse of the thoracic wall

2. To know the inter fascial space of erector plane block

Lecture 2: The block performance and safety tests– Pr Philippe Macaire DR Chinh Quah for live demos on models

1. Learn the 3 steps of US scanning,

2. learn the mistake to not do,

3. safety tests for single shot and catheter insertion to perform

4. To learn on the models: 1 on slim model and 1 on overweight model

Lecture 3: ESP Diffusion space and infusion of LA with pump settings – Pr Philippe Macaire

1. Learn the data from the literature concerning the spread of local anesthetic and the contraversies

2. Discover of the new concept of intermittent auto bolus instead of continuing infusion regiment.

3. Learn the low volume technique, increasing safety of this block

4. The learn the posologies of Local anesthestics for single shot and catheter from infant ages to adult ages and based on ideal body weight.

Lecture 4: ESP The outcomes in cardiac surgery – Dr Nga Ho

1. Learn from first 3 studies published relating to ESP: Benefit and outcome

2. Discover the data of our 450 catheters performed since October 2017

Lecture 5: ESP for Breast, Thorax, Abdominal surgeries – Philippe Macaire

1. To discover the indication and thoracic level puncture recommended for breast thorax and abdominal surgeries from the literature and from the VinMec Anaesthesia team daily practice.

2. To see the combined blocks if needed

 

Educational material

e-Book with:

The check list for open heart surgeries with ESP catheters

The settings list

The pdf of 101 Articles published on September 2018 1st

The training plan for your facility

the catalogue of the devices

The speaker slides in PDF

The infusion regimen for

  • Adults
  • infants
Faculty members
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Philippe Macaire MD

Director of Anesthesiology and Pain

VinMec Healthcare System
Hanoi - Vietnam

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Nga Ho MD

Anesthesiologist in cardiac surgery

VinMec International Hospital Central Park
Ho Chi Minh City – Vietnam

Philippe MACAIRE, (M.D.), Ph.D
Dr. Nga Ho MD
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Nguyen Thi Quy

Head of Anesthesiology

Heart Institute Alain Carpentier
Ho Chi Minh City – Vietnam

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Chin Quach MD

Anesthesiologist

VinMec International Hospital Time City
Hanoi – Vietnam

Nguyen Thi Quy
Chin Quach MD
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Tan Luong Nguyen

Head of cardiac surgery

VinMec International Hospital Central Park
Ho Chi Minh City – Vietnam

Tan Luong Nguyen

Registration & Fees

Registration: Dead Line October 12th limited seats ++++

Send e mail to block your seat to Miss Mai in charge of the coursev.maihn@vinmec.com

Registration fees

  •  Vietnamese : 2 M VND
  • International : 150 USD
  • Discount for low income countries

1 day intensive Course combining lectures, workshops hands on model, live demonstrations and simulation on phantom. (2 sessions per year)

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