Clinical Study Of Ultrasound-guided Transversus Thoracis Muscle Plane Block

Transversus thoracis muscle plane(TTMP)block is a newly developed fascial nerve block technique,which can provide good perioperative analgesia for the median sternotomy incision.Combined with other nerve blocks,it can also provide effective anesthesia for the incision of the chest wall.The TTMP was located between the intercostal muscle and transverse pectoralis muscle and the TTMP block can cover the anterior branches of intercostal nerves from T2 to T6 and can provide effective analgesia in the internal mammary area.With the clinical application and popularization of ultrasound visualization technology in anesthesia,ultrasoundguided TTMP block has gradually come into the vision of anesthesiologists,and its clinical application in cardiac surgery,thoracic surgery,breast surgery and cardiology is increasing.However,the related clinical and basic research of TTMP block at home and abroad are mostly concentrated in case reports,and its related clinical application specifications and randomized controlled clinical studies have not been reported.This study discussed the best clinical strategy of ultrasound-guided TTMP block,the clinical application of ultrasound-guided TTMP block in patients undergoing open heart surgery,and the clinical application of ultrasound-guided TTMP block combined with serratus anterior plane block(SAPB)in patients with pacemaker implantation.Part Ⅰ The best clinical strategy of ultrasound-guided transverse thoracic muscle plane blockObjective: To investigate the diffusion range,optimal puncture space,puncture approach and safety of ultrasound-guided transthoracic muscle plane(TTMP)block.Methods: 150 patients undergoing open heart surgery were randomly divided into two groups: group A: TTMP block in T3 / 4 space;group B: TTMP block in T4 /5 space.The difference of diffusion plane between the two groups was recorded,and the diffusion range of all patients was analyzed to determine the diffusion range of TTMP block.At the same time,150 patients were randomly divided into parasternal sagittal plane puncture method and parasternal transverse plane puncture method.The puncture time,puncture times,times of touching bone and display rate of internal thoracic artery and vein were observed.At the same time,the incidence of complications related to TTMP block(infection,hematoma,pneumothorax,internal thoracic artery and vein injury,pericardium and heart injury)was recorded.Results: The block range of TTMP was mainly T2-T6 level(left T2 rib block rate: 64.3%;right T2 rib block rate: 42.8%;left T3 rib block rate: 89.3%;right T3 rib block rate: 87.9%;left T4 rib block rate: 99.3%;right T4 rib block rate: 100%;left T5 rib block rate: 100%;right T5 rib block rate: 100%;left T6 rib block rate: 100%;right T6 rib block rate: 99.3%).There were a few patients with T1 and T7 plane to TTMP block(left T1 costal block rate: 7.14%;right T1 costal block rate: 2.86%;left T7 costal block rate: 5.71%;right T7 costal block rate: 10.7%).There was no significant difference in T1,T3,T4 and T5 diffusion between group A and group B,but the diffusion rate of T2,T6 and T7 in group A was significantly lower than that in group B(T2: 46.4% vs 61.4%,P < 0.05;T6: 76.4% vs 100%,P < 0.05;T7: 3.57% vs 8.57%,P < 0.05).Compared with parasternal sagittal plane puncture,ultrasound-guided TTMP block with parasternal transverse plane puncture required longer puncture time(8.3 ± 2.7 vs 5.4 ± 2.1,P < 0.05),more puncture times(3.5 ± 0.5 vs 1.5 ± 0.5,P <0.05),and lower display rate of dynamic and static pulse in chest(64.3% vs 86.4%,P< 0.05),but there was no significant difference in the number of times of touching bone.There was only one case of mild infection and one case of mild hematoma in all patients with TTMP block.There was no pneumothorax,internal thoracic artery and vein injury,pericardium and heart injury.Conclusion: 1)The diffusion range of ultrasound-guided TTMP block was mainly at T2-T6 level in the medial anterior median region of breast,and a few patients also had block effect at T1 and T7 levels.2)Parasternal sagittal plane puncture is more suitable for ultrasound-guided TTMP block.3)T4 / 5 space for ultrasound-guided TTMP block has a wider range of block diffusion,so it is recommended to use T4 / 5 space for ultrasound-guided TTMP block.4)Ultrasound guided TTMP block is safe in clinical application.PartⅡ Clinical application of ultrasound-guided transverse