Regional Anesthesia With Fascial Plane Blocks for Pediatric Cardiac Surgery With Sternotomy: A Narrative Review

Undertreated pain in children who undergo sternotomy for cardiac surgery can lead to cardiopulmonary complications, the development of chronic pain, and long-term maladaptive stress response. Opioids have dose-dependent side effects that may interfere with postoperative recovery. With the increasing availability of ultrasound, regional anesthesia is often included in multimodal analgesic approaches. Fascial plane blocks targeting the intercostal nerves or ventral rami are of particular interest for patients requiring full heparinization for cardiopulmonary bypass as they avoid manipulation of neuraxial and noncompressible paravertebral spaces. This narrative review summarizes the literature on fascial plane blocks for pediatric patients undergoing cardiac surgery via midline sternotomy and may serve as a guide for clinicians. Both prospective and retrospective studies are reviewed, as are prior review articles. We describe individual fascial plane block techniques including the transversus thoracic muscle plane, pectointercostal fascial plane, serratus anterior plane, and erector spinae plane blocks and provide clinical considerations for each block. Additionally, we provide an analysis of individual studies stratified by anterior or posterior approach and block type. The majority of described studies examine single-shot blocks; the existing catheter literature, which includes erector spinae plane block catheters, is also included. Our findings suggest that fascial plane blocks decrease intraoperative and postoperative opioid use, pain scores, time to extubation, and length of stay in the intensive care unit and hospital. Notably, prospective studies in this field are small, typically fewer than 100 patients, and overall include a homogenous patient population, focusing primarily on patients with acyanotic congenital heart defects. Nonetheless, despite the limitations of individual studies, there is substantial evidence to support the use of regional anesthesia, particularly for patients in whom early extubation is planned. There is a need for large, prospective multi-center studies to evaluate the effectiveness and safety of specific single-shot block types, optimal local anesthetic dosing strategies compared to active comparators, and generalizability of results across institutions. Future studies should also consider evaluating the role of regional block catheters for continuous local anesthetic infusion and the inclusion of additional surgical populations, including neonates, patients with cyanotic lesions, and those with longer postoperative mechanical ventilation courses.