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.