thoracic muscle plane block in patients undergoing open heart surgeryBackground: The mid-sternum is the main source of pain after open cardiac surgery.The ultrasound-guided transversus thoracis muscle plane(TTMP)block can cover the anterior branches of intercostal nerves from T2 to T6.The aim of this study was to investigate the effect of bilateral transversus thoracis muscle plane(TTMP)blocks on open cardiac surgery.Methods: One hundred and six patients were randomly divided into two groups:bilateral TTMP blocks(TP group)or no nerve block(CO group).The primary endpoint was perioperative sufentanil consumption.The secondary outcome measures included postoperative pain,flurbiprofen axetil administration,quality of sleep after extubation,time to extubation,incidence of postoperative nausea and vomiting(PONV),time to the return of gastrointestinal function,time to drain removal,the Intensive Care Unit(ICU)stay time and hospital stay.Results: The resting NRS scores at 1 hour(1.2 vs 3.2,P < 0.01),2 hours(1.3 vs3.3,P < 0.01),6 hours(1.2 vs 3.5,P < 0.01),12 hours(1.4 vs 3.7,P < 0.01)and 24hours(1.7 vs 3.8,P < 0.01)in TP group were lower than those in CO group,but there was no significant difference between the two groups at 48 hours.The NRS scores of TP group at 1 hour(1.4 vs 4.3,P < 0.01),2 hours(1.5 vs 4.5,P < 0.01),6 hours(1.6vs 4.6,P < 0.01),12 hours(1.5 vs 4.7,P < 0.01)and 24 hours(1.9 vs 4.8,P < 0.01)were significantly lower than those of CO group at these five time points,but there was no significant difference between the two groups at 48 hours after operation.The amount of sufentanil used during operation(74 ± 10 μ g vs 125 ± 30 μ g,P < 0.01)and after operation(60 ± 10 μ g vs 98 ± 10,P < 0.01)in TP group were lower than those in CO group.The dosage of flurbiprofen axetil 48 hours after operation in CO group was significantly higher than that in TP group(225 ± 100 mg vs 125 ± 100 mg,P < 0.01).Compared with CO group,the extubation time(8.6 ± 2.7h vs 2.6 ± 1.1h,P= 0.03),the first exhaust time(34 ± 16 h vs 26 ± 6h,P < 0.01),ICU stay(25 ± 10 h vs15 ± 8h,P = 0.04)and hospital stay(195 ± 36 h vs 152 ± 28 h,P < 0.05)in TP group were significantly lower.The sleep quality of TP group on the first night(4.1 ± 2.8 vs6.8 ± 3.2,P < 0.05)and the second night(6.7 ± 2.8 vs 4.6 ± 2.3,P < 0.05)was significantly improved compared with CO group.The incidence of PONV in TP group was significantly lower than that in CO group(8% vs 20%,P < 0.05).There was no significant difference in the time of drainage tube removal,re intubation rate and first defecation time between the two groups.Conclusion: Bilateral TTMP blocks can provide good perioperative analgesia for patients undergoing open cardiac surgery and promote postoperative recovery.Part Ⅲ Clinical application of ultrasound-guided transverse thoracic muscle plane block combined with serratus anterior plane block in patients with pacemaker implantationObjective: Patients undergoing the pacemaker placement usually suffer from substantial perioperative pain.The aim of this study was to investigate the effect of the transversus thoracic muscle plane(TTMP)block combined with serratus anterior plane block(SAPB)in patients undergoing pacemaker placement.Methods: A group of 100 patients were randomly allocated to either receive combined nerve blocks(NR group)or no nerve block(CN group).The primary endpoint was pain during pacemaker placement.The secondary outcome measures included pain intensity at rest and after movement 1,3,6,12,24,48 h after surgery;the dose of dexmedetomidine and remifentanil during operation;24-hour ketorolac administration;postoperative sufentanil dosage;the total duration of hospitalization;intraoperative sedation and the incidence of hypoxemia.Results: Mean CPOT scores were significantly higher during pocket creation,lead tunneling A and lead tunneling B in CN group compared with NR group.The NR group required significantly less intraoperative dexmedetomidine consumption;intraoperative remifentanil consumption;postoperative sufentanil consumption and ketorolac consumption.Compared to the NR group,the CN group had higher Numerical Rating Scale(NRS)pain scores at 24 hours after operation both at rest and after movement.Intraoperative Ramsay score and the incidence of hypoxemia were significantly higher in the CN group compared with the NR groupConclusion: Ultrasound-guided TTMP block and SAPB in patients undergoing pacemaker placement could provide effective analgesia.