Introduction
Subcutaneous implantable cardioverter-defibrillators (SICDs) are a type
of cardiovascular implantable electronic device that defibrillate
malignant ventricular arrythmias. SICD can be a good alternative to a
transvenous implantable cardioverter defibrillator (ICD); SICD avoids
complications associated with ICDs such as cardiac perforation, lead
fracture, and venous thrombosis.1 The procedure
involves the placement of the generator subcutaneously in the left
lateral chest wall and tunneling of the lead across and up the left
parasternal border. Since this is a densely innervated region of the
chest wall; analgesia can be a challenge. Traditionally, perioperative
pain management for SICD placement is dependent on wound infiltration
with local anesthetics and opioids. However, wound infiltration can
result in unreliable efficacy due to the need to cover a large area of
the anterior chest wall, variable spread of the local anesthetic and
limited duration of action. Furthermore, this patient population has
multiple comorbidities resulting in higher risk for opioid-related side
effects.
Regional techniques such as the erector spinae plane block (ESP) can
provide good analgesia while attenuating the risk of opioids especially
in this patient population. The ESP block is proposed to provide
multi-dermatomal sensory block of the posterolateral and anterior thorax
via anterior diffusion of local anesthetics to target the dorsal and
ventral rami.2 This block was chosen because it is
relatively easy to perform and its sensory distribution may give
coverage to both the parasternal and the inframammary tunneling sites
during SICD placement.
In this feasibility study, we compared single shot Erector Spinae Plane
(ESP) block to surgical infiltration of local anesthesia for SICD
placement. The authors hypothesize that the ESP block is a safe block
that will provide adequate analgesia for during the perioperative period
and therefore reduce narcotic requirement in patients undergoing SICD
implantation.