• Tomohiro Yamamoto, Yutaka Seino, Keiichiro Matsuda, Hidekazu Imai, Keiko Bamba, Ai Sugimoto, Shuichi Shiraishi, and Ehrenfried Schindler.
• Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan. Electronic address: yamatomo270@hotmail.com.
• J. Cardiothorac. Vasc. Anesth. 2020 Dec 1; 34 (12): 3367-3372.

AbstractSystemic intravenous administration of opioids is the main treatment strategy for intraoperative and postoperative pain management in patients undergoing cardiac surgery with sternotomy. However, using lower doses of opioids may achieve the well-established benefits of the fast-track approach, with minimal opioid-related side effects. Postoperative pain is coupled with a long stay in the intensive care unit. Although neuraxial anesthesia has some benefits, its use remains controversial due to the potential development of epidural hematoma after anticoagulation for cardiopulmonary bypass and coagulopathy after cardiac surgery. Therefore, there is a need for other effective postoperative analgesic strategies, such as peripheral nerve blocks other than neuraxial anesthesia, for cardiac surgery with sternotomy. The effects of real-time ultrasound-guided transverse thoracic muscle plane (TTP) block on postoperative pain after sternotomy have been reported; however, the pain and discomfort in the epigastric area caused by chest drainage tubes placed through the rectus abdominis muscle also are major postoperative problems after cardiac surgery. Herein, the authors report on a preoperative combination of TTP block and rectus sheath block (RSB) for postoperative pain management after cardiac surgery with sternotomy that addresses pain in both the chest and epigastric areas. Considering previous studies, it is presumed that preemptive analgesic effects can be expected via a combination of the TTP block and RSB, and indeed, the preemptive effect was observed in the present study's patients. In this article, the procedure and tips for combining the TTP block and RSB are introduced.Copyright © 2020 Elsevier Inc. All rights reserved.

